Optimize Your Specialty Lens Fitting Success

Specialty lenses provide eye care practitioners with an opportunity to restore vision to patients with limited options for visual improvement. Our clinical time with these patients can be consumed with optimizing the fit characteristics to improve visual outcomes. The clinical reality is that this is only a part of our responsibility with these patients.

Ocular surface health plays an integral role in the success or failure of specialty lens fittings. Not only is a healthy ocular surface important for ensuring the appropriate comfort of the lenses, but also for enhancing the vision that can be compromised with an insufficient tear film. In this article, I discuss the critical components for maximizing ocular surface health in our specialty lens wearers.

LOOK FOR OSD BEFORE YOU FIT

It is important that we identify ocular surface disease (OSD) before beginning any specialty lens fit so the patient understands their condition and some of the challenges it can create in fitting a lens comfortably on the eye. Identifying OSD also gives us an opportunity to optimize compliance efforts in treating the condition. If OSD is identified after the lens fitting process has started or when the patient has been wearing the lens, they may inaccurately blame the lens for any issues they are experiencing.

One way to ensure that we successfully diagnose OSD is by applying fluorescein dye to the surface of the eye while examining the ocular surface with a cobalt blue light and Wratten #12 filter. This will pinpoint abnormalities such as line of Marx irregularities and anterior migration, lid wiper epitheliopathy, reduced tear film breakup time, corneal staining, and conjunctival staining.

DON’T SKIP THE LIDS

Closely examine the lid margin for potential problems related to the specialty lens fitting process. Examine the anterior lid margin and pay attention to the base of the lashes. Under normal circumstances, there should be no deposits at the base of the lashes, and the skin should be either flat around the lash margin or slightly involuted at the base. Address any volcano signs (elevated skin at the base of the lash) or collarettes at the lash margin, even in the absence of symptoms, to minimize their influence on healthy contact lens wear.

It’s also critical to assess the meibomian glands, looking at either the presence or absence of liquid secretions and the quality of the meibum secreted by the glands. This can be done by gently applying pressure to the upper and lower lid margin with your finger or through a more controlled means such as a meibomian gland evaluator. With the meibomian gland evaluator, typical clinical assessment involves evaluating the nasal, central, and temporal regions of the lower lid margin. The meibomian gland structure can also be assessed via direct visualization of the meibomian glands, eyelid transillumination, and infrared imaging of the tarsal plate.

ASSESS FOR INFLAMMATION

The InflammaDry (Quidel) is a diagnostic test that checks for elevated levels (> 40 ng/mL) of matrix metalloproteinase-9 (MMP-9) on the ocular surface. If the concentration is greater than 40 ng/mL, a positive signal, represented as a red line, will appear in the well. This signal is an antibody-antigen reaction and is concentration-dependent.

David Kading, OD, FAAO, FCLSA, and I published a poster examining the signal strength showing a clear darkening of the signal with increasing concentrations of MMP-9 (Figure).¹ This is critical, as it will guide the path of ocular surface therapy, depending on the results of the test. For an individual who tests a strong positive, antiinflammatory therapeutics may be the best initial option. For patients who measure a negative, other therapeutic paths may be more appropriate (see A Case Example).

A Case Example

A 67-year-old female presented to our office as a new patient. She had a history of radial keratectomy (RK). Anterior segment examination was remarkable for prominent RK scars, mild corneal staining inferiorly OU, and loose lid apposition OU. She had mild nuclear sclerosis OU, and her retinal health was unremarkable. The patient’s manifest refraction was as follows: +3.00 -1.00 x 070; 20/40-1 OD and +4.00 -1.50 x 120; 20/40-1 OS; Add +2.50 20/30 OU.

The patient complained about her eyes feeling dry and said she uses artificial tears three to four times daily. Her chief complaint was wanting to update her glasses because she felt as though her vision had worsened.

Topography maps demonstrated central corneal flattening OU. Anterior segment OCT pachymetry scans demonstrated thickened epithelial maps centrally OU (Figure). InflammaDry was ordered and produced negative results OU.

We discussed the patient’s options with her and felt that her vision could be improved with specialty lenses. We also discussed the dryness she was experiencing. She worked 10 hours a day and noticed the dryness much more when working on the computer. In the absence of inflammation, we discussed the option of punctal occlusion and the benefits of scleral lenses as a moisture chamber for the covered ocular surface. We placed temporary 0.5-mm collagen intracanalicular plugs that dissolve around 7 to 10 days after application in the lower puncta OU. We also fit her in a scleral lens with a toric landing zone. With the diagnostic lenses, her BCVA was 20/20 OU.

The patient came back 10 days later to pick up the final scleral lenses. At that visit, she reported significant improvement in her dry eye symptoms and noted that she had only used the artificial tears once since she saw me last. We placed 6-month, 0.5-mm dissolvable intracanalicular plugs in her lower puncta OU and dispensed the scleral lenses. She couldn’t believe how good her vision was as she was leaving the office that day.

OPTIMIZE THE LENS SURFACE

Rigid gas permeable (RGP) lenses provide us with opportunities to restore vision. We now have advanced technologies that optimize surface hydrophilicity. Tangible Hydra-PEG (THP; Tangible Science) is a new surface treatment that is applied to the front and back of the lens surface. It is highly hydrophilic and optimizes the wettability of the lens surface. This has several benefits for patients: It provides a more moisture-rich surface, improving the lens-wearing experience, and its hydrophilicity resists lipid deposits.

Certain rules apply to the care for these lenses to ensure that the THP surface treatment stays intact over time. Lenses coated with THP (and any RGP lenses) should not be rinsed with water, as doing so will remove the coating. Multipurpose disinfecting solutions approved for use with THP-treated lenses include Boston Simplus Multi-Action Solution (Bausch + Lomb), Tangible Clean (Tangible Science), Unique pH (Menicon America), Clear Care (Alcon), and Clear Care Plus (Alcon).² Abrasive cleaners should also be avoided with THP-coated lenses; however, if they are used and do take the THP coating off, the lenses will still be functional.

This surface treatment works well to help those with OSD wear their lenses more comfortably. We have a standing order with our specialty lens labs to have it applied to every RGP lens we order.

KEY TAKEAWAY

Optimizing ocular surface health will improve your patients’ specialty lens experience.