In Contact - September 2007

Recurrent Themes?

we've all pretty well had enough of contact lens solution issues. Recalls are by now pass?? Complications, staining and alleged cytotoxicity have had more than enough coverage. There?ve been plenty of opportunities to attend conferences, CPD and surf sites that detail and explain it all. Different clinicians, companies and researchers all put their spin on it, as does Brien Levy in an editorial in the CLAO journal; Eye & Contact Lens: Science & Clinical Practice: Volume 33(4)July 2007pp 165-166 I'd recommend one reads it, in the interest of balance.
The majority of experts now seem to agree on one thing: To minimise issues with solutions, allergy, GPC, complications, MK, CLPU and all the other nasties, what should one do?
Fit daily disposables.
If that's not possible many now suggest peroxide disinfection.
I've been talking up peroxide for a quarter century now and increasingly promoted one day disposables as the best option, over the past ten years.
At least the scientists are now proving our clinical anecdotes correct so now hopefully the sceptics - blinded by an over-reliance on EBM - will jump on the bandwagon.
We should see a decline in recalls and complications if this sensible, healthy approach is followed. It will however take some years to filter through the broader, over-commercialised contact lens business.
Instead of taking all the solution and other contact lens related dramas negatively, turn them into positives. Reinforce to your patients why It's important to keep in contact, attend regular aftercare and purchase lenses and solutions from you. That way they are on the RADAR and one can much more easily and efficiently sort out a problem or upgrade them to safer, better products.
Before It's too late?

Recurrent Erosion?

It seems to me that some of the most misdiagnosed or untreated symptomatic-conditions in anterior segment management are those of recurrent corneal erosions.
Pilosebaceous distichiasis (or ?retro-lashes? as I more simply like to call them) is another oft missed but irritating condition.
RCEs are often linked with EBMD, a history of corneal abrasion, injury and ocular surface issues. Review of Optometry?s excellent Handbook of Ocular Disease Management provides a good overview and images.
Most of the ones I see in clinical practice are chronic and have often been overlooked by practitioners as a source of the patient?s symptoms. Many RCEs, following injury or abrasion, could be avoided if additional therapy was provided, beyond the Rx of antibiotic drops?
I've found that most of these relatively small RCE?s can be effectively treated with something like preservative-free PolyVisc at night. A ?worm? of the ointment can be placed into the lower fornix. With a few blinks and gentle massage through the lids to coat the eye, they?re ready for some shuteye. In my experience Polyvisc works well and is well tolerated. Lacrilube and Viscotears are worth a try too. Use unpreserved and single dose options where possible.
Remember though that some of these ?Vaseline-like? lubes are derived from or may contain ?wool fat? [lanolin], mineral oil, paraffin, carbomer, cetrimide, chlorobutanol and other chemicals that may cause allergic and toxic reactions, especially if preserved.
I also recommend a lubricant eye drop for daytime use. I also treat any underlying ocular surface disorders and inflammatory lid problems - such as ?blepharitis? and MGD with things like SteriLid externally and TheraTears Nutrition internally. The TheraTears family of products generally work well. In some mild cases of RCE, TheraTears Liquid Gel - or other gel products - can be used in place of the more viscous ointments, nocte.
Aquify, with its so called ?disappearing preservative? - and others with similar properties - may also be good options for day time use, particularly for potential non-compliant?s and those patients who dislike ?single dose? drops. Systane also provides benefits in some cases, with its muco-mimetic properties. These are especially useful if there's a ?mucin-deficiency? aspect to the case.
If these relatively simple treatments don't solve the problems within a month then more specific and intensive treatments - as discussed in the aforementioned handbook - can be tried, followed by surgical options like stromal micropuncture & PTK
I've also published a case report relating to one of the early uses of silicone hydrogels, as a therapeutic bandage, for a case of RCE that did not respond well to ointments or surgical treatments. Check out the full case here at siliconehydrogels.org.
I saw the patient recently as she's moving to Canada. She continues to be problem free with over six years of limited EW in Purevision as an Rx, bandage lens. I provided her with a year?s supply of lenses and prepared a detailed referral letter for a colleague in Quebec for ongoing management.

Accelerated Stabilisation.

Some wearers of prism-ballasted astigmatic soft lenses complain of reduced, variable vision in certain postures. The classic case is that of the couch potato who finds the TV blurred when chilling out, lying on their side. Yogi?s doing head-stands are another case as are golfers who find they get disturbing rotationally-induced metamorphopsia when putting.
I recently saw the astigmatic prism-ballast-wearing father of one of my younger soft lens wearing astigmats. The daughter incidentally has worn toric softs for some years. In her second year of soft lens wear, at the tender age of eleven, she developed a CLPU, secondary to inflammatory lid disease. She now regularly uses SteriLid and her lid margins and lashes are now pristine with no recurrence of CLPU. She prefers the SteriLid option to the more ?abrasive? gauze pads many still use, but I digress.
Her father complained of variable vision and distorted perception of the lay of the green, with his head down for putting. I suggested we trial some Acuvue Advance for Astigmatism due to its accelerated stabilisation design instead of his habitual prism ballasted torics.
Within a week he reported back positively and now benefits from more stable vision in most conditions. As a bonus he gets around twice the Dk, improved comfort and reduced dryness. He tells me he's won a few prizes since his performance improving refit?
Of course there are astronauts too who would find that an ever rotating toric would be somewhat problematic; never mind the vestibulo-ocular cyclorotational nystagmus they also encounter?

In Your Dreams

By the time your read this Rugby World Cup will be about to kick off.
May the best team win. All Black or Green & Gold would be satisfactory in my book. You can guess where my money might be.
In Hungary, Lewis Hamilton suffered a blemish on his previously relatively untarnished F1 career. It's shaping up to be a good one.
When travelling and where possible I take the opportunity to soak up some local culture, sights and sounds. On the Aussie leg of the ?be the best you can be? road show I managed to get in a good day of sightseeing around Melbourne. Checking out the Guggenheim exhibition was a treat I thoroughly enjoyed. This was preceded by an equally enjoyable Bratwurst and sauerkraut mit brot und senf from the Victoria Market.
I used to love strolling around the galleries of Europe - during my travels in the ?70s and ?80s - followed by a pavement meal, as described, or a fresh roll with Dutch Gouda cheese. This is indeed how I followed the Guggenheim art, in the park across the road from the NGV. Later that day I was treated to my first game of AFL, an interesting experience.
It's been a long time since I had one of those days?
In Sydney I managed to fit in a great night out at Rockpool, one of my favourites. It was an excellent meal, with great company and service. I'm pleased to see that Neil Perry has lifted his game after a slight drop from his lofty heights in the ?90s. Rockpool still rates in the ?Top Fifty? restaurants in the world but no longer as close as it was to Tetsuya, who manages to remain in the Top Five, consistently these past few years.
Unfortunately I never have enough notice to make a reservation the required six months ahead that one needs to secure a weekend table at Tetsuya?s and my Black AMEX seems to be perpetually lost in the post!
It seems my July prediction of economic reality did indeed transpire?
See what became of Jimi?s torched guitar.
For now It's off to the 12th ICLC at Sea World with a few days post-conference R&R at Noosa.
I am sooo looking forward to a few days at the beach!
Yeeehah.
I'm sure there?ll be some interesting things to report on from the proceedings at the ICLC for the October edition.

 

For more information or any comments email Alan at incontact@optom.co.nz.