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. 

• If a patient complains of discomfort, especially if they are a long-term wearer, it is worthy of attention. Determine when the symptoms occur and how often. There may be microscopic lens damage. Mr. Norman does very few modifications for this, a re-order is typical in his practice.
   
• Questions to ask symptomatic patients are: When did the symptoms first begin, what is the duration, do they remain after the lens is removed - is your eye uncomfortable prior to lens insertion, etc.
   
• CASE: thanks to the wonders of technology, one of the participants was able to upload the topographies for a problem case to the internet so the others were able to see the corneas first-hand. The patient was a presbyopic male, prior rigid lens failure and post-RK. VA is 20/30 OD and 20/70 OS. Trial lenses were not stable due to significant distortion. A 10.7 mm OAD with a 45.00 D base was stable on the right eye, but the patient experienced edema. None of the diagnostic lenses were stable OS. The fitter had tried small & steep, large & flat, and reverse geometry lenses. The consensus was a). Thank Goodness this isn't our patient, and b). this might be a good candidate for piggy-back fitting.
   
• Mr. Norman is not a fan of truncation, he orders all initial translating bifocals non-truncated and adds it later if needed.
   
• The usual question was asked about what bifocals are working best; this group liked the Contex Aspheric and Tangent Streak No-line.
   
• For presbyopes who show residual cylinder the group discussed adding cylinder correction to the front surface versus aspheric designs. The aspherics were favored due to ease of fitting and reproducibility. The role of the lab in fabricating tough designs was discussed. There was much disagreement about polishing: is it good or bad? does long or hot mean poor optics? The group seemed very divided or confused on this issue.
   
• Deposits play a big role in oxygen transmission; there is a functional reduction as lens deposits build up. This is especially noticeable on very high Dk materials. This is another reason to stress good cleanliness.
   
• There was a long discussion of how to decide which material for which patient. Participants generally prefer higher Dk materials for hyperopes, also for high minus lenses which may be thick in the periphery. The consensus was that in the absence of signs a general purpose material is used and if the need for more oxygen presents itself to move up.
   
• Question from the participants: how to differentiate Pellucid's from keratoconus. Diagnosis of a kone includes a number of signs besides corneal curvature: Vogt's striae, increased nerve fibers, iron lines, and possible Munson's sign. Pellucid's will show thinning in the periphery, keratoconus centrally. K readings are the LEAST indicative sign for either condition.
   
• Most GP problems are peripheral: 3/9 stain, dellen, VLK, etc. Part is because the peripheral cornea and limbus are hydrophobic (this from an attendee).
   
• Low Dk lenses wet better, when combined with a thin lens design and low edge profile they work well for allergy/dry eyed patients.

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