Staining grid lecture
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The document presents a staining grid that summarizes ocular responses and corneal staining levels associated with different contact lens and multipurpose solution combinations. The grid uses color coding to indicate minimal, marginal, and excessive staining levels based on staining area percentages. It provides staining results from multiple studies involving over 3,000 patient visits testing various lens materials and solutions. The grid is intended to help practitioners easily identify lens-solution combinations that are more likely to cause clinically insignificant or significant corneal staining.
Staining grid lecture
- 1. The Staining Grid: A Summary of Ocular Responses to Lenses and Solutions Compatibility Gary Andrasko, O.D., M.S. Columbus, Ohio
- 2. Now Around 2000 silicone hydrogels introduced Better oxygen transmission Less protein / more lipid deposits Incompatibilities with some solution preservatives
- 3. Previous Studies Indicate Some Multipurpose solutions, when used with some lens material, including newer Silicone Hydrogel materials, some may induce clinically significant… Corneal Staining.
- 4. MPS Preservatives Solution Preservative Manufacturer Opti-Free Express Polyquaternium-1 Alcon POLYQUAD (POLYQUAD & ALDOX) RepleniSH Polyquaternium-1 Alcon (POLYQUAD & ALDOX) ReNu MultiPlus Polyaminopropyl biguanide B&L (DYMED) BIGUANIDES AQuify Polyhexanide Ciba Vision (PHMB) Complete Moist. Plus Polyhexamethylene AMO Complete MPS biguanide (PHMB) Walmart/Target Polyaminopropyl biguanide B&L CVS/Walgreen MPS (DYMED) (Renu Multi- Plus)
- 5. Warning Some lens/solution combinations especially when used with silicone hydrogel lenses cause toxic keratitis. Discomfort Redness Loss of intact epithelial barrier function Discontinuation of lens wear Which are the incompatible combinations?
- 6. Scientific evidence… 1997 Jones L, Jones D, Houlford M. Clinical Comparison of Three polyhexanide- preserved disinfecting solutions. Contact Lens Ant. Eye 1997;20(1)23-30. Caroline P, Campbell R. Multipurpose Non-Keratitis. Spectrum March1997. 2002-2003 Epstein A.B. SPK with Daily Wear of Silicone Hydrogel Lenses and MPS. Contact Lens Spectrum. 2002;17(11): 30. Jones L, MacDougall N, Sorbara LG. Asymptomatic Corneal Staining with the use of Balafilcon Silicone-hydrogel Contact Lenses Disinfected with Polyaminopropyl Biguanide-preserved Care Regimen. Optom Vis Sci 2002, Dec;79(12):753-61. Young G, Pritchard N, Hunt C, Coleman S. Subjective and Objective Measures of Corneal Staining Related to Multipurpose Care Systems. Contact Lens & Anterior Eye 26 (2003) 3-9.
- 7. Even more scientific evidence… Lebow KA, Schachet JL. Evaluation of corneal staining and patient preference with use of three multi-purpose solutions and two brands of soft contact lenses. Eye Contact Lens. 2003;29(4):213- 20. 2005 Garofalo R, Dassanayake D, Carey C, Stein J, Stone R, David R. Corneal Staining and Subjective Symptoms with Multipurpose Solutions as a Function of Time. Eye & Contact Lens 2005;31(4): 166-174 Dassanayake N, Garofalo R et. al. Correlating Biocide Uptake and Release Profiles with Corneal Staining and Subjective Symptoms. ARVO 2005 2007 Carnt N, Wilcox M, Evans V, Naduvilath T, Tilia D, Papas E, Sweeney D, Holden B. Corneal Staining: The IER Matrix Study. Contact Lens Spectrum 2007;22(9):38.
- 8. Multiple Studies 11 different solutions 9 different lens materials Looked at comfort and staining One masked observer Randomized order of solution testing N=30 for each combination
- 9. Study Procedures Successful hydrogel CL wearers CL soaked in solution overnight-precycled cases Baseline exam CL inserted 2 & 4 hour exam Rated comfort and symptoms (100-point scale) Examined cornea for staining NaFl with cobalt and Wratten (yellow) filter
- 10. Staining Scales Staining TYPE 1. Micropunctate 2. Macropunctate 3. Coalesced 4. Patch Staining AREA Divided cornea into 5 sectors 0% to 100% in 10% increments
- 11. Corneal Staining Example Area A (Central): 0% B (Superior): 0% C (Temporal): 10% D (Nasal): 0% E (Inferior): 0% Total 10% Total Avg. Corneal Staining Area = 2% OD (10% / 5 = 2%)
- 12. Corneal Staining Example Area A (Central): 30% B (Superior): 0% C (Temporal): 10% D (Nasal): 0% E (Inferior): 10% Total 50% Total Avg. Corneal Staining Area = 10% OS (50% / 5 = 10%)
- 13. Corneal Staining Example Area A (Central): 0% B (Superior): 70% C (Temporal): 50% D (Nasal): 40% E (Inferior): 30% Total 190% Total Avg. Corneal Staining Area = 38% OD (190% / 5 = 38%)
- 14. Study Results Preformed nearly 3000 patients visits Majority of staining was micropunctate Heavier staining can be coalesced Staining evident soon after lens insertion Peaks at 2 hrs.
- 15. Important Message Nearly impossible to predict (and remember) which lens/solution combinations will cause unacceptable/marginal staining. Staining Grid!
- 16. Staining Grid Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 ProClear Soflens 66 Advance Oasys Biofinity PureVision O2 Optix N&D Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 17. Staining Grid Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 ProClear Soflens 66 Advance Oasys Biofinity PureVision O2 Optix N&D Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 18. Staining Grid Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 ProClear Soflens 66 Advance Oasys Biofinity PureVision O2 Optix N&D Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 19. Staining Area Color Code MINIMAL – less than 10% Green MARGINAL – 10% to 20% Yellow EXCESSIVE – greater than 20% Red Disclaimer The colors used in the corneal staining grid are intended only to differentiate the identified data groupings and are not meant to suggest that the lens-solution combinations designated red or yellow indicate danger or caution or that such combinations are associated with an increased risk of corneal infection.
- 20. Corneal Staining Example 4% Green Zone (about 60 dots)
- 21. Corneal Staining Example 10% Yellow Zone (hundred of dots)
- 22. Corneal Staining Example 76% Red Zone (thousands of dots)
- 23. Staining Grid Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 ProClear 57% 61% 54% 53% 42% Soflens 66 73% 66% 62% 63% 56% Advance Oasys Biofinity PureVision 73% 21% 71% 76% O2 Optix 24% 41% 28% 28% 24% N&D 24% 36% 24% 26% 22% Last Updated: June 17, 2008 H2O2 POLYQUAD BIGUANIDES
- 24. Renu MultiPlus & PureVision Coalesced Staining
- 25. Renu MultiPlus & PureVision Coalesced Staining
- 26. Target MPS & PureVision
- 27. Target MPS & PureVision Micropunctate Staining
- 28. Staining Grid Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 ProClear 57% 12% 61% 54% 53% 42% Soflens 66 73% 17% 66% 62% 63% 56% Advance 13% 12% 16% 13% 12% 12% Oasys 12% 13% 10% Biofinity PureVision 73% 15% 21% 71% 76% O2 Optix 24% 41% 28% 28% 24% N&D 24% 36% 24% 26% 22% Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 29. Walmart MPS & Advance Macropunctate Staining
- 30. Target MPS & Oasys
- 31. Staining Grid Branded Solutions Private Label Solutions Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 1% 1% 2% 5% 1% 1% 1% 1% 1% 1% 1% ProClear 1% 1% 1% 2% 57% 6% 12% 61% 54% 53% 42% Soflens 66 1% 1% 1% 1% 73% 17% 8% 66% 62% 63% 56% Advance 1% 1% 1% 1% 13% 12% 2% 16% 13% 12% 12% Oasys 2% 1% 3% 5% 9% 4% 3% 12% 8% 13% 10% Biofinity 2% 2% 3% 2% 4% 2% 2% 4% 3% 3% 2% No Testing No Testing PureVision 2% 1% 4% 7% 73% 15% 21% 71% 76% Planned Planned O2 Optix 2% 1% 2% 5% 24% 3% 3% 41% 28% 28% 24% N&D 2% 1% 2% 3% 24% 1% 3% 36% 24% 26% 22% Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 32. OptiFree Replenish & O2 Optix
- 33. OptiFree Express & O2 Optix
- 34. Walmart MPS & Advance
- 35. Staining Grid Branded Solutions Private Label Solutions Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 1% 1% 2% 5% 1% 1% 1% 1% 1% 1% 1% ProClear 1% 1% 1% 2% 57% 6% 12% 61% 54% 53% 42% Soflens 66 1% 1% 1% 1% 73% 17% 8% 66% 62% 63% 56% Advance 1% 1% 1% 1% 13% 12% 2% 16% 13% 12% 12% Oasys 2% 1% 3% 5% 9% 4% 3% 12% 8% 13% 10% Biofinity 2% 2% 3% 2% 4% 2% 2% 4% 3% 3% 2% No Testing No Testing PureVision 2% 1% 4% 7% 73% 15% 21% 71% 76% Planned Planned O2 Optix 2% 1% 2% 5% 24% 3% 3% 41% 28% 28% 24% N&D 2% 1% 2% 3% 24% 1% 3% 36% 24% 26% 22% Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 36. Staining Grid Branded Solutions Private Label Solutions Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 1% 1% 2% 5% 1% 1% 1% 1% 1% 1% 1% ProClear 1% 1% 1% 2% 57% 6% 12% 61% 54% 53% 42% Soflens 66 1% 1% 1% 1% 73% 17% 8% 66% 62% 63% 56% Advance 1% 1% 1% 1% 13% 12% 2% 16% 13% 12% 12% Oasys 2% 1% 3% 5% 9% 4% 3% 12% 8% 13% 10% Biofinity 2% 2% 3% 2% 4% 2% 2% 4% 3% 3% 2% No Testing No Testing PureVision 2% 1% 4% 7% 73% 15% 21% 71% 76% Planned Planned O2 Optix 2% 1% 2% 5% 24% 3% 3% 41% 28% 28% 24% N&D 2% 1% 2% 3% 24% 1% 3% 36% 24% 26% 22% Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 37. Staining Grid Branded Solutions Private Label Solutions Unisol 4 Clear Optifree Optifree Renu Complete Walmart Target CVS Walgreen Aquify Saline Care Express Replenish MPlus Easy Rub MPS MPS MPS MPS Acuvue 2 1% 1% 2% 5% 1% 1% 1% 1% 1% 1% 1% ProClear 1% 1% 1% 2% 57% 6% 12% 61% 54% 53% 42% Soflens 66 1% 1% 1% 1% 73% 17% 8% 66% 62% 63% 56% Advance 1% 1% 1% 1% 13% 12% 2% 16% 13% 12% 12% Oasys 2% 1% 3% 5% 9% 4% 3% 12% 8% 13% 10% Biofinity 2% 2% 3% 2% 4% 2% 2% 4% 3% 3% 2% No Testing No Testing PureVision 2% 1% 4% 7% 73% 15% 21% 71% 76% Planned Planned O2 Optix 2% 1% 2% 5% 24% 3% 3% 41% 28% 28% 24% N&D 2% 1% 2% 3% 24% 1% 3% 36% 24% 26% 22% Last Updated: H2O2 POLYQUAD BIGUANIDES June 17, 2008
- 38. Mechanism of Staining Amount of staining depends: Uptake – Amount of preservative absorbed into the lens during overnight soak Release - Amount & Rate that preservative is released from the lens to the eye Toxicity - How irritating a specific preservative is to corneal epithelial cells
- 39. Keys to Diagnosis Consult the Staining Grid Use fluorescein w/ cobalt & yellow filter Look early in wearing period - within 4 hours of insertion Listen to Patient - discomfort, dryness, red eyes EARLY in day
- 40. Wratten Filter Advantages Staining is much easier to visualize using a Wratten Filter
- 41. So What??? Four Important Questions… 1) Has anyone else found staining? 2) How consistent is staining? 3) What are consequences of staining? 4) How long does staining last?
- 42. IER Matrix Study
- 43. IER vs. Staining Grid Results 70 60 Staining Grid - % Subj. in Shows that 2-hr staining observations Red/Yellow Zones 50 predict long-term results 40 30 20 10 R2 = 0.81 0 0 5 10 15 20 25 IER Study - % Subj. With Staining
- 44. So What??? Four Important Questions… 1) Has anyone else found staining? 2) How consistent is staining? 3) What are consequences of staining? 4) How long does staining last?
- 45. Staining Consistency PureVision/Renu MultiPlus formulation 100 90 80 Avg. = 70 73% % Staining 60 50 40 30 20 10 0 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 Patient # 98% in Red Zone 1% in Yellow Zone 1% in Green Zone
- 46. So What??? Four Important Questions… 1) Has anyone else found staining? 2) How consistent is staining? 3) What are consequences of staining? 4) How long does staining last?
- 47. What Does Staining Mean? Consequences of corneal staining Chronic in nature Disruption of epithelial barrier layer Increase risk of infiltrates Discomfort (Staining NOT asymptomatic) “Wearers who experience corneal disruption as a result of solution toxicity are three times more likely to experience such an event (asymptomatic corneal infiltrates and infiltrative keratitis) than those without staining.” - Carnt N, Jalbert I, Stretton S, Naduvilath T Papas E. Solution toxicity in soft contact lens daily wear is associated with corneal inflammation. Optom Vis Sci. 2007Apr;84(4):309-15 .
- 48. Comfort Score vs. Staining (2 hrs.) 100 90 24-point loss of comfort! 80 70 Comfort Score 60 50 40 30 20 10 0 0 20 40 60 80 Staining Area (%)
- 49. So What??? Four Important Questions… 1) Has anyone else found staining? 2) How consistent is staining? 3) What are consequences of staining? 4) How long does staining last?
- 50. Daily Staining Cycle – PV lens 80 Renu MP 70 Saline 60 Staining Area (%) 50 40 End of day observations 30 will MISS signif. staining 20 7 hrs/day 10 0 0 hrs 2 hrs 4 hrs 6 hrs 8 hrs 10 hrs 12 hrs Time of Wear
- 51. Closing Thoughts Consult the “Staining Grid” Examine patients 2-4 hours after insertion Recognize that solution is as important as the contact lens Emphasize to patients importance of continuing to use solution which was prescribed Staining affects health and decreases comfort Refer to www.StainingGrid.com for updates
- 52. Common Sense Approach Recent events of 2006/2007, solution recalls, corneal infections, etc. have taught us: We don’t have all the answers concerning MPS Cautious, conservative approach is best Minimize all RISK FACTORS (known and suspected) corneal staining For any lens material, at least 3 solutions are biocompatible Minimize staining + = happy/healthy patients maximize comfort
- 53. Avoid the “RED” Combinations
- 54. THANK YOU!!!
Editor's Notes
- #7: There have been several reports in the literature regarding corneal staining or ocular stress due to solution properties or interactions with materials. [advance]
- #22: This example demonstrates the method used to determine average corneal staining area. The calculation is straightforward. The total is added and then divided by the 5 sectors to derive an average. CHUCK NOTE: Photo is missing [Advance]
- #48: Now that we know that significant corneal staining can occur with some lens/solution combinations, what are the consequences of this staining? (dissolve in “Chronic in nature”) First, it is important to keep in mind that staining induced by toxic keratitis is chronic in nature. In other words, it is likely to occur every time a patients uses a particular lens/solution combination. (dissolve in “Disruption of epithelial barrier layer”) Corneal staining is always a concern for the optometrist as it represents a disruption in the epithelial barrier layer of the cornea. This layer is important in protecting the deeper layers of the cornea from microorganism invasion. (dissolve in “Increase risk of infiltrates”) In a retrospective record review of over 600 patients Pappas and his group found a three-fold increase in the risk of corneal infiltrative events, that is asymptomatic corneal infiltrates and infiltrative keratitis, when chronic solution toxicity exists. (dissolve in “Discomfort”) Andrasko, in his Staining Grid study, found a definite trend in decreased lens wearing comfort as staining increases past a moderate level. This trend is shown in the figure plotting Staining Area vs. subjective comfort ratings with 2 lens brands. (show next slide).