I recently attended a meeting related to Sjögren’s Syndrome that included both patients and many of the healthcare disciplines involved in managing the manifestations of the disease. I overhead a rheumatologist speaking with some patients about managing their dry eyes. The practitioner was making the case that all treatment for eye dryness is the same—we treat it by just adding drops (over-the-counter and/or prescription). Later, I was able to speak with my colleague to ensure that there was more awareness around the many potential contributors to dryness (e.g., meibomian gland dysfunction), all of which may require different management approaches than the use of drops. The abstract this week provides good evidence of the heterogeneity of factors leading to dryness in Sjögren’s syndrome.
Jason J. Nichols, OD, MPH, PhD
The Cooper Companies Acquires Paragon Vision Sciences
The Cooper Companies, Inc. announced that CooperVision has acquired Paragon Vision Sciences, a leading provider of orthokeratology (ortho-k), specialty contact lenses, and oxygen permeable rigid contact lens materials. CooperVision stated that the acquisition provides the opportunity to grow its myopia management presence worldwide. The transaction is valued at approximately $80 million and is expected to be neutral to earnings per share in fiscal 2018 excluding one-time charges and deal-related amortization. Terms of the acquisition were not made public.
Paragon, headquartered near Phoenix, will continue to operate as an independent yet complementary business, retaining its offices and brands. Customers should continue to work with their current representatives. Rich Jeffries, president of Paragon, will remain with the company, responsible for its day-to-day operations. Former Paragon CEO Joe Sicari will become a consultant to CooperVision.
Kala Pharmaceuticals Submits New Drug Application to FDA for Inveltys
Kala Pharmaceuticals, Inc. has submitted a New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) for Inveltys (KPI-121 1%), a topical twice-a-day product candidate for the treatment of inflammation and pain in patients who have undergone ocular surgery. If approved, Kala expects that Inveltys would be the first twice-daily ocular corticosteroid indicated for the treatment of post-operative ocular inflammation and pain. The brand name for KPI-121 1%, Inveltys, has been conditionally approved by the FDA.
Inveltys utilizes Kala’s proprietary Mucus Penetrating Particle (MPP) technology. MPPs are selectively sized nanoparticles with proprietary coatings that are designed to significantly enhance drug penetration and distribution in ocular tissues. In pre-clinical studies, MPPs increased delivery into ocular tissues more than three-fold by facilitating penetration through the tear film mucus.
American Academy of Optometry Launches New Website
The American Academy of Optometry launched a newly designed website for both the Academy and the American Academy of Optometry Foundation. The new website has been designed to offer the ultimate user-friendly experience with improved navigation and functionality, while allowing visitors to access key information more easily.
The site includes many new features designed to help users quickly and easily navigate the site and find what they need. New features include an updated and more modern look and design; an enhanced fellow and diplomate directory that allows users to easily identify diplomates who appear in the search results; optimized and enhanced responsive design leading to better viewability on mobile devices and a variety of browser types; and a thorough search feature that encompasses website pages, past meeting abstracts and outlines, and directory information.
TFOS DEWS II Report Available Via iOS and Android Devices
The Tear Film and Ocular Surface Society (TFOS) recently announced that the TFOS International Dry Eye Workshop II (DEWS II) report is now available for iOS and Android devices for free. DEWS II involved 150 clinical and basic research experts from around the world and utilized an evidence-based approach and a process of open communication, dialogue, and transparency to achieve a global consensus concerning multiple aspects of dry eye disease. All subcommittee reports and the Executive Summary are available on the app. The language translations and diagnostic videos will be available soon. Visit the App Store or Google Play.
Want to See Your Clinical Image on the Cover of Contact Lens Spectrum?
Images can be submitted to the Global Specialty Lens Symposium Photo Contest in one of two anterior segment categories: Contact Lens or Cornea/Conjunctiva/Lids. Simply e-mail your photo with your name, category, and title of the photo to Julia.McNamee@pentavisionmedia.com. Winning entries will be featured on a future cover of Contact Lens Spectrum. Submit your entry no later than December 30.
When working with a patient who has an irregular cornea, which GP lens design are you more likely to use?
Michelle Mann, Massachusetts College of Pharmacy and Health Sciences, Class of 2018
This image shows a post-radial keratotomy eye with a very old, poorly fitting lens. The patient was refit with a scleral lens in the highest-Dk material available, keeping vault to a minimum.
We thank Michelle Mann for this image and welcome photo submissions from our other readers! It is easy to submit a photo for consideration for publishing in Contact Lenses Today. Simply visit http://www.cltoday.com/upload/upload.aspx to upload your image. Please include a detailed explanation of the photo and your full name, degree or title, and city/state/country.
S. Barry Eiden, OD
Shouldn’t We Start with Toric PCs?
Scleral contact lenses are being utilized more and more in clinical practice. We are well aware of the advantages of these lenses, especially in the management of irregular corneas and ocular surface disease. Initially, it seemed to be a relatively simple thing to do—just find a lens that vaults the entire cornea and lands relatively aligned to the scleral conjunctival surface. Surely, those of us who have fit large numbers of patients with scleral lenses realize that it is not so simple.
Complexities regarding proper vaulting of the cornea, lens thickness issues, material oxygen transmissibility, retro-lens debris accumulation, and appropriate scleral landing among others can have a negative impact on scleral lens performance. Our understanding of corneal shape has dramatically improved with the advent of corneal topography; however, we are just beginning to understand the details pertaining to scleral shape.
A recent article was published that further elucidates the intricacies of scleral shape.1 Researchers evaluated the shape of the anterior sclera by measuring the sagittal height and corneo-scleral transition angles in the four cardinal and four oblique segments of the eye. In the study, 78 normal eyes of 39 subjects were evaluated using optical coherence tomography (Zeiss Visante AS-OCT). Sagittal height, corneo-scleral angle, and scleral angle were measured at three chord lengths (10.0mm, 12.8mm, and 15.0mm) in all eight segments of the anterior eye. Scleral toricity was calculated for each eye, defined as the greatest sagittal height difference found between two perpendicular meridians.
Results indicate that, at a 12.8mm chord length, the shape of the anterior eye was nearly rotationally symmetric. However, at a chord of 15.0mm, the shape became more asymmetric. Significant differences between opposing segments were found in the sagittal height and scleral angle measurements at a chord of 15.0mm (sagittal height p ≤ 0.0021; scleral angle p ≤ 0.0105). The nasal measurements revealed flatter scleral angles and concave corneo-scleral transitions, whereas temporal scleral angles were steeper, with tangential or convex corneo-scleral transitions. The researchers concluded that these findings are important to consider when designing and fitting contact lenses that rest beyond the boundaries of the limbus, such as scleral lenses.
With the advent of technologies such as anterior segment OCT, anterior segment Scheimpflug-based tomography, and other types of corneo-scleral measurement devices, we are now getting a much better understanding of the complexity of scleral shape and its potential influence on fitting outcomes for corneal vaulting contact lenses such as sclerals. Because we realize that it is more common to find toric scleral shapes as we go out further in chord diameter measurements, would it not make logical sense to utilize toric-peripheral-design diagnostic scleral contact lenses (at least for larger diameter sclerals) as a default starting point?
Ultimately, as technologies that measure corneo-scleral profiles become more commonly utilized in clinical practice, we may find ourselves “virtually fitting” scleral contact lenses without the need for diagnostic lenses. Until then, consider using toric-periphery diagnostics when fitting your larger-diameter sclerals; these kinds of diagnostic sets are becoming more commonly accessible from many laboratories.
1. Ritzmann M, Caroline PJ, Börret R, Korszen E. An analysis of anterior scleral shape and its role in the design and fitting of scleral contact lenses. Cont Lens Anterior Eye. 2017 Nov 9. [Epub ahead of print]
OCULAR SURFACE UPDATE
Katherine M. Mastrota, MS, OD
A Pattern of Tears
I haven’t thought about tear ferning for a while. Tear ferning is the characterization of the pattern of tears that have dried on a slide. Fern testing is also performed on cervical mucus, amniotic fluid, and saliva. Changes in the pattern of the dried fluids are an indicator of a particular fluid’s dysfunction.
Rolando1 classified tear ferning into four groups, from a uniform, florid arborization drying pattern to a little branching and amorphous pattern. Other grading scales also exist.2,3
The most recent tear ferning scale was developed in 2014 by Masmali et al.4 Interestingly, but not surprisingly, Masmali et al reported in a different study that there are significant differences between smokers and nonsmokers according to the tear ferning test, McMonnies questionnaire, and tear breakup time (TBUT) test. 5 In that study, the mean values for McMonnies, tear ferning, and TBUT tests in smokers compared to nonsmokers indicate that smoking has an effect on the ocular tear film. Masmali and colleagues observed that the tear ferning patterns clearly show the differences in tear quality between dry and normal tear samples among smokers and nonsmokers.5
Should we revisit the utilization of this simple test in our dry eye assessments? What clinical value or direction does it offer for therapeutic management of ocular surface disease? More has yet to be elucidated.
1. Rolando M. Tear mucus ferning test in normal and keratoconjunctivitis sicca eyes. Chibret Int J Ophthalmol. 1984;2(4):32-41.
2. Norn M. Ferning in conjunctival-cytologic preparations. Crystallisation in stained semiquantitative pipette samples of conjunctival fluid. Acta Ophthalmol. 1987 Feb;65:118-122.
3. Vaikoussis E, Georgiou P, Nomicarios D. Tear mucus ferning in patients with Sjögren's syndrome. Doc Ophthalmol. 1994;87(2):145-151.
4. Masmali AM, Murphy PJ, Purslow C. Development of a new grading scale for tear ferning. Cont Lens Anterior Eye. 2014 Jun;37:178-184.
5. Masmali AM, Al-Shehri A, Alanazi SA, Abusharaha A, Fagehi R, El-Hiti GA. Assessment of Tear Film Quality among Smokers Using Tear Ferning Patterns. J Ophthalmol. 2016;2016:8154315.
Meibomian Gland Features in a Norwegian Cohort of Patients with Primary Sjögren’s Syndrome
The purpose of this study was to assess the tear film and meibomian gland (MG) features in a Norwegian cohort of patients who have primary Sjögren’s syndrome (pSS) and in age- and gender-matched control subjects.
Thirty-four female patients who have pSS (age 52.9 ± 11.9 years) and 32 female control subjects (age 49.0 ± 11.5 years) were recruited. After completion of the Ocular Surface Disease Index (OSDI) questionnaire and McMonnies Dry Eye Questionnaire, participants underwent measurements of tear osmolarity, tear breakup time (TBUT), ocular surface and corneal staining, Schirmer I test, corneal sensitivity, MG expressibility evaluations, and lid margin morphology examination using slit lamp microscopy. Non-contact infrared meibography images were assessed by computer-assisted analysis. The MG loss, calculated as (tarsal area-MG area)/tarsal area, was evaluated in both upper (UL) and lower lids (LL).
Compared to the control group, pSS patients demonstrated higher MG loss in both UL (33.8% ± 13.2% versus 24.4% ± 8.5%, p < 0.01) and LL (52.5% ± 15.7% versus 43.0% ± 9.6%, p < 0.05) as well as a higher lid abnormality score (0.8 ± 0.8 versus 0.2 ± 0.6, p < 0.01). Furthermore, pSS patients showed higher OSDI and McMonnies questionnaire scores, elevated osmolarity, shorter TBUT, shorter blink interval, less wetting in Schirmer I test, more ocular surface staining, and more corneal staining. MG loss in UL correlated negatively with TBUT (r = –0.386, p = 0.029) in the pSS group, whereas MG loss in LL correlated negatively with TBUT (r = –0.380, p = 0.035) in the control group.
Significantly elevated dry eye symptoms and signs were found in the pSS group compared to the control group, which might be attributed to both decreased aqueous tear production and increased tear evaporation.
Chen X, Utheim ØA, Xiao J, Adil MY, Stojanovic A, Tashbayev B, Jensen JL, Utheim TP. Meibomian gland features in a Norwegian cohort of patients with primary Sjögren´s syndrome. PLoS One. 2017 Sep 8;12(9):e0184284.