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Controversies in Scleral Lenses 2019 Curvature Versus Elevation

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Controversies in Scleral Lenses 2019 Curvature Versus Elevation Controversies in Scleral Lenses Normal Keratoconus PMD Keratoglobus 2019 Curvature versus Elevation Axial Display Elevation Map Power Map Height Map Axial Display Elevation Display Patient CB Moderate KC Axial Display Map +180um +180 +379 +379um Elevation Display -110 - 276 Elevation Map 655 Above the 290 microns Micron Sphere Height -276um Differential Depression Below the -110um Sphere N = 87 Patients 127 CL Fits Less than 350um Greater than 350um Patients with 350um or less of corneal elevation difference (along the greatest meridian of change) have an 88.2% chance of success with a corneal GP lens. The Re-Birth of Scleral Lenses Glass Scleral Lenses 1887 Molding Glass Scleral Lenses Average 8.5 High DK Scleral Materials Traditional Corneal / Scleral • Menicon Z Dk = 163 Shape • B & L, Boston XO2 DK = 141 • Contamac, Optimum Extreme DK = 125 • B & L, Boston XO DK = 100 • Paragon HDS 100 DK = 100 • Contamac, Optimum Extra DK = 100 • Lagado, Tyro -97 DK = 97 Scleral Shape Cone Angle Circa 1948 Klaus Pfortner New Understandings Argentina Scleral Lens Fitting Objectives Anatomy of a Scleral Lens 1. Central Vault Zone (250 to 400 microns) 2. Peripheral Lift Zone 4 3 2 1 2 3 4 3. Limbal Lift Zone 4. Scleral Landing Zone Ocular Surface Disease Scleral Lens Indications Scleral Irregular Astigmatism Lens • Keratoconus Indications • Pellucid Marginal Degeneration • Post Corneal Trauma • Post keratoplasty • Post K-Pro • Post Refractive Surgery RK, PRK and LASIK • Post HSV and HZV • Athletes • GP stability (rocking) issues Corneal Irregularity Ectasia/Scar/Post Surgery •) Scleral Lenses Pathologic Ocular Surface Disease • Chemical Burns for Ocular • Ocular Pemphigoid Surface Disease • Stevens-Johnson Syndrome • Symblepharon formation • Graft vs Host Disease • Persistent Epithelial Defect • Exposure Keratitis • Neurotrophic Keratopathy • Sjogren’s Syndrome, • Filamentary Keratitis • Limbal Stem Cell Deficiency • Radiation Keratopathy SJS 20/400 6 months Ocular Surface Disease… Post Scleral Lens 20/25 Pre-Scleral 2 Months Post Scleral 9 Lens Ampleye Low Sag Eyes and Scleral Lens Normal Eyes Fitting bySagittal Height Diagnostic Set 3,800 microns 4,000 microns 4,200 microns Mild KC, Mild PMD and Corneal Transplants 4,400 microns 4.600 microns Advanced KC, PMD Bulging Grafts 4,800 microns 5,000 microns Extreme Ectasias 5,200 microns 5,600 microns Markings on Ampleye Diagnostic and Patient Lenses Rotation Markings Along the Flat Meridian Initial diagnostic lens selection is based on Diadmostic Fitting…. corneal height/optical condition. Filamentary Keratitis Scleral Lens Application Preservative Free Saline Options (in the USA) The unit dosed 5 or 10 ml Inhalation PF saline.... 0.9% Sodium Chloride Solution by Rx only The 12 OZ aerosol saline… Simply Saline by Arm and Hammer OTC The 4 OZ bottle Purilens Plus Ultra PF Saline from Purilens OTC Application Bubble LacriPure Saline from Menicon Re-Application Central Vault Zone 250 to 400 microns of Apical Clearance Scleral Lens Setteling 8 hour Approx. White Light Cobalt Light Lens Baseline 130 um Settling 400 um 30 mts. 4 hr. 1 hr. 340 um (60 um) 6 hr. 8 Hours 2 hr. 270 um (130 um) Limbus Dispensing 4,200 Inadequate Peripheral Corneal Clearance Appropriate Peripheral Corneal Clearance Dispensing Peripheral Lift Zone 4,000 um PLZ Changes The change in sag between the Standard and +5 PLZ is: 125 microns. Post 4 Hours Peripheral Inadequate Limbal Clearance Lift Zone Light +5 increase = 125 um Peripheral Bearing Adequate Corneal and Limbal Clearance Over-Refraction Patient: TW KATT for KC Axial Map TW Elevation Map Initial Diagnostic Lens Selection TW Right Eye Inadequate Appropriate Apical Clearance Apical Clearance Sag = 4,400 9 Lens Ampleye Low Sag Eyes and TW Right Eye Normal Eyes Diagnostic Set 3,800 microns Sag = 5,000 4,000 microns 4,200 microns Mild KC, Mild PMD and Corneal Transplants 4,400 microns 4.600 microns Advanced KC, PMD Bulging Grafts 4,800 microns 5,000 microns Extreme Ectasias 5,200 microns 5,600 microns Right Eye Pellucid Marginal Degeneration Right Eye Initial Diagnostic Lens Selection Peripheral Lift Zone Right Eye PLZ Changes The change in sag between the Standard and a +5 PLZ is 125 microns. KC With Intacs Ten Days Post-Surgery Budging Graft Sag = 5,780 um Normal Eye Sag = 3,735 um One Week After Scleral Lens Wear Axial Display Map Total Height Differential 485 microns Increase PLZ +10 = 250 microns Elevation Display Map Diagnostic Lens Final Lens 193 um Elevation 292 um Depression Precision Ocular Metrology sMap3D Eaglet ESP Eye Surface Profiler 150 un Temporal Nasal Differential between steep and flat meridians LR MR Temporal Nasal Average Sagittal Height and Scleral Lens Position OCT Toric Scleral Lens Design Spherical Corneal Zone Lowest Scleral Toric Scleral Lens Design Meridian Highest Spherical Scleral 9.5 mm Meridian Optical Zone Toric Scleral Lens Design Scleral Landing Zone Scleral Landing Zone Conjunctivial “Compression” Summary of Fitting Techniques Scleral Lenses 2016 Corneal Astigmatism vs Scleral Medmont Topography Astigmatism Beth Kinoshita Sheila Morrison The sMap 3D was used to measured the position of 20 subjects SCLERL astigmatism. All 20 subjects had with-the-rule CORNEAL astigmatism. Visionary sMap3D 20.0 mm Chord 16.0 mm Chord 16.0 mm Chord 17.5 mm Scleral Lens Low Corneal Astigmatism < 0.75 D High Corneal Astigmatism > 1.75 D The sMap 3D was used to measured the Lowest Scleral position of 20 subjects SCLERL astigmatism. Meridian All 20 subjects had with-the-rule CORNEAL astigmatism. • 7 had Asymmetric scleral toricity at a 15.0 mm Spherical Highest Scleral chord. 9.5 mm Meridian • 4 had Against the rule scleral toricity at a 15.0 Optical Zone mm chord. • 5 had Oblique scleral toricity at a 15.0 mm chord. • 4 had With the rule scleral toricity at a 15.0 mm chord. Toric Scleral Design Highest Scleral Meridian Spherical 9.5 mm Optical Zone Lowest Scleral Meridian Toric Scleral Design Difficulties with Scleral Lenses A B C Right Eye Left Eye Right Eye Left Eye Uncomfortable Uncomfortable Uncomfortable Comfortable Right Eye Left Eye Uncomfortable Comfortable Is the oxygen permeability of our When Things Go current GP lens materials adequate Wrong With for today’s scleral lens designs? Scleral Lenses Pacific University 12 SubjectsIndividual Overnight OvernightCorneal Swelling Swelling Scleral Lens Corneal Swelling Project No ContactAverage Lens = 2.85 Wear 6 Contamac Comfort DK 65 5.54 5 Average 4.48 4.18 Contamac Extra DK 100 4 Corneal Swelling 3.56 3.56 3.41 3.31 3.25 2.8% Contamac Extreme DK 125 3 2 1.78 1.36 1 0.38 0 -1 -1.25 -2 1 2 3 4 5 6 7 8 9 10 11 12 Normal Non-Lens-Wear Corneal Clear PKP with Endothelial Swelling = 2.80% Dysfunction Contamac Comfort DK 65 N = 16 Average Swelling in Percentage: 2.27% Contamac Extra DK 100 N = 16 Average Swelling in Percentage: 1.54% Contamac Extreme DK 125 N = 16 Average Swelling in Percentage: 1.39% Normal 18 y/o 78 y/o Post PKP 3,065 cells/mm2 480 cells/mm2 High DK Scleral Materials • Menicon Z DK = 16o • B & L, Boston XO2 DK = 141 • Contamac, Optimum Extreme DK = 125 • B & L, Boston XO DK = 100 • Paragon HDS 100 DK = 100 • Contamac, Optimum Extra DK = 100 • Lagado, Tyro -97 DK = 97 Scleral Lenses on an Overnight / Do Scleral Lenses Provide Adequate Extended Wear Basis??? Oxygen Permeability for Overnight Lens Wear? Primary reasons: Paul Nefedov, Sheila Morrison OD, MS, Patrick Caroline, Randy Kojima and Beth Kinoshita OD • to provide protection • Ten normal eye subjects participated in this two part for persistent corneal study. erosions • In Phase 1 baseline overnight corneal swelling for each • to promote more subject with no CL wear. rapid wound healing. • In Phase 2, only the right eye of each subject was fitted with a 0.45 mm thick, plano scleral lens manufactured in the Boson XO2 material (Dk 141). The lens was worn Is there adequate oxygen permeability overnight on the right eye for 8 hours. • Corneal thickness was measured immediately upon through scleral lenses in the closed eye awakening, and the percent of corneal swelling was environment ??? calculated. Range of 7.5% to 14.1% Pre Overnight Lens Wear Post One Week Overnight Lens Wear Post Two Week Overnight Lens Wear Post One Month Overnight Lens Wear What is the best scleral lens AMPLEYE Application application solution PF Unisol saline, PF inhalation saline or PF artificial tear....other? pH = 7 pH = 5 Preservative Free Saline Options (in the USA) LacriPure Saline from Menicon The unit dosed 5 or 10 ml Inhalation PF saline.... 0.9% Sodium Chloride Solution by Rx only The 12 OZ aerosol saline… Simply Saline by Arm and Hammer OTC The 4 OZ bottle Purilens Plus Ultra PF Saline from Purilens OTC Right Eye Boston What are the mechanisms for Conditioning “Epithelial Bogging” and should we Solution be concerned about it? for Lens Application Left Eye Epithelial Post Lens Tear Film “Fogging” “Bogging” Baseline OCT 1 Week Post-Fitting 4h post application 8h post application 2 Months Post-Fitting Scleral Lens Tear Film Cornea Tear Film “Fogging” 1600 1400 1200 Turbid Clear 1000 800 600 400 200 # ofpeptides# per 12.5ul sample 0 r r in -1 C o in o n n B in r e t io io - e r in e rs t p t fe l m u o e g g in o s a y c r c re re b r c z e p e p n o o r e r C C lo o ra p s p l r g c t i y b G in i a y o L L in i g a a l t c i h h m g c m u c c c m - a u d ri a 2 L b in e 1 a - l a p M a in m h p a t ly p a h m c o l k lp ru la P a G a e o - I - S r g c P I in Z Proteins Mucous Layer • • Mucopolysaccharide • glycoproteins • N The Human Tear Film • sialic-Ac
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