Melissa Barnett, OD, FAAO, FSLS, FBCLA

Transcription

1 ??????? Melissa Barnett, OD, FAAO, FSLS, FBCLA??

2 Melissa Barnett has received honoraria from: Acculens Alcon Allergan Bausch + Lomb Coopervision JJVC Vistakon Novabay Gas Permeable Lens Institute (GPLI) Paragon Bioteck Scleral Lens Education Society Shire Sjogren s Syndrome Foundation STAPLE program SynergEyes

3 Part I

4 The Presbyopic Patient Population Continues to Grow Presbyopic Population in the United States Presbyopes will be the largest patient segment by 2016 and will continue to grow 91% of contact lens wearers age 35 to 55 are committed to continuing Slide courtesy with of Alcon wearing contact lenses. 2

5 Yet Contact Lens Usage Drops Off Dramatically With Age 1 Presbyopia contributes to patient dropout from contact lenses starting around age 40 1,2 Presbyopic contact lens dropout rates by age 93% of presbyopes were not wearing multifocal lenses at dropout 1 Slide courtesy of Alcon Recommendations from the Dry Eye Summit 2014

6 The Multifocal Decision-Making Process Whom do we fit? Current contact lens wearers Those who would enjoy the benefits

7 Benefits of Multifocal CLs Cosmetic Functionality Freedom

8 Let Science Speak

9 MULTIFOCAL vs MONOVISION: MV vs Essential GP (Johnson, 2000) 75% preference for multifocal MV vs Acuvue Bifocal (Situ et al, 2003) 68% preference for multifocal MV vs Soflens MF (Richdale et al, 2006) 76% preference for multifocal MV vs Air Optix Aqua MF (Woods et al, 2015) 51% preference for multifocal 37% preference for monovision 12% didn t like either

10 That s not been my experience

11 MULTIFOCAL vs MONOVISION: MV vs Acuvue Bifocal (Situ et al, 2003) 68% preference for multifocal Issues with near vision in low light MV vs Soflens MF (Richdale et al, 2006) 76% preference for multifocal Issues with near vision in low light

12 Restaurant Tools Magnifiers Light Apps

13 What s the best way to assess MF performance? Woods, J, et al (2009) Assessed both objective and subjective results/ratings Objective testing (exam room) Monovision best performer for high- and low-contrast near vision tests Subjective ratings ( real world ) Monovision lowest performer Multifocal contact lenses highest performer in areas such as: Night driving, television, computer Woods, J, et al. Early Symptomatic Presbyopes What Correction Modality Works Best? Eye & Contact Lens 2009;5:

14 Setting the Stage for Success Know the science Multifocals out-perform monovision: 7/10x Know the strengths and weaknesses Freedom and functionality Eg. Challenges at near in low light Prepare the pre-presbyopes

15 Presbyopia is not a surprise!

16 The Multifocal Decision-Making Process Whom do we fit? When do we fit?

17 Setting the Stage for Success Know the science Multifocals out-perform monovision: 7/10x Know the strengths and weaknesses Challenges at near in low light Prepare the pre-presbyopes Fit them early

18 Setting the Stage for Success Know the science Multifocals out-perform monovision: 7/10x Know the strengths and weaknesses Challenges at near in low light Prepare the pre-presbyopes Fit them early Define success for your patient

19 The New Rules of the Vision Game Multiple tools Magnification Light Apps Goal: Meet most of your needs most of the time

20 Setting Expectations The Sandwich Approach

21 The Multifocal Decision-Making Process Who do we fit? When do we fit? Early! What do we fit?

22 What do we fit? The Decision Drivers Astigmatic error

23 The Astigmatic Component 0.75 DC is the flinch level Is it corneal astigmatism?

24 Corneal Astigmatism Spectacle Astigmatism Toric Soft Options Monovision Toric SV Soft Distance OU with readers Toric MF Soft

25 Multifocals for Astigmats Soft Toric Multifocals ASTERA multifocal toric (Alden) C-vue Hydravue toric multifocal (Unilens) Intelliwave multifocal toric (Art Optical) Proclear multifocal toric (CooperVision) SpecialEyes toric multifocal (SpecialEyes)

26 Visual Performance of MF Toric SCL 20 subjects 45 to 65 yo 0.75DC to 2.75 DC Cross-over design Soft Toric MF vs Soft Toric MV 1 month wear of each design Madrid-Costa D. et al, Visual Performance of a multifocal toric soft contact lens. Optom. Vis Sci. Nov 2012;89(11):

27 Visual Performance of MF Toric SCL Results: Performance of MV and MF within 1-2 letters Reduced contrast sensitivity mainly at higher spatial frequency closely linked to VA Note: 60% of subjects: < 50 yo Near add lower than Astigmatic error in study population? Madrid-Costa D. et al, Visual Performance of a multifocal toric soft contact lens. Optom. Vis Sci. Nov 2012;89(11):

28 Corneal Astigmatism = Spectacle Astigmatism A Host of Multifocal Options! Toric Soft MF GP MF Hybrid MF

29 Happy SV GP Wearer Lens centers on cornea Front surface asphere MF Slightly superior (lid attached) Back and front surface! High rider Low eccentricity posterior asphere MF Extremely high rider Modify fit / Monovision / Overreaders

30 High Index Materials Paragon HDS HI 1.54 Paragon Vision Science Optimum HR Contamac Highest refractive index available Refractive Index: 1.54 Dk= 22

31 What determines the degree light will bend as it passes from one medium to another? F= n - n r

32 High Index Materials Same amount of asphericity Achieves a higher add Less asphericity to achieve same add Fewer corneal topographic issues

33 The Evils of a Low Riding Lens Peripheral dessication Conjunctival injection Discomfort Optical misalignment MF s worse!

34 Happy SV GP Wearer Lens centers on cornea Front surface asphere MF Slightly superior (lid attached) Back and front surface! High rider Low eccentricity posterior asphere MF Extremely high rider Modify fit/ Monovision/ Overreaders Low rider Modify fit/ Translating/ Overreaders If high plus: high eccentricity posterior asphere

35 Translating GP Multifocals

36 Selecting Seg Height

37 Selecting Seg Height

38 Selecting Seg Height Goal: Just below lower pupil margin Where to start? 1mm below geometric center of lens 10.0 mm /2 = 5.0 mm -1.0 mm 4.0 mm

39 How s this look?

40 What changes would you employ in this case? 0.50D flatter Another option: increase prism 0.50D

41 What changes would you employ in this case? Flatten BC 0.50D (WTR) Increase Prism 0.50D Truncation Offset prism by 15

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43 What changes would you employ in this case? Flatten BC 0.50D Increase Prism 0.50D (thin upper edge?)

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45 Expert Progressive Multifocal Contact Lens - designed like a progressive spectacle lens! The EXPERT Progressive lens design features: Power blended like a progressive spectacle Translation with lower eyelid at downward gaze Customizable intermediate zone Equal thickness of the edge all around the contact due to slab-off technology Excellent comfort due to nanotechnology - smooth, continuous profile

46 Expert Progressive Ideal fit Centrally align to slightly steep. Pupil position in superior half of lens. Limited movement on blink. Parameters: Diameter 8.5mm, 9.0mm, 9.5mm, and 10.0mm Base curves from 6.90mm to 9.00mm in 0.05 steps Powers D to D Up to +4.00D add Standard 1.5 prism

47 Duette Multifocal Designs Duette Multifocal Adds: Small and Large Duette Progressive Adds: +1.00, +1.75,+2.50

48 Duette Progressive Patient Candidates Presbyopes with any amount of corneal astigmatism Moderate to advanced presbyopes New astigmatic presbyopes Soft multifocal patients seeking to eliminate their readers Soft multifocal patients with astigmatism Soft toric monovision patients who want better vision Slide courtesy of SynergEyes 48

49 Other Great Duette Progressive Patients Any presbyope seeking better vision in a contact lens Emerging presbyopes wanting best possible vision Occupations or hobbies that demand great vision Anybody whose work requires them to look above their head (mechanics, carpenters, medical assistants) People who do a lot of computer work (engineers, architects, graphic designers) Anyone whose hobby requires precision (athletes, hunters) Slide courtesy of SynergEyes 49

50 Duette Progressive High performance vision for astigmatic presbyopes Hybrid platform offers centration and stability; Vision Not Affected by Lens Rotation* Uncompromised GP Optics provide a seamless progression of power from near to distance; available in three add powers SoftCushion Comfort Technology Excellent Ocular Health: 130-Dk GP center; 84-Dk silicone hydrogel soft skirt UVA and UVB blocker Straightforward Empirical Fitting +1.00, and powers available *GP optics negates corneal astigmatism; rotation of lens inconsequential 100% Retention of Repeat Business Slide courtesy of SynergEyes

51 How well do Hybrid MFs work? Method: 16 presbyopic eyes Duette MF vs Air Optix Aqua MF and Biofinity MF Conclusion: The Duette multifocal hybrid lens seems to provide similar visual quality outcomes (as soft multifocals) in presbyopic patients with low corneal astigmatism.

52 Scleral Multifocals! Barnett M. Multifocal Scleral lenses. A look at available lenses that can help our presbyopic patients. Contact Lens Spectrum. December 2015.

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54 Recommendations from the Dry Eye Summit 2014

55 Recommendations from the Dry Eye Summit 2014

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57 Part II

58 What do we fit? The Decision Drivers Astigmatic error What are they used to? Are they happy?

59 What do we fit? The Decision Drivers Astigmatic error What are they used to? Are they happy? Safety and Convenience

60 Presbyopes & Daily Disposables Many presbyopes are interested in occasional wear Actually LESS expense with DD 1 Reduced case contamination concerns 1. Efron, N et al, An international survey of daily disposable contact lens prescribing. Clin.Exp. Optom. Jan 2013;96(1):58-64.

61 CL Case Care Daily Disposable No case!

62 Presbyopes & Daily Disposables Great for part-time wear Convenience Presbyopes have dry eye issues

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64 Prevalence of Dry Eye Disease An estimated 25 million Americans report suffering from dry eye million postmenopausal women 3 million men age 65 and older

65 TFOS CL Discomfort Classification Figure courtesy of TFOS

66 TFOS CL Discomfort Management Change care solution or care system Eliminate care-system / change to daily disposable Adjust replacement frequency Change lens design and / or material Tear supplementation Dietary supplementation Topical medication (Azithromyin) Improve environment Figure courtesy of TFOS

67 Consensus on Screening Questions 1. Do your eyes ever feel dry or uncomfortable? 2. Are you bothered by changes in your vision throughout the day? 3. Are ever bothered by red eyes? 4. Do you ever use or feel the need to use drops? Recommendations from the Dry Eye Summit 2014

68 Consensus on Baseline Diagnostic Options for Entry Level Dry Eye Disease 1. The lid 2. Staining 3. Tear stability

69 Consensus on Baseline Management 1. For all patients: A. Ocular lubrication B. Lid hygiene C. Nutrition 2. Topical anti-inflammatories Recommendations from the Dry Eye Summit 2014

70 Presbyopes & Daily Disposables Great for part-time wear Convenience Presbyopes have dry eye issues Dry eyes lead to lens coating Dirty lenses are responsible for many contact lens problems

71 Contact Lens Safety Incidence of CIEs: DD vs Reusable: 12.5 X less likely with DD 1 DD SiHy vs DD Hyd: SiHy DD: 0.4% Hyd DD: 0% 1.Chalmers, Robin L. et al, Multicenter Case-Control Study of the Role of Lens Materials and Care Products on the Development of Corneal Infiltrates, Optometry & Vision Science. 89(3): , March Chalmers RL et al, Rates of Adverse Events With Hydrogel and Silicone Hydrogel Daily Disposable Lenses in a Large Post Market Surveillance Registry: The TEMPO Registry. Invest Ophthalmol Vis Sci Jan 8;56(1):654-63

72 Multifocal Daily Disposables Alcon Focus Dailies Progressive Center near One add

73 Multifocal Daily Disposables Dailies AquaComfort Plus Center near Same optics as Air Optix Aqua Multifocal Three adds Alcon CooperVision Proclear 1 Day Multifocal Center near One add Davis R. Fitting Tips for Presbyopic Success, Rev Corn CL, Oct 2010 Quinn TG. Clinical Experiences With a Daily Disposable Multifocal, Contact Lens Spectrum, 28(11):19, November 2013

74 Multifocal Daily Disposables Dailies Aquacomfort Plus Center near Same optics as Air Optix Aqua Multifocal Three adds Alcon CooperVision Proclear 1 Day Multifocal Center near One add Clariti 1-Day Multifocal Center near Two adds Silicone hydrogel material

75 Multifocal Daily Disposables JJVC 1-Day AV Moist for Presbyopia Moist material Center near pupil smart design Changes with age Changes with refractive error VTI NaturalVue Multifocal 1 Day Center distance Extended depth of focus Single add (up to effect) JJVC = Johnson&Johnson Vision Care VTI = Visioneering Technologies, Inc

76 Multifocal Daily Disposables Bausch+Lomb BioTrue ONEday for Presbyopia HyperGel material Center near Same optics as PV2 for Presbyopia 2 adds Newly released in 2016: Ultra for Presbyopia Same optics as BioTrue ONEday Ultra material Monthly replacement

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78 Contact Lens Examination Motivation to wear contact lenses? Part time? Full time? Social occasions or work? Specific visual needs when wearing contact lenses? Computer use? If so, how many hours / day? Hobbies? Sports? Water sports? Night driving?

79 CL Exam Previous contact lens history? Any history of contact lens wear? Tried monovision or multifocal lenses previously? Previous failures / success stories and why? Interest in colored lenses?

80 Contact Lens History Average wearing time? Wearing time today? Solution? Rub lenses? Replacement frequency? Age of current lenses? Extended wear?

81 Lens Selection Detailed refraction Push Plus! No more minus than absolutely necessary No more add than absolutely necessary Evaluate each eye monocularly to make sure not overminusing Demonstrate binocular vision Distance, mid-range and near vision in free space binocularly

82 Lens Selection Determine eye dominance Sighting dominance Sensory dominance

83 Sighting vs Sensory Dominance Pointer J, J of Optom, (2012) 5, Method: 72 Emmetropes Sighting method: hole in the card Sensory method: blur test Results: Right eye dominance Sighting method: 71% Sensory method: 54% Laterality was in agreement only 50% of the time!

84 Lens Selection Follow the fitting guide! Distance Rx: most plus power equivalent sphere ADD: follow the charts

85 Follow the Fitting Guide! Ultra for Presbyopia

86 Air Optix for Astigmatism Keep it simple Spherical equivalent and vertex Only adjustment is if power is 0.12D, ALWAYS err on the side of plus Choose the ADD based on fitting Guidelines Keep them equal Don t cut the add in one or both eyes

87 1 day Acuvue Moist Multifocal

88 Clariti 1 day Mulitfocal Step 1 Up-to-date spectacle refraction Establish ocular dominance Step 2 Lens selection Refer to fitting guide Step 3 Initial 20 minute adaption Step 4 Evaluation & dispensing

89 NaturalVue Multifocal 1 Day Contact Lenses Slide courtesy of VTI Clear vision at every distance with a novel extended depth of focus design 14 Patents Awarded Worldwide Neurofocus Optics Channels light for clear distance, intermediate, and near vision through the lens center Lens design optics independent of pupil size Technology designed to work with the visual cortex to correct what is seen Optimizing visual clarity and enabling spectaclelevel stereo acuity for greater depth perception Center distance Daily replacement

90 Virtual Aperture Extended Depth of Focus Technology Distance Intermediate Near Pupil BLUR ZONE BLUR ZONE Blur Suppressed Retina + Visual Cortex Virtual Aperture Zone-----Clear Vision Blur Suppressed Pupil Slide courtesy of VTI Recommendations from the Dry Eye Summit 2014

91 Extended Depth of Focus Lens Patient Perspective Patient sees the world like a picture from a disposable camera All points in focus at the same time Patient experiences full effect of the design after about 10 minutes of settling Slide courtesy of VTI

92 NaturalVue Multifocal Parameters Available Powers: to D Expanded Full Range: +4.00D to D (0.25D Steps) ADD Power: 1 Universal ADD power, effective up to +3.00D Design: Extended Depth of Focus (Center Distance) Pack Sizes: 90 Lens Revenue, 30 Lens Revenue, 10 Lens Trial Base Curve: 8.3 Diameter: 14.5 Lens Material: etafilcona (58% water) with light blue visibility tint Modality: Single-Use Daily Wear UV Protection: Class 2 UV Blocker*. The UV Blocking averages 98% in the UVB range of 280 nm to 315 nm and 84% in the UVA range of 316 nm to 380 nm.** Replacement Schedule: Daily Disposable *UV absorbing contact lenses aren t substitutes for protective UV absorbing eyewear for example, protective UV absorbing goggles or sunglasses because they don t completely cover the eye and surrounding area. Patients should continue to use UV absorbing eyewear as directed. Note: Long term exposure to UV radiation is a part of risk factors associated with cataracts. Exposure is according to a number of factors, for instance environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-absorbing contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-absorbing contact lenses reduces the risk of developing cataracts or other eye disorders. Consult your Eye Care Professional for more information. **Of the 44 subjects who expressed an intent to either continue wearing or not to continue wearing the lenses, 91% stated they were likely or very likely to continue wearing NaturalVue Multifocal 1 Day contact lenses. Slide courtesy of VTI Recommendations from the Dry Eye Summit 2014

93 Assessing Performance Scouting report Open-ended questioning Real world environment Lights up Binocular conditions Real world tasks Loose lenses

94 Assessing Performance 20/40 line Text based near tasks Don t recheck too soon Don t make changes too soon

95 Adaptation to Multifocal Optics Sheedy et al, Optom Vis Sci, June 1993 Noted significant improvement in complex task performance with concentric bifocal lenses No improvement with monovision Pappas et al, Eye Contact Lens, May 2009 Assess performance of 88 subjects at dispensing and after 4 days of wear Early assessment is relatively unrepresentative of performance later on during multifocal contact lens wear. Fernandes et al, Optom Vis Sci, Mar 2013 Over 15 days, MF acuity at D and N improved MV acuity remained the same or worsened

96 Adaptation to Multifocal Optics Lunghi C, Sale A A cycling lane for brain rewiring Curr Biol. Dec 7, 2015 Old School: Plasticity (of the brain) is maximal in early development abruptly declines in adulthood. Recent studies have revealed a significant residual plastic potential of the adult visual cortex

97 Enhancing Performance 1: Always start with OR using loose lenses To confirm distance Rx 2: Follow the manufacturer s guide!

98 When is enough enough. You ve set the right tone The Sandwich Approach You ve confirmed the Rx Always confirm distance Rx first You ve shared The 3 Revelations The goal is to meet most of your needs most of the time You may need to give up a little bit of crispness for freedom This is as good as it gets

99 The Current Monovision Wearer Do you have difficulty with night driving? Do you have problems at intermediate distances? Do you have problems with depth perception?

100 Transitioning Monovision Wearers to Multifocals Most common challenge? Distance vision Why? Interference from the add Treatment strategy? Reduce add in dominant eye What s the lowest add?

101 Transitioning Monovision Wearers to Multifocals Most common challenge? Distance vision Why? Interference from the add Treatment strategy? Reduce add in dominant eye What s the lowest add? NO ADD!

102 The Emmetropic Presbyope

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