Latest News. CCLS Conference attracts large turnout.

Rapid-fire presentations was the format used by the organisers of this year Cornea & Contact Lens Conference held at the Novotel in Rotorua last month. With a focus on world class education in the customary informal and fun-filled atmosphere, the new design of the programme format met with a positive response from delegates who found it stimulating and held their interest.

A world class line-up of speakers addressed over 200 delegates throughout the three days at this beautiful lakeside setting. The conference is highly regarded and is able to attract some of the most highly respected professionals as speakers in both ophthalmology and optometry related topics. They shared their knowledge and wisdom to help practitioners keep up-to-date with all the latest developments in the contact lens and related fields. A conference like this would not be possible without the tremendous financial support from industry. Gold sponsors were Bausch & Lomb, CIBA Vision and Corneal Lens Corporation. Silver sponsors were Alcon and Ophthalmic Instrument Company.

The conference was well supported by a trade exhibition involving 14 companies.

The report below by Keren Dravitzki and Hannah Kersten*, highlights some of the key points from the programme.

Lights, smoke, music, action! The CCLS Conference started with its trade-mark audiovisual extravaganza displaying photos and images from past events. Society President Greg Nel opened the programme by pointing out the high calibre of this year’s speakers in both optometry and ophthalmology. The next few days then cemented this biennial conference as being a fantastic event in both educational and social terms.

Nathan Efron
Nathan covered a range of topics, and his famous bow-ties changed with every presentation. We have experienced ten years of the silicon hydrogel revolution and Nathan sung the praises of these lenses. Although the ten materials on the market have different Dk values he pointed out that there is no difference in oxygen flux to the eye. Improving contact lens comfort is in high demand and he outlined some lens factors that can help in that process. For example; design, modulus, lubricants.

Confocal microscopy allows views of the live cornea up to 680x magnification. Both silicone and conventional hydrogel lenses lead to reduced keratocyte count after six months of lens wear and also post cessation. This may be the result of mechanical stress leading to the production of inflammatory mediators and subsequent keratocyte apoptosis. Confocal microscopy has shown an increase in stromal microdots and endothelial blebs following contact lens wear, and useful in the diagnosis of acanthamoeba keratitis.

Nathan advocated that infiltrates found in contact lens associated keratitis is a disease continuum and disagreed with the Sweeny et al polynomial classification scheme. He pointed out that contact lens peripheral ulcers and microbial keratitis do not have to have peripheral and central infiltrates, respectively, but can occur in any location on the cornea.

A study looking at the fine plexus of nerves at the base of corneal epithelium using corneal confocal microscopy correlated well with the loss of nerves in diabetic peripheral neuropathy. Nathan raised the prospect of using this as a possible supplement of replacement of the invasive skin punch biopsy done on diabetics.

Stephen Pflugfelder
Stephen was on the Delphi panel on Dry Eye in 2005 which recommended the term Dysfunctional Tear Syndrome (DTS). He outlined the severity and therapy of these levels; including pulse steroid therapy and cyclosporin-A.

When speaking on the anaesthetic cornea he outlined the causes and consequences of neurotrophic keratopathy. Then discussed treatment options from lubricants, to contact lenses (particularly the Boston Ocular Surface Prosthesis), to autologous serum. Corneal endothelium transplantation is an evolving new procedure to treat corneal endothelium disease that offers significant advantages over penetrating keratoplasty. Stephen discussed some of the pitfalls and approaches to deal with them.

Art Epstein
Dry eye is a multifactorial disease of both the tears and the ocular surface, resulting in ocular discomfort and visual disturbance. Art discussed the many causes of dry eye, including systemic medications, blepharitis, sex steroid hormone imbalance and a neurotrophic cornea. Then the therapeutic strategies which range from palliative care to over-the-counter therapeutics including cellulose and HP-Guar based lubricants and prescription medications.

Seasonal allergic conjunctivitis and perennial allergic conjunctivitis are the most common forms of ocular allergy. Art explained that the allergic response is a three step process, beginning with sensitisation and followed by mast cell degranulation (early phase response) and a late phase response. The late phase response is not typically found in the eye. He urged that when treating patients with ocular allergy, convenience is paramount and dosing frequency should be as low as possible. He outlined some studies that compared Olopatadine to Ketotifen, and mentioned steroids specifically targeted at allergy treatment. Art discussed the risk factors for infections from contact lens and solutions. He encouraged the prescription of products that would disinfect properly, stop organism growth and prevent chemical keratitis (staining) due to preservative toxicity.

Contact lens complications are largely preventable and their causes are either primary or secondary. Primary causes are things the optometrist, patient or manufacturer does. Secondary causes include things the contact lens does to the eye, such as the disruption of normal ocular physiology.

Eric Papas
Corneal infiltrates indicate the presence of inflammatory activity. Eric summarised the results of a study which showed risk factors for infiltrates were; tight contact lenses, extended wear, multipurpose solutions compared to hydrogen peroxide, and corneal staining. Corneal staining with silicon hydrogel lenses has been a hot topic; especially the colour coded staining grids. Eric concluded that staining is a marker of corneal stress and we can reduce it by using daily disposables, hydrogen peroxide, and low risk combinations of solutions with contact lenses.

When he studied the visual performance of various contact lenses correcting for spherical aberration there was no difference between the brands on a variety of clinical tests. However, lens power can be different to that on the label so if you swap brands then check the new power on the eye.

While one third of new contact lens fits drop out of lens wear there is poor correlation between the symptoms of ocular discomfort and both corneal and conjunctival sensitivity. Therefore, more research needs to be conducted into the neurosensory factors that might cause this discomfort.

Eric was involved with a study that compared the objective and subjective clinical tests on the day of dispensing a multifocal contact lens to the results after four days of wear. Objective measurements were similar but the subjective responses were worse by day four. Again proving that fitting presbyopic patients can be a challenge!

Trevor Gray
Fuchs’ endothelial dystrophy is the most common visually significant corneal dystrophy to be seen by optometrists and is usually asymptomatic in early stages. Trevor described the appearance and then outlined management options for symptomatic patients. These included hypertonic solutions (Muro-128 drops), a cool hair-dryer, high Dk bandage contact lenses, lubrication, and surgery as a final resort.

Penetrating keratoplasty has been the traditional surgical management of the disease. However, more recently posterior lamellar keratoplasty (endothelial cell transplantation) has provided much faster vision recovery and ever-improving outcomes.

Trevor mentioned that optometrists play a significant role in recognition, monitoring and appropriate referral of patients with Fuchs’ dystrophy.

Perry Binder
Dry eye is a major issue relating to LASIK surgery because of the severance of the superficial corneal nerves during flap creation. Perry discussed results of a study conducted on unpreserved lubricants after surgery and found that they were effective in aiding visual acuity recovery and quality of vision.

Jennifer Craig
We’ve all wondered whether spraying a liposomal spray like TearsAgain on the eyelids can help with evaporative dry eyes. Jennifer was cynical too and was surprised when her study showed positive results for up to 90 minutes after using the spray.

Russell Lowe
Russell dispelled many of the myths commonly associated with orthokeratology; including that it is painful, time consuming, complex, and that too many lenses are involved. He mentioned that 6/6 vision can often be achieved overnight if the patient’s initial refractive error is less than -2.00 DS, and 90% of treatments are achieved in one to two weeks. Russell explained that the lenses affect the corneal epithelium and leave the corneal stroma unchanged. He advocated ortho-K as an alternative to laser refractive surgery for patients with less than 4 dioptres of myopia.

Dean Corbett
Dean outlined the five year outcome results of implantable contact lenses (ICL) in Auckland. The lens is additive to the eye, reversible, accurate and can include up to 6D of astigmatism.

Sean Every
The Hudson Stahli line is caused by corneal ferritin distribution. In white light it can be difficult to see, but UV photography unmasks this line and shows its vortex pattern. Sean presented some interested photographs and discussed the changes with corneal surgery and disease.

Sue Ormonde
The aetiology and presentation of corneal recurrent erosion syndrome (RES) was explained by Sue, who then went on to discuss its management. A useful tip was to use lubricants at night for two months after corneal trauma to significantly lower the risk of getting RES.

Malcom McKellar
Malcom briefly outlined the numerous treatment options for posterior blepharitis. The one that created the most interest was expression of the inferior Meibomian glands using ciliary forceps. Warning: if trying this on yourself at home make sure to use a topical anaesthetic first!

Warren Hill
There have been advances in corneal astigmatism correction with the newest generation of toric intraocular lenses (IOL). Warren outlined the preoperative measurements required, the use of an on-line calculator and where to place the surgical cut. He found that 97% of patients were spectacle free bilateral after having toric IOL surgery.

Rob Allen
Rob presented several case studies of RGP fitting in keratoconics and post-graft patients. He encouraged practitioners not to shy away from these more complex contact lens fits.

Peter Walker
Peter gave a practical guide to fitting toric RGP lenses. This talk was predominantly aimed at optometrists with limited RGP experience.

Nisha Jeyaseelan
Nisha discussed the importance of obtaining accurate corneal topography in all areas of CL fittings, how to interpret it and some aspects of modern Ortho-K in the light of currently emerging scientific evidence.

Workshops
A wonderful opportunity provided at the conference was the option for delegates to attend one of three workshops. They included: RoseK fitting for keratoconus, sorting ocular surface disorders, and fitting semi-scleral or reverse geometry contact lenses. These workshops were very popular and limited in size with some “live” patients that enabled delegates to observe the theory in practice.

Student Presentations
Jagrut Lallu and Shonit Jagmohan’s research ventured into the previously uncharted territory of forensic optometry where they investigated the potential to use soft contact lenses in victim identification. Soft contact lenses were placed on pig eyes, with covered lids, and buried for three months with the lens parameters being re-measured following exhumation. It was found that, in closed eye burial, most soft contact lenses could be accurately identified by matching four of the five initial parameters. Jagrut and Shonit intend to further their research in this area.

In Jenny Wu’s study they fitted neophyte subjects with second generation silicone hydrogel contact lenses and checked their adaptation time. Over an eight hour period the objective and subjective measures of ocular surface and corneal responses did not differ significantly. They concluded that the neophyte wearer may not need to gradually increase wearing time of silicone hydrogel lenses.

Graft rejection is the leading cause of corneal graft failure in the first year post surgery. Endothelial rejection appears as circular hyper-reflective changes that are most likely inflammatory cells. Rachael Niederer’s research showed that regardless of the initial site of rejection, alterations in all layers of the cornea can be seen with confocal microscopy of human corneal allograft rejection.

Charlotte Jordan’s study aimed to analyse the characteristics of anterior segment maps in keratoconic patients presenting to a tertiary eye care centre. There was no statistically significant difference in severity between different ethnic groups and no statistical association between ethnicity, cone type and elevation. Keratoconus is a multifactorial disease with relatively asymmetric in its morphology.

Gala Dinner – Go Bush
The Saturday night of the conference was a great success, with many of the speakers, delegates and exhibitors attending the ‘Go Bush’ themed dinner, held in a marquee half-way down the scenic luge track nestled amongst towering Redwood trees. As has become the tradition, everyone dressed for the occasion. Costumes ranged from hunters with impressive moustaches to Tarzan and Jane to a Banana. George Bush himself even made an appearance! Prizes were presented for the optical pioneers vs. serial killers quiz with the range of answers being as varied as the costumes. All in all a fabulous night was had, with plenty of good food, wine and some not so spectacular dancing.

* Keren Dravitzki and Hannah Kersten are optometrists at Black, Gates, Meek & Dong Optometrists in Lower Hutt

More stories and photos from the CCLS conference will appear in the June issue of NZ Optics