On the Thursday, I was involved with the corneal reshaping wet lab. During the session new Orthokeratology practitioners were exposed to the different Orthokeratology systems available.  Patients were fitted with the various systems where after a discussion held as to how the fit was done, signs to look out for and how to do trouble shooting.

The Vision By Design meeting officially started on the Friday.  The OAA academy meeting yearly attracts Orthokeratologist from all over the world and this year it was no exception.  Eye Care Practitioners came from countries far as the UK, Australia, South Africa, China, Italy, Puerto Rico and Russia.  Meeting up with everyone was like seeing family again and soon everyone was talking, laughing and catching up on the years events.

The meeting was opened by the OAA president Dr Cary Hertzberg who welcomed everyone back and congratulated the Academy on it’s 10 year anniversary. The Keynote speaker was Prof Earl Smith speaking on the mechanics of Myopia control.  According to Prof Smith, both peripheral form deprivation and peripheral hyperopic defocus can produce axial myopia at the fovea, even in the presence of unrestricted central vision.  When there are conflicting visual signals for eye growth, the signals from the periphery can dominate ocular axial growth and refractive development. According to his image shell theory to stabilise axial growth in Myopes, it is important to not only correct central vision but to independently correct peripheral visual errors as well.

By the nature of how Orthokeratology lenses shape the cornea, it creates this peripheral myopic defocus and with its associated benefits to patient lifestyle make it an ideal vehicle to perform myopia control with young children.

Global OK Vision (GOV) also attended the meeting in full strength and the team, when not lecturing, manned the booth.  The GOV team from left to right is Lachlan Scott-Hoy, Charl Laäs, Chris Eksteen, Hal Ostrom and in front Arthur Tung.

I also had the opportunity to give two lectures at the Vision By Design meeting, one on how to fit GOV lenses and one on the Future of Orthokeratolgy.  The topics I covered included the fitting of high minus, hyperopia, multifocal, keratoconus and post LASIK with overnight Orthokeratology lenses.

The rest of the GOV team also had opportunities to lecture at the Vision By design meeting. Chris Eksteen lectured on the Interpretation of Topography Maps, Arthur Tung on the Visual Mechanics of soft Myopia control lenses and Multifocal Orthokeratology lenses.  Lachlan Scott-Hoy gave an in depth lecture on the theory of Hyperopic and Presbyopic Orthokeratology lenses.

After a successful US Vision By Design meeting, I will be off to Madrid in a month’s time to lecture at the Euro-OK meeting and a month later down to the Gold Coast of Australia for the Orthokeratology Society of Oceania Orthokeratology (OSO) meeting.  Exciting times for Orthokeratology!

One of the areas in contact lenses which has seen the biggest increase in options is the Multi-focal contact lens group.  It is now possible to fit a big portion of the over forties group who suffer from Presbyopia with a pair of multi-focal contact lenses.  The freedom that these lenses offer to an active person is priceless.  Imagine being able to scuba dive and see your dive watch, or play a round of golf and be able to read the menu at the 19th without having to wear glasses.  As for the ladies the biggest advantage is applying make up and actually seeing what your doing!

So if your next eye test exam sounds like the one below, put your foot down and ask to be fitted with a pair of contact lenses.  Who knows, it might change your life! 

Frustration with fitting Multifocal Contact Lenses
by: baskotze

Personally I would choose Government.  Pay is better, hours are less, they have a good medical plan and they never go to jail.

Keratoconus is a bilateral non-inflammatory corneal ectasia with an incidence of approximately 1 per 2,000 in the general population (1). The treatment of Keratoconus can be implemented by the use of spectacle lenses, contact lenses of various kinds and surgery.

In more advance Keratoconus cases where severe irregular astigmatism with resultant higher order aberrations are present, the use of Rigid Gas Permeable (RGP) lenses are indicated to restore the patients vision.  Unfortunately in some Keratoconus cases, contact lens intolerance develops and many patients consider Penetrating Keratoplasty (cornel graft). Lim, et al found that 83% of patients opting for Penetrating Keratoplasty was due to intolerance to contact lens wear (2).

However, Smiddy, et al found that 87% of the Keratoconus cases referred for Penetrating Keratoplasty to the Wilmer Institute at the Johns Hopkins Medical Institution could be successfully refitted with contact lenses.  Of the successfully fitted cases ultimately 31% needed keratoplasty after an average of 38.4 months of lens wear and 69% did not require Keratoplasty over an average follow-up interval of 63 months of wearing contact lenses.

Of the postoperative penetrating Keratoplasty eyes 60% had to wear contact lenses for best vision. Their conclusion was that Penetrating Keratoplasty can be delayed or avoided in many Keratoconus patients by using proper fitting contact lenses and further that Keratoconus eyes often need contact lenses after Keratoplasty (3).

Piggyback system

One option to improving the comfort of RGP lenses on Keratoconic and irregular corneas is to use a piggyback system. A piggyback system comprises of a soft contact lens first placed on the cornea and then followed by a RGP lens fitted on top of the soft lens.  With the birth of Silicone Hydrogel soft lenses and hyper DK RGP materials, piggyback systems have become a safe and viable option for vision correction of the compromised cornea. Tsubota, et al found that the oxygen pressure under piggybacked oxygen-permeable hard contact lenses was 95 +/- 14 mmHg after 5 minutes wear which was almost three times higher than the 34 +/- 14 mmHg when PMMA and low water-content lenses were used (4). Clare O'Donnell first reported on the fitting of a hyper-Dk piggyback contact lens system in Keratoconus and other irregular corneas in 2004 (5).

Biofinity Silicone Hydrogel lens

Comfilcon A (Biofinity) is a third-generation polymer with no TRIS-based derivatives. It uses a unique long-chain siloxane macromer combined with other components to result in a lens that features high oxygen permeability (DK 128) and a relatively low modulus (0.75 MPa). The Comfilcon A material is inherently wettable with no internal wetting agent or surface treatment required.  It has a fundamentally different chemistry that breaks the relationship between oxygen permeability and water content that other silicone hydrogel materials follow. (6) (7) (8)

Biofinity as Piggyback lens

The combination of high oxygen permeability and low modulus make the Biofinity lens an ideal piggyback lens.  The low modulus allows the lens to follow the irregular keratoconus topography more closely without fundamentally changing the pre fit K-values. This low modulus of the lens allows the practitioner to trial fit the keratoconus RGP lenses without the Biofinity lens on the eye and only introduce the Biofinity lens at the final stages of fitting with minimal impact on the RGP fit.

Image 1 shows the piggyback system with the Biofinty lens placed directly on the cornea and the Keraton RGP lens fitted on top.

Image 2 shows the Oculus tangential topography map of an irregular cornea due to Pellucid Marginal Degeneration with no contact lens on it.

Image 3 shows the Oculus tangential topography map of the same cornea with a Biofinity contact lens fitted on it.

Conclusion

This hyper-Dk piggyback contact lens combination of Biofinity soft lenses and HDS 100 RGP lenses satisfy the ocular and visual requirements for patients with compromised corneas for cases where normal RGP lens wear has been unsuccessful. This system can be implemented with most cases requiring visual rehabilitation like, Keratoconus, Pellucid Marginal Degeneration, Penetrating Keratoplasty (corneal grafts), and most cases of unsuccessful refractive surgery.

Biofinity Silicone hydrogel lenses’ hyper DK and low modulus nature make this lens the ideal soft lens choice when a dual-lens fitting system is needed to fit the compromised cornea.

Bibliography

1. Keratoconus. Rabinowitz, Yaron S. 4, s.l. : Survey of Ophthalmology, January-February 1998, Vol. 42, pp. 29-319.

2. Characteristics and functional outcomes of 130 patients with keratoconus attending a specialist contact lens clinic. Lim, N and Vogt, U. s.l. : Eye, 2002, Vols. 16, 54-59.

3. Keratoconus. Contact lens or keratoplasty? Smiddy WE, Hamburg TR, Kracher GP, Stark WJ. 4, Apr 1988, Ophthalmology, Vol. 95, pp. 487-492.

4. A piggyback contact lens for the correction of irregular astigmatism in keratoconus. Tsubota K, Mashima Y, Murata H, Yamada M. Jan 1994 , Ophthalmology, pp. 101(1):134-9.

5. A Hyper-Dk Piggyback Contact Lens System for Keratoconus. O'Donnell, Clare. 1, Jan 2004, Eye & Contact Lens: Science & Clinical Practice:, Vol. 30, pp. 44-48.

6. B, Tighe. Trends and developments in silicone hydrogel materials. Editorial. www.siliconehydrogels.com. [Online] Sept 2006.

7. Carnt, Nicole. 3rd Generation Silicone Hydrogel Lenses. Editorial. http://www.siliconehydrogels.org. [Online] May 2008.

8. Chou, Brian. The Evolution of Silicone Hydrogel Lenses. www.clspectrum.com. [Online] Jun 2008.

We want to thank everyone who made 2011 a wonderful year for us all and hope that 2012 may bring you good health, fulfilment and joy.

Warmest regards

Charl, Basil, Johann, Nick, Ina-Marie, Jean, Ilse and Adre

In our own practice we have seen many cases of keratoconus and healthy corneas distorted due to vigorous rubbing of the eye. The picture below shows the topography of an otherwise normal cornea that is chronically rubbed at the 6 o’clock position. The patient had best corrected vision of about 6/75 (20/25) at the time. Once her allergies were managed and she stopped rubbing the cornea her vision returned back to a normal 6/6 (20/20) after about 2 months.

Back in 1976, Karseras and Ruben wrote in their paper on the aetiology of Keratoconus that most keratoconus patients rub their eyes excessively. Eye-rubbing is considered the dominant aetiological factor in two-thirds of patients with keratoconus who progress to contact lens wear. Charles McMonnies in 2007 seemed to agree that abnormal rubbing may increase the likelihood of the development of some forms of keratoconus. He postulated that when vigorous knuckle-rubbing forces are located on the normal peripheral cornea, the thinner or weakened cone apex may be exposed to high intraocular pressure distending forces that may tend to promote ectasia.

Most recently Dr Alan Carlson wrote a comprehensive article on the dangers of rubbing the eye in patients with Keratoconus and post-LASIK:

Keratoconus: Time to Rewrite the Textbooks

Recent work is showing that many patients with keratoconus or post-LASIK keratoectasia are contributing to their own condition.

The renowned historian and author Daniel J. Boorstin famously said: " … the greatest obstacle to discovery is not ignorance—it is the illusion of knowledge."

Consider how appropriate this is in our understanding of keratoconus.The more we have learned about this condition in recent years, the more reason we have to question what we thought we knew. In this article, I hope to use the recent work of my colleagues and others not to solve the mystery but to challenge the consensus about the disease, to add another set of questions that I hope will move the discussion forward and help us remove the obstacles to discovery regarding keratoconus.

The Dots That Need Connecting

Cornea specialists have long asked themselves, what happens to our older keratoconus patients?(1) How real is my perception that more KC patients should be returning among our large group of "over 70" patients? In fact, KC was a common indication for young patients to undergo penetrating keratoplasty 20 to 25 years ago. So where are these middle-aged and elderly post-PK patients today? KC patients are told they have a genetic condition, and then a significant number of them want to know why they are the only one in their family with this problem. I reassure them that it does not mean they were adopted. The textbooks and classical teaching list a number of conditions associated with KC such as Down's syndrome, Ehler's-Danlos syndrome, Leber's Congenital Amaurosis and atopy. Are these associations primary with a genetic link, or do they represent a secondary association in response to environmental or behavioural factors (secondary to the eye rubbing associated with these other conditions)?

There are a host of unanswered questions with regard to KC. Consider the eye-rubbing controversy: Is eye rubbing merely a phenomenon observed within those patients considered to have both KC and allergic eye disease, or is this something more integral to KC and its progression? Does KC cause eye rubbing? Does eye rubbing cause KC?

What role does eye rubbing play in compensating for a vision or surface-related problem caused by KC? Does unilateral KC truly exist, or do these patients represent highly asymmetric cases of bilateral disease? How do we account for the enormous variability we routinely encounter with these patients? Consider, for example, the age of presentation, rate of progression, and the asymmetry between eyes. Why do KC patients have better Snellen acuity than non-KC patients with similar levels of uncorrected astigmatism—as though they have learned to compensate when processing image signals from visual "noise" caused by aberrations? Is KC an isolated corneal disease or is it perhaps a syndrome, not isolated to the cornea? Is it better represented as a condition of inherited vulnerability or susceptibility (altered dose-response curve to mechanical trauma such as eye rubbing)? Is post-LASIK keratoectasia linked to KC beyond the simple explanation that early, or forme fruste cases escape diagnosis and unfortunately undergo further weakening by LASIK surgery? Why do some patients develop post-LASIK keratoectasia despite having a minimal score by risk-factor analysis? Is "aging" the cornea with collagen cross-linking really the best way to go, and are there other factors we should be addressing in these patients that might help slow down or halt the progression of this condition?

The Danger of Complacency

In medicine, when we have treatment options that are reasonably successful, our efforts tend to shift away from better understanding of the fundamental disease process. This is certainly the case with KC. We have been told for decades how successful corneal transplantation is relative to that of other organs in the body and that patients receiving a graft for KC tend to do even better relative to other PK patients with respect to rejection rate. Hence, our attention and clinical effort are increasingly directed toward earlier diagnosis and the application of newer keratoplasty procedures (IEK) as well as other recently developed treatment options including Intacs, DALK, and collagen cross-linking (See Figure 1). Meanwhile, we develop a complacency around our perception of adequacy and success despite the many unanswered questions and our continued poor understanding of the aetiology and pathophysiology leading to progression of KC.

KC is thought to represent a genetic disorder with a poorly defined pattern of inheritance leading to central corneal thinning, progressive steepening, irregular astigmatism, and a host of other slit-lamp findings, depending on its severity. Considering the genetic basis for this disease, why do only 7 percent of patients report awareness of other family members with this condition? This may be because KC is a complex genetic disease that requires interaction with environmental factors to make a genetically determined predisposition clinically apparent. Consider the hypothesis that KC includes a genetically altered dose-response curve to eye rubbing. If the corneal changes are more readily apparent in the eye rubbers, then KC could be more widespread genetically within the same family that includes "genetically positive" non-eye-rubbers. This could also make it difficult to find an adequate control group when trying to investigate genetic patterns of inheritance, as subclinical disease could reside in the non-eye-rubber.

The major textbooks mention eye rubbing in anecdotal terms suggesting an observed association, connected mostly to allergies and possibly contributing to those more severe cases that develop acute hydrops. For the most part, this association is presented as genetics at work in the keratoconic cornea of patients who share a genetic association with allergies and on this basis, they have a predisposition and propensity toward an allergic pattern of eye rubbing. Under these conditions, the features of eye rubbing should be less pronounced in KC patients who do not have allergies. Also, in those patients having both allergies and KC, the eye rubbing should largely mimic the eye rubbing seen in purely allergic patients. On closer examination, however, this does not appear to be the case.

Distinguishing Eye Rubbing

All eye rubbing is not the same. Eye rubbing performed by the purely allergic patients is fairly straightforward. It is in response to allergic symptoms which patients consistently report as "itching." There may be a few other descriptive words but itching is far and away the leading response. In fact, when asked about eye rubbing, allergic patients are highly aware of their behaviour and a typical response might be, "when my eyes itch, I rub them and if they didn't itch, I wouldn't rub them." KC patients are very different in this regard.2 While they may have allergies and their symptoms can certainly overlap with allergic complaints, their observations often include comments not typically associated with allergies. The motivation behind their eye rubbing may include itching as a complaint, but unlike the allergic patient, they often report a number of other reasons such as, "burning" or "it just feels good" or commonly, "I need relief." KC patients also describe motivating factors for eye rubbing that are never offered by the purely allergic patient, such as, "It helps me see better." Previous studies have demonstrated the ability of warm compresses with pressure to temporarily produce thinning of the corneal epithelium.3 However, it is unclear precisely what mechanisms are invoked by the eye rubbing KC patient to gain this perceived improvement in vision—whether it is a temporary alteration in surface topography or more likely, an improvement in the quantity, quality and distribution of surface lubrication.

Allergy vs. Keratoconus

Upon further observation, not only is the perceived need to rub different, but the timing, contact method, pressure applied, duration, motion, location over the lid and the derived benefit are all remarkably distinct between these two groups. KC patients, even when they have allergies, offer identifiably distinctive eye rubbing characteristics that stand out in comparison to the allergic patient. For example, the purely allergic patient, in response to allergic itching, generally begins by using a flat instrument (back of hand, front of hand or palm; See Figures 2 & 3) applied broadly, rubbing back and forth, horizontally over the eyelids generating eyelid movement and pressure and "traction" within the lid itself with only modest pressure transmitted to the cornea. This is often followed by a transition to using the tip of the index finger as allergic rubbing tends to migrate nasally, concentrating point pressure over the caruncle for the follow through and completion of the effort. Added contact pressure is then applied at this stage when the caruncle is being rubbed and a circular component may also be added to the motion after this transition to the caruncle (See Figure 4). Patients with long fingernails adjust their angle of attack and apply this last portion most commonly with the ball of their index finger. This may be relatively short and seldom lasts longer than 15 seconds. The KC patient, on the other hand, has a limited number of favourite techniques, the majority of which begin with a pointed instrument, either a knuckle (middle knuckle more commonly than distal or proximal knuckle; See Figure 5) or finger tip(s) (See Figure 6).

The hallmark of the KC rub is the circular motion of this point-like pressure confined over the cornea, often with pronounced pressure transmitted posteriorly—much more than with the allergic rub (apart from the allergic caruncle rub). The intensity and duration (10 to 180 seconds, up to 300 seconds) are much greater in KC patients, as is the repetitive nature. The perceived benefit and relief reported by the KC patient is different from the relief from itching sought and achieved by the allergic patient. Interviewing these patients "in action," the KC patient is more likely to elucidate an experience of ecstasy and euphoric rapture during and toward the completion of the rub, wanting to do even more. The purely allergic patient describes the process as filling a need, wishing he did not have to do this, and in the end reports more of a "mission accomplished."

Eye rubbing also incorporates complex patterns of behaviour. There are profound distinctions between these two groups even extending to the accuracy with which patients report their eye rubbing activities. The "itch-rub-itch" cycle in the allergic patient is simpler to explain as a clinical response to an allergic challenge. Allergic patients are highly aware of these episodes and tend to be fairly accurate when reporting their symptoms, as well as the frequency and severity of eye rubbing, in response to these allergic challenges.

In contrast, KC patients often under-report eye rubbing when first asked about it, perhaps reflecting a desensitized awareness as this repetitive behaviour or habit becomes increasingly incorporated into their daily routine. This habitual nature of eye rubbing may be exposed by handing a patient a tissue while distracting him during an interview; this is best performed before bringing up any questions about eye rubbing. Patients will often spontaneously blot or rub their worse eye while they are talking to you, often unaware that they are doing this. I have had patients deny eye rubbing during an interview in which they unknowingly demonstrate their tendency to rub.

Scratching the Itch

KC patients may also exhibit repetitive and even ritualistic behavioural tendencies compounding the physical need they feel to rub their eye. This can include profound eye rubbing at certain times of the day or associated with specific activities such as immediately after awakening or after removal of their contact lenses. This can be even more severe if they are alone and uninhibited. The timing for this eye rubbing after contact lens removal is not simply a pent-up level of desire that is repressed while the contact is in but continues to build until fully expressed when the contact is removed.

Patients learn to avoid eye rubbing while wearing a contact lens, yet there is something additional here that occurs immediately after the contact is removed. Interviewing and examining these patients supports that this pattern of behaviour is not attributable to eyelid or conjunctival allergy. Rather, it appears directed at a stimulus derived from the cornea or from the interaction between the eyelid and corneal surface in the absence of a contact lens. While eye rubbing facilitates lubrication and the interaction between the eyelid and the corneal surface in the absence of a contact lens, I also wonder if contact lens removal improves oxygenation to corneal nerves that are stretched and stressed from KC but also somewhat hypoxic after contact lens wear. This improvement in oxygenation immediately after contact lens removal might initiate a pain signal that responds favourably to eye rubbing—perhaps in the same way that the gate-control theory of pain explains the benefits of acupuncture or therapeutic massage. Relative hypoxia from eyelid closure and the need for better surface lubrication are both factors that might also explain why some patients report early morning as another favourite time to rub their eyes.

Eye rubbing may also be incorporated in behavioural tendencies associated with obsessive compulsive disease (OCD) as some of these patients reveal these tendencies in other activities in their life. Interestingly, it is not uncommon for KC patients to report their eye rubbing more accurately when they return for a follow-up visit, noting that it was called to their attention either by the eye doctor raising the question during the first visit or by family, friends or co-workers the patients might survey with regard to their behaviour. Another reason for under-reporting this behaviour is an embarrassment that some of these patients feel; they may have been chastised growing up or told over the years to stop rubbing their eyes by their peers or by those in authority. For these patients, it is like nail biting, and when asked to demonstrate their eye rubbing technique, they will often blush and remark on the embarrassment this brings.

How Sleep Positions Contribute

The most clinically challenging patients with respect to eye rubbing, however, are those who deny it initially and repeatedly deny it on follow-up examination, stating that their family, friends and co-workers all confirm that they are not eye rubbers. What I have found in these patients is a tendency toward putting pressure on or around the more severely affected eye while they sleep at night. This was brought to my attention when I investigated two separate patients who had evidence of KC that was completely unilateral, isolated to only one eye. Both patients admitted that their sleeping position was exclusively on the affected side and involved a hand position that placed considerable pressure on the eye itself. Since those initial two patients, I have made a number of additional observations including the consistent tendency for patients to sleep on the side that is more severely affected or progressing more rapidly. Some of these patients like to sleep with their hand or fist directly against their eyelid (See Figure 7) and are more likely to hug their pillow in a manner that generates some compression around their eyes (See Figure 8). While some generate substantial pressure—in effect, grinding their eye into the pillow—even the milder forms of pressure can deliver considerable cumulative effect over time. Adding further to this is the thermal impact of compressing a pillow against the closed eyelid, reducing the normal dissipation of heat.

My observations support that these patients with asymmetric KC are also more likely to develop floppy eyelids to a greater degree on their sleeping side. More recently, I have identified a surprising number of patients with previously undiagnosed obstructive sleep apnoea (OSA), a condition that may lead to a host of cardiac and pulmonary problems, hypertension, oesophageal reflux, weight gain and shortened lifespan. Some KC patients develop OSA symptoms prior to acquiring their weight gain, further supporting the need for a heightened sense of awareness among clinicians who may otherwise overlook this condition. I recommend having a low threshold for referring these patients to a sleep lab for formal study if they report restless sleep, snoring, periodic apnea, daytime restlessness, unexplained hypertension or any of the other symptoms commonly associated with OSA. For those patients already diagnosed with OSA, one should be aware that their favourite sleeping position may be altered by their need to wear a CPAP or BiPAP mask, some of which require patients to sleep on their back to maintain an adequate seal. We are exploring this association with OSA further as we try to investigate what might be behind the perception that KC is less prevalent among our patients with advancing age.

In a previously reported study, we observed a link between KC and obesity. (Kristinsson JK, et al. IOVS 2003;44:E-Abstract 812) Our study compared patients over a three-year period undergoing keratoplasty for KC (53 patients) with age-matched controls (34 patients) undergoing keratoplasty for corneal scarring. Patients undergoing PK for KC weighed an average of 31.7 pounds more than our age-matched control group (p=0.015). Comparing body mass index using National Centre for Health Statistics, the difference between groups was highly significant (p=0.006). KC patients were 1.6 times (74 percent vs. 47 percent) more likely to be classified as overweight, 2.2 times (53 percent vs. 24 percent) more likely to be classified as severely overweight, and 8.7 times (26 percent vs. 3 percent) more likely to be classified as morbidly obese against our control group. These heavier patients were also more likely to demonstrate a floppy eyelid.

Recognizing the small size of our original study and also that previous attempts to link KC to mitral valve prolapse failed to conclusively identify a connection, I remain cautious about making a formal association here between KC, obesity and OSA until we accumulate further data. Nevertheless, a hypothesis that a subset of KC patients represents a syndrome that includes a floppy eyelid, "floppy" keratoconic cornea, and floppy soft palate leading to OSA is intriguing and worth pursuing as we try to better understand aging and mortality among our KC patients. The perception that KC is a "young person's disease" in our clinic population is intriguing as we try to better understand what happens to our older patients. The recent emphasis on ruling out KC and the risk for ectasia in our younger patients contemplating vision correction surgery contributes to a heightened awareness and earlier diagnosis of KC; however, this still does not fully account for the observed reduction in disease prevalence with advancing age.

Surgical Influence

I have already mentioned contact lens removal as a factor stimulating eye rubbing, which can be severe. Surgical procedures can also alter this pattern of behaviour. Patients with Intacs corneal ring segments learn to rub their eyes less because they have an immediate painful feedback that teaches them to refrain from this behaviour. Some patients even report specific locations and techniques that cause the segment to shift in a painful manner. One of the unreported benefits of these ring segments may be their ability to reduce eye rubbing in patients with keratoectasia.

One factor implicating a strong link between eye rubbing and KC is that patients usually point to the more advanced eye as their favourite eye to rub prior to PK. After PK; however, patients often switch so that the other eye becomes the favourite eye to rub. I used to think this was entirely related to two factors: a) the postoperative instructions admonishing patients against eye rubbing after PK, eventually causing them to unlearn this behaviour, and b) the painful feedback from rubbing the surgical eye, similar to the Intacs patients. More recently I have found an additional factor that involves the post-PK eye producing less of a stimulus for eye rubbing. Their need for relief diminishes, further supporting that it is not the conjunctiva or eyelids producing this need to eye rub, in contrast to what we see with allergic patients. Instead, this may be a product of neurotrophism making the dry-eye symptoms of lid wiper epitheliopathy less symptomatic. Alternatively, this may provide added support to the gate-control theory of pain with neurogenic factors originating in the cornea "short-circuited" by vigorous eye rubbing and then dramatically reduced when tissue containing these stretched or altered nerves is eventually removed with PK. Do the prominent corneal nerves seen by slit-lamp biomicroscopy anatomically represent either a response or a contribution to the viscious eye rubbing cycle we see clinically?

The case is strong that eye-rubbing tendencies of KC patients are overall quite distinct from those seen in the purely allergic patient. Interestingly, these same tendencies are seen in a number of patients with post-LASIK keratoectasia. What this means is that there might be controllable factors beyond the initial screening process to rule out early keratoconus and then perform surgery that maintains a statistically adequate stromal bed thickness. While I applaud the work of J. Bradley Randleman, MD, and colleagues on identifying risk factors for the development of keratoectasia after LASIK, we should strive to identify severe eye rubbers as having a preventable contribution to this unfortunate problem.4 In fact, using a risk-factor score card and identifying a patient as low risk could give a false sense of security in the patient who is self-administering profound eye rubbing or nocturnal eye pressure. It may be analogous to the lack of a Hutchinson's sign leading to a false sense of confidence and an under-treated zoster patient. Furthermore, given the recent emphasis directed toward "aging" the cornea using corneal collagen cross-linking to make it more rigid, doesn't it make more sense to also address eye rubbing and nocturnal eye pressure as a source of local micro trauma rather than simply assuming that these patients need a stronger cornea?

'Rubbing' the Surface of Understanding

Meticulous examination confirms that KC patients and many of the post-LASIK keratoectasia patients differ substantially from allergic patients in terms of eye rubbing and nocturnal eye pressure. These observations suggest that external microtrauma plays a more integral role in the pathophysiology of both of these conditions. Admittedly, I am making fine distinctions between allergic and KC patients, yet some patients have both conditions. Also, I am not making an attempt here to distinguish the hay fever, vernal and atopic patients from each other, when in fact they have enormous differences in terms of allergic presentation.

The reality is that KC patients are so magnificently distinct in their eye-rubbing tendencies and behaviours that they stand out as uniquely different from the allergic groups. I believe this will become increasingly apparent to the newly initiated connoisseur of eye rubbing. When was the last time you had an allergic patient tell you, " … when I rub my eyes after I take out my contact lenses, doc, it's better than sex." This type of experience and comment is unique to the KC patient. These are unusual and complex patients and we are still only scratching or "rubbing" the surface. We know that given enough eye rubbing trauma, patients can develop a condition indistinguishable from KC isolated to only one eye. Could this be like the cauliflower ear that develops in the traumatized wrestler? Perhaps the best model for KC is a genetic condition that is particularly susceptible and even accelerated by trauma resulting from eye rubbing or mechanical weakening from LASIK surgery?

The observed association with OSA brings to mind a number of plausible hypotheses, the most intriguing of which would be a syndrome that includes KC, floppy eyelid and OSA. Consider the genetically susceptible host with the environmental "second hit" provided as follows: a) eye rubbing or nocturnal eye pressure leading to the "floppy" keratoconic cornea; b) sleeping position and eye rubbing leading to the floppy upper eyelid; and c) the genetically affected soft palate that has a greater propensity for developing OSA due to a greater susceptibility to become "floppy" and obstruct from airway turbulence at lower levels of weight gain. We are sorely in need of better understanding of the aetiology and underlying pathophysiology of this condition, despite our present ability to offer newer, better and safer contact lens and surgical options.

Dr. Carlson is a professor of ophthalmology and chief of the Cornea and Refractive Surgery Service at the Duke Eye Centre. Contact him at alan.carlson@duke.edu or at (919) 684-5769.

1. McMonnies CW. Where are the older keratoconus patients? Cornea 2009;28:836

2. Carlson AN. Keratoconus. Ophthalmology 2009;116:2036-7.

3. Solomon JD, Case CL, Greiner JV, Blackie CA, et al. Warm Compress Induced Visual Degradation and Fischer-Schweitzer Polygonal Reflex. Optom Vis Sci 84(7):580-587, 2007.

4. Randleman JB, Russell B, Ward MA, et al. Risk factors and prognosis for corneal ectasia after LASIK. Ophthalmology 2003;110:267-275.

Recently, Denise Mann wrote the following article for Health Day highlighting the matter:

Agency giving practitioners 90 days to curtail inflated promises, missing safety info in ads

The U.S. Food and Drug Administration is once again cracking down on eye care professionals who make false safety claims and promises about the popular LASIK eye surgery.

The agency's Letter to Eye Care Professionals, issued this week, follows an earlier warning from May of 2009. In its latest salvo against deceptive, potentially harmful advertising, the FDA is now giving eye doctors 90 days to get in line and update any advertising or promotional materials that make false claims. After this time, the agency will take regulatory action, said FDA spokeswoman Erica Jefferson.

"It's about the false claims and not adequately providing consumers with information about the risks associated with the procedure," she said.

LASIK, a laser cornea-shaping procedure, does come with risks. Those risks are small but can include vision loss, under- or over-correction of vision, dry eye, infection, glare, halos and or double vision.

And LASIK isn't for everyone. At this point in time, the procedure can help repair vision among people who are near-sighted, farsighted or have an astigmatism (irregular curvature of the cornea), all conditions known as refractive errors.

The FDA refrained from pointing out examples of misleading advertising by LASIK practitioners, but a 2008 guidance to eye care doctors, issued by the U.S. Federal Trade Commission (FTC), lists a few:

• Unproven claims. "A company must have a 'reasonable basis' for its claims before it runs an ad," the FTC said. "For example, the statement, 'clinical studies show that the laser used by Dr. X results in 20/20 vision 85 percent of the time,' must be supported by clinical studies to that effect for Dr. Xs patients ... Statements from satisfied customers are not sufficient to support a health or safety claim or any other claim that requires objective evaluation."
• Important omissions. Some ads tell the truth, but not the whole truth, the FTC said. For example, a LASIK ad that claimed that nearsighted people can "'throw away their eyeglasses' may be deceptive without further qualification, if, after surgery, a significant number of patients require eyeglasses for best vision, for reading, or under particular circumstances, such as for night driving," the agency said.
• Claims of complete safety. "An advertisement with express or implied representations that the procedure is 'safe,' or 'clinically proven to be safe,' for example, also should tell consumers that, like any surgery, Lasik, or other advertised refractive surgery, has risks and potential complications, and that they will be discussed during a surgical consultation prior to the procedure," the FTC said.

Eye care professionals agreed that deceptive ads must be stamped out. Speaking on behalf of the American Society of Cataract and Refractive Surgery, Dr. Eric D. Donnenfeld said the group supports the FDA's efforts.

LASIK is exceptionally safe when done by the right doctor on the right patient, stressed Donnenfeld, who is an ophthalmologist with offices throughout Long Island, NY. However, he said that "choosing the right doctor is the most important thing one can do." According to Donnenfeld, LASIK surgeons should be members of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. LASIK surgeons should also be board-certified by the American Board of Ophthalmology.

"A lot of patients make a decision based on an ad in a magazine or an audio clip on radio," Donnenfeld said. This may not be the smartest approach, he said, because "there are a lot of very good doctors who advertise, but it doesn't mean a doctor is good because he advertises or offers group discounts."

"We have to go beyond the advertising or Groupons and have to treat [LASIK] as a surgical procedure," he said.

Not everyone is a good candidate for LASIK, either, Donnenfeld added. People with thin or irregular corneas and other eye diseases such as dry eye, glaucoma (increased pressure in the eye) or cataract (cloudy areas in the lens) might be advised against the procedure, for example.

Donnenfeld's advice for finding a good LASIK surgeon: ask your eye doctor who he or she would see for their own eyes.

But he also stressed that as LASIK technology has improved many risks have been minimized, if not eliminated. For example, "the risk of glare and halo have largely gone away," Donnenfeld said.

"Dry eye is common after LASIK and it almost always goes away after three or six months," he noted, and people who already have dry eye prior to the surgery are not candidates for LASIK.

Infection is also a risk with any surgery, Donnenfeld said, but following preoperative instructions -- including taking antibiotics -- can help reduce this risk. Another potential risk may be larger pupils.

"These should all be discussed during your consultation," he said.

Conclusion

It is important to once again stress that the concern of the FDA is not related to the safety of the LASIK refractive surgery procedure, but rather to the fact that some eye care providers advertise false claims about the procedure. Like any surgical procedure it is important to do your home work and discuss any concerns you have with the surgeon before consenting to the procedure. In this manner the patient will have the correct expectation of the surgery outcome and the surgeon will have a happy patient.

Article source: http://consumer.healthday.com/Article.asp?AID=657349

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On November 8, a long-living botnet of more than 4,000,000 bots was taken down by the FBI and Estonian police in cooperation with Trend Micro, a leading Internet content security and threat management solutions company and a number of other industry partners.

In this operation, dubbed “Operation Ghost Click” by the FBI, two data centres in New York City and Chicago were raided and a command & control (C&C) infrastructure consisting of more than 100 servers was taken offline. At the same time the Estonian police arrested several members in Tartu, Estonia.

According to an FBI press release, Rove Digital founder Vladimir Tsastsin along with five other Estonian nationals have been arrested and charged with running a sophisticated Internet fraud ring that infected millions of computers worldwide with a virus and enabled the thieves to manipulate the multi-billion-dollar Internet advertising industry. Users of infected machines were unaware that their computers had been compromised—or that the malicious software rendered their machines vulnerable to a host of other viruses.

The botnet consisted of infected computers whose Domain Name Server (DNS) settings were changed to point to foreign IP addresses. DNS servers resolve human readable domain names like  www.charllaas.com or www.wikipedia.org to IP addresses that are assigned to computer servers on the Internet. Most Internet users automatically use the DNS servers of their Internet Service Provider.

DNS-changing Trojans silently modify computer settings to use foreign DNS servers. These DNS servers are set up by malicious third parties and translate certain domains to malicious IP addresses. As a result, victims are redirected to possibly malicious websites without detection.

A variety of methods of monetizing the DNS Changer botnet is being used by criminals, including replacing advertisements on websites that are loaded by victims, hijacking of search results and pushing additional malware.

Trend Micro knew what party was most likely behind the DNS Changer botnet since 2006. They decided to hold certain data and knowledge from publication in order to allow the law enforcement agencies to take proper legal action against the cybercriminals behind it.

With the main perpetrators arrested and the botnet taken down, Trend Micro today share in a newsletter to their costumers some of the detailed intelligence they gathered in the last 5 years.

Rove Digital

The cybercrime group that was controlling every step from infection with Trojans to monetizing the infected bots was an Estonian company known as Rove Digital. Rove Digital is the mother company of many other companies like Esthost, Estdomains, Cernel, UkrTelegroup and many less well known shell companies.

Rove Digital is a seemingly legitimate IT company based in Tartu with an office where people work every morning. In reality, the Tartu office is steering millions of compromised hosts all over the world and making millions in ill-gained profits from the bots every year.

Esthost, a reseller of webhosting services, was in the news in the fall of 2008 when it went offline at the time its provider Atrivo in San Francisco was forced to go offline by actions of private parties.

Around the same time a domain registrar company of Rove Digital, called Estdomains, lost its accreditation from ICANN because the owner, Vladimir Tsastsin, was convicted of credit card fraud in his home country, Estonia.

These actions were the result of public pressure that arose from the suspicion that Esthost was mainly serving criminal customers. Rove Digital was forced to stop the hosting services offered by Esthost, but it continued with its criminal activities. In fact those behind Rove Digital learned their lesson, and they spread the C&C infrastructure all over the world and moved a great deal of the servers previously hosted at Atrivo to the Pilosoft datacenter in New York City where they already had some servers running.

In 2008, it was widely known that Esthost had many criminal customers. Not publicly known was that Esthost and Rove Digital were heavily involved in committing cybercrime.

Trend Micro knew that Rove Digital was not only hosting Trojans, but was controlling C&C servers and the rogue DNS servers, as well as the infrastructure that monetized fraudulent clicks made by the DNS Changer botnet. Besides DNS Changers, Esthost and Rove Digital were also spreading FAKEAV and Trojan clickers, and it was involved in selling questionable pharmaceuticals and other cybercrimes we will not discuss in this blog posting.

The six cyber criminals were taken into custody yesterday in Estonia by local authorities, and the U.S. will seek to extradite them. In conjunction with the arrests, U.S. authorities seized computers and rogue DNS servers at various locations. As part of a federal court order, the rogue DNS servers have been replaced with legitimate servers in the hopes that users who were infected will not have their Internet access disrupted.

It is important to note that the replacement servers will not remove the DNSChanger malware—or other viruses it may have facilitated—from infected computers. Users who believe their computers may be infected should contact a computer professional, or register as a victim of the DNSChanger malware.

A new sensation of lightness on the mountains

TERREX^TM FAST outdoor eyewear from adidas eyewear

Maximum function and minimum weight. The sports eyewear specialist adidas eyewear is extending its successful TERREX^TM range with a lightweight and narrowly shaped outdoor model, bringing optimal vision within the reach of extreme mountaineers and speed hikers, as well as those with a more leisurely approach to mountaineering. The TERREX^TM FAST is distinguished by its light weight, modern design, simple handling and first-class function - for ultimate peak experiences.

Light and fast.

These are key requirements for today's outdoor equipment. With the TERREX^TM FAST, adidas eyewear is now launching mountain sports eyewear that more than meets these requirements. Alix von Melle, a German extreme mountaineer, has tested the TERREX^TM FAST before its market launch: "When you're scaling high peaks, every gram counts. The TERREX^TM FAST is particularly light, and that makes it ideal for me. It's good to know that my eyes will be perfectly protected on my Broad Peak expedition this summer".

Made from extremely light and shatter-proof SPX material, you will hardly notice you're wearing the TERREX^TM FAST. The nose pads and temples can be adjusted individually to ensure a first-class fit. The narrow front section makes them suitable even for smaller faces. "The TERREX^TM FAST fits even smaller faces and sits perfectly," explains the Austrian mountaineer Gerlinde Kaltenbrunner, shortly before setting off in June 2011 to tackle K2, the last of the 14 eight-thousand metre peaks on her list. "The TERREX^TM FAST will be my constant companion on K2".

When climbing high mountains, the eyes are exposed to particular risks in the form of strong UV light and extreme weather conditions. The TERREX^TM FAST is equipped with a foam frame that clicks into place behind the front part and sits close to the face. It effectively protects the eyes from UV rays, damp or cold air, as well as snow and ice crystals. The proven LST^TM filter technology also guarantees maximum protection from even extreme UV rays. Contrasts are intensified; light variations are compensated, allowing you to plan your next move on the rocks precisely and quickly. However, as you make you way to the summit the weather can change very quickly. Therefore, the filters can be easily replaced by orange-coloured filters if fog or clouds descend without warning, restoring the mountaineer's perfect view. The strong curvature of the filters also allows an extremely wide field of vision.

If the mountaineer works up a sweat during an ascent, the anti-fog coating and the ClimaCool^TM ventilation system ensure condensation-free vision. For anyone intent on making speedy progress or tackling difficult climbing sections, the temples can be replaced with the headband supplied.

Practical: with just a few simple movements, the eyewear can be converted from outdoor eyewear to versatile lifestyle eyewear. All you need to do is remove the foam frame. The nose section stays where it is - no need to waste time putting it back into position. The TERREX^TM FAST will be available from September 2011 in black/black, dark grey/red, white met/lime and coordinated with adidas women's outdoor clothing in magenta/pink.

The TERREX^TM Swift basic model is supplied without a foam frame, replacement filters and headband, making it a lighter all-rounder in stores. Colours: black/black, chocolate/black, ice-blue brown and silver/black.

For those requiring visual correction, both outdoor eyewear models can be fitted with the adidas eyewear optical insert - the Performance Insert^TM. The terrex fast can also be fitted with direct glazing by us .

Optimal vision for an improved handicap

The new raylor from adidas eyewear

Golf is a complex sport, with absolute concentration and a clear view being essential requirements to achieve a successful handicap. With its new raylor model, the sports eyewear specialist adidas eyewear is launching extremely lightweight golf glasses, designed to ensure optimal vision to boost your success on the green.

As well as a skilful driving technique and a strong mental attitude, the ability to read and assess the terrain is a decisive factor in golfing. Where does the fairway end and the green start? How much of a slope is there, how long is the grass? To achieve a perfect drive or putt, it is essential for golfers to form a precise picture of their surroundings on the course. High-quality golf glasses help - like the raylor from adidas eyewear.

As well as its first-class function and modern design, the new raylor is distinguished by its extremely light weight. The highly curved LST^TM filters are specially designed for golfing, guaranteeing an all-round view as well as perfect protection from glare, UV rays and insects. The filters also increase contrast and compensate for light variations. This helps the golfer to clearly identify all bumps and texture variations on the ground and plan his or her next stroke with precision. To allow golfers to respond to different weather conditions, adidas eyewear offers a wide range of filters. The frame is made from very lightweight and robust SPX material. The eyewear is very comfortable to wear, thanks to the bridge which is adjustable in two directions and the non-slip temples, which also fit unobtrusively under a cap or visor. Ensuring that the eyewear stays firmly in place and barely noticeable on your head, even during energetic swings.

The raylor is available in shiny black, shiny white, shiny pink and shiny brown. It guarantees a perfect, sporty look both on and off the green.
To compensate for poor vision, the sports eyewear can be equipped with optical correction: either with direct glazing using an adapter system or by means of an optical insert secured on the bridge behind the filters.

To view the adidas range of sports eyewear, book a viewing with one of our optical dispensers at 021 976 8046.

They will gather information about every person living at each address, including name, age, gender, race and other relevant data. Con artists will also be using this time as an opportunity to ‘steal’ identities and information for fraud purposes.

Important things to remember during Census 2011

• A Census worker will have a badge, a handheld device, a Census Bureau canvas bag and a confidentiality notice.
• Always ask to see their identification and badge before answering any questions.
• You do not need to invite the Census worker into your home and currently they are only knocking on doors to verify address information.
• Do not give your identity number, credit card, banking or financial situation information to anyone even if they claim to need it for the Census.
• Census workers will not be asking for donations.
• The company Acorn is not working with the Census Bureau and you should not share any information with anyone from Acorn.
• Census workers may contact you by telephone, post or in person at home. They will not contact you by email – do not click on links or attachments supposedly from the Census Bureau.

The only information that you are obliged to disclose is the number of people who live at your address.

It is important to share this information as it will be useful to you and your clients and will go a far way in preventing them from becoming victims of fraud or identity theft.