Fast forward 10 years: How will we treat myopia?

Liverpool, UK-The British Contact Lens Association meeting features several panel discussion on a theme. Topics included a look into the future for managing myopia and contact lens discomfort. In addition, improve the success of your multifocal contact lens fits with expert suggestions.

Related: Myopia and public health

Panel roundups

Myopia

Professor Brien Holden, BAppSc, PhD, DSc, chief executive officer of the Brien Holden Vision Institute, says that that in 10 years, optometrists will be in the myopia management business. He posed this question to the panel:

What do you think will be the best combination in 10 years’ time being delivered by optometry?

Professor James Wolffsohn: I suspect it will be a contact lens with myopia-controlling optics, but with a drug release as well. If you push any one treatment to the extreme, it presents side effects which are undesirable. Having multiple type of treatments in lower doses will be desirable.

Dr. Noel Brennan: There will be multiple options-contact lenses but nothing that looks like what we’re using today; drugs but nothing that looks like what we’re using today; indoor lighting that captures what we’re missing from the environment. We’ll use all of these in some way.

Dr. Kate Gifford: We’re going to have things available that we don’t know about now. I don’t think we’re going to have any one panacea, and we will need to have multiple options.

Dr. Pauline Cho: We did a survey asking patients if ortho-k, contact lenses, and glasses show the same effect, which one would they choose. More than 50 percent chose ortho-k. Some chose spectacles plus contact lenses. Patients do want options.

Dr. Holden: Why aren’t companies pushing it in the marketplace?

Dr. Cho: Patients look to ortho-k as a very successful treatment. But with glasses, you don’t see the effect right away. It may take years.

Shelly Bansal: We will see a semi-rigid daily disposable overnight ortho-k lens. You get all the benefits from each modality.

Dr. Ian Flitcroft: My wish list is that we’ll have a fully informed population with supportive politicians and algorithms identifying which kids are at risk. We will see them and measure axial lengths. We’ll hit them with drugs first, then get them into contact lens designs.

Dr. Nicola Logan: A tailored approach to each particular child and a contact lens with a drug delivery system. You may not need to wear the lens every day. Do it, then stop, then try something else. Do short bursts of treatments. Keep a changing approach.

Dr. Janis Orr: A more tailored approach, including getting kids outside, pharmaceutical delivery and myopia control lenses.

Dr. Loretta Szczotka-Flynn: I’d be interested in genetic testing to individualize and determine if I should use a multifocal contact lens or drugs. Ten years might not be long enough for this to come to pass.

Patrick Caroline: Hopefully we’ll have clarity. Right now we have three different approaches. We need clarify why these strategies all seem to influence the myopia story. Until we get choroidal clarity on what’s happening with optical defocus and these other techniques, we won’t understand it. We know these treatments work, but we don’t know why they work.

Dr. Holden: It is absolutely essential that any child who is young and myopic is fitted with contact lenses that will bring the center forward.

Related: Brien Holden on contact lens myopia management

Contact lens discomfort

Professor Philip Morgan, chair of the contact lens staining and discomfort session, asked panelists to describe contact lens discomfort, in one word if possible.

Dr. Robin Chalmers: Tear instability

Dr. Eric Papas: Lid changes

Dr. Lyndon Jones: Eye

Dr. Michael Read: Blink

Related: Dry eye and contact lens wear

Says Dr. Chalmers: It’s very puzzling that we have people who are so robust with lens wear and do fine all day long while others don’t. That’s why I think the difference is in the instability of the tear film while it’s interacting with other surfaces.

“There’s something about the biology of the eye over the course of the day that affects comfort,” says Dr. Jones.

Digital devices are adding to the problem of comfort with contact lens wear, according to Dr. Chalmers.

“The way people are using their eyes have changed,” she says. “Now we stare and stare and stare. In the past, only a certain strata of people had that type of job. Now we’re all staring at screens all the time. Things had improved with lens comfort, but then we loaded demand onto it.”

Suggestions for improving contact lens discomfort include increased use of daily disposable lenses in addition to minimizing evaporation and managing meibomian gland problems.

Multifocal contact lens fitting decision questions

About 60 percent of patients are presbyopic, but on average only 4 percent are wearing multifocal contact lenses, says Peter Ivins, BSc (Hons) MCOptom DipTp (IP). Today’s patients want to wear multifocals in addition to PALs.

“These patients are coming through your practice every day,” he says, “so all you have to do is raise visibility of multifocal contact lenses.”

Related: Managing aging and vision

In fitting multifocal contact lenses, there are many questions to be answered.

• Which modality, daily or reusable?

Many presbyopes prefer to wear their contact lenses on a part-time basis. Daily disposability is the best choice for such wearers.

• Which material?

“This decision is really about comfort and vision,” says Dr. Ivins. “Comfort is related to wettability and lubricity. Hydrogel is then the material of choice.”

• Which design, center distance or center near?

Most designs today are center near, according to Dr. Ivins, and you have a wide choice of them.

• Which patients to fit?

You’re fitting for success, so fit those who are most likely to succeed.

Dr. Ivins follows the rule of three yeses. If the patient answers “yes” to the following three questions, then he is a good candidate for multifocal contact lenses:

1. Are you finding you’re becoming more reliant on your spectacles?

2. Are you finding some situations where you’d like to be without them?

3. If I could offer you something that could help you with that, would you be interested?

Related: Preventing lens dropout with presbyopia patients

When fitting, advises Dr. Ivins, it’s important to get the best sphere power and maximize the plus. Determine eye dominance with the +1.00 D blur test. But most importantly, follow the fitting guide.

“People have spent a lot of time trying to optimize the best way to fit a certain lens,” he says, “and following the fitting guide allows you to maximize your chair time.”

When assessing the fit, the lens is not centered or wetting well, move on to another design because that lens is unlikely to succeed.

“Centration is more important than ever with multifocal lenses because of the optics,” says Dr. Ivins. “If the lens is decentered, other aberrations are introduced and you won’t get a good visual result.”

Be sure to conduct a real-world assessment with your patients instead of handing them a quick card to read while seated in the chair. Ask the patient how she sees while driving, especially at night, and looking at her computer monitor and her phone. If she responds less than seven out of 10, you need to make adjustments.

One lens design is unlikely to meet all of a patient’s needs. Dr. Ivins wears one design while playing golf and another while he’s lecturing or seeing patients. Consider a “wardrobe of lens designs” to be sure your patients’ needs are met.

Related: Embracing contact lens technology

Measure your success by looking at the number of trial lenses you’re using during a week. Then look at your conversion rate: How many of those patients you’ve trialed are purchasing lenses? That number should be about 75 percent, according to Dr. Ivins.

Next, take a longer view by looking at the number of multifocal contact lens fits you’re performing. That number should increase each week.

Dr. Ivins’s 10 tips for success

1. Embrace the concept of a presbyopic solution

2. Design a strategy to increase your fits of multifocal contact lenses

3. Increase internal visibility

4. Use a selection of designs

5. Create an efficient fitting process

6. Follow the fitting guide

7. Measure and adapt process

8. Have a multichannel supply. Match that convenience of the internet

9. Craft transparent fee structure

10. Communicate for retention

“You need to wear a few hats,” he says. “You need to be able to understand the science and use it in the clinic. You need a bit of psychology when working with multifocal contact lens patients. You need to set the fees and sell the concept of presbyopic contact lens correction. Last but not least, you need to market it.”

Related: Five myths about scleral lenses debunked

More on contact lenses and glaucoma, 4 men in a pub

Contact lenses can play a role in measuring and monitoring intraocular pressure (IOP), according to Dr. Eric Papas. Measuring IOP over a contact lens provides convenience due to no need for anesthetic; however, the lens material and power may affect results.

“Measurement on top of a contact lens doesn’t give much different of an answer than if you do it without a contact lens,” he says. “As a single measure, it might be leading.”

Triggerfish, a contact lens sensing device, monitors changes in the corneal curvature just inside the limbus as a result of IOP changes.

According to Dr. Papas, the device provides data in measurement of voltage, not mm Hg, and this makes monitoring more challenging.

“We can’t measure directly,” he says, “but we can measure relative change in pressure. There are questions of how repeatable it is, and it’s quite expensive.”

Continuous drug delivery via contact lenses is another idea that was first proposed by Otto Wichterle, the father of soft contact lenses.

“It may be that we can use this simple delivery technique by soaking lenses in the drug and then wearing overnight or applying drops on top of the contact lens to be absorbed into the lens,” Dr. Papas says.

Related: Examining the symptoms, causes, and treatments of contact lens discomfort

Drs. Lyndon Jones, Philip Morgan, Noel Brennan, and Eric Papas gathered in the “pub” to discuss silicone hydrogel vs. hydrogel lenses. Newly inducted BCLA President Dr. Brian Tompkins served as waiter, delivering genuine beers, to the pub patrons. Attendees felt like they were overhearing a discussion, and this innovative yet casual presentation format was effective and well received.

Interesting points raised:

• There’s a law of diminishing returns with higher and higher Dk/t.

“It stands to reason that you can’t keep getting more oxygen,” says Dr. Brennan. “It’s gotta level off somewhere. The Dk/t level required to give the cornea enough oxygen is 20. Once you get above that, it doesn’t make any difference. Industry has been built around this. Dk/t has been primary parameter of interest. I say we’ve been duped.”

• No relation between contact lens comfort and Dk/t.

• Other things are much more important to comfort than oxygen.

• The corneal infiltrative event (CIE) rate is twice as high in silicone hydrogels than in traditional hydrogels.

“That’s the opposite of what we might have expected,” says Dr. Morgan.

• The presence of more oxygen with silicone hydrogel materials may be exacerbating an existing inflammatory problem.

• Good wetting is important, but correlating that with comfort is difficult.

• Comfort is today’s driving factor. Poor comfort leads to contact lens dropout.

The consensus of the pub discussion is that hydrogel contact lenses still have a role to play, and eyecare practitioners should still be fitting them.

“As time goes I’m beginning to realize that there’s a role to play for both hydrogels and silicone hydrogels,” says Dr. Jones.

Related: Hottest stories of 2014: Contact lenses