Diapositiva 1

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Report of the Management Therapy
Subcommittee Members Eric Papas, Chair
(Australia) Joseph Ciolino (US) Deborah Jacobs
(US) William Miller (US) Heiko Pult (Germany),
Afsun Sahin (Turkey) Sruthi Srinivasan
(Canada) Joseph Tauber (US) James Wolffsohn
(UK) J Daniel Nelson (US - Harmonization
Subcommittee Member)
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• General Approach
• Provide a clinical framework for treating an
  individual complaining of CLD
• Systematic Approach includes
• History taking
• Establishing the Current Status of the Lens and
  its Relationship with the Eye and Adnexa plus Px
  requirements, needs and expectations
• Elimination of confounding issues
• Identifying Treating Non-Contact Lens Related,
  Co-existing, Systemic and Ocular Diseases
• Treating Evident Contact Lens Related Problems
• Treatment of the Symptomatic CL Patient with a
  Clinically Acceptable Lens

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• Levels of Evidence Clinical Studies
• Level I
• Evidence obtained from at least one properly
  conducted, well-designed randomized controlled
  trial or evidence from studies applying rigorous
  statistical approaches
• Level II
• Evidence obtained from one of the following
• Well-designed controlled trial without
  randomization
• Well-designed cohort or case-control analytic
  study from one (preferably more) center(s)
• Well-designed study accessible to more rigorous
  statistical analysis.
• Level III
• Evidence obtained from one of the following
• Descriptive studies
• Case reports
• Reports of expert committees
• Expert opinion
• Meeting abstracts, unpublished proceedings

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• Adjusting Replacement Frequency
• Few relevant studies
• No Level I evidence for efficacy of increased
  replacement frequency
• Level II evidence supports use of Daily
  Disposables
• Silicone Hydrogel
• Mechanism may be via elimination of care system
• RGPs
• More frequent replacement is ineffective
• 3 months vs non replaced

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• Changing Material
• Hydrogel to Silicone Hydrogel
• No firm consensus
• Studies on both sides (pro and con)
• Methodological problems in many cases undermine
  value
• Balance of evidence mildly favourable
• Need for more well designed studies

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• Wetting Agents
• Internal (Manufacturer Incorporated)
• HA, PVA
• No clear effect demonstrated (level II)
• External (Packaging solution additive or
  pre-conditioning treatment)
• CMC, HPMC, Guar
• Pre-conditioning may increase comfortable wearing
  time (level II III)
• Incorporation into lens packing solution
  generally gives short term benefits evident early
  in the wearing cycle (level II III)

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• Lens Factors (Soft Lenses)
• Edge shape (Level I-)
• Thin, knife edge gt chisel gt round
• Base curve (Level I-,II,III)
• Steeper better (down to 8.3 mm)
• Diameter (Level I-)
• Larger better (up to 13.5mm)
• Back Surface Shape Design (Level I-)
• No systematic pattern
• Monocurve least preferred
• Centre thickness (Level II-)
• Ineffective
• Practical Issues
• Manipulation of individual parameters difficult
  due to design component interdependence and
  unless lenses are custom made, control may lie
  with manufacturer

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• Lens Factors (Rigid Lenses)
• Favourable
• Larger diameters
• 10mm (Level II)
• Rounded anterior edge shape (Level II)
• Respecting the corneal contour
• Toric back surfaces for astigmatism (Level III)
• Unfavourable
• Excessively steep fitting
• Optimal and slightly flat preferred (Level II)
• Very thin lenses
• Flexure (Level I)

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• Changing the Care System
• Clinical study evidence conflicting as to
  benefits of change with a given material (Level
  I)
• Comfort benefits can accrue from optimising the
  combination of lens type and solution type (Level
  II)
• Optimum combination may involve products from
  different manufacturers
• Evidence for any effect with RGPs is scant

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• Tear Supplementation
• Eye Drops, Wetting Agents
• Widely regarded as mainstay of treatment
• Clinical benefit generally evident in trials
• 0.9 saline (Level II)
• CMC, PVA (Level III)
• 2 povidone (Level III)
• Recent studies tend to favour more complex
  solutions over saline alone
• Hydroxypropyl Cellulose Ophthalmic Inserts
• Effective in reducing dryness symptoms after 1 m
  (Level II III)

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• Nutrition
• Essential Fatty Acid (EFA) Supplementation
• Beneficial in dry eye BUT..
• Little evidence in CL wearers
• No studies of omega-3
• Omega-6 (evening primrose oil) beneficial
• (Level I - female sample)
• Hydration
• No studies

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• Punctal Occlusion
• Balance of evidence suggests increased tear
  volume is beneficial
• Silicone plug superior to dissolvable collagen
• Upper and lower occlusion better than lower lid
  alone
• Other factors need consideration
• Relative invasiveness
• Specialist skills needed

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• Topical medication
• Azythromycin
• Only one relevant study
• 1 b.i.d. beneficial over 1 month (Level II)
• Cyclosporin
• No clear evidence of benefit
• Two studies with contradictory results (Level I
  II)
• Steriods
• No studies
• Use not justified in view of potential risks
• NSAIDs
• Soft CLs
• No studies
• RGPs
• 0.1 diclofenac q.i.d may reduce post fitting
  adaptation (Level III)
• Anaeshtetics
• Long term use insupportable

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• Environment
• Few studies
• Low humidity gives poorer RGP comfort (Level III)
• SCLs avoid dust, pollen, smoke, low humidity
  (Level III)
• Blinking Behaviour
• Can modify number of complete blinks
• No evidence for effect on CL comfort

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• Alternative Approaches
• RGP to SCL
• Generally beneficial (Level II)
• Vision worse
• SCL to RGP
• No studies
• Orthokeratology, Refractive Surgery
• No studies
• Future
• Neuromodulation

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• Summary of management strategies for contact lens
  related discomfort
• Determine most likely cause
• Identify corresponding treatment strategy
• Stepwise (additive) application of treatments to
  achieve maximum effect

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Thank you
QUESTIONS?