Please note that the comments below are representative of remarks made in the chat room, and do not necessarily reflect the views of the moderators, the guest expert, or the GPLI. 

• Some of the most challenging corneas are those scarred from Herpetic Keratitis. They are best fitted with a GP lens. Some experts say the lens will reactivate the virus, but our faculty & guests have not found this to be true.
   
• GP's are ideal for diseased corneas that need 'resurfacing', and the high Dk materials are especially useful. Flexure resistance is also an important attribute.
   
• The RoseK design was mentioned as before. Dr. Epstein notes it is dangerous to think that a specific design is more important than the fitter. Even if a design works well for some patients the fitter needs to understand how & why and be proficient with several designs.
   
• The group finds the RoseK most useful for nipple kones.
   
• The CLEK study is finding that minimal apical clearance is achieved by a lens fitted on steep K in keratoconus and 3 point touch is achieved by going slightly flatter than steep K. But as they use lenses of a single diameter this may not be the case in the 'real world'.
   
• Most post-refractive surgery cases are from RK and LASIK, the PRK patients seem not to mind any residual blur.
   
• Wetting problems persist, but the participants are excited about new materials as they become available.
   
• Aspheric designs work best for post-PK fittings. Start with a large diameter (~9.8) with a base curve around 8.0 mm. Shelley Cutler OD recommends a bitoric on these cases when the topography shows regular cylinder. Dr. Epstein has tried bitoric/PK with success, but feels the surfaces are too irregular in most cases and uses aspheres about 70% of the time. Most of these fits look awful but work fine.
   
• Dry eye patients: there is much new research. We have to start thinking of the tear film as a living tissue (or sea) rather than a static pool. This will explain many of the biocompatibility/dry eye issues.
   
• Participants would like to see a large-scale multi-center bifocal study similar to CLEK to determine scientifically which types of patients really do best with each type of design.
   
• Maller uses topography for bifocals looking for apex location, cylinder orientation and any unusual "refractive maps". He feels they are very predictive of outcome. If the refractive map is irregular - i.e. decentered, fitting a bifocal and getting vision would be harder than winning the lottery.

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