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Keep it Up
No, this is not a discussion about Viagra.
The title refers to the need to continually strive to stay up to date, ideally ahead of the pack.
With the commercialism of the eye care market it is ever more critical to have a competitive edge. Around one third of NZ optometrists remain independent. There are numerous things independents can do to differentiate themselves from the mass market. (See archives) Embracing new and emerging technologies is one key strategy. An independent is more able to take on new specialised niche products and help build a practice that is less dependent on ‘Joe Average’ who is more likely to be fodder for the chain store wars.
With my travels and continually keeping in touch with manufacturers and colleagues around the world I am fortunate to be exposed to numerous new options.
An example would be the SynergEyes range of hybrid contact lenses. If you search my archives you will note that I first started commenting on this lens around four or five years ago. It took me a few years to actually get my hands on a fitting set in 2009, the first in NZ, as they initially limited the roll out to the USA. My colleagues and I have done various trials. I’ve fitted one pair for occasional use in a successful RGP wearer who wanted them for badminton. We obtained a classic fit and good results. They produced less flare and are less likely to fall out or suffer foreign bodies. He happily continues to wear his RGPs with good comfort and vision most of the time. I also advised this as small diameter Boston XO Custom Tetracurve RGPs still deliver much more oxygen. That’s the downside of the current generation of SynergEyes, although they are way better than former hybrid lenses in the Dk stakes, they are still limited by the low Dk soft lens skirt. One hears of cases of significant neovascularisation. Some argue that these lenses can help people function when all else fails, thus delaying corneal grafts. The downside of this argument is that by the time they then need a graft there may be significant neovascularisation which may increase the risk of graft rejection.
Catch 22.
I now also have the updated ClearKone fitting set that addresses some issues relating to tight lenses and fitting limitations with the older KC series of SynergEyes lenses and will keep you posted on any results.
I am, however, holding out for the next generation hybrid from SynergEyes with a high Dk skirt that we are told should be available ‘within a year’.
Here’s hoping!
It may well be that a competitor has a high Dk hybrid ready for market by then?
As with all things, time will tell.
KeraSoft
This heading does not imply a condition of soft cornea, as a literal translation may lead you to believe but in fact refers to a new lens I am trialing.
I reported on a visit to Contamac UK in December 2009. I also met with a representative of UltraVision UK as they had a new lens I had been keeping an eye on.
Known as KeraSoft IC (for Irregular Cornea) it promised much in terms of being a specialised custom soft lens for Keratoconus.
As background, in the late ‘90s I had lectured and written on promising results I was getting with the then SofLens66 Toric. Its specialised Lo-torque reverse geometry design, aberration controlled, cross-cyl moulded bitoric optics and high repeatability helped where others had failed. Impressive stability and visual results in RGP intolerant cones, grafts and assorted irregular eyes was the net result. Its only downside was low Dk/L from a relatively thick design. These days I use the high Dk si-hy PureVision Toric as it’s based on the same design, with further optical enhancements. I continue to get good results with KC, PKP, LASER complications, CXL, Kera-Rings and other weird corneas.
Of course there are many, usually more extreme cases where off the shelf disposable lenses do not work.
That’s where the KeraSoft IC comes in. My fitting set, the only one in NZ as far as I know, arrived early in the New Year. Since my return from travels in February I have now trialed and fitted a few complex cases with some great results. One travelled up from Dunedin for the fittings and aftercare and another was a referral from Christchurch who is now studying medicine in Auckland.
I think they’re developing cones down South from all the eye rubbing after watching the Crusaders falter?
As any contact lens specialist will tell you there are always a few cases lurking about, clogging one’s desk, that one simply doesn’t know what to do with. Some simply put the file in the too hard basket, while others prefer file thirteen. One sometimes feels referral to a colleague may be the best option and indeed sometimes a different approach may be all that’s needed. In a similar vein I get referred a lot of grief cases. More often than not one succeeds in resolving problems. Sometimes the benefit of hindsight is all that’s needed and I usually avoid options that have been tried and focus on getting results with a totally different series of lenses. One often gets it right first time. We thus may look good compared to the referrer but I take great pains to inform the patient that it is the mere fact that the previous colleague had already done a lot of the spade work and eliminated options that helped us nail down the successful one.
KeraSoft IC is a development of the earlier KeraSoft 2 & 3 series. The IC version is available in Contamac’s Definitive 74 Si-Hy material (and also a more traditional 77% water content hydrogel). Why is this important? Specialised soft lenses for irregular corneas are traditionally quite thick to start with (0.4mm and thicker) and thus with a low Dk HEMA material there is close to no Dk/L. I was thus always amazed at practitioners who promoted the use of ultra-thick low Dk soft KC designs and for that matter, first-generation hybrids.
The KeraSoft lenses come in various base curves with Steep or Flat peripheries. What really makes it special is the option for asymmetric peripheries with what they call SMC (Sector Management Control), where ‘sectors’ of the lens can be ordered with different degrees of flattening or steepening and specified in degrees that defines where these asymmetric peripheries are applied. Thus one can have a lens with a ‘tuck’ inferiorly and say a flatter superior periphery.
Of course it doesn’t have to be top or bottom: It can be oblique and one can control this by ordering the desired specifications.
Challenging Cases
It’s never fair to a new lens design to throw all the grief cases at it that have been building up on ones desk for the past six months. Such cases have generally failed outright or failed to obtain decent wearing time, comfort, vision or physiology. Trialing a new lens on such cases will likely increase the failure rate. I am pleased to report that of the trials I did the success rates were pretty impressive. Two cases have decided to think about it and one simply had too poor vision to benefit. Such cases are really at the graft stage as RGPs, piggybacks, semi-sclerals and other options have failed to date.
I currently have three cases that are all doing rather well: One such patient tells the waiting room what a great guy I am (in G*D like terms of reference). It seems to have made a massive difference in this medical student’s life, who is otherwise so limited by poor vision that she has special dispensation to have her notes printed out in large print format. One can imagine the truck loads of notes she has.
Here are some relevant findings;
Refraction revealed:
R +0.50/-7.00 x 68 6/12p (no improvement with pinhole)
L -0.75/-5.00 x 107 6/60 (pinhole 6/15)
CL Rx;
KeraSoft IC lenses Definitive 74 silicone hydrogel material:
R 8.20/14.5/-1.00/-3.00x77 with a very satisfactory 6/12 to 6/9
L 7.80/14.5/-0.25/-6.75x116 providing 6/18: A remarkable improvement from that found refractively.
She has large inferior cones with cone apex of 53D and 60D respectively. To complicate matters she has severe atopia and is being managed by the referring ophthalmologist with Maxidex and Cromolux. So far she has obtained great results and I hope she doesn’t develop any si-hy reaction…
The other case was also a severe cone who has had CXL bilaterally and Kera-rings in one eye but still needs contact lens correction. Some years ago he travelled to Sydney to obtain SynergEyes but doesn’t wear them much. He has been happy so far with his new KeraSofts.
Another case is a unilateral severe Pellucid Marginal Degeneration case who generally wears a Quad-Sym RGP, for limited wearing hours for professional golf. Although the RGP provides the best vision he feels that at least he can wear the KeraSoft more regularly with improved comfort and wear time.
In general I have been suitably impressed with the lenses and in particular the stability and accuracy of fit and lack of rotation, particularly considering the complexity of the lenses and corneas involved.
My results with a variety of NZ, AUS and UK manufactured custom silicone hydrogel torics in high powers over the past few years have been an almost universal disappointment. The KeraSoft results were thus a pleasant surprise.
As usual I temper my comments with the fact that these are initial results but the true test is time.
That’s not to say they are or will ever be the be all and end all choice in keratoconus. I am opposed to statements made at the GSLS by one of the speakers promoting this lens (while slagging off a badly fitted Rose K lens in comparison). The speaker more or less said that RGP lenses sucked and that they would never fit an RGP (as first choice). A number of people took umbrage to this comment. I noted that this stance had been toned down considerably in a later session.
Such lenses have their place but RGPs remain a very successful and safe option. Most patients are not RGP intolerant and the fact that I see patients everyday with twenty, thirty, forty and more years of successful, comfortable hard lens wear confirms that. Where people are RGP intolerant then such lenses are a great blessing but remain a niche product.
As always it’s all about balance.
Keep it Real
It’s in the best interests of independent and passionate practitioners to get stuck in and get the latest technology. In my experience the chain stores are not geared to specialised niche work and indeed I am told actively discourage these ‘time wasting’ cases.
A large behemoth such as a corporate chain takes time to change direction and take on new products. This is where independent practitioners need to focus: They are light on their feet and don’t have layers of international management to bog them down.
Of course we can still do the simple stuff but the run of the mill, straight forward cases are more likely to migrate to the mall-based, convenient, low-cost special offer chains.
The way I see it optometry has, over the years, largely lost much of our market. Sunglasses have been lost to a myriad of other outlets, as has the presbyopic market to the ready-made readers available at every turn. Our myopes are being nuked by LASERS and myopia control promises to get rid of the rest.
The internet is taking large chunks out of the contact lens market and deregulation is taking a slice of dispensing work. Older people too are getting elective refractive cataract surgery as soon as they drop off quality 6/6, so that leaves us with a few frustrated hyperopes, astigmats, and of course, all the complex cases.
Specialist practitioners are however doing very well in areas of contact lenses, low vision, learning disorders, child vision, behavioural optometry, sports vision, acquired brain injuries and so on.
The numbers may be down for some but we are not out by a long shot and my independent specialist colleagues around the world tell me great success stories.
They remain passionate and focussed, as do their patients. They continue to thrive.
Keep It!
On a completely different subject I have to say; Go the Bulls!
RWC 2011 beckons too and unless the ABs come up with something special I think the Boks have a good shot at taking the Webb-Ellis trophy back home, this time for keeps!