Rapid Fire: What s New in Scleral Lenses?

Transcription

1 Rapid Fire: What s New in Scleral Lenses? Chandra Mickles OD, MSc, FAAO, FSLS Melissa Barnett, OD, FAAO, FSLS, FBCLA Gregory Denayer, OD, FAAO, FSLS Jennifer Harthan, OD, FAAO, FSLS Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Disclosures Speaker Consultant Research funding Dr. Mickles Alcon, J&J Vision Tangible Science Dr. Harthan Allergan, B+L Contamac, Metro Shire, Synergeyes, Tangible Science Dr. Denayer Visionary Optics Precision Ocular Metrology (Shareholder) Dr. Barnett ABB-Concise Acculens Alcon Allergan Anthem, INC Bausch + Lomb Contamac Coopervision EveryDay Contacts Gas Permeable Lens Novabay Ocusoft Paragon Bioteck Percept Raayonnova Scleral Lens Education Society Shire Sjogren s Syndrome Foundation STAPLE program SynergEyes Tangible Science Visioneering Technologies

3 K- Max 53.4D Scleral OR Corneal GP

4 2018 Survey Of ECPs Sclerals, Sclerals, Sclerals The scleral lens surge What % of Your Irregular Corneal Patients Do You Fit Into Scleral lenses? Scleral Small Diameter GP 26% Intralimbal GP 10% Hybrid 8% Custom Soft 8% Piggyback 3% Bennett. ES. Annual GP Report. Contact Lens Spectrum. April 2016 Bennett ES. Annual GP Report. Contact Lens Spectrum. October 2017 Bennet ES. Annual GP Report. Contact Lens Spectrum. October % (of patients) 39% of respondents Sclerals were the predominant choice This was 1.5 X that of corneal GPs Corneal GPs were preferred in the 2015 survey

5 Ocular Surface Disease Expansion of Scleral Lens Applications Beyond the Irregular Cornea Before 26 yo with Sjogren s Syndrome After Regular Corneas: Astigmats & Presbyopes Soft Multifocal Toric VA 20/30 Poor stability, fluctuating vision Multifocal Scleral GP VA 20/20 Stable, clear vision 55 yo Oblique Astigmatic Presbyope with Dry eye

6 The patient experience I got my life back

7 What s New in Scleral Lenses? The Big picture What s new in Optimizing the fitting relationship Instrumentation Care and Handling Managing lens surface issues

8 What s New in Scleral Lenses? Optimizing the fitting relationship

9 No Two GP s are the Same Both GP lenses Optimizing the fitting relationship is unique in scleral lenses as they Vault the cornea Land on the sclera

10 Optimizing the fitting relationship is scleral lenses is unique as these lenses can potentially create hypoxia Due to: Thicker post-lens reservoir Thicker lenses Limited to no tear exchange/ flow of oxygenated tears Than other GP lens modalities Post-lens reservoir - SGP: µm, CGP ~30 µm Lens thickness - SGP: µm, CGP: 80 ~160 µm SGP=Scleral GP CGP = Corneal GP

11 Too Much of a Good Thing Don t Settle for Less Excessive lens clearances may lead to hypoxia & degrade visual quality Low clearances can lead to corneal epithelial compromise

12 What is the optimal lens clearance? For optimizing vision & health

13 Theoretical Model Too Much of a Good Thing Excessive lens clearance may lead to hypoxia & degraded visual quality To avoid corneal edema. Central clearance not to exceed µm Limbal clearance not to exceed 60 µm Limbal clearance not to exceed 60 µm Michaud L, et al. Predicting estimates of oxygen transmissibility for scleral lenses. Contact Lens Anterior Eye (2012). Lens: High DK > Lens: Max High central DK > thickness um Jaynes JM et al. Predicting scleral GP lens entrapped tear layer oxygen tensions. Cont Lens Anterior Eye Feb;38:44-47 Compan et al. Modeling Corneal Oxygen with Scleral Gas Permeable Lens WearỌptom Vis Sci Nov;93(11): Max central thickness

14 What s New? Excessive lens clearance may lead to hypoxia In-vivo studies Prior theoretical models = new clinical evidence Several published studies in 2018 Optometry & Vision Science 2018 Investigating optimal lens clearances to prevent corneal edema

15 What s New? Small studies Young, healthy adults Short-term wear Max 8 hours Lens clearances up to 500 µm 1 study up to 600 µm (Art et al 2015) Produced low corneal edema in the physiological range (<4%) ~4% is the normal overnight swelling without a lens Vincent SJ. Cont Lens Ant Eye 2018 Tan, B. et al. OVS 2018 Kim, H. et a.l Current Eye Research 2018 Vincent SJ et al. OVS Nefedov, P. et al. OVS Sci E-Abstract Arlt. C. Thesis. Pacific University 2015 Typical post-lens tear thicknesses (<400 µm) fitted by clinicians produce corneal swelling < 2% New Theoretical model is agreement with in-vivo experiment (Kim et al 2018)

16 1.5 hours of lens wear Corneal edema is primarily stromal in nature Central corneal thickness peaks (<2%corneal swelling) Gradually thinning thereafter Young healthy adults with normal corneas Vincent SJ et al. The time course and nature of corneal oedema during sealed miniscleral contact lens wear Cont Lens Ant Eye 2018 Tan B et al. Effects of scleral-lens tear clearance on corneal edema and post-lens tear dynamics: A pilot study. Optom Vis Science 2018

17 What about Irregular Corneas? Corneal swelling at apex <2% High DK material (>85) Lens clearances ~ µm 8 hours of wear Limited number of studies Warrants further exploration Serramitoa et al. Posterior cornea and thickness changes after scleral lens wear in keratoconus patients. Cont Ant Eye Esen F. Toker E. Influence of Apical Clearance on Mini-Scleral Lens Settling, Clinical Performance, and Corneal Thickness Changes. Eye& CL. 2017

18 Special Considerations Patients with compromised endothelial cell layer Post-PK, Older patients (presbyopic) & Overnight wear (all patients) Recent studies (small sample size) have shown clinically significant corneal edema in these patients with lens clearances of ~ µm High DK materials 6-8 hours of wear Endothelial cell count < 800 cells/mm 2 & overnight wear sclerals maybe contraindicated Further study is warranted 46 YO M Keratoconus s/p PK Specular microscopy of a patient CellChek (Konan Medical) Lafosse et al. Comparison of the influence of corneo-scleral and scleral lenses on ocular surface and tear film metrics in a presbyopic population. Cont Ant Eye 2018 Nefedov, P., et al. Do Scleral Lenses Provide Adequate Oxygen Bhattacharya. P et al. Cont Lens Spectrum 2018 Permeabilty for Overnight Wear. Optom Vis Sci E-Abstract Severinsky B. et al. Cont Lens Anterior Eye Alternative: Trial a scleral lens for 2-3 hours Check for signs & symptoms of edema

19 The Lens Thickness Factor In-vivo What s New? There is a reduction in corneal edema with lens thicknesses from 1200 to 300 μm, however, a plateau in the reduction of corneal edema was observed between 300 and 150 μm. Minimizing the center thickness to 300 μm may be of benefit to reduce hypoxia Vincent SJ. The influence of centre thickness on miniscleral lens flexure. Cont Ant Eye. 2018

20 On the Horizon A soon-to-be introduced material with a 200 DK should minimize hypoxia related complications

21 Too Much of a Good Thing Excessive lens clearances may lead to hypoxia & degrade visual quality Excessive clearance (> 500 µm ) may degrade visual quality cause more lens fogging, & a fish bowl effect TIP: Avoid excessive clearances particularly in high myopes & multifocal patients Less clearance, less minus greater mag/ better quality of vision

22 Don t Settle for Less Prevent complications from corneal touch Lens settles on average ~100 microns over 8 hours µm/8 hours (mean µm of settling for various studies) Settling can vary due to the lens design +individual variations in the conjunctiva insertion 8 hours Most (80%) occurs during first 4 hrs, stabilization 4 hrs Minimal further reduction between (3-4 µm) 4 & 8 hrs Maybe> settling in eyes with corneal ectasia >settling in smaller diameter (<17 mm) scleral lenses Vincent SJ et al Cont Lens & Ant Eye 2018 Esen and Toker Eye & CL 2017 Kauffman et al (OVS 2014) Tan et al OVS 2018 Michaud (GSLS 2014)

23 Don t Settle for Less Prevent complications from corneal touch Lens settles on average ~100 microns over 8 hours Majority of settling (80%) by 4 hours Settling varies by design & individual Settling can vary due to the lens design +individual variations in the conjunctiva Recommendations: Assess clearance at 4 hours &/OR At insertion, add an extra 100µm over the desired final apical clearance OR add a 80% buffer i.e. Desired clearance at 8 hours is 100 µm, accept 200µm at insertion or accept 120µm (0.80x120 µm)= 100µm

24 What is the optimal lens clearance? For optimizing vision & health

25 Putting it into practice Practice Apical clearances between microns With lenses of high DK material & minimal thickness as possible Should prevent corneal & visual compromise in patients with healthy endothelia Proceed with caution in patients with low endothelia cell counts The above is a suggestion based on recent research The understanding of hypoxia associated with scleral lenses is incomplete. Corneal edema is a result of individual corneal metabolic reactions to 02 availability Further studies are needed to explore other factors related to O2 transmissibility & effects of long-term low grade hypoxia

26 What s New in Scleral Lenses? Optimizing the fitting relationship Design innovations for enhancing the fitting relationship

27 Optimizing the fitting relationship is unique in scleral lenses as they Land on the sclera which can create some fitting challenges

28 Overcoming Conjunctival Speed Bumps Avoid it Vault over it Notch

29 Notch What s New? Vault over it More quadrant specific designs What s NEW? Microvault (Alden Optical) Precision Lift (Visionary Optics) -/ Berke-Silva S, Janoff AJ. GSLS

30 What s New? Microvault or Lift More quadrant specific designs Microvault (Alden Optical) Precision Lift (Visionary Optics) The Difference Can lift from the optic zone all the way to the edge of lens, no matter the diameter with the Precision Lift Helpful with mid-peripheral elevations

31 When All Else Fails.The Cutting Edge a Impression molding technology Customized to the individual ocular surface EyePrintPRO TM (Eyeprint Prosthetics) High Success rate, Minimal Revisions Nguyen MTB et al. Can Ophthahlmol 2018 Courtesy of Julie DeKinder, OD, FAAO

32 Optimizing the Fitting Relationship Summary: New Strategies for Success ` Utilize the latest clinical based evidence for optimal clearances Prevents complications When conjunctival speed bumps get in the way Utilize new design innovations Prevents frustrations & improves success rate

33 What s New in Scleral Lenses? The Big picture What s new in Optimizing the fitting relationship Instrumentation Care and Handling Managing lens surface issues

34 What s New in Scleral Lenses? Instrumentation

35 Scleral Lenses Fitting scleral lenses Art Science

36 Scleral Shape Sclera Non-rotationally symmetric Mismatch between lens haptic and eye create the most common fitting complications

37 Topography Corneal Topography Placido Power maps cornea Corneo-scleral Topography Elevation maps Sagittal height Scleral shape Software for lens design

38 Qualitative Assessment of Scleral Shape The Scleral Shape Study Group Gregory DeNaeyer Donald Sanders Eef van der Worp Jason Jedlicka Langis Michaud Sheila Morrison JCLRS.org Objective: Examine new findings of conjunctival/scleral shape and to propose a new classification system for scleral shape

39 Methods: Retrospective study of 152 eyes of prospective scleral lens patients

40 40 Elevation (SAG) Scleral Elevation Map (Qualitative) Scleral Shape Plot (Quantitative) 16mm Axis (Degrees)

41 Table 1 Scleral Surface Patterns Observed in 140 Scleral Lens Patients Group Pattern Description N(%) 1 Spherical 8 (5.7%) 2 Toric-Regular 40 (28.6%) 3 Asymmetric High or Low Points 57 (40.7%) 4 Periodicity different from (25%) 65.7%

42 Diagnostic Lens Fitting Measure Trial and Error

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44 Measure Sclera Cornea

45 Scleral Shape Categories The SSSG J Cont Lens Res Sci Vol 1(1):12-22; November 16, % 30% 65% SPHERICAL TORIC ASYMMETRIC

46 Right Sphere Inter-ocular differences Left Toric

47 Keratoconus 43 year-old ectasia S/P LASIK C/O Blurred vision Failed SCL

48 Scleral Elevation Keratoconus Spherical Design

49 Spherical Keratoconus Toric 252μ SCOR X 075

50 Keratoconus 16.5 mm BC D Back Surface Toric 252μ Front Surface Toric X /25 112μ CCC

51 OSD 70 YO Severe OSD OS- 4+ SPK Consultation for scleral lens fit

52 OSD 300µ

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54 Sphere Toric 2 Meridians Custom- 96 Meridians

55 OSD

56 OSD

57 Pinguecula 35 year-old S/P LASIK Corneal Scars

58 Pinguecula 16

59 Pinguecula 158μ

60 Pinguecula

61 What s New in Scleral Lenses? Care & Handling

62 New scleral lens wearer My Eyes Are Burning Ran out of prescribed fill solution Using contact lens disinfecting solution to fill lenses with prior to application

63 What Solutions Are They Using? Ideally, the cornea should be clear Diffuse corneal staining rule out medicamentosa Fill Solutions Preservative Free Ocular Medications Prescription and OTC Frequency Preserved with BAK?

64 Current Scleral Fill Solutions ScleralFil (Bausch+Lomb) FDA approved Non-preserved, sterile 10mL unit dose Buffered Rinsing & application LacriPure (Menicon) FDA approved Non-preserved, sterile 5mL unit dose Non-buffered, 0.9% saline Rinsing & application Sodium Chloride Inhalation Solution Non-FDA approved Off-label Non-preserved, sterile Non-buffered, 0.9% sodium chloride PuriLens Plus Saline Non-FDA approved Non-preserved, sterile Buffered

65 LATEST INDEPENDENT RESEARCH COMPARISONS OF THE FILLING SOLUTIONS

66 PF single use vials SCOPE Study: Fill Fill Solutions Solutions PF bottled saline 22% 40% 38% PF artificial tears n=653 Harthan J, Nau CB, Barr J, et al. Scleral Lens Prescription and Management Practices: The SCOPE Study. Eye Contact Lens Apr 6. Nau CB, Harthan J, Shorter E, et al. Demographic Characteristics and Prescribing Patterns of Scleral Lens Fitters: The SCOPE Study. Eye Contact Lens Jun 14.

67 AAO 2017 Courey C. Predicting End- of- Day Clearance and Effect of Solution Viscosity in Scleral Lens Wear Over Time 18 mm lens had a mean central settling of 70.0 ± 9.8 μm after 6 h of wear 36.7 ± 9.8 μm of which occurred within the first 30 min of wear Non-preserved saline or non-preserved viscous solution does not influence settling Courey C, Michaud L, Variation of clearance considering viscosity of the solution used in the reservoir and following scleral lens wear over time. Cont Lens Anterior Eye Aug; 40(4): Gorofolo R., What Contact Lens Patients Want to Know About Their Disinfection Products Top categories: directions for use, how products supplied, contents, indications, and storage

68 AAO 2017 Yeung, D. Osmolarity and ph of Non-Preserved and Preserved Saline Solutions 7 commonly used saline solution products with a concentration of 0.9% sodium chloride were measured Osmolarity ranged from 278 to mmol/kg Addipak had lowest, Sensitive Eyes Plus Saline had highest ph ranged from 6 to 7.2 ph of 6 = Addipak, LacriPure, hydrasense and Mylan sodium chloride Dahms, Taylor. Is Buffered Better? Compared ph of Addipak, Modudose, LacriPure, ScleralFil and neutralized ClearCare ph ranged from 4.50 to 7.52 Most acidic = Modudose and Addipak (widest ranges) ClearCare had least variability ph of LacriPure was much lower than the claimed 7.0 Neutralized ClearCare and ScleralFil = within the ph range of ocular comfort

69 Latest Research Abstract to be presented at the Global Specialty Lens Symposium 2019 Which is Better? Addipak versus ScleraFil for Dry Eye Scleral Lens Wearers Mickles C., Harthan J., Barnett M.

70 Update on Disinfection Solutions Hydrogen peroxide solutions Effective for all scleral lenses Patients sensitive to chemicals and preservatives Menicon Progent for heavy depositors Deposit and protein remover compatible with all GP contact lenses Do not use with Hydra-PEG Strong and rapid disinfection in 5 minutes Case designed for large diameter lenses (up to 23mm) Professional and patient packaging Alcohol based cleaners High-Dk materials

71 SCOPE Study: Products for Disinfection and Storage Hydrogen Peroxide Disinfection Systems GP Conditioning Solutions 28% 6% 35% GP MP Solutions 31% Hydrogel MPS n=651 Harthan J, Nau CB, Barr J, et al. Scleral Lens Prescription and Management Practices: The SCOPE Study. Eye Contact Lens Apr 6. Nau CB, Harthan J, Shorter E, et al. Demographic Characteristics and Prescribing Patterns of Scleral Lens Fitters: The SCOPE Study. Eye Contact Lens Jun 14.

72 Tap Water? Recommendation for Tap Water Rinse Never Rarely 9% 13% 7% Sometimes 9% 82% Most of the time All of the time n=650 Schornack MM. The SCOPE study: an overview. Contact Lens Spectrum. Volume 32, Issue: December 2017, page(s): 25-28, 30, 31 Figure 9. Frequency of recommendation for tap water rinse.

73 Coming Soon Tangible Clean Daily cleaning and disinfecting solution for GP lenses coated with Tangible Hydra-PEG Tangible Boost Monthly conditioning solution for GP lenses coated with Tangible Hydra-PEG

74 Latest Tools for Scleral Lens Application and Handling See Green Lens Inserter (Dalsey Adaptives) Ezi Applicator Ring (Q-case) CHIO (Cliara) Ezibyqcase.com Cliaraeyes.com

75 Application and Removal Cards gpli.info bausch.com

76 Putting it Into Practice Review fill solutions and disinfection solutions at each visit Tailor solutions to each patient s ocular condition/s New products being developed Tools available to enhance application and removal Pflugfelder, S. Recognizing ocular surface disease in your office. Ophthalmology Management, 2011.

77 References Pflugfelder, S. Recognizing ocular surface disease in your office. Ophthalmology Management, Harthan J, Nau CB, Barr J, et al. Scleral Lens Prescription and Management Practices: The SCOPE Study. Eye Contact Lens Apr 6. Nau CB, Harthan J, Shorter E, et al. Demographic Characteristics and Prescribing Patterns of Scleral Lens Fitters: The SCOPE Study. Eye Contact Lens Jun 14. Courey C. Predicting end-of-day clearance and effect of solution viscosity in scleral lens wear over time. AAO Gorofolo R. What contact lens patients want to know about their disinfection products. AAO Gromacki SJ. Contact lens care & compliance. Handling and care of scleral GP lenses, Part 2. Contact Lens Spectrum. Volume 27, Issue: January 2012, page(s): 19. Barnett M. 10 tips to enhance scleral contact lens success. Optometry Times. June 10, 2017 Schornack MM. The SCOPE study: an overview. Contact Lens Spectrum. Volume 32, Issue: December 2017, page(s): 25-28, 30, 31 Shorter E, Barr J, Nau A et al. SCOPE Study: current consensus of presribers scleral lens wear and care recommendations. AAO 2015.

78 What s New in Scleral Lenses? Managing Lens Surface Issues

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81 Poor Surface Wettability Decreases vision Diminishes lens comfort Increases chair time Increases patient costs Photo Credit Karen Lee, OD

82 Ocular surface disease Ocular rosacea MGD Filamentary keratitis Patients at Risk Excessive lipids in the tear film create a foggy, hydrophobic lens surface Photo Credit James Thimons, OD

83 Patients at Risk Exposure Ptosis Stroke / nerve palsy Eyelid repair

84 External Causes Poor plunger hygiene Makeup/Skincare regime (oil-based products) Hand soaps with moisturizing agents Older blocking compounds such as pitch Mechanical irritation Allergic or toxic reaction Manufacturing difficultly

85 Preventing and Managing Poor Surface Wettability

86 Treatment Strategies Increased lubrication with preservative-free artificial tears over the lens throughout the day Remove, manually clean, rinse and reapply Squeegee technique On-eye surface cleaning using a saline moistened cotton swab or eye shadow applicator Polish front surface of lenses BUT remove plasma surface

87 First and Foremost Treat and manage ocular surface disease! Lipids and mucins are attracted to hydrophobic GP material Re-evaluate care and handling of lenses Evaluate and treat GPC Change lens material Punctal occlusion

88 Prevention Through Education Wash hands before handling contact lenses Ask patients about hand soap Hand soaps Mild, basic hand soaps Contact lens handsoap Acne treatment hand soaps Ask patients about face and eye creams

89 Prevention Through Education Do not apply oil-based moisturizers to the eyelids Do not apply any makeup to the inside area of the eyelid margin (waterline) or meibomian gland orifices Increases risk for mgd and gland obstruction over time Apply creams and makeup after lens insertion Remove contact lenses, then remove makeup Image O Dell, Sullivan, Perriman AOC January 2017

90 Images O Dell, Sullivan, Perriman AOC

91 Image credit Laura Perriman

92 Prevention Through Patient Education Use eyeliner pencils sharpen them before every application Replace moist cosmetics (mascara) monthly Remove makeup daily Never use facial cleansers or hand soap to remove eye makeup Clean eye makeup brushes regularly O Dell, Sullivan, Perriman AOC January 2017

93 Solutions Change to peroxide based solutions Consider enzymatic cleaner / Menicon Progent If deposit-prone, alternate a daily GP lens cleaner with an extra strength or an alcohol-based daily cleaner

94 Plasma treatment Finished lens bombarded with high-energy radio waves in an oxygen-rich environment Hydrophobic surfaces become more hydrophilic Exotic oxygen radicals strike the surface of the lens Dislodges hydrocarbons such as oils Molecules on the surface of the lens are rearranged Carbon migrates away from the surface Oxygen and nitrogen migrate toward the surface The lens surface becomes ionized, increasing its ability to attract liquids Image credit Contamac

95 Plasma treatment Results in Improved wetting angle Improved surface tension Fewer lipid, protein and bacteria deposits Improves surface wettability Less lens awareness Improved comfort Reduced fogging Wetting angle before and after plasma treatment Photo Credit Dr. Chrysostomou

96 Lower wetting angle = better wetting surface In-Vitro Results

97 Scleral Lens Fogging and Comfort Study Dr. Maria Walker (Principal Investigator) 18 subjects years old All habitual scleral lens wearers

98 Hydra-PEG Improves End of Day Comfort Scleral Lens Fogging and Comfort Study Patients Prefer Hydra-PEG Lenses

99 Wear Time and Preference n = 34 eyes n = 11 eyes Falco Linsen, Switzerland

100 Wear Time and Preference Hetych Kontaktlinsen, Austria

101 WHICH WOULD YOU CHOOSE FOR YOUR PATIENT?

102 Slide courtesy of Tangible Science

103 Tangible Hydra-PEG: Patient Education Educate patients that the Tangible Hydra-PEG surface will result in a more slippery lens May require a brief adjustment period for handling, inserting and removing the lens

104 Tangible Hydra-PEG: Patient Selection May be used by any patient No contraindications No need for fit changes Patients who may benefit the most: Those experiencing dryness or discomfort associated with lens wear Moderate to heavy depositors Scleral lens wearers experiencing fogging

105 Compatible solutions with Tangible Hydra-PEG Multipurpose Solutions Menicon Unique ph Boston Simplus Hydrogen Peroxide Solutions Clear Care Clear Care Plus with HydraGlyde

106 Incompatible Solutions Tap water, abrasive or alcohol-based cleaners Abrasive Cleaners Boston Advance Alcohol Based Cleaners Miraflow Others Menicon Progent Boston One Step Liquid Enzymatic Cleaner Optimum by Lobob ESC Extra Strength Cleaner

107 Tangible Hydra-PEG by the Numbers With proper care, coating lasts months Hydra-PEG was launched in January ,000 patients treated in 2017 Hydra-PEG coated lenses available from 23 global manufacturers Price is minimal compared to price of lens

108 Tangible Authorized Labs United States Acculens Advanced Vision Technologies Art Optical Blanchard Contact Lenses Boston Foundation for Sight Essilor Lenses GP Specialists Metro Optics Synergeyes TruForm Optics Valley Contax Visionary Optics Visionary Lens X-cel Specialty Contacts Global Corneal Lens Corporation Falco Linsen AG Hetych Kontaktlinsen Northern Lenses Multilens Coming Soon ABB Optical Alden Optical No7 Contact Lenses Galifa Contactlinsen Mediphacos Iovino

109 Before Hydra-PEG Images Tom Arnold, OD

110 With Hydra-PEG Image Tom Arnold, OD

111 New Research Paper to be presented at GSLS 2019

112 Video Testimonials

113 Video credit Tom Arnold

114 How to Create a Slick Surface Treat and manage ocular surface disease Review solutions Patient education Hand soap Lotions Makeup Utilize plasma and Tangible Hydra-PEG

115 Keeping up with the latest and greatest will improve patient outcomes K- Max 53.4D OR

116 Thank you for your attention Drs. Mickles, Barnett, Denayer, & Harthan

117 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18