By 2030, 1 in 5 Americans will be 65 years or older

 As the US population continues to age, the demand for 

 treatment options has grown. 
Many patients are searching for options outside of glasses to correct their intermediate and near vision. 

They want choices that fit seamlessly into their daily routines and do not highlight the fact that their eyes are aging.

Multifocal contacts lenses are a great solution for presbyopia and are certainly not a new modality. Yet some eye care providers still struggle with utilizing multifocal contact lenses in their practices. 



Contact lens regimen crucial in removing coronavirus traces




Getting comfortable with this treatment not only ensures that patients have access to the latest technology in eye care, but it also maximizes practice success from a business standpoint.

Here are 4 tips to maximize the multifocal contact lens potential in your practice:



 is a growing market. More than 120 million Americans have presbyopia and many do not realize they are a candidate for multifocal contact lenses.

Some patients believe that progressive lenses, bifocals, or OTC reading glasses are their only options for correcting near vision impairment from presbyopia.

Other patients have been told in the past that multifocal contact lenses were not an option for them because of their prescription values or astigmatism presence. 

But the world of multifocal contact lenses has evolved and there are many options for patients of all prescriptions. 

A recent study showed that 31 million individuals buy OTC reading glasses every year, often from a supermarket or drugstore.

As primary eye care providers, optometrists (ODs) have the opportunity to educate patients on all options available for them to see better and improve quality of life.

Start by telling patients that multifocal contact lenses can be the primary mode of vision correction or an option for part-time, hobby, or weekend wear. Explain how the contacts are designed, how they work, and how they can be integrated into daily life. 

Even if a patient declines multifocal 

 this year, they may want to revisit the option in the future.



Researchers test 3D-printed, self-moisturizing contact lens

Eye care staff members often have unique interactions with patients outside of the exam room, which may offer opportunities for them to educate patients about multifocal contact lenses.




It is important to follow the fitting guide that accompanies each contact lens. This is especially true for multifocal contact lenses because different brands have different optical zones and fitting strategies. 

Companies often revise their fitting guides as more data about the contact lenses become available through patient use. Many clinicians create their own fitting techniques. 

This may work a small percentage of time but often it ends in more chair time and patients having subpar success with their multifocal contact lenses. It is a good idea to periodically revisit the fitting guides of contact lenses you fit frequently.

I learned this lesson the hard way when I first began fitting with Alcon’s Dailies Total 1 multifocal lenses many years ago. I followed a fitting approach similar to other multifocal contact lenses on the market that correlated a low/medium/high multifocal lens with a patient’s addition (ADD) power. 

My fitting strategy did not follow the fitting guide and resulted in more chair time, multiple contact lens follow-ups, and patients with mediocre vision in their 

It all changed when I went back to the fitting guide and followed it. For this particular contact lens, adding +0.25 to the spherical correction and going with the lowest ADD possible made it fit best. These simple shifts led to better outcomes with the first trial contact lens and translated to less chair time and happier patients.



 Take time to set up realistic yet positive expectations. Instead of chasing perfect 20/20 for distance and near vision, a more appropriate end point should be functional vision for both distance and near. 

Every patient has different visual demands and functional vision is going to vary tremendously for each patient. It is important to educate patients that success is them being able to go through most of their daily activities with the contact lens. 



Research finds significant lack of contact lens knowledge in consumers



I also tell patients not to compare their vision in multifocal contact lenses with their vision in glasses, as it is comparing apples with oranges. Setting these clear expectations lets patients know it is OK not to reach a perfect 20/20. 

That said, many patients do obtain 20/20 at both distance and near with modern day multifocal contact lenses.

In 2021, McDonald et al proposed a categorization of 

 that breaks the condition into mild, moderate, and advanced categories.

 Their approach was centered on classifying presbyopia by distance corrected near acuity rather than age. 

In their system, the mild 

 category is best corrected visual acuity ranges of 20/25 to 20/40, moderate presbyopia is 20/50 to 20/80, and advanced presbyopia is greater than 20/80.


Taking this approach to presbyopia classification is more fitting and explains why sometimes a 53-year-old patient’s presbyopia may be classified as mild whereas a 38-year-old patient’s presbyopia may be classified as moderate.

This categorization approach to presbyopia has helped me select the best candidates for multifocal contact lenses and set realistic expectations for patients.



Multifocal contact lenses will not be a perfect modality for every patient, even after setting appropriate expectations and following fitting guides. 

One troubleshooting technique I have found success with is using Vuity (Allergan, 1.25% pilocarpine) with a multifocal contact lens in patients who are not able to achieve the clarity they need at intermediate or near. Vuity is an FDA-approved, first-in-class medication for the management of presbyopia in adults. 



Tackling the problem of contact lens dropout from presbyopia



An optimized concentration of 1.25% pilocarpine combined with a proprietary pHast technology makes Vuity different and more effective clinically for presbyopia in comparison with pilocarpine.

Vuity, a cholinergic muscarinic agonist, has a dual mechanism of action. It activates the iris sphincter and ciliary smooth muscles to cause an extended depth of focus and increase amplitude of accommodation. By making the pupil smaller, similar to pinhole optics, the near vision improves.

Vuity went through 2 parallel phase 3 clinical trials (Gemini 1 [NCT03804268] and Gemini 2 [NCT03857542]) and included participants aged 40 to 55 years who had a distance corrected visual acuity of 20/40 to 20/100. 

The clinical trials found that at least 3 lines of improvement at near in mesopic (low light) conditions was observed without compromising more than 1 line (5 letters) of distance vision.

In photopic conditions, 9 out of 10 trial participants saw an improvement in near vision better than 20/40 in photopic conditions. In bright light, one-third of participants were able to achieve 20/20. 

The clinical trials also showed improvement in intermediate vision. The most common adverse events of Vuity were conjunctival hyperemia (5%) and headaches (15%). 

In my experience, patients who have experienced headaches reported them as mild, transient, and only occurring on the first day of using Vuity.

Vuity is taken once a day and becomes effective within 15 minutes after instillation. Most patients report that it lasts for 6 to 10 hours. 

If using Vuity with contact lenses, the drop should be instilled in the eyes without a contact lens. After 10 minutes, contact lenses can then be inserted into a patient's eye. Vuity is a prescription eye drop that can be sent to any pharmacy. 

Although Vuity has not been studied in combination with multifocal contact lenses, I have found that, in some cases, this combined adjunct approach allows multifocal contact lens patients to achieve the improvement in near vision they are seeking.


1. Rural Health Information Hub. Demographic changes and aging population. Accessed 4/22/2022. https://www.ruralhealthinfo.org/toolkits/aging/1/demographics#:~:text=The%20U.S.%20population%20is%20aging,grow%20to%20almost%2090%20million

2. Chang DH. Presbyopia: rethinking approach to better meet patients’ needs. 

. July 21, 2020. Accessed March 1, 2022. https://www.ophthalmologytimes.com/view/presbyopia-rethinking-approach-to-better-meet-patients-needs

3. VisionWatch. The Vision Council. September 2016. Accessed March 1, 2022. https://www.thevisioncouncil.org/sites/default/files/research/VisionWatch_VisionCouncil_Member_Benefit_Report_September%202016_FINAL.pdf

4. McDonald MB, Barnett M, Gaddie IB, et al. Classification of presbyopia by severity. 

. 2022;11(1):1-11. doi:10.1007/s40123-021-00410-w

Articles

Help presbyopia patients by following fitting guides and embracing new adjunct therapy options.

4 ways to maximize success with multifocal contact lenses 

As primary eye care practitioners, we acutely know how essential early detection, treatment, and management of 

can be for best maintenance of vision in our patients. 

We also know that, as of summer 2021, 3 million Americans older than 40 years were living with glaucoma—and that counts only those who were already diagnosed.


We also know that not every patient’s diagnosis is caught early on. This translates to innumerable opportunities for us to drive timely diagnosis and save vision. 



Typically, our go-to routine for ruling glaucoma in or out is a combination of an intraocular pressure (IOP) check and visualization of the nerve. 



Glaucoma: More pressures than meet the eye




Both are helpful and can reveal a great deal about patients’ glaucoma status. However, we can also get a peek into their risk factors from their anterior segment—specifically, the peripupillary findings.


Examination of the peripupillary area is unique because it is one of the only structures (to use that term loosely) that can be visualized both by direct viewing outside and using the slit lamp as well as by retroillumination. 

Both can reveal unique preglaucomatous findings that might steer us toward more careful examination.

Direct viewing of the peripupillary area can be done externally from the slit lamp, using a penlight, indirect light, or any similar bright light source. Beginning with the basics, not only are we looking for afferent pupillary defects comparatively between the eyes, but we are also analyzing each individual pupil for shape and size.

Irregular shape on a still motile pupil can alert a practitioner to the potential for posterior synechiae—or a partial adhesion—between either the iris and the lens or the iris and the intraocular (IOL) implant. 

This is sometimes indicative of a previous inflammatory event, traumatic or otherwise. The incidence of glaucoma after an inflammatory event (uveitis)—regardless of which type of uveitis—is 7% to 11%, and that risk increases with time.



If the pupil appears quite small and entirely nonmotile, it could be an indication of a posterior synechiae around the entire pupil (360) or iris bombé, which could show that it is aqueous and has been prevented from flowing to the anterior chamber, with a secondary glaucoma invariably following.

Pearls on diagnosing and managing glaucoma for optometrists


The iris bombé malformation can be better appreciated on slit lamp, with an anterior bowing of the middle of the iris. Taking those extra few milliseconds to examine the shape and motility can be vital.


After examining the pupils from afar, slit-lamp analysis will give more information. The integrity of the pupillary ruff presents a vital peek into potentially glaucomatous eyes. It has been found that pupillary ruff changes; its absence, mostly, and irregularity between the eyes are predictive of IOP.4 

To clarify: The eye with more pupillary ruff loss is more likely to have a larger cup-to-disc ratio and higher IOP.

Pseudoexfoliative material around the pupillary border is well known—but not always easy to spot. Often appearing white and believed to be amyloid and/or fibrillarlike material, it can be more challenging over a light-colored iris and more obvious on a dark.

 for a 360° deposition of white fibrillar material on a dark iris with some loss of healthy pupillary ruff. You can also appreciate some flaking of the material from the pupil onto the anterior portion of the lens.

Approximately 20% of patients with newly diagnosed pseudoexfoliative syndrome have either glaucoma or increased IOP.

 

Overall, 50% of patients with pseudoexfoliation syndrome are ultimately diagnosed with 

 Taking an extra few moments during the exam to scan the peripupillary ruff can be of paramount importance.



After completing the slit-lamp examination of the anterior segment, it is tempting to instantly lift the fundoscopy lens and push through to view the posterior pole. 

Although this is an important step, first take a pause: A direct slit-lamp beam shone through the pupil, gifting us a retroilluminated view, can provide a great deal of information.



Preserving the ocular surface in glaucoma patients

The red reflex and reflection from the retina can be used to highlight opacities and defects in both the iris and the lens. 





The most well-known retroilluminated view is the classic radial pattern of pigmentary dispersion ring changes in the iris midline via transillumination defects, the presence of which indicates approximately a 15% chance of conversion to glaucoma.

 

That same iris from Figure 1, with pseudoexfoliative changes, just may have a peripupillary transillumination from the atrophy of the pupillary ruff. You might also be able to see the flaked fibrillar material on the natural lens retroilluminated as an opacity, which can sometimes be difficult to appreciate from a direct view.

A peripupillary retroilluminated view can also divulge great information on the integrity of the lens, natural or implant. 

With a direct view, we can sometimes assume that the lens, a fairly clear structure, is in place; however, it can be bowed so posteriorly or inferiorly that we are not able to see it.

, a retroilluminated view demonstrates an inferiorly decentered IOL implant, with the top edge visible through the top third of the pupil. 

The center of the pupil houses a clear portion of the IOL, which would give a fairly decent quality view through the pupil and might not flag that the patient has a decentered lens in direct light.



Case report: 16-year-old presents with asymptomatic glaucoma

It is unknown what the true probability is of lens decentration—and subsequent risk of glaucoma—but in some sulcus-placed IOLs, decentration was as high as 14% and 

 

Although they paint an incomplete picture, these statistics highlight the need to examine the positioning of the IOL via various methods, as it may reveal the need for more careful investigation.


Effective glaucoma screening is paramount for the detection, treatment, and management of the disease. This is especially important because the nature of glaucoma is asymptomatic, particularly early in the disease and even in later stages—particularly if it is asymmetrical.

This places greater gravity on early discovery and management. Mainstays of evaluation such as the IOP and optic nerve appearance are vital and here to stay, but many other tools are also at our disposal.

The pupil—our passageway to the posterior segment—can be indispensable in providing clues. From direct views of pupillary deposition and atrophy to retroilluminated clues on the lenticular integrity, this viewing is rapid and can be a richly revealing peek at glaucomatous risk factors.



1. Glaucoma: facts & figures. BrightFocus Foundation. July 14, 2021. Accessed April 5, 2022. 

https://www.brightfocus.org/glaucoma/article/glaucoma-facts-figures#:~:text=Glaucoma%20is%20a%20leading%20cause,Americans%20age%2040%20and%20over

2. Neri P, Azuara-Blanco A, Forrester JV. Incidence of glaucoma in patients with uveitis. 

 2004;13(6):461-465. doi:10.1097/01.ijg.0000146391.77618.d0

4. Ang GS, Wong T, Nicholas S, Wells AP. Pupil ruff atrophy correlations with intraocular pressure and cup-to-disc ratio in a glaucoma clinic population. 

. 2012;119(8):1546-1551. doi:10.1016/j.ophtha.2012.02.028

5. Repo LP, Naukkarinen A, Paljärvi L, Teräsvirta ME. Pseudoexfoliation syndrome with poorly dilating pupil: a light and electron microscopic study of the sphincter area. 

 1996;234(3):171-176. doi:10.1007/BF00462029

6. Khawaja A, Patel AS, Salim S, et al. Pseudoexfoliative glaucoma. American Academy of Ophthalmology: EyeWiki. November 2, 2021. Updated March 23, 2022. Accessed April 5, 2022. 

https://eyewiki.aao.org/Pseudoexfoliative_Glaucoma

7. Siddiqui Y, Ten Hulzen RD, Cameron JD, Hodge DO, Johnson DH. What is the risk of developing pigmentary glaucoma from pigment dispersion syndrome? 

2003;135(6):794-799. doi:10.1016/s0002-9394(02)02289-4

8. Kemp PS, Oetting TA. Stability and safety of MA50 intraocular lens placed in the sulcus. 

2015;29(11):1438-1441. doi:10.1038/eye.2015.105

9. Kastner A, King AJ. Advanced glaucoma at diagnosis: current perspectives. 

 2020;34(1):116-128. doi:10.1038/s41433-019-0637-2

Examine the anterior segment for risk factor identification and early diagnosis.

Peripupillary prognosticators of glaucoma

 disease (DED) affects approximately 1.5 billion people worldwide and is the most common disorder of the ocular surface.

 But it doesn’t have to be debilitating, especially for patients who wear 

The condition remains somewhat underdiagnosed—even as more patients are wearing lenses— and symptoms range essentially limitless, due to patients believing the symptoms they experience are normal and therefore do not report them to their eye care practitioner.

Redness, burning, and gritty sensations are all common among patients with DED, as well as sensitivity to light, blurred vision, and the accumulation of water and/or mucus in the eye. 



These symptoms are often most severe in those who wear contact lenses and can cause persistent irritation, pain, and decreased quality of life.

Characterized by a loss of homeostasis of the eye’s tear film and what some researchers have described as “a vicious cycle of corneal epithelial damage and inflammation,”

 DED is exacerbated by the amount of time that many adults spend looking at screens. 

According to a 2018 Nielsen report, screen time has increased to more than 11 hours per day for the average American adult.

In addition, the ongoing COVID-19 pandemic has put its stamp on DED by complicating underlying disease among patients who frequently wear face masks. 

When one’s breath travels upward toward the eyes during masking, premature evaporation of tears can occur.

The pandemic has also led to more patients opting to wear contact lenses because their glasses fog when wearing masks, perhaps increasing current estimates by the CDC that 45 million individuals in the US wear 

Q&A: Pandemic's effect on dry eye patient numbers


These patients are, therefore, also more susceptible to lens intolerance—yet another adverse effect of DED.

Despite these troubling trends, today’s eye care practitioners have options for treating DED at various levels of severity when patients are appropriately assessed at disease onset.



 in patients is meibomian gland dysfunction (MGD), which is typically treated with lid margin hygiene, the removal of the meibomian gland obstruction, and the reduction or elimination of inflammation.

The Tear Film and Ocular Surface Society (TFOS) defines DED based on 4 levels of disease severity.


In the more severe forms, patients experience constant, disabling discomfort with accompanying symptoms such as marked conjunctival staining, severe punctate erosions, filamentary keratitis, corneal ulceration, trichiasis, keratinization, and symblepharon.

DED is also a leading cause of lens intolerance among patients who wear contacts, with symptoms typically including blurred vision, eye discomfort and irritation, eye fatigue, and the sensation of a foreign body in the eye.

To successfully prescribe contact lenses for patients living with DED, physicians must be able to optimize the ocular surface to promote lens tolerance. 

If the ocular surface is compromised or the tear film is inadequate, contact lenses as a foreign body could exacerbate signs and symptoms.



The goal should be to reduce inflammation, restore stability to the ocular surface and the homeostasis of the tear film, and relieve any obstruction related to MGD.

General treatment algorithms are available from the TFOS,7 the Cornea External Disease and Refractive Society,

and the American Society of Cataract and Refractive Surgery.

 

Depending on severity level, the following modalities and products are also recommended for the care of DED and can be utilized collaboratively, depending on the patient’s response to treatment.



Q&A: Factors to consider when treating dry eye patients

Regener-Eyes Professional Strength (Regenerative Processing Plant, LLC): This novel biological treatment is preservative free and uses the company’s d-MAPPS (derived multiple allogeneic proteins paracrine signaling) platform technology to stimulate stem cell communication without cell contact. It is becoming more commonly prescribed as a maintenance therapy for mild to moderate or severe DED, particularly with corneal findings such as punctate epithelial keratitis. It is also very effective in patients with Sjögren syndrome and those with numerous ocular surface issues resulting from surgery.

These drops can also be useful in patients with DED who have not responded to traditional therapies to assist in improving comfort and preventing disease progression. It is a versatile product that can be used in patients who wear contact or scleral lenses, is quick acting, and can serve as a primer for other treatments.

Additionally, it is a go-to product for patients who are experiencing significant DED discomfort. The drops are also more convenient than autologous serum eye drops.

Regener-Eyes Lite (Regenerative Processing Plant, LLC): This product is typically reserved for patients experiencing more mild or moderate cases of DED. It has also proven effective when used in conjunction with the Regener-Eyes Professional Strength version. For instance, patients can be prescribed to take the professional strength drops in the morning and evening and to work in the lite drops during the day as needed.

Immunomodulators such as Cequa (Sun Ophthalmics), Restasis (Allergan), and Xiidra (Novartis)

Eysuvis (loteprednol etabonate ophthalmic suspension) 0.25%: This is the first and only FDA-approved, short-term (up to 2 weeks) prescription treatment for the signs and symptoms of DED. It is also a great modality for flare-ups. It received FDA approval in 2021.

Preservative-free artificial tears and omega-3 supplementation; autologous serum tears

Tyrvaya (Oyster Point Pharma, Inc): a varenicline nasal spray solution that increases natural tear production and is the most recent FDA-approved therapy for DED

LipiFlow Thermal Pulsation System (Johnson & Johnson Vision Care, Inc): a thermal pulsation system that simultaneously delivers heat to the inner eyelid and pressure to the outer eyelid

Systane iLux (Alcon): an in-office treatment that utilizes LED-based heat to warm the inner and outer surfaces of the eyelids to melt away waxy secretions within the meibomian glands

TearCare System (Sight Sciences, Inc): wearable eyelid technology that provides targeted, adjustable thermal energy to the meibomian glands and a personalized experience via its software-controlled operating system

BlephEx (Alcon): an in-office procedure that removes excess bacteria and toxins that live along the lash margin and contribute to DED

OptiLight (Lumenis Ltd): a noninvasive treatment that is the first and only FDA-approved intense pulsed-light treatment for DED

Avenova Lubricant Eye Drops (NovaBay Pharmaceuticals, Inc)



Scleral lenses are also an effective treatment approach, especially when utilized as a combination therapy. The tear film reservoir is typically a preservative-free saline between the eye and the lens that can be modified as a “cocktail” for DED when a preservative-free saline, artificial tears, serum tears, or Regener-Eyes is mixed with the fluid within the lens. 

This is a benefit that is not available with any other type of contact lens.

, Regener-Eyes is most effective when used approximately 10 minutes prior to applying and approximately 10 minutes after removing lenses.

When steroids are prescribed for more quick-acting relief, Regener-Eyes is effective as a transition due to its ability to lubricate the eye and reduce inflammation. 

Steroids can work well for patients who are experiencing mild to moderate dry eye, but severe conditions require modalities that offer more long-term benefits.

It is important to determine the underlying condition of the dryness—aqueous deficient versus evaporative, or perhaps mixed. 



Higher risk of dry eye disease linked to post-COVID-19 patients




The goal of treatment in aqueous-deficient DED is to improve tear volume, whereas the goal in evaporative DED is to improve the tear quality.

Both quality and quantity are important to have an adequate tear film. In aqueous-deficient DED, many treatments are aimed at increasing volume, such as punctal plugs and artificial tears, whereas others are aimed at decreasing inflammation. 

Still other modalities are aimed at helping to protect, restore, and heal the ocular surface, such as scleral lenses and biological eye drops.

In evaporative DED, restoring normal evaporation can be accomplished through lid health and hygiene, such as warm compresses and artificial tears with lipid components. These treatments indirectly reduce inflammation and reduce signs and symptoms of 

1. Brissette A. What is dry eye disease? NewYork Presbyterian: Health Matters. Accessed April 29, 2022. 

https://healthmatters.nyp.org/what-is-dry-eye-disease/

2. Nichols K, Bloomenstein M, Devries D, Hom M, Whitley W. Updates in dry eye disease: diagnosing and treating patients with ocular surface disease. 

 May 2019. Accessed 4/18/2022. https://modernod.com/articles/2019-may-supplement/updates-in-dry-eye-disease-diagnosing-and-treating-patients-with-ocular-surface-disease

3. Promising novel treatment for dry eye disease revealed by new research. News release. University of Manchester. January 13, 2022. Accessed April 6, 2022. 

https://www.manchester.ac.uk/discover/news/promising-novel-treatment-for-dry-eye-disease-revealed-by-new-research/

4. Time flies: US adults now spend nearly half a day interacting with media. Nielsen. July 31, 2018. Accessed April 6, 2022. 

www.nielsen.com/us/en/insights/article/2018/time-flies-us-adults-now-spend-nearly-half-a-day-interacting-with-media

5. Contact lenses: fast facts. Centers for Disease Control and Prevention. Accessed April 18, 2022. https://www.cdc.gov/contactlenses/fast-facts.html#:~:text=An%20estimated%2045%20million%20people,is%2031%20years%20old%202

6. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). 

. 2007;5(2):75-92. doi:10.1016/s1542-0124(12)70081-2

7. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and therapy report. 

 2017;15(3):575-628. doi:10.1016/j.jtos.2017.05.006

8. Majmudar PA. CEDARS dry eye algorithm. 

February 27, 2019. Accessed April 6, 2022. 

www.ophthalmologymanagement.com/newsletters/ocular-surface-news-for-mds/february-27,-2019

9. Starr CE, Gupta PK, Farid M, et al; ASCRS Cornea Clinical Committee. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. 

. 2019;45(5):669-684. doi:10.1016/j.jcrs.2019.03.023

A plethora of treatments are available when patients, particularly contact lens wearers, are assessed at disease onset. 

Therapy options based on DED severity


Keratoconus (KC) affects approximately 1 in 2000 individuals, with the prevalence of the disease possibly higher in certain populations.

 so it is important that eye care practitioners are particularly alert to the potential for KC in young patients and prepared to refer them for further evaluation and treatment.


As gatekeepers to the young vision-corrected population, optometrists are on the front lines of KC diagnosis and referrals—a role that can have life-changing implications for our patients. 



Business basics: understanding how to manage and code for keratoconus



Using a simulation model, researchers have shown that treatment with the FDA-approved cross-linking procedure iLink (Glaukos Corporation) could reduce the time patients spend in the advanced stages of KC by 28 years, lower the rate of penetrating keratoplasty by 26%, and contribute to a lifetime cost savings of $43,759 per patient.

Be aware of 4 red flags when screening patients for KC:

 Failure of a young patient (< age 30 years) to correct to 20/20 in at least 1 eye, unless the limited best-corrected vision can be explained by some other ocular pathology

1.0 diopter (D), even if the patient is still


If any of these red flags are present—and especially if I see more than one of them—the next step should be topography. On topography, I look for greater than 2.0 D

inferior-to-superior asymmetry, central steepening of greater than 2.0 D, or mean topographical keratometry greater than 47 D.


It is important to look at the absolute dioptric values, not just the topography map, because color scales are not always standardized. What looks like a red “hot spot” may actually be an artefact if the dioptric value within the area is lower than the color would normally indicate.


In patients with worse than 20/20 best-corrected vision and irregularities on topography, a good slit lamp exam is also needed to ensure that other conditions (such as dry eye, meibomian gland dysfunction [MGD], or a corneal scar) aren’t masquerading as KC. 



Corneal keratometry and corneal astigmatism changes after surgery for acquired ptosis



Although this is somewhat unusual, I have seen highly suspicious corneas become totally normal once the ocular surface was treated appropriately. 

Eyes with suspicious topography should be monitored every 3 to 6 months—and potentially even more frequently in young patients

—to determine whether there is any progression of topographical signs and then referred right away for a cross-linking evaluation once progressive KC is diagnosed or strongly suspected.


Given the availability of an FDA-approved treatment that can actually slow or halt KC progression, it is no longer clinically appropriate just to manage patients’ vision and ignore the degenerative aspect of their condition until they can no longer be fit with 

In fact, delaying care could expose one to legal liability. Rigid gas-permeable or scleral lenses may be needed to obtain the patient’s best vision, both before and after cross-linking, but they do not slow or cease disease progression in the way that cross-linking does.



For practices that don’t have a topography device, performing retinoscopy to determine whether there is a normal reflex versus a scissor reflex or Charleaux (“oil droplet”) sign is another useful tool.

In addition to retinoscopy and the 4 clinical red flags, clinicians should perform a very careful slit lamp exam to see if there is any inferior corneal thinning or an inferior “iron line.” 



Augmenting corneal thickness with FDA-approved hypotonic riboflavin


 

If the findings continue to be concerning or there are multiple red flags, refer the patient out for topography.


I have a very low threshold for performing topography because it is an easy, noninvasive test that doesn’t take much time to do. 

Although it is true that a topography exam with normal findings may not be reimbursed, I would much rather absorb the cost of some unreimbursed imaging than miss a diagnosis and unnecessarily delay treatment for the patient. 

Ultimately, in my experience, this type of best practice–oriented care is what it takes to earn patient loyalty and develop long-term patient retention.


Historically, many optometric practices have not offered topography, but the technology is becoming both more accessible and affordable—and also more critical to full-scope practice. 

Optometrists may be pleasantly surprised at how many different medical diagnoses justify topography.

Many insurance companies will reimburse for topography when it is used to evaluate irregular astigmatism, ectasia, corneal dystrophies, pterygia, corneal scars, and other corneal pathology. 

Glaukos and Topcon Healthcare have a partnership program that can lower the cost of entry for practices that are considering acquiring topography.

Topography is also very useful for anyone comanaging laser corneal surgery or cataract surgery. Intraocular lens power calculations can vary dramatically with either dry eye or anterior basement membrane dystrophy—and 1 or both of those conditions are present in a significant percentage of the geriatric population with cataract. 



Share care of the ocular surface before and after cataract surgery

Referring optometrists who establish a healthy medical practice with topography will also be able to provide top-of-the-line care in preparing patients for cataract surgery and screening out those who are poor candidates for laser refractive surgery.


Even for primarily vision care–oriented practices, topography can still be useful. Not only will it facilitate early identification of KC, but it can aid in
sizing and fitting rigid or scleral lenses and even in understanding why otherwise routine toric contact lens fits may be particularly challenging.

A combination autorefractor/topographer may be a good choice for practices that are short on space or need any new diagnostic equipment to do double duty.

Many resources are available for learning to interpret topography and distinguish normal, suspicious, and clearly keratoconic maps (see 

). 

One of the best options for optometrists who already refer patients for laser vision correction may be to spend a couple of hours at the LASIK center, learning how the clinicians there evaluate topographies.


Although there are many nuances, paying close attention to the simple dioptric guideposts I mentioned at the beginning of this article is a helpful start.


We are fortunate to have these excellent diagnostic tools, and it is very rewarding to use them to catch progressive KC cases early and be able to offer cross-linking treatment before patients lose significant vision.



1. Chan E, Chong EW, Lingham G, et al. Prevalence of keratoconus based on Scheimpflug imaging: the Raine Study. 

. 2021;128(4):515-521. doi:10.1016/j.ophtha.2020.08.020

2. Godefrooij DA, de Wit GA, Uiterwaal CS, Imhof SM, Wisse RP. Age-specific incidence and prevalence of keratoconus: a nationwide registration study. 

. 2017;175:169-172. doi:10.1016/j.ajo.2016.12.015

3. Torres Netto EA, Al-Otaibi WM, Hafezi NL, et al. Prevalence of keratoconus in paediatric patients in Riyadh, Saudi Arabia. 

. 2018;102(10):1436-1441. doi:10.1136/bjophthalmol-2017-311391

4. Ferdi AC, Nguyen V, Gore DM, Allan BD, Rozema JJ, Watson SL. Keratoconus natural progression: a systematic review and meta-analysis of 11,529 eyes. 

. 2019;126(7):935-945. doi:10.1016/j.ophtha.2019.02.029

5. Romano V, Vinciguerra R, Arbabi EM, et al. Progression of keratoconus in patients while awaiting corneal cross-linking: a prospective clinical study. 

. 2018;34(3):177-180. doi:10.3928/1081597X-20180104-01

6. Lindstrom RL, Berdahl JP, Donnenfeld ED, et al. Corneal cross-linking versus conventional management for keratoconus: a lifetime economic model. 

. 2021;24(1):410-420. doi:10.1080/13696998.2020.1851556

Early diagnosis enables cross-linking treatment before significant vision loss.

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