2018 AZOA Bronstein Contact Lens & Cornea Seminar Handouts - (Dr. Thomas Quinn Lecture Notes)
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2018 AZOA Bronstein
Contact Lens &
Cornea Seminar
Handouts
(Dr. Thomas Quinn Lecture Notes)12/27/2017
Disclosures
Alcon
Practical Problem-Solving Allergan
of Red Eye Bausch & Lomb
in the Contact Lens Patient BioScience Communications
Thomas G. Quinn, OD, MS CooperVision
Athens, OH GPLI
tgquinn5@gmail.com
STAPLES Program
JJ VC Vistakon
Red = Inflammation Red = Inflammation
Rubor (redness) A protective response
Tumor (swelling)
Calore (heat)
Dolore (pain)
Courtesy of Bart Pemberton, OD
Red = Inflammation Red Eye:Potential Causes
A protective response Contact lens wear
If persists, can contribute to disease Non-CL related conjunctivitis
o Bacterial
A red flag that something is amiss!
o Viral
o Allergic
Dryness
Other irritants
o Smoke
o Dust
o Pool Chlorine
112/27/2017
First Step: A Good History
While modern medical technology has
greatly enhanced our ability to diagnose
and treat disease, it has also promoted
laziness—especially mental laziness—
among many physicians. Habitual reliance
on sophisticated medical gadgetry for
diagnosis prevents physicians from using
the most sophisticated, intricate machine
they'll ever and always have—the brain.
Herbert L. Fred, MD
Professor, Department of Internal Med.
The University of Texas
A Good History A Good History
Most valuable tools? Res. Physn
442 consecutive patients
o History alone 19.8 19.3%
Compared experience: Correct Dx o Physical examination alone 0.8 0.5%
o Senior Resident 80.1% o Basic tests (BT) alone 1.1 1.3%
• (4 yrs) o Hx + Physical examination 39.5 38.6%
o Experienced Clinician 84.4% o Hx + BT 14.7 14.7%
• (>20 yrs) o Hx + Physical exam +BT 16.9 18.5%
o Imaging studies 6.5 6.1%
Paley L, et al. Utility of Clinical Examination in the Diagnosis of Paley L, et al. Utility of Clinical Examination in the Diagnosis of
Emergency Department Patients Admitted to the Department Emergency Department Patients Admitted to the Department
of Medicine of an Academic Hospital Arch Intern Med. 2011;171(15):1393-1400 of Medicine of an Academic Hospital Arch Intern Med. 2011;171(15):1393-1400
HPI Location
Where’s the red?
o One or both eyes?
o Overall?
o Paralimbal?
212/27/2017
“My eye is red” “My eye is red”
• 22 year old college student
• SCL wearer/DW/Reusable
• MPS
• corneal infiltrates OD
“My eye is red” “My eye is red”
OS: What we did…
o minimal injection o Switched her to Hydrogen Peroxide-based
o 1+ infiltrates superior cornea care system
o Asked to return in 2 weeks
What To Do?
“My eye is red” Location
Where’s the red?
o One or both eyes?
o Paralimbal?
o Sectoral?
o Overall?
o In the aperture? Dryness
o At the eyelid margin? Blepharitis/MGD
Before After
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[ 19 ] [ 20 ]
MGD Treatment HPI
Hot compresses
o MGDRx heat mask
Hygiene
o Foaming eyelid cleanser
o Avenova
Medications
o Topical
o Oral
• Doxycycline
• Azithromycin
Quality Quality: Itch
How do your eyes feel? Where?
o Both eyes? Allergy
o Itch Allergy? o Nasal canthus? Allergy
o Eyelid margins? Blepharitis
o Burn Dryness?
412/27/2017
Quality: Itch Quality: Burn
Where? Where?
o Both eyes? Allergy o Both eyes? Dryness
o Nasal canthus? Allergy o One eye? Host of possibilities
o Eyelid margins? Blepharitis When?
When? o After reading/computer use? Dryness
o Seasonal? Allergy o After CL application? Soln/Hands?/Lotion
o After computer use? Dryness Modifying factors?
Modifying factors? o Rubbing? Dryness: helps comfort and vision
Worse Allergy
o Rubbing? Does it help?
Better Dryness
HPI Associated symptoms
Produce matter?
o Stringy vs globular Allergy vs Infection
o White vs green Allergy vs Infection
o Matted shut in am? Conj or Bleph?/ RCE?
Watery? Viral? Dryness?
Photophobia? Uveitis/Cornea?
Red Eye: Potential Causes HPI
Contact lens wear
Treat Non-CL related conjunctivitis
o Bacterial
o Viral
o Allergic
Treat Dryness
Remove Other irritants
o Smoke
o Dust
o Pool Chlorine
512/27/2017
Is redness associated with CL wear? Is redness associated with CL wear?
Modifying factors (What helps?) Dosymptoms get worse when you wear your
o Removing CL’s!!! CL’s?
Dosymptoms get better when you remove
your CL’s?
Do you wake up with red eyes?
o DW?
o EW?
Causes of CL Red Eye The Quest for Safety
Hypoxia Oxygen!
Enter Silicone Hydrogels
o 67% of US market
J Nichols, CL Spectrum, Jan 2017
Benefits of Silicone Hydrogels Benefits of Silicone Hydrogels
Fewer hypoxic changes Fewer hypoxic changes
o Less limbal redness o Less limbal redness
• 31% (EW) - 35% (DW) with o Less neovascularization
hydrogels2 • 18% with hydrogel EW
Papas EB, Vajdic CM, Austen R, Holden
BA: High oxygen transmissibility soft
contact lenses do not induce limbal Dumbleton KA, Chalmers RL, Richter DB,
hyperaemia. Curr Eye Res 1997; 16: Fonn D. Vascular response to extended
942-948, wear of hydrogel lenses with high and
low oxygen permeability.
2. Chalmers RL, Dillehay S, Long B, et al. Impact of previous extended and Optom Vis Sci 2001, 78(3): 147-151.
daily wear schedules on signs and symptoms with high Dk lotrafilcon A
lenses. Optom Vis Sci. 2005;82:549-554.
[ 35 ] [ 36 ]
612/27/2017
Benefits of Silicone Hydrogels Benefits of Silicone Hydrogels
Fewer hypoxic changes Fewer hypoxic changes
o Less limbal redness o Less limbal redness
o Less neovascularization o Less neovascularization
o Fewer corneal microcysts o Fewer corneal microcysts
• 90-100% in hydrogel EW o Less myopic creep
• 49% of EW Hyd wearers
Low Dk lens wearers switched
to high Dk lens
Dumbleton KA, Chalmers RL, Richter DB,
High Dk lens wearers Fonn D. Changes in myopic refractive error
with nine months` extended wear of
Keay L, Sweeney D, Jalbert, I et al, hydrogel lenses with high and low oxygen
Microcyst Response to High Dk/t permeability. Optom Vis Sci 1999;76:845-9 .
Silicone Hydrogel Contact Lenses,
Optom Vis Sci 2000; 77(11):582-585.
[ 37 ] [ 38 ]
Silicone Hydrogels Silicone Hydrogels
However:
MK rates unchanged (~5xDW)
1. Poggio EC, Glynn RJ, Schein OD, et al
MK rates unchanged with EW The incidence of ulcerative keratitis Mechanical issues
(~5xDW) among users of daily-wear and o Patient comfort/adaptation
o 19891(Hyd): 20.9/10,000 extended-wear soft contact lenses o Contact lens-induced papillary
N Engl J Med 1989 Sep 21; 321(12) :779-83. conjunctivitis (CLPC)
o 20052 (SiHy): 18.0/10,000
3
o 2008 (SiHy): 25.4/10,000 • Higher rate of local CLPC
with SiHy lenses (4.6%)
2. Schein OD, McNally JJ, Katz J et al. The
Incidence of microbial keratitis among wearers • DD SiHy: rate significantly
of a 30-day silicone hydrogel extended-wear reduced
contact lens. Ophthalmology 2005 Dec; 112(12):
2172-9
Skotnitsky C, et al. The incidence of local and general contact lens induced
papillary conjunctivitis in silicone hydrogel contact lenses.
3. Stapleton F et al. The incidence of contact lens-related Invest Ophthalmol Vis Sci 2005 46: E-Abstract 2064.
Microbial keratitis in Australia. Opththalmology 2008 Oct;
115(10):1655-62.
[ 39 ] [ 40 ]
Causes of CL Red Eye GPC (CLPC)
Symptoms:
Hypoxia o Itchy/ mucous
o Len decentration/
Mechanical/Allergic intolerance
Onset:
o Variable/ allergy season?
Treatment:
o D/C CL wear
o Steroids/antihistimine/
mast cell stablizer
o Refit DD
712/27/2017
Scleral Blanching
A (Lid) Flip Should Be Part of Every CL Exam!
Gabby Douglas, US Olympian
Causes of CL Red Eye Silicone Hydrogels
Hypoxia MK rates unchanged (~5xDW)
Mechanical concerns
Mechanical/Allergic Concern about corneal
inflammatory events (CIEs)
Corneal Infection/ Inflammation o 26.7% incidence1
o 2x increase vs hydrogel 1,2
1. Szczotka-Flynn L, Diaz M, Risk of corneal inflammatory events with silicone
hydrogel and low Dk hydrogel extended contact lens wear: A meta-analysis
Optom & Vis Sci April 2007;84(4):247-256
2. Radford CF, et al.Risk factors for nonulcerative contact lens complications in
an ophthalmic accident and emergency department: a case-control study.
Ophthalmology 2009 Mar;116(3):385-92.
[ 46 ]
CLARE (Contact Lens Associated Red Eye) CLPU (Contact Lens Peripheral Ulcer)
Symptoms Symptoms
o Watery, painful eye o mild-moderate redness/ discomfort/ tearing
• 50% asymptomatic
Onset – Bandage CL effect?
o On waking with EW Etiology
Etiology o Gram positive bacteria
o Gram neg bacteria exotoxins (staph)
Treatment Treatment
(Courtesy: CCLRU/LVPEI Guide to
o D/C CL Wear;Meds? 1. Fonn, D and Sivak, A. o D/C CL Wear;Meds? Corneal Infiltrative Conditions)
o 1/3 will recur1 CL Spectrum, Feb 2005. o Lid hygiene
812/27/2017
Sterile vs Infectious Silicone Hydrogels
MK rates unchanged (~5xDW)
Mechanical concerns
Concern about corneal
inflammatory events (CIEs)
o 26.7% incidence1
o 2x increase vs hydrogel 1,2
• Material/wear sch/other?
1. Szczotka-Flynn L, Diaz M, Risk of corneal inflammatory events with silicone
hydrogel and low Dk hydrogel extended contact lens wear: A meta-analysis
Optom & Vis Sci April 2007;84(4):247-256
2. Radford CF, et al.Risk factors for nonulcerative contact lens complications in
an ophthalmic accident and emergency department: a case-control study.
Ophthalmology 2009 Mar;116(3):385-92.
[ 50 ]
What about mucin balls? Risk factors for adverse events
Early mucin balls Age
o suggests greater – Greatest risk: late adolescence and early adulthood
propensity to CIEs
Years of contact lens wear
Late mucin balls
Silicone hydrogel material
o suggests protective
– Unreported overnight wear?
Carnt N, et al., Contact lens-related
– Higher lens modulus? adverse events and the silicone
– Care system issues? hydrogel lenses and daily wear
Photo from Lakshman N. Subbaraman care system used, Arch. Opthal,
Lens replacement schedule 127(12):1616-1623.
– Other than daily disposable
Loretta B. Szczotka-Flynn et al. Mucin Balls Influence Corneal Infiltrative Events,
Optometry and Vision Science , April 2017 Wagner H, et al (CLAY Group), Risk factors for interruption to soft contact
lens wear in children and young adults, Optom Vis Sci, Aug 2011;88(8):973-980.
[ 51 ] [ 52 ]
Risk factors for CIE’s Contact Lens Safety
Bacteria bind in higher levels to SiHy lenses Incidence of CIEs:
– Related to increase in CIEs? • DD vs Reusable:
– 12.5 X less likely
with DD1
• DD SiHy vs DD Hyd:
– SiHy DD: 0.4%
– Hyd DD: 0%
Pseudomonas aeruginosa
Source: CDC 1.Chalmers, Robin L. et al, Multicenter Case-Control Study of the Role of Lens
Subbaraman LN, et al. Influence of Materials and Care Products on the Development of Corneal Infiltrates,
protein deposition on bacterial Optometry & Vision Science. 89(3):316-325, March 2012.
adhesion to contact lenses.
2. Chalmers RL et al, Rates of Adverse Events With Hydrogel and Silicone
Optom Vis Sci Aug 2011;88(8):959-966 Hydrogel Daily Disposable Lenses in a Large Post Market Surveillance Registry:
The TEMPO Registry. Invest Ophthalmol Vis Sci. 2015 Jan 8;56(1):654-63
[ 53 ] [ 54 ]
912/27/2017
Take-Aways
Detailed History: is a powerful tool: give time to it
Where’s the red?
Itch doesn’t necessarily mean allergy (though it might!)
Burn doesn’t necessarily mean dryness (it might!)
Key Indicators that CL’s are contributory to redness:
– Improvement with contact lens removal
– Worsening with contact lens application
Likely Contact Lens Culprits:
– Hypoxia (especially with extended wear and high Rx)
– Mechanical/ Allergic
– Infection/ Inflammation
Clean Lenses and Clean Hands!
Illegal CL Sales Illegal CL Sales
• Contact lenses are being sold without an Rx • WatchDog Work*
or with an expired Rx – recorded 102 websites selling CLs illegally
– In the decorative CL segment*: – stopillegalCLs@aoa.org
• 2013: 24% purchased without an Rx
• 51 separate reports of illegal CL sales
• 2014: 53% purchased without an Rx
– 19 physical stores
• 2015: 26% purchased without an Rx – 32 websites
• stopillegalCLs@aoa.org to: • 13 adverse events from wear of illegally purchased CLs
– Report suspected illegal sales • Next Steps
– Report adverse events from illegal CLs – Develop WatchDog network in each state
• AOA reports illegal sales to appropriate authority
* American Optometric Association’s
American Eye-Q® consumer survey * As of April 2016
1012/27/2017
Disclosures
• Alcon
Medical Management of the • Allergan
• Bausch & Lomb
Presbyopic Patient • BioScience Communications
Thomas G. Quinn, OD, MS • CooperVision
Athens, OH • GPLI
tgquinn5@gmail.com • STAPLES Program
• JJ VC Vistakon
Cornea
Contact Crystalline
Who are we talking about? Lens Lens
Gen Xers (45-54 yo) Baby Boomers (55-64 yo)
• Tech savy • Desire to stay active
• High level of activity ▫ Socially
• Adaptable ▫ Intellectually
• Value freedom ▫ Physically
Intraocular Implants (IOLs)
Scleral Expansion
Eye drops?
112/27/2017
Refractive Lens Exchange
• Replacement of CLEAR crystalline lens with an
IOL
• Potential Complications:
Corneal decompensation
Cystoid macular edema
Retinal detachment
Myopes: 1-8%* vs 0.68% (>-10.00)
• Employed with high hyperopia (>+3.00 D)
▫ LASIK and other refractive techniques not viable
▫ Narrow angles
*Jorge L et al, Surv Opthal, Nov-Dec 2014
IOLs Monofocal IOL-Monovision
•Distance eye set for plano
• Generally reserved for those with visually • Near eye set for -1.25
significant cataracts
Advantages Challenges
• Can work well • If no prior experience:
• Options: ▫ Particularly with those who ▫ can be difficult to assess
▫ Monofocal set to monovision have successfully worn anticipated response in
▫ Multifocal monovision CL presence of a cataract
▫ Accommodative
Multifocal IOL Multifocal IOLs
•Refractive- bending of a wave when it enters a
Diffractive Optics
medium where its speed is different
• Step height • Apodization
• Diffractive- bending and spreading of a wave as
The higher the step height, the gradual shortening of
a result of passing through a narrow aperture or the more light is distributed step heights toward the
across an edge to near focal point periphery of the diffractive
• Distance between steps zone.
determines the add power
of the lens
212/27/2017
J&J
ReSTOR MF IOL (Alcon) Tecnis MF IOL (Abbott)
• 2 designs • 3 designs
• Diffractive optics on anterior surface • Diffractive optics on posterior surface
Monovision IOL vs Multifocal IOL Monovision IOL vs Multifocal IOL
• 212 patients • Results:
• Randomly assigned preoperatively ▫ Monovision IOL patients more than 7x more likely to need glasses at
▫ Monofocal aspheric IOL least some of the time
Near eye target: -1.25 D (actual: -0.92D) ▫ Total spectacle independence
▫ 3-piece multifocal IOL 26% of monovision IOL subjects
Tecnis ZMB00 +4.00(AMO) 71% of multifocal IOL subjects
• Assessed at 4 months post-op ▫ Binocular Unaided Acuity
Distance: similar
Intermediate: best with monovision
Near: best with multifocal
Wilkins MR, Allan BD, Rubin GS, et al. Randomized Trial of Wilkins MR, Allan BD, Rubin GS, et al. Randomized Trial of
Multifocal Intraocular Lenses Versus Monovision After Bilateral Multifocal Intraocular Lenses Versus Monovision After Bilateral
Cataract Surgery. Ophthalmology. 2013;120:2449-2455 Cataract Surgery. Ophthalmology. 2013;120:2449-2455
Monovision IOL vs Multifocal IOL Glare with Multifocal IOL
• Causes of Glare:
• Results: ▫ Posterior capsule opacification (66%)
▫ Glare/Halos
▫ IOL decentration (12%)
18% of monovision IOL patients
▫ Retained lens fragment (6%)
43% of multifocal IOL patients
▫ Dry eye (2%)
• Causes of Blur:
▫ Posterior capsule opacification (54%)
▫ Ametropia (29%)
▫ Dry eyes (15%)
Wilkins MR, Allan BD, Rubin GS, et al. Randomized Trial of ▫ Unexplained (11%)
Multifocal Intraocular Lenses Versus Monovision After Bilateral
Woodward MA, Randleman JB, Stulting RD, Dissatisfaction after
Cataract Surgery. Ophthalmology. 2013;120:2449-2455
multifocal intraocular lens implantation. J Cat & Ref Surg. 35(6):992-
997, June 2009.
312/27/2017
Stretching the optics… Accommodative IOL
• Tecnis Symfony MF IOL (Abbott/J&J) • Powered by action of the ciliary muscle
▫ Extended depth of focus optics ▫ Haptics are placed in the capsular bag
modification of the height and the profile of the
diffractive optics
Unique wavefront-designed aspheric surfaces
Reduced spherical aberrations
reduced chromatic aberration
Effective add around 1.50 D
Accommodative IOL Accommodative IOL
• Powered by action of the ciliary muscle
• Creates 1.00-1.50 D of add
▫ Crystalens (Bausch + Lomb)
▫ Trulign toric IOL (Bausch + Lomb)
“broader range of vision” lens
1.25-2.75 DC
What about astigmatism? On the MF IOL Horizon…
• Mechanical accommodating IOLs
• Corneal relaxing incisions ▫ Acrylic optic
▫ 1 to 3 D of corneal astigmatism (0.50D/3 mm) Tetraflex IOL(Lenstec) acrylic optic
Tek-Clear IOL (Tekia)
• Trulign toric IOL (Bausch + Lomb) Lumina IOL(Akkolens)
▫ May 2013 designed for placement in the sulcus
may be less affected by fibrosis than placement in the
▫ 1.25 to 2.75 DC capsular bag
• Tecnis Symfony MF IOL (Abbott/J&J) ▫ Fluid lens
▫ July 2016 FluidVision IOL (PowerVision)
▫ 1.00 to 6.00 DC 3-4 D of accommodation reported
• Acrysof IQ ReSTOR Toric MF IOL (Alcon) ▫ Silicone gel lens
▫ December 2016 NuLens IOL (NuLens Ltd.)
“designed to provide up to 10 D of accommodation”
▫ 1.50 to 6.00 DC
412/27/2017
On the MF IOL Horizon…
Comparison of the Visual Outcomes after Cataract Surgery with
Implantation of a Bifocal and Trifocal Diffractive Intraocular Lens • https://www.fda.gov/NewsEvents/Newsroom/P
Sung Yu, MD, et al, Clin Ophthalmol, Mar 2016.
ressAnnouncements/ucm586405.htm
• To evaluate and compare visual outcomes and optical quality after implantation of
a bifocal (Acrysof ReSTOR® SN6AD1) or trifocal (AT LISA® tri 839MP) diffractive
intraocular lens (IOL). • FDA approves first implanted lens that can be
• Conclusions: Trifocal diffractive IOLs provide significantly better adjusted after cataract surgery to improve
intermediate vision than bifocal IOLs, with equivalent postoperative levels vision without eyeglasses in some patients
of distant and near vision and ocular optical quality.
On the MF IOL Horizon… Pharmacological Treatments
• Most have used Parasympathomimetics
• THE STALLED (in combination with other agents):
Sapphire Autofocal (Elenza, Inc.) Miosispinhole effectincreased depth of focus
▫ first “electro-active” accommodating IOL • Results (all pilot studies):
▫ Improvement in near vision for 5-10 hours, then fades
▫ Accommodation occurs by means of a liquid ▫ Some side effects
crystal optic that changes power in response to Burning/stinging
Conjunctival injection
an electronic signal Dull headache
Nausea
▫ The lens contains a rechargeable battery and Dimming of vision
changes focus based on physiological triggers
Pharmacological treatments of presbyopia: a review of modern perspectives
Antonio Renna,Jorge L. Alió and Luis Felipe Vejarano, Eye and Vision,
Published: 7 February 2017
Pharmacological Treatments Pharmacological Treatments
• Pilocarpine • EV06 (Encore Vision Novartis in Dec 2016)
▫ Creates pinhole effect (goal: consistent 1.6 mm) ▫ Lipoic Acid Choline Ester 1.5%
▫ US Patent Application 20150174105 A prodrug that penetrates cornea
2% Pilo diluted to 1% Pilo with Balance Salt Soln ▫ Lipoic acid- enzymes in lens fiber cells reduce it to
Combined with bromfenac dihydrolipoic acidreduces disulphide bondsimproved
▫ to reduce potential inflammation flexibility
▫ Derek Cunningham, OD
effect lasts 8 hours
anticipate approval in 1-2 years
512/27/2017
Pharmacological Treatments
• EV06 –Phase I and II Trials (50-test/25-control)
▫ B.i.d. dosing
▫ Safety:
Well tolerated (comfort scores equivalent to control)
No loss in best corrected distance vision
▫ Effectiveness:
Improvement in near vision noted as soon as 2 wks
At 90 days (statistically significant change vs control):
20/40 or better in 82%
20/32 or better in 60%
20/25 or better in 36%
Pharmacological Treatments
• EV06
What is the durability of effect?
Long-term safety?
Investigational procedure
Might it help slow nuclear sclerotic cataracts?
Theories of Accommodation Scleral Expansion
• Helmholtz Theory • Schachar Theory • Tightening zonules by inserting “tissue barriers”
▫ Zonular tension is decreased ▫ Zonular tension is increased with
with ciliary body contraction ciliary body contraction ▫ Titanium, silicone, PMMA
▫ stretching causes an increase in the
▫ Relaxation allows lens to volume, curvature, and power of the
expand central lens
▫ Lens age = lens hardening ▫ Lens age = growth in equatorial
diameter, forces become less effective
due to increased zonular laxity
612/27/2017
Scleral Expansion Scleral Expansion for Presbyopia
Benefits Challenges • American Academy of Ophthalmology website
• May increase accommodative • Very little evidence it actually
function has an effect!! ▫ “ Schachar’s theory…has not been supported by
• May reduce IOP
primate and human physiology studies.”
▫ increased baseline tension
of the ciliary muscle
leads to increase in ▫ “Clinical results with these approaches have
trabecular meshwork pore
size been disappointing, leaving little support for the
Schachar theory or scleral expansion as an
effective means of presbyopia correction.”
Scleral Expansion for Presbyopia
• University of Houston College of Optometry study
• Subjective measures
• Objective measures
• Shape modification
• Laser
• Conclusion: • Molding devices
• Radio energy (Conductive Keratoplasty)
• “No increase in accommodative amplitude … Patient
satisfaction may have come from the high expectations • Corneal Inlays
this patient had for a positive surgery outcome.”
Ostrin LA et al, Evaluation of a satisfied bilateral scleral expansion
band patient. J Cataract Refract Surg. 2004 Jul;30(7):1445-53.
Presbyopic Corneal Shape Modification Multifocal LASIK- 1 yr Post-Op
• Laser Treatment (monovision or multifocal) The Promising The Concerning
▫ Strength ▫ 20/20 distance acuity: 93% ▫ 7% lost two Snellen lines
▫ J2 near acuity: 90% ▫ 19% retreatment rate
Permanent
▫ 3% reversal rate
▫ Limitation
Irreversible if outcomes less than desirable Currently investigational
▫ Outcomes?
Luger MH et al. Presbyopic LASIK using hybrid bi-aspheric micro-
monovision ablation profile for presbyopic corneal treatments.
Am J Ophthalmol, 2015 Sep;160(3):493-505.
712/27/2017
Presbyopic Corneal Shape Modification Presbyopic Corneal Shape Modification
• Corneal Molding Devices (orthokeratology) • 16 emmetropic presbyopes
▫ Strength • Fit with hyperopic OK lenses
Reversible if outcomes less than desirable ▫ Induces central corneal steepening: myopia
▫ Limitation • Results:
Device must be applied each night ▫ Approximately 1 to 1.50 D max of myopic shift
Currently limited to monovision ▫ Effect lasts longer after more days of wear
Under-correct myopia in one eye
Induce myopia in an emmetropic eye
Gifford P and Swarbrick HA, Refractive Changes from Hyperopic
▫ Outcomes? Orthokeratology Monovision in Presbyopes. Optom & Vis Sci,
April 2013.
Presbyopic Corneal Shape Modification Presbyopic Corneal Shape Modification
• IntraCor (B+L) • Conductive Keratoplasty
▫ Investigational in USA Low-level radio frequency energy
Approved in Europe April 2004: approved for temporary improvement of presbyopia
Performed on non-dominant eye of emmetrope
• Procedure:
▫ Femtosecond laser ▫ Strength
▫ Precisely placed gas bubbles Minimally invasive
▫ Reshapes interior of cornea Complications are rare
▫ Epithelium remains intact
▫ Limitation
• Pros and Cons: Must be emmetropic
▫ Safe! (no epi break) Cost: approx $2300/eye
▫ Halos (diminish with time) Results are temporary Collagen shrinkage creates a
belt-tightening effect
Presbyopic Corneal Shape Modification
• Conductive Keratoplasty
6 pts had CK after LASIK or PRK
12 pts had CK without LASIK or PRK
Shape altering
• Results: Refractive altering
0.033 D regression/month= 0.396 D/year Pinhole
▫ Approximately 2.5 yrs to lose 1 D
Rate of regression similar in both groups
Moshirfar M et al. Comparing the rate of regression after
conductive keratoplasty with or without prior laser-assisted in
situ keratomileusis or photorefractive keratectomy, Middle East
Afr. J Ophthal. October 2012.
812/27/2017
Corneal Inlays- shape altering Raindrop Inlay (shape changing)
• Raindrop Near Vision Inlay (Revision Optics) Strengths Challenges
Approved June 2016 • Significant improvement in • Centration is vital
near and intermediate vision ▫ Slippery decentration
2.0 mm hydrogel disk (approx 80% H2O)
• Binocular function remains 20% per Whitman et al*
▫ Promotes nutrient movement through cornea
good (vs monovision) NO eye rubbing!
• Safety well established • Slow steroid taper
▫ Easily removable
* Whitman et al, Ophthalmology, 2016;
123:466-475.
Raindrop Near Vision Inlay
Corneal Inlays- Refractive altering Corneal Inlays- Pinhole effect
• High index inlay • Kamra Corneal Inlay (AcuFocus)
▫ Presbia Flexivue
Microlens Inlay (Presbia) ▫ Approved in U.S. April 2015
0.15 mm center hole ▫ Implanted in non-dominant eye
Nutrient flow
1.6 mm plano zone
Distance vision
3.2 mm diam
+1.25 +3.50
GP lens
Kamra Inlay
Investigational in USA (1.6 mm aperture)
Phase 2 trials
Available in over 40
countries
Corneal Inlays- Pinhole effect Kamra Corneal Inlay (pinhole effect)
Strengths Challenges
• Significant improvement in • Distance vision reduced
near and intermediate vision slightly
• Binocular function remains • Night driving issues
good (vs monovision) ▫ Reduced illumination
• Quick procedure ▫ glare
▫ Approx 15 minutes • Best dist Rx -0.50 -0.75
▫ Can be performed in office • Cost: $4000-5000 (one eye!)
• Quick recovery
▫ 24-48 hrs to return to work
• Safety well established
▫ Easily removable
912/27/2017
Let Science Speak
MULTIFOCAL vs MONOVISION:
• MV vs Essential GP (Johnson, 2000)
▫ 75% preference for multifocal
• MV vs Acuvue Bifocal (Situ et al, 2003)
▫ 68% preference for multifocal
• MV vs Soflens MF (Richdale et al, 2006)
▫ 76% preference for multifocal
• MV vs Air Optix Aqua MF (Woods et al, 2015)
▫ 51% preference for multifocal “That’s not been my experience”
▫ 37% preference for monovision
▫ 12% didn’t like either
MULTIFOCAL vs MONOVISION: Restaurant Tools
MV vs Acuvue Bifocal (Situ et al, 2003) • Magnifiers
68% preference for multifocal • Light
Issues with near vision in low light • Apps
MV vs Soflens MF (Richdale et al, 2006)
76% preference for multifocal
Issues with near vision in low light
1012/27/2017
What’s the best way to assess
MF performance?
• Woods, J, et al (2009) What do we fit?
▫ Assessed both objective and subjective
results/ratings • The Decision Drivers
Objective testing (exam room) ▫ Astigmatic error
Monovision “best performer” for high- and low-contrast Where’s the flinch level?
near vision tests
Subjective ratings (“real world”)
Monovision “lowest performer”
Multifocal contact lenses “highest performer” in areas
such as: Night driving, television, computer
Woods, J, et al. “Early Symptomatic Presbyopes – What Correction Modality Works Best?” Eye &
Contact Lens 2009;5: 221 – 226.
Sphere versus Toric
• 30 eyes with 0.75- 2.00DC fit with spherical and
toric lenses
Acuvue Advance, Biomedics 55, Frequency 55, Softlens 66
• Two groups:
▫ Less than or equal to 1.00 DC
▫ 1.25-2.00DC
Richdale, Kathryn et al, Visual acuity with spherical and toric soft contact Richdale, Kathryn et al, Visual acuity with spherical and toric soft contact
lenses in low-to moderate- astigmatic eyes, Optom and Vision Science, lenses in low-to moderate- astigmatic eyes, Optom and Vision Science,
84(10):969-975, Oct 2007 84(10):969-975, Oct 2007
The Astigmatic Component Prevalence of 0.75 DC or greater
• 0.75 DC is the “flinch level” • In at least one eye: 47.4%
• In both eyes: 24.1%
• Myopes vs Hyperopes: 31.7% vs 15.7%
• WTR vs ATR: 32.9% vs 29.1%
• Conclusion:
▫ “We estimate that approximately 1/3 of
potential CL wearers require astigmatic
correction Young G et al, Prevalence of
astigmatism in relation to soft contact
lens fitting, Eye Contact Lens. Jan 2011
1112/27/2017
Astigmatism and Age The Astigmatic Component
• Prevalence of astigmatism increases with • 0.75 DC is the “flinch level”
age1,2,3 ▫ Especially if:
• Amount of astigmatism increases with age3 Low spherical error
▫ 0.05D per decade Dominant eye
• Axis changes from WTR to ATR2,3,4 ATR axis
▫ Due to corneal shape changes • Is it corneal astigmatism?
1. Sanfillippo PG et al, Acta Ophthalmol, 2015 (Australia)
2. Liu YC et al, Invest Ophthalmol Vis Sci, 2011 (China)
3. Schuster AK et al, Graefe’s Arch Clin Exp Ophthalmol, 2017 (Germany)
4. Leung TW et al, Optom Vis Sci, 2012 (Hong Kong)
Corneal Astigmatism ≠ Spectacle
Astigmatism
Multifocals for Astigmats
• Toric Soft Options • Soft Toric Multifocals
Toric SV Soft Distance OU with readers
▫ ASTERA multifocal toric (Alden)
Monovision
SV Toric one eye/ Multifocal one eye ▫ C-vue Hydravue toric multifocal (Unilens)
Toric MF Soft ▫ Intelliwave multifocal toric (Art Optical)
▫ Proclear multifocal toric (CooperVision)
▫ SpecialEyes toric multifocal (SpecialEyes)
Visual Performance of
Visual Performance of MF Toric SCL
MF Toric SCL
• 20 subjects • Results:
▫ 45 to 65 yo ▫ Performance of MV and MF within 1-2 letters
▫ 0.75DC to 2.75 DC ▫ Note:
60% of subjects:
• Cross-over design < 50 yo
• Soft Toric MF vs Soft Toric MV Near add lower than +1.50
• 1 month wear of each design Astigmatic error in study population?
Madrid-Costa D. et al, Visual Performance of Madrid-Costa D. et al, Visual Performance of
a multifocal toric soft contact lens. Optom. a multifocal toric soft contact lens. Optom.
Vis Sci. Nov 2012;89(11):1627-1635. Vis Sci. Nov 2012;89(11):1627-1635.
1212/27/2017
Soft Toric Multifocals Soft Toric Fitting Tips
• Benefits • Fix astigmatism correction first
▫ Come in custom parameters • Then employ multifocal fitting strategies
High cylinder powers
Custom add sizes • Order 3 diagnostics per eye
• Challenges ▫ on spectacle axis and either side
▫ Currently limited to monthly, quarterly or annual What axes?
replacement options
▫ No or limited diagnostic fitting sets
Toric Lens Degrees of Lens Rotation Inducing
Initial Diagnostic Axes Power (D) 0.75D* of Residual Astigmatism
0.75 30
• Assume 0.75DC of residual cylinder and above is 1.25 18
unacceptable 1.75 12
• How much axis mislocation of a given toric power 2.25 10
will induce this level of residual astigmatism? 2.75 8
▫ 30°mislocation: Residual cyl = toric power in lens 3.25 7
Eg. -2.25 DC lens misaligns 30°= 2.25DC residual 3.75 6
-2.25 DC lens misaligns 10°= 2.25/3= 0.75DC residual 4.25 5
4.75 4.5
• Spectacle Rx: –1.00-2.25x090 5.25 4
▫ Order axes: 090, 080, 100 5.75 3.5
Corneal Astigmatism = Spectacle
What do we fit?
Astigmatism
• A Multitude of Multifocal Options! • The Decision Drivers
▫ Toric Soft MF ▫ Astigmatic error
▫ GP MF (Corneal and Scleral) ▫ What are they used to?
▫ Hybrid MF Are they happy?
1312/27/2017
Hybrid Multifocal Designs
How well do Hybrid MF’s work?
• Duette Multifocal • Duette Progressive
▫ Adds: ▫ Adds:
Small and Large +1.00, +1.75,+2.50
• Method:
▫ 16 presbyopic eyes
▫ Duette MF vs Air Optix Aqua MF and Biofinity MF
• Conclusion:
“The Duette multifocal hybrid lens seems to
provide similar visual quality outcomes (as soft
multifocals) in presbyopic patients with low
corneal astigmatism….”
Hints on Hybrids Scleral Multifocals!
Barnett M. Multifocal Scleral lenses. A look at
• Rigid Center available lenses that can help our presbyopic
patients. Contact Lens Spectrum. December 2015.
▫ 0.50-0.75 STK
▫ 0.1 mm BC steps
• Soft Skirt
▫ Flat
Good comfort
No edge lift
Good centration
• Corneal GP Lenses
1412/27/2017
Selecting Seg Height Selecting Seg Height
Selecting Seg Height How’s this look?
Goal: Just below lower pupil margin
Where to start?
1mm below geometric center of lens
10.0 mm /2 = 5.0 mm
-1.0 mm
4.0 mm
What changes would you
employ in this case?
0.50 D flatter
Also consider increasing prism 0.50D
1512/27/2017
The Intermediate Distance?
Expert Progressive
Over Specs for Computer GP Multifocal Developments
High Eccentricity Translating Design
Back Surface
Low Eccentricity
Back Surface
• Lenses compliments of Front Surface
Irving Yaross, OD (Chicago)
Asphere
Presbyopes & Daily Disposables
What do we fit? • Great for part-time wear
• Convenience
• The Decision Drivers • Presbyopes have dry eye issues
Dry eyes lead to lens coating
▫ Astigmatic error
Dirty lenses are responsible for
▫ What are they used to?
many contact lens problems
Are they happy?
▫ Safety and Convenience
1612/27/2017
Multifocal Daily Disposables
Contact Lens Safety Alcon CooperVision
Incidence of CIEs:
○ DD vs Reusable: • Dailies AquaComfort Plus • Proclear 1 Day Multifocal
12.5 X less likely ▫ Center near ▫ Center near
▫ Same optics as Air Optix Aqua ▫ One add
with DD1 Multifocal
○ DD SiHy vs DD Hyd: ▫ Three adds
SiHy DD: 0.4%
Hyd DD: 0% • Dailies Total 1 for Presbyopia
Same optics as Dailies
1.Chalmers, Robin L. et al, Multicenter Case-Control Study of the Role of Lens AquaComfort Plus
Materials and Care Products on the Development of Corneal Infiltrates, DT1 material
Optometry & Vision Science. 89(3):316-325, March 2012.
2. Chalmers RL et al, Rates of Adverse Events With Hydrogel and Silicone
Hydrogel Daily Disposable Lenses in a Large Post Market Surveillance Davis R. Fitting Tips for Presbyopic Success, Rev Corn CL, Oct 2010
Registry: The TEMPO Registry. Invest Ophthalmol Vis Sci. 2015 Jan 8;56(1):654-63 Quinn TG. Clinical Experiences With a Daily Disposable Multifocal,
Contact Lens Spectrum, 28(11):19, November 2013
Multifocal Daily Disposables
Alcon CooperVision
Multifocal Daily Disposables
JJVC VTI
• 1-Day AV Moist for Presbyopia NaturalVue Multifocal 1 Day
• Dailies AquaComfort Plus • Proclear 1 Day Multifocal
▫ Moist material Center distance
▫ Center near ▫ Center near
▫ Center near Extended depth of focus
▫ Same optics as Air Optix Aqua ▫ One add
Multifocal “pupil smart” design Single add (up to +3.00
Changes with age effect)
▫ Three adds • Clariti 1-Day Multifocal Changes with refractive
▫ Center near error
• Dalies Total 1 for Presbyopia
▫ Two adds
Same optics as Dailies
AquaComfort Plus
▫ Silicone hydrogel material
DT1 material
JJVC = Johnson&Johnson Vision Care
VTI = Visioneering Technologies, Inc
Multifocal Daily Disposables
Bausch+Lomb
• BioTrue ONEday for
Presbyopia
▫ HyperGel material
▫ Center near
Same optics as PV2 for
Presbyopia • Corneal GP Multifocals
2 adds • Soft Multifocals
• Hybrid Multifocals
• Scleral Multifocals
1712/27/2017
Lens Selection
• Detailed refraction
Examination ▫ “Push” Plus at distance
No more minus than absolutely necessary
Procedures Techniques ▫ No more add than absolutely necessary
Lens Selection
• Determine eye dominance Sighting vs Sensory Dominance
▫ Sighting dominance
• Pointer J, J of Optom, (2012) 5, 52-55
▫ Sensory dominance
▫ Method:
72 Emmetropes
Sighting method: hole in the card
Sensory method: +1.50 blur test
▫ Results:
Right eye dominance
Sighting method: 71%
Sensory method: 54%
Laterality was in agreement only 50% of the time!
Lens Selection Assessing Performance
• Follow the fitting guide! • Scouting report
▫ Distance Rx: most plus power equivalent sphere
▫ Open-ended questioning
▫ ADD: follow the charts
• Real world environment
▫ Lights up
▫ Binocular conditions
▫ Real world tasks
▫ Loose lenses
1812/27/2017
Assessing Performance Adaptation to Multifocal Optics
• 20/40 line • Sheedy et al, Optom Vis Sci, June 1993
▫ Noted significant improvement in complex task
performance with concentric bifocal lenses
• Text based near tasks ▫ No improvement with monovision
• Pappas et al, Eye Contact Lens, May 2009
• Don’t recheck too soon ▫ Assess performance of 88 subjects at dispensing and after
4 days of wear
• Don’t make changes too soon ▫ “Early assessment is relatively unrepresentative of
performance later on during multifocal contact lens wear.”
• Fernandes et al, Optom Vis Sci, Mar 2013
Over 15 days, MF acuity at D and N improved
MV acuity remained the same or worsened
Adaptation to Multifocal Optics Enhancing Performance
• Lunghi C, Sale A • 1: Always start with OR using loose lenses
A cycling lane for brain rewiring ▫ To confirm distance Rx
Curr Biol. Dec 7, 2015 • 2: Follow the manufacturer’s guide!
• Old School: “Plasticity (of the brain) is maximal
in early development…abruptly declines in
adulthood.”
• “Recent studies…have revealed a significant
residual plastic potential of the adult visual
cortex…”
When is enough…enough. The Current Monovision Wearer
• You’ve set the right tone • Do you have difficulty with night driving?
▫ The Sandwich Approach • Do you have problems at intermediate
• You’ve confirmed the Rx distances?
▫ Always confirm distance Rx first
• Do you have problems with depth perception?
• You’ve shared The 3 Revelations
▫ “The goal is to meet most of your needs most of
the time”
▫ “You may need to give up a little bit of crispness
for freedom”
▫ “This is as good as it gets”
1912/27/2017
Transitioning Monovision Wearers to Transitioning Monovision Wearers to
Multifocals Multifocals
• Most common challenge? • Most common challenge?
▫ Distance vision ▫ Distance vision
• Why? • Why?
▫ Interference from the add ▫ Interference from the add
• Treatment strategy? • Treatment strategy?
▫ Reduce add in dominant eye ▫ Reduce add in dominant eye
What’s the lowest add? What’s the lowest add? NO ADD!
The Emmetropic Presbyope
Smart Lens for Presbyopia
• Process:
▫ Liquid crystal changes in response to an
electrical signal
curve change
index change
• Trigger:
▫ Convergence
Change in PD?
Gaze change?
Many Thanks!
2012/27/2017
Disclosures
Alcon
Thomas G. Quinn, OD, MS Allergan
Athens, OH Bausch & Lomb
tgquinn5@gmail.com
BioScience Communications
CooperVision
GPLI
STAPLES Program
JJ VC Vistakon
The Role of Contact Lenses Today Current Contact Lens Services
Three Legs of the Stool of Success Cosmetic
Good Vision Vanity
Good Comfort Improved self esteem (Walline)
Good Health
Adult Perceptions: Adult Perceptions:
Judgements Toward Male Judgements Toward Female
Spectacle Wearers Spectacle Wearers
More feminine Generally less attractive
More physically attractive Less honest
More honest Less successful
More successful More of a follower
More of a leader
RL Terry, October 1989 RL Terry, October 1989
112/27/2017
Adult Perceptions:
Judgements Toward Female
Spectacle Wearers
Generally less attractive
Less honest
Less successful
More of a follower
RL Terry, October 1989
Child Self Esteem The ACHIEVE Study
Survey* of 711 females and 309 males The Adolescent and Child Health Initiative
aged 12 to 17 years to Encourage Vision Empowerment
95% of teens said appearance effected Study
their confidence
52% said not having to wear glasses A 3-year randomized clinical trial to
would make them feel more confident investigate the effects of contact lenses vs.
spectacle wear on children’s self-perception
Ages 8 to 11 yo
* by Johnson and Johnson, 2006
Five clinical sites (OH,OR,MA,TX,TN)
The ACHIEVE Study Current Contact Lens Services
Physical appearance Cosmetic
Largest difference; independent of initial attitude Vanity
Athletic competence Improved self esteem (Walline)
Peripheral vision; prior removal of spectacles? Visual Freedom
Social acceptance
Stable for spectacles, but increased for CL’s
Scholastic competence
More if initial dislike of spectacles; removed?
Walline et al, Optom Vis Sci, Mar 2009
212/27/2017
Current Contact Lens Services
Cosmetic
Vanity
Improved self esteem (Walline)
Visual Freedom
Optics
Irregular cornea
occluder
Current Contact Lens Services
Cosmetic
Vanity
Improved self esteem (Walline)
Visual Freedom
Optics
Irregular cornea
occluder
Bandage
Protection
Comfort
New Applications Therapeutic applications
Therapeutic Myopia control
Digital Drug delivery
312/27/2017
Optics to reduce myopic Optics to reduce myopic
progression progression
The Problem: The Problem:
Peripheral rays normally focus Peripheral rays normally focus
behind the retina (hyperopic defocus) behind the retina (hyperopic defocus)
Leads to axial elongation Leads to axial elongation
The Solution:
Add plus into the periphery of the optical
system to create myopic defocus
How?
From Paul Gifford and Kate Johnson
From Paul Gifford and Kate Johnson
Optics to reduce myopic
The LORIC Study
progression
Longitudinal Orthokeratology Research
Corneal reshaping in Children
(orthokeratology)
Control= SV spectacle wearers
*Cho, P et al, Curr Eye Res, Jan 2005
Optics to reduce myopic Optics to reduce myopic
progression progression
Corneal reshaping (orthokeratology)
Corneal reshaping 1. Li SM et al., Studies using concentric ring bifocal and
Peripheral add multifocal contact lenses to slow myopia
32-62% reduction Progression in school-aged children: a meta-analysis, Opthal.
Dual Focus Soft Lenses Physiol Opt, Jan 2017
30-50% myopia control rate over 2 years1
Comparison?
2. Turnbull PR et al, Contact Lens Methods for Clinical Myopia
No difference in efficacy2 Control, Optom Vis Sci. Sept 2016
Bickle K and Nichols J, Myopia Control
Today, CL Spectrum, Aug 2014.
412/27/2017
Optics to reduce myopic Optics to reduce myopic
progression progression
Corneal reshaping Soft multifocal Soft Lens Options?
32-62% reduction 34-79% reduction
Nothing approved yet
Off-label use: Center Distance multifocals
○ Biofinity Multifocal: D design (CooperVision)
Monthly replacement
○ NaturalVue Multifocal (Visioneering Technologies)
Daily disposable
○ Various custom lenses
Bickle K and Nichols J, Myopia Control
Today, CL Spectrum, Aug 2014.
Drug delivery Drug delivery
Anti-allergy Anti-allergy
Anti-inflammatory Anti-inflammatory
Anti-infective Anti-infective
Tools:
○ Vitamin E
hydrophobic
○ Nanoparticle encapsulation
Thick gel; inconsistent release
○ Molecular Imprinting Technology (MIT)
Alterations in CL parameters
Hui,A. et al Inv Ophthal and VisSci 2014;55,8:48. 96-4904
Anti-infective Drug delivery
Bug resistant lens! Anti-allergy
Melimine-coated contact lens Anti-inflammatory
Not an antibiotic Anti-infective
○ From bee venom and salmon sperm
Anti-glaucoma
Cationic peptide (antimicrobial)
Drug delivery
Possible issue: IOP monitoring
Increased corneal staining
Dutta et al. Optom & Vis Sci, May 2014
512/27/2017
The Digital Revolution! Digital applications
IOP monitoring
Digital applications Digital applications
IOP monitoring IOP monitoring
Asrani SJ et al. Glaucoma 2000;9:2:134-42.
Realini T, Weinreb RN, Wisniewski SR. Ophthalmology 2010;117:9:1700-4
Digital applications Digital applications
IOP monitoring IOP monitoring
Triggerfish (Sensimed) Triggerfish (Sensimed)
US Approval: March 2016 ○ detects tiny changes or fluctuations in the
Specifications: eye’s volume
1-7% change in volume with IOP changes
○ Silicone hydrogel
○ 14.1 mm diameter
○ 585 microns center thickness (vs 70-80 microns)
○ BC: 8.4, 8.7, 9.0 mm
(From Dunbar GE et al, Clin.
Ophthal, May 2017)
612/27/2017
Digital applications Digital applications
IOP monitoring IOP monitoring
Triggerfish (Sensimed) Triggerfish (Sensimed)
○ 30 sec measurement every 5 min for 24 hrs ○ Accurate when compared to 2 other methods
86,400 data points (millivolt equivalents) ○ Upright lower than supine
May be less of a difference in low/moderate myopes
Liu et al. Inv Ophth Vis Sci, 8/2002; 43(7):2351-5.
Two 24 hour profiles of the same patient before and one month after treatment. Twa M. J. Glaucoma. 5/2011; 21(8):539-44.
Triggerfish Triggerfish
Tolerability Cost
95% willing to use device again Upfront reusable items
Safety ○ data recorder, cable, software
○ $7,310 (approx.)
Mild adverse events common (75-95%)
○ Transient blur, conj hyperemia, SPK Single use items
○ CL, orbital antenna and recorder sleeve
Reproducibility
○ $526-682
Fair to good
Validity at estimating IOP
Still in question
Dunbar GE et al, Clin Opthalmol., May 2017. Dunbar GE et al, Clin Opthalmol., May 2017.
Triggerfish Application Triggerfish Application
IOP monitoring Wind Instrument Player IOP
Triggerfish (Sensimed) Professional: +2.5 + 1.5 mmHg
○ One study findings lead to immediate Amateurs: +1.1 + 2.3 mmHg
treatment change in two-thirds of patients
Conclusion:
“These peaks may be relevant for
glaucomatous field progession and
treatment in glaucoma patients.”
Mansouri K, Shaarawy T, Br J Ophthalmol, 2011;95(5):627–9
De Cromdf RMPC et al, J. Glaucoma, Aug 2017.
712/27/2017
Digital applications Night Vision Goggles
IOP monitoring
Night vision
Infrared light
“Heat Vision”
Digital applications Graphene
IOP monitoring
Night vision
Infrared light
“Heat Vision”
○ Graphene
Single layer of carbon atoms
○ Stays cool!
Digital applications Digital applications
IOP monitoring IOP monitoring
Night vision Night vision
Cancer detection Cancer detection
Elevated tear protein: lacryglobin
Diabetic monitoring
○ Condition (%) with lacryglobin detected in tears
Breast cancer (88%)
Colon cancer (100%)
Lung cancer (83%)
Prostate cancer (100%)
Ovarian cancer (33%)
Control (60%)
Evans V et al. Clin Experiment Ophthalmol. 2001 Jun;29(3):161-3
812/27/2017
Impact of Diabetes Impact of Diabetes
In 2010: Daily pills
25.8 million Americans Blood sugar
8.3% of the population Blood pressure
In 2012: cholesterol
29.1 million Americans Injections?
9.3% of the population Diet control
In 2015: Finger prick readings
30.3 million Americans
9.4% of the population
Impact of Diabetes Diabetic Monitoring
“Between 10% and 18% of patients
reported that they would be willing to
give up eight to 10 years of life in good
health to avoid life with treatment”
Huang ES. Diabetes Care. 2007 Oct;30(10):2478-83
Diabetic Monitoring Indefinite Delay
Google’s “smart” contact lens November 21, 2016 Press Release
“It is too early to say when exactly
human clinical trials for these lenses will
begin. This is a very technically complex
process and both sides are learning as
we go along. We will provide updates at
the appropriate time.”
Novartis Spokesperson
Note: 20 minutes between change in blood glucose and tear glucose
912/27/2017
Diabetic Monitoring Self Generating Power Source
Transparent Sensor! (Nov 2016) Smart CL Power Source:
Oregon State University College of Engineering Wireless external source
Nanostructure
New Idea from Switzerland:
○ Amorphous indium gallium oxide field effect transistor
(IGZO FET) Electric Eel-Inspired Battery (knifefish)
○ Employs innovative techniques ○ Energy created from fresh and salty water
Acts like an inkjet printer, but: mixing together
- finer drop sizes
Renewable fluid stream:
- biological materials instead of ink
○ Low cost fabrication
The Tear Film!
Schroeder, TBH et al., An electric-eel-inspired
○ Working on communication soft power source from stacked hydrogels,
Nature; 14th December 2017
system
Digital applications Smart Lens for Presbyopia
IOP monitoring Process:
Night vision Liquid crystal changes in response to an
electrical signal
Cancer detection
○ curve change
Diabetic monitoring ○ index change
Presbyopia Trigger:
Convergence
○ Change in PD?
○ Gaze change?
Digital applications Mood Regulation
IOP monitoring Seasonal Affective Disorder
Night vision Contact Lens regulates light
Cancer detection Emits desired wavelength and brightness
○ Stimulates cells to downregulate melatonin
Diabetic monitoring and upregulate serotonin
Presbyopia
Mood Regulation
1012/27/2017
Digital applications Augmented & Virtual Reality
IOP monitoring Virtual Reality (VR)
an artificial, computer-generated simulation or recreation
Night vision of a real life environment or situation. It immerses the user
Cancer detection by making them feel like they are experiencing the
simulated reality firsthand, primarily by stimulating their
Diabetic monitoring vision and hearing.
Uses:
Presbyopia ○ Video and computer games
Mood Regulation ○ 3D movies
○ Enhanced training (eg. Flight simulators)
Augmented & Virtual Reality
Virtual Reality Augmented & Virtual Reality
Augmented Reality (AR)
a technology that layers computer-
generated enhancements atop an existing
reality in order to make it more meaningful
through the ability to interact with it.
Uses:
○ Telecasted sports games
○ Pop out 3D emails
○ Mobile device photos or texts
○ Medicine
https://www.youtube.com/watch?v=AB-dhUs9U1k
Augmented & Virtual Reality Google Glass
Camera
North America Photos and videos
Largest market due to: Touchpad
Weather
○ Highest penetration of AR and VR technology Phone calls
Maps
○ Higher spending on such technologies
Apps
○ Higher R&D investments by major players Exercise programs
Google Inc Facebook, Twitter
News
Microsoft Corp. Face recognition?
Vuzix Corp. In a contact lens?
Samsung Electronics Co., Ltd Controlled by blinks
Qualcomm Inc Discreet
Privacy concerns?
Sony- after 4 mo of sales, nearly 1 million sold @$500 ea.
PR Newswire, Jan 19, 2017
1112/27/2017
Google Glass Augmented & Virtual Reality
What happened? Major Applications:
Unnatural! Gaming
○ Low resolution Medical
○ Off-angle display Aerospace and Defense
○ 15 degree diagonal Commercial
field of view
Others
○ Display in one eye
only
Augmented Reality Digital applications
IOP monitoring
Night vision
Cancer detection
Diabetic monitoring
Augmented reality
Google Glass in a Contact Lens
iOptik (Innovega)
https://www.youtube.com/watch?v=kC7OlweCJ8I
Augmented & Virtual Reality eMacula (Innovega)
Benefits of CL over Spectacles AR/VR through combination
Eye tracking important feature of spectacles and CLs
○ CLs do no interfere Approval: early 2018?
Allows for less bulk and lighter headsets Cost?
Contact lenses approx. 20%
more than regular disposables
Glasses will cost “little more”
than the price of regular
designer spectacles
www.emacula.io
1212/27/2017
eMacula (Innovega) Our Role in the Future
Basic Contact Lens Rules still apply!
Good vision: “Looking through wires”
Good comfort: IOP sensing device is 8x
thicker than standard CL
Good health: staining with melamine-coated
anti-microbial lens
Our Role in the Future Our Role in the Future
Lens Surface remains important Growing need for our services!
Current strategies New populations
○ Surface chemistry New possibilities!
○ Frequent disposal: 12.5 x reduction in
inflammatory events with DD vs Reusable
○ Can these high tech devices be disposed of
frequently?
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