Clinical Controversies: The Ocular Surface and Lens Wear
A recent AOA event looks at preparing the ocular surface for contact lens success.
By Jeffrey J. Walline, OD, PhD; Jeffrey Sonsino, OD; Edward S. Bennett, OD, MSEd; Shalu Pal, OD; Pam Lowe, OD; & Thomas G. Quinn Jr., OD, MS
For the third consecutive year, the American Optometric Association (AOA) Contact Lens and Cornea Section (CLCS) presented an interactive program pertaining to clinical controversies at the 2015 Optometry’s Meeting in Seattle. The topic for this specific presentation was “Preparing the ocular surface for contact lens success.” During this two-hour presentation, audience members were polled prior to the presentation regarding information on a number of topics pertaining to dry eye and contact lens wear. The audience responses were then compared to current evidence-based outcomes on these topics.
The ocular surface is a very complicated part of the eye, and its health is vital to comfortable, safe contact lens wear. It is also the part of the eye for which optometrists not only diagnose complications, but also manage and treat the various maladies. However, there are several controversies regarding the most appropriate management of the ocular surface. Here, the AOA CLCS Council highlights some of those controversies and provides evidence-based reasoning for the most appropriate management when evidence exists, or it highlights areas in which no evidence is available, to determine the most appropriate management technique.
1. What method(s) do you use to diagnose dry eye disease (DED) in your patients?
Dry eye is a multifactorial disease of the tears and ocular surface (International Dry Eye Workshop [DEWS], 2007). The multifactorial nature of this disease results in there being many ways to test for and diagnose dryness. Respondents were given seven options to answer the question above: a) symptom questionnaire, b) corneal staining, c) tear breakup time, d) Schirmer’s tear test, e) InflammaDry (Rapid Pathogen Screening, Inc.) dry eye test, f) tear osmolarity test, and g) all of the above.
Symptom Questionnaires We believe that this is an underutilized test, as many questionnaires have been designed to help identify a problem both to practitioners and to patients while also helping to track a patient’s progress with treatment.
Dry Eye Tests Common clinical tests currently being used include tear breakup time, corneal staining, and Schirmer’s tear testing. More advanced testing includes topography and anterior segment ocular coherence tomography (OCT) evaluation of the tear film, meibomography to evaluate patency of the meibomian glands, and also blink testing to evaluate for completeness and rate.
InflammaDry Several new tests have been designed to evaluate the composition of the tear film. It is believed that DED is an inflammatory process (Tear Film and Ocular Surface Society [TFOS], 2007). Inflammation is present in all severity levels of DED and is present even before clinical signs may arise (Behrens et al, 2006; Stern et al, 2005; Nelson et al, 2000; Stern et al, 1998; and others. Full list available at www.clspectrum.com/references.).
Pro-inflammatory cytokines are present in patients who have dry eyes altering their tear composition (Chotikavanich et al, 2009). MMP-9 is a specific inflammatory marker that is consistently elevated in the tears of dry eye patients (Chotikavanich et al, 2009). Increased MMP-9 activity contributes to deranged corneal epithelial barrier function, increased corneal desquamation, and corneal surface irregularity (Sambursky and O’Brien, 2001). InflammaDry is an in-office procedure designed to test for a higher level of MMP-9 markers in the tear film.
Tear Osmolarity This test is designed to evaluate the severity of DED. Hyperosmolarity and the difference in osmolarity between the two eyes increases as the disease worsens. Hyperosmolarity induces apoptosis of corneal epithelial cells (Sullivan et al, 2012). A normal osmolarity reading is also beneficial to guide you away from the diagnosis of DED so you can look for anatomical, lid, and neurotrophic conditions.
Tear breakup time (76%), and corneal staining (69%) were the overwhelming choices of symposium attendees, with the symptom questionnaire a distant third at 37% (Figure 1).
Figure 1. Methods used to diagnose dry eye.
2. What is your preferred method of dry eye treatment?
Several algorithms and flow charts have been created to differentiate levels of dryness and to outline the treatment strategies for the particular levels. These are used as guides to help with treatment. However, due to the multifactorial nature of the disease, you may need to alter your treatment plan according to your clinical findings.
We believe that the best approach to treat dryness is to evaluate the various parts of the eye that could be contributing to the disease and then treat based on the findings. The anatomical position of the eyelids as well as the eyelashes, the eyelid glands, the ocular surface, and the tear film composition should all be evaluated.
Common treatment options for DED include artificial tears, punctal plugs, omega-3 supplements, cyclosporine, autologous serum, anti-inflammatory treatments, steroids, hot compresses, meibomian gland expression, and lid cleaning.
Artificial Tears Artificial tears provide temporary palliative relief and reduce the hyperosmolarity of the tear film, but 74% of patients do not obtain satisfactory relief from artificial tears alone (TFOS, 2007; Jackson, 2009). Understanding the differences among available drops will help you to recommend the appropriate one based on clinical findings.
Punctal Plugs Use punctal plugs with caution to avoid exacerbation of allergies, meibomian gland dysfunction, and inflammation. However, from a clinical perspective, those of us who utilize punctal plugs know that they can provide significant relief for some patients.
Omega-3s The use of oral omega-3 fatty acids is associated with a decrease in the rate of tear evaporation, an improvement in dry eye symptoms, and an increase in tear secretion (Bhargava et al, 2013; Kangari et al, 2013). The concentration, dosage, purity, and form all have to be properly selected to achieve maximum benefit.
Autologous Serum and Anti-Inflammatory Treatments T cells, when activated, produce inflammatory cytokines that cause apoptosis of lacrimal gland tissues, decrease in goblet cell density, and decrease in corneal barrier function. For example, cyclosporine prevents T-cell activation to reverse the effects of the inflammatory cytokines (Kunert et al, 2002).
Other Considerations Environmental changes, lifestyle changes, management of systemic disease, and management of lid diseases are all needed to complete the treatment plan in managing DED.
The attendees were asked which of the first five options listed above would be their preferred method of treatment. It is evident that the three most preferred methods were omega-3s, artificial tears, and cyclosporine at 50%, 25%, and 19%, respectively (Figure 2).
Figure 2. Preferred method of dry eye treatment.
3. What advice are you most likely to give allergy sufferers to optimize their environment and potentially lessen the problem?
Allergies represent a significant problem for contact lens wearers, with as many as 11 million sufferers (Karpecki et al, 2002). This results in a high dropout rate; 42% of contact lens wearers who have allergy symptoms discontinued contact lens wear and returned to spectacle wear without informing their eyecare practitioner (ECP) (www.medicalnewstoday.com/releases/47322.php). The symptoms of allergy sufferers include tearing, burning, itching, grittiness/foreign body sensation, redness, and dryness. This is often accompanied by clinical signs including redness, lid inflammation/edema, and watery discharge.
There are a number of environmental treatments for allergy sufferers. The attendees were polled about six such treatments and were asked specifically what advice they would be most likely to give these patients. The most popular response was for patients to not rub their eyes (58%), followed by change sheets and pillow cases more often (22%), reduce outdoor exposure/activities and reduce or eliminate turning on ceiling fans (both 8%), and shower more often (4%); no one selected the suggestion of telling patients to increase the bathing frequency of pets (Figure 3).
Figure 3. Common advice given to allergy sufferers to alleviate their situation.
In addition, we believe it is important to recommend that patients regularly clean both their bathrooms and the kitchen and keep their windows closed. It is evident that all of these treatments combine to make patients more comfortable during allergy season; this is often accomplished by minimizing the impact of pollen, dust mites, animal dander, and mold.
In addition, contact lens wearers suffering from allergies often benefit from being fit into daily disposable lenses (Hayes et al, 2003; Wolffsohn et al, 2010; Wolffsohn et al, 2011). Frequent replacement soft lens or GP lens wearers can be successful if they make sure to rub and rinse their lenses upon removal, use preservative-free artificial tears, and wear the lenses on a daily wear schedule. Hydrogen peroxide-based care systems offer the benefits of effective cleaning and disinfection.
4. What is your preferred pharmaceutical of choice for contact lens wearers suffering from ocular allergies?
Attendees were asked this question and provided the following four options: a) mast cell stabilizer, b) combined mast cell stabilizer, c) topical steroids, and d) none; recommend cold compresses and changing environment. The overwhelmingly preferred option was combined mast cell stabilizers at 82% (Figure 4).
Figure 4. Preferred pharmaceutical of choice for contact lens wearers suffering from ocular allergies.
These results are consistent with the literature (Brujic and Miller, 2012; Epstein, 2014). Combined mast cell stabilizers have both the characteristics of mast cell stabilizers (i.e., prevent degranulation and subsequent release of mediators) and preventing histamine release. Therefore, it is considered the first-line treatment. Once-daily formulations are very convenient. However, most are twice-a-day formulations and can be applied in the early morning and before bed in the evening. Topical steroids—which suppress mast cell proliferation, inhibit production of inflammatory mediators, and reduce influx of inflammatory cells—are useful in severe allergy cases, including severe vernal keratoconjunctivitis and allergic keratoconjunctivitis.
When allergy medications are being used in conjunction with contact lens wear, they should be applied, at minimum, 15 to 20 minutes prior to contact lens application (Bennett et al, 2014).
5. What is thought to be the leading cause of DED?
More than half (55%) of those polled correctly identified rapid evaporation of the tear film (Figure 5). This rapid evaporation is a result of inadequate levels of oil in the tear film due to meibomian gland dysfunction (MGD).
Figure 5. Leading causes of dryness.
The reported incidence of MGD varies widely, partly due to the condition being poorly defined in the past (Nichols K et al, 2011). Incidence among Caucasians has been reported to be between 3.5% and 19.9%. The incidence appears to be much higher in the Asian population, with reports ranging from 60.8% to 69.3%.
In 2011, the International Workshop on Meibomian Gland Dysfunction arrived at a definition for MGD. The definition, which describes terminal duct obstruction and changes in glandular secretion, can serve as a guide for detecting MGD. The definition is as follows: “Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease” (Nichols K et al, 2011).
Detecting MGD Patients suffering from MGD will often complain of ocular discomfort (dryness, burning, grittiness), itching (eyes or eyelid margins), photophobia, and fluctuating vision. Visual instability results from rapid tear breakup that leads to irregularity in the optics of the ocular surface.
External examination often reveals generalized bulbar injection as well as reddened and thickened eyelid margins (Figure 6). However, in some patients who have MGD, the slit lamp findings can look remarkably normal (Qazi et al, 2015). It is therefore critical, as the MGD definition suggests, that the meibomian gland openings be examined and the glands expressed. A cloudy, turbid, or waxy (toothpaste-like) expression, or lack of expression, suggests the presence of MGD (Blackie and Korb, 2012).
Figure 6. Patient who has thickened eyelid margins.
Treatment Strategies for MGD Treatment for MGD depends upon the severity of the condition, which the MGD Workshop has classified into four stages. Figure 7 outlines the various stages and the recommended treatment approaches, which include education, eyelid hygiene, and topical and oral medications (Nichols K et al, 2011). As the severity increases, more aggressive treatment strategies should be employed.
Figure 7. Table from International Workshop on MGD showing stages and associated treatments.
6. What are risk factors for developing contact lens-induced papillary conjunctivitis (CLPC)?
The multiple choice answers for this question included a) lipid and protein deposits, b) bacterial bioburden, c) change to higher-modulus materials, and d) a knife-edge design. About two-thirds of the audience (63%) correctly answered that lipid and protein deposits and change to higher-modulus materials are risk factors (Figure 8).
Figure 8. Risk factors for developing contact lens-induced papillary conjunctivitis (CLPC).
In 1977, Allansmith et al identified that lipid and protein deposits on lenses are associated with CLPC. Tagliaferri et al (2014) found that bacterial bioburden had no relation to the development of CLPC. Sorbara et al (2009) found that changing to a silicone hydrogel (SiHy) (higher modulus) material is positively associated with CLPC formation. A knife-edge design on contact lenses has never been shown to be associated with CLPC.
7. What are effective ways to treat CLPC?
Treatment for CLPC can include topical steroids, discontinuing contact lenses, or change to a daily disposable lens modality. Eighty-nine percent of the audience correctly responded that all three of those options are viable treatments for CLPC (Figure 9). Diao et al (2012) showed that tacrolimus 0.05% and topical fluorometholone ophthalmic ointment 0.1% are effective treatments for CLPC, as are saline rinses and discontinuing contact lenses.
Figure 9. Effective ways to treat CLPC.
Donshik et al (1999) found that one-day to three-week replacement schedules for contact lenses carry a lower risk compared to longer replacement schedules.
Practitioners can be aided in making proper diagnosis and grading of CLPC by using readily available grading scales. Two popular grading scales are the CCLRU, now Brien Holden Vision Institute, grading scale and the Efron Grading Scale for Contact Lens Complications. These are both pictorial scales for use in clinical settings (Figure 10).
Figure 10. Brien Holden Vision Institute Grading Scale (left) and Efron Grading Scales for Contact Lens Complications (right) can both be used for diagnosing and grading CLPC.
Managing patients who have CLPC can be summarized to include three components: medical management with topical pharmaceuticals, contact lens management (whether that be discontinuation of lenses or refitting into a more frequently replaced modality), and future care and compliance with contact lenses.
8. Which eyelid condition is the most underdiagnosed?
Blepharitis is a well-known ocular surface condition that can seriously affect healthy contact lens wear due to its inherent infectious nature. Being inflammatory, this condition leads to red, irritated lid margins that accumulate dandruff-like scales on the eyelashes. The two types of blepharitis are classified as anterior (occurring at the outside front edge of the eyelid where the lashes attach) and posterior (occurring at the inner edge of the eyelid that makes contact with the globe). Both types of blepharitis can cause itching, burning, and foreign body sensation, leaving the patient with varied ocular comfort.
Blepharitis severity is related to the cause and chronicity of the condition. Common etiologies for this condition are allergic, seborrheic (dandruff), bacterial (staph infection), Demodex mites, irregular oil production of glands, and inflammatory skin conditions, such as acne rosacea and scalp dandruff.
There is no cure for blepharitis, but it can be treated and controlled through proper lid hygiene (e.g., gentle scrubbing with eyelid cleansing products), warm compresses, and, in some cases, topical and/or oral antibiotic use. The chronic nature of this condition warrants proper follow-up care and monitoring; patients receiving oral therapy should be monitored more frequently at three- to six-month intervals.
One of the more severe causes of blepharitis that warrants special care is Demodex infestation. The attendees were asked which of four different eyelid conditions (i.e., Demodex, anterior blepharitis, posterior blepharitis, ocular rosacea) was most underdiagnosed, and the overwhelming response was Demodex (59%), with ocular rosacea second (24%) (Figure 11). This etiology for blepharitis leads to more recalcitrant cases due to the failure of many clinicians to accurately identify these mites as the culprit. Studies have revealed interesting incidence rates and clinical presentation that shouldn’t be overlooked, such as:
Figure 11. Most underdiagnosed eyelid conditions.
• More than 75% of patients over age 45 test Demodex-positive (Inceboz et al, 2009).
• More than 40% of blepharitis patients test Demodex-positive (Inceboz et al, 2009).
• There is a 30-fold higher count of Demodex mites in patients who have cylindrical dandruff (CD) than in those who do not have CD (Gao et al, 2005).
• There is a strong correlation between the number of Demodex and the severity of ocular discomfort (Lee et al, 2010).
The key in accurate diagnosis of this condition is timely identification of these often elusive, tiny creatures. There are three ways to identify Demodex mites.
The first is an accurate clinical history noting blepharitis, conjunctivitis, or keratitis in adult patients; blepharoconjunctivitis or recurrent chalazia in young patients who are refractory to conventional treatments; or when there is madarosis or recurrent trichiasis (Liu et al, 2010).
The second diagnostic tool is slit lamp evaluation. Identification of CD at the roots of lashes is a telltale sign of this condition and the easiest way to quickly differentiate from the usual triangular scurfs traditionally associated with blepharitis (Figure 12) (Liu et al, 2010; Liu and Tseng, 2010).
Figure 12. Clinical features of Demodex blepharitis.
Third, microscopic confirmation of Demodex eggs, larvae, and adult mites on epilated lashes (Liu et al, 2010) can be performed, but this is timely and labor intensive for busy primary care offices.
Once proper identification of Demodex is made, the key to long-term therapy and maintenance is controlling the infestation with tea tree oil. Chemically, tea tree oil is 4-Terpineol, an organic compound that safely and effectively cleans and soothes the skin. It naturally has antifungal, antiseptic, and antibacterial properties that quell Demodex.
Several tea tree products are available for this use. One product is pure tea tree oil and is available in disposable eyelid wipes for home use and as part of an in-office treatment kit. It is important not to expose the eye or tear film to this concentration due to its stinging properties; application is strictly for the lids and face only. Another product contains a lower concentration of tea tree oil along with coconut oil, which renders it gentle to the tear film and eye (although it is meant for use with the lids and face). It is available in eyelid wipes as well, but it is also available as a foaming lid cleanser for home use and as in-office disposable swabs for practitioner use. Chronic and frequent use of this form of treatment may be necessary, depending on the severity of the condition.
The good news is, patients who suffer with blepharitis don’t necessarily have to give up on successful contact lens wear. As with any treatable condition, timely, accurate diagnosis and treatment are key to returning healthy lid function. Healthy lids support a healthier tear film, rendering more comfortable, complication-free contact lens wear.
9. What contact lens type puts patients at the highest risk of microbial keratitis?
Approximately two-thirds of all microbial keratitis cases can be attributed to contact lens wear (Dart et al, 1991; Green et al, 2008), and there are several factors related to contact lens wear that may contribute to the risk of sight-threatening complications.
The most commonly cited risk factor for microbial keratitis is extended wear (Dart et al, 1991; Schein and Poggio, 1990; Matthews et al, 1992; Schein et al, 1994; and others), which increases the risk of an eye infection by three to 10 times (Shein and Poggio, 1990; Matthews et al, 1992; Schein et al, 1994; Radford et al, 1995; and others). Issues related to hypoxia experienced during extended wear were thought to be the primary determinant of associated side effects, but SiHy contact lenses with greater oxygen permeability did not significantly reduce the risk of microbial keratitis (Stapleton et al, 2008; Stapleton et al, 2013), so factors such as bacterial bioburden and tear stagnation are now considered as agents in the disease.
The question posed to the audience was, “What contact lens type puts patients at the highest risk of microbial keratitis?” Two-thirds of the audience responded “frequent replacement SiHy,” and one-third responded “frequent replacement hydrogel” (Figure 13).
Figure 13. Type of contact lens that puts patients most at risk for microbial keratitis.
The literature indicates that the correct response is “it depends.” SiHy and hydrogel contact lenses both provide approximately 10 times greater risk of microbial keratitis when the contact lenses are worn overnight. SiHy contact lenses provide approximately that same risk with daily wear, while hydrogel contact lenses increase the risk of microbial keratitis less than five times.
Other risk factors for contact lens-related microbial keratitis include smoking, poor hygiene, Internet purchase of contact lenses, unclean contact lens cases, and patient age. Current smokers were approximately three times more likely to experience microbial keratitis than were non-smokers (Stapleton et al, 2013).
Poor hygiene during contact lens care is also a risk factor for microbial keratitis. While more than 90% of patients know to wash their hands prior to handling contact lenses, only half report that they actually do so prior to touching their lenses (Robertson and Cavanagh, 2011). A report of not washing hands prior to handling contact lenses increases the risk of microbial keratitis approximately 50% (Stapleton et al, 2008; Dart et al, 2008).
The risk of an eye infection is approximately five times greater for patients who purchase their contact lenses via the Internet (Stapleton et al, 2008). This is thought to be related to the fact that people who purchase contact lenses online are less likely to visit their eyecare practitioner for well visits.
Another strong risk factor for contact lens-related microbial keratitis is poor case hygiene, which increases the risk three to four times (Stapleton et al, 2008). The best method to clean bacteria from cases includes rubbing with a clean finger, rinsing with contact lens solution, wiping with a tissue, and air-drying upside down on a tissue (Wu et al, 2010; Wu et al, 2011), and cases should be replaced every one to three months (Stapleton et al, 2012).
Many eyecare practitioners won’t fit contact lenses on children until they become teenagers (Sindt and Riley, 2011), presumably because they believe that children are incapable of responsible contact lens care. However, the group at highest risk of complications related to contact lens wear is college-age students (Wagner et al, 2011; Chalmers et al, 2011). This age group reports poorer compliance with contact lens care instructions, including a higher propensity to nap and shower while wearing contact lenses; to wear contact lenses after alcohol use, when traveling, and when away from home; and not washing hands prior to lens application.
Several risk factors for contact lens-related microbial keratitis are modifiable, so we should remind our patients to not sleep in contact lenses, wash and dry their hands prior to touching contact lenses, clean and replace their contact lens case appropriately, report for well visits, and to cease smoking. Table 1 lists many of the risk factors for contact lens-related microbial keratitis and the associated ways to help prevent the likelihood of sight-threatening outcomes. Remember, eliminating even just case hygiene and replacement as risk factors would remove 62% of the disease load (Stapleton et al, 2012).
|Overnight wear||No overnight wear|
|Smoking||Smoking cessation program|
|Not washing hands||Wash with antibacterial soap|
|Internet order||Regular follow-up with practitioner|
|Poor case hygiene||Rub, rinse, tissue-wipe, air-dry|
|Frequent CL wear||Give eyes a break|
Early diagnosis of an eye infection leads to early care and better outcomes, but diagnosis is not always simple. In fact, Efron and Morgan (2006) attempted to separate contact lens-related corneal infiltrative events into four categories based on literature-based definitions of microbial keratitis, contact lens-induced peripheral ulcer, contact lens-induced acute red eye, and infiltrative keratitis. Only 20% of the cases in that report were clearly defined as one entity. Two-thirds of the cases were identified as two different diseases, and more than 10% were categorized as three diseases. The incidence of microbial keratitis associated with extended wear ranged from 25 cases per 10,000 years of wear to 120 cases per 10,000 years of wear when using various definitions of microbial keratitis.
A single case of microbial keratitis was presented to the audience, but only one-quarter of the respondents properly identified the condition. Just over one-half of the respondents indicated contact lens-associated red eye (CLARE), and most of the remainder indicated a non-infectious infiltrative keratitis.
Various definitions of microbial keratitis used in the literature to estimate the incidence of the problem, when applied to other studies, can result in very different rates that may be as much as two to five times greater than the original study (Efron and Morgan, 2006).
These examples indicate the difficulty in definitively diagnosing microbial keratitis, so it should be presumed and treated as such when there is even a suspicion because a delayed response may lead to more severe outcomes and increase the likelihood of permanent vision loss.
Hopefully this clinical controversies article has helped answer questions pertaining to popular ocular wellness conditions and issues. The fourth annual clinical controversies program will be presented at Optometry’s Meeting in June 2016 in Boston. CLS
Acknowledgements: The authors would like to acknowledge Harvard Sylvan, OD, and CooperVision for their support of this program.
For references, please visit www.clspectrum.com/references and click on document #242.
Dr. Walline is an associate professor at The Ohio State University College of Optometry. He has received research funding from Johnson & Johnson Vision Care (JJVC). You can reach him at firstname.lastname@example.org. Dr. Sonsino is in private practice in Nashville, Tenn. He is a diplomate in the Cornea, Contact Lenses, and Refractive Technologies section of the American Academy of Optometry (AAO). He is also a member of the American Optometric Association’s (AOA) Council on Cornea and Contact Lenses, a fellow of the Scleral Lens Education Society, and he is on the advisory board of the Gas Permeable Lens Institute (GPLI). He is a consultant or advisor to Alcon, Optovue, SynergEyes, and Visionary Optics, and he has proprietary interest in LVR Technology. Dr. Bennett is assistant dean for Student Services and Alumni Relations at the University of Missouri-St. Louis College of Optometry and is executive director of the GPLI. You can reach him at email@example.com. Dr. Pal is in a solo practice in Toronto. She is a member of the AOA Contact Lens and Cornea Section Council, chair of the AOA Student & New Graduate Committee, a member of the Canadian Association of Optometrists, and she is on the Continuing Education committee of the Ontario Association of Optometrists. She is a speaker, writer, or consultant for Allergan, Alcon, B+L, CooperVision, JJVC, Menicon, Novartis, and TruForm Optics. Dr. Lowe is currently director/president of Professional Eye Care Center, Inc., a full-scope primary care practice in Chicago, and she serves as an adjunct clinical professor for Illinois College of Optometry. Dr. Lowe is a past president of the Illinois Optometric Association and a member of the AOA, currently serving on the AOA External Communications Committee and holding a council seat on the AOA Contact Lens and Cornea Section. She is a Fellow with the AAO and a Diplomate of the American Board of Optometry. Dr. Quinn is in group practice in Athens, Ohio. He is an advisor to the GPLI and an area manager for Vision Source. He is an advisor or consultant to Alcon and B+L, has received research funding from Alcon, AMO, Allergan, and B+L, and has received lecture or authorship honoraria from Alcon, B+L, CooperVision, GPLI, SynergEyes, and STAPLE program. You can reach him at firstname.lastname@example.org.