How Well Do You Know Your Contact Lens Complications Contact Lens Complications ???

Australian MK Incidence Study Why ??? Tear Exchange Incidence per 10,000 Gas Permeable Lenses GP’s 20% Over Night Wear* 19.5 Tear Exchange

Occasional* Per -Blink Over Night 10 Wear

Daily Disposable* 2 Soft Contact Lenses

Daily Wear* 1.7

RGP 1.2 SCL’s < 1% Tear Exchange 0 10 20 Per -Blink * Hydrogel lens materials only (silicone hydrogels not included)

Dart J., Epidemiology of MK – Have Silicone Hydrogels Had Any Impact? Paper presented at British Contact Lens Association Clinical Conference, June 2007 from The incidence of contact lens related microbial keratitis in Australia. Stapleton F, Keay L, Edwards K, Naduvilath T, Dart J, Brian G, Holden B in submission.

Many of the Ocular Complications 3 & 9 O’Clock Staining Associated With GP Lenses Occur Outside the Contact Lens, Near the Limbus

1 Physiologic 3 & 9 Staining Physiologic 3 & 9 Staining Bridging Effect

Mechanical 3 & 9 Staining

Vascularized Limbal Keratitis 3 & 9 Staining (VLK)

2 Vascularized Limbal Keratitis

Sub-Bowman’s elevated mass

Vascularized Limbal Keratitis Vascularized Limbal Keratitis (P) Plan Early Stages (A)Assessment • Reduce of discontinue Stage I: wearing time • Micro superficial • Begin lubricating drops punctate keratitis. • Redesign the lens • Heaping of corneal ARdA. Reduce lens di amet er and/or limbal epithelium. B. Flatten base curve relationship • ? Heaping secondary to C. Flatten peripheral mechanical trauma, curves to increase low edge lift to RGP edge clearance design. • Follow closely for recurrence

Vascularized Limbal Keratitis Vascularized Limbal Keratitis

Stage IV Late Stages (P) Plan- Late Stages • Significant patient • Discontinue lens wear symptoms of pain. for 1 to 3 weeks • Increased • Treatment with conjunctival injection. combination • Erosion of the antibiotic/steroid elevated epithelial • Culture if necessary mass. • Redesign Lens

3 Post VLK Corneal Scaring Conjunctival Xerosis or Bitot Spots

Conj Xerosis or Bitot Spots Conj Xerosis or Bitot Spots

(O) Objective (P) Plan • Slightly elevated conjunctival lesion. • Consider thin lens design. • Localized along to 180 meridian. • Follow for changes in patient • Keratinization of the symptoms or conjunctival epithelium. clinical appearance.

Dellen Dellen

• Local saucer-like depression in the peripheral cornea. • Caused by localized dryy,ness, resultin g in stromal dehydration. • Occasionally occurs in conjunction with 3 & 9 staining. • May scar and become vascularized.

4 Dellen Foreign Body Tracking Pre Corneal Hydration

Post Corneal Hydration

GP Lens Induced Ptosis

5 GP Lens Induced Ptosis GP Lens Induced Ptosis

The Unexplained Red Eye The Unexplained Red Eye Syndrome • Manufacturing compounds (polish, solvents).

• Surface debris toxicity.

• Methacrylic acid toxicity.

The Unexplained Red Eye GP Surface Scratches

• Plasma (surface treated) GP’s • Material changes • Soft contact lenses

6 Surface Polishing Surface Plaque

Surface Plaque Surface Plaque

Surface Plaque Surface Plaque P

7 GP Induced Giant Papillary Conjunctivitis GP Complications

Scleral Lenses Complications Ask Yourself the Following Question’s????? 1. What are there “settling effects” of scleral lenses at 30 mts, 1 hour, 2 hours, 4 hours, 6 hours, and 8 hours? 2. How much does the cornea swell beneath a scleral lens with a DK of 100 and a center thickness of 350 microns (0.35 mm)? 3. How much tear exchange takes place beneath a scleral lens over an 8 hour period? 4. What are the long term effects of scleral lenses on the cornea, limbus, conjunctiva and sclera? 5. Does the diameter and/or design of the scleral lens effect any of the above?

How Much Do We Know About Observation the Sclera????? Why do scleral lenses frequently decenter 1. Is the scleral height symmetrical 360 degrees temporally??? around the eye? 2. Is the scleral similar in shape… right eye vs left eye? 3. What are the differences in scleral shape between non-diseased and diseased eyes?

8 Temp Nasal

Right Eye Left Eye T N

N T

Horizontal 15.0 mm Chord N = 18 Horizontal 15.0 mm Chord N = 18 Temporal 3 eyes Higher Nasal 15 Eyes Higher Nasal 7 Eyes Higher Temporal 11 Eyes Higher RT Average 173 um Higher Nasally LT Average 2 um Higher Nasally Horizontal 20.0 mm Chord N = 18 Horizontal 20.0 mm Chord N = 18 Temporal 0 Eyes Higher Nasal 18 Eyes Higher Nasal 18 Eyes Higher Temporal 18 Eyes Higher RT Average 838 um Higher Nasally LT Average 659 um Higher Nasally

Right Right Eye Eye

Left Eye Left Eye

9 Right Eye Left Eye

T N N T

At 15.0 mm nasal higher by 210 um At 15.0 mm temporal higher by 50 um At 20.0 mm nasal higher by 1,060 um At 20.0 mm nasal higher by 490 um

SA Right Eye 3,650 um Right Eye

Left Eye

Right Eye

Left Eye

10 T N How much oxygen is available to the cornea beneath full scleral contact lenses???

Pacific University Individual Overnight Swelling Scleral Lens Corneal Swelling Project Average = 2.85 • Eight normal eye subjects (16 eyes) 6 • Wore three different DK scleral lens materials 5.54 Average 5 • For 8 hours of open eye lens wear 4.48 Corneal Swelling 4.18 • All lenses were 16.5 mm with a CT of 0.35 mm 4 3.56 3.56 2.8% 3.41 3.31 3.25 • Pachemetry was measured after 8 hours 3 • Baseline pachemetry was a 4:00 PM OCT with 2 1.78 1.36 no contact lens wear. 1 0.38 0

-1 -1.25 -2 123456789101112

MA Right Eye Pacific University Pre-Fitting Post-Eight Hours Scleral Lens Corneal Swelling Project Contamac Comfort DK 65 Contamac Extra DK 100 Contamac Extreme DK 125

601 um 602 um Difference, 1 um Increase

11 Pacific University AC PMMA Scleral Lens OS Scleral Lens Corneal Swelling Project Alex Contamac Comfort DK 65 N = 16 Average Swelling in Percentage: 2.27%

Contamac Extra DK 100 N = 16 Average Swelling in Percentage: 1.54% Baseline Corneal Thickness 513 um Corneal Thickness after 8 Hours 606 um Contamac Extreme DK 125 N = 16 8 Hour Corneal Swelling 93 um Average Swelling in Percentage: 1.39% Percent Swelling 18%

High DK Scleral Materials Post Penatrating Keratoplasty

• 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

Normal Abnormal

Clear PKP with Endothelial Dysfunction GP Lenses…. Soft Lenses….

20% per blink <1% per blink

How much tear exchange takes place beneath a scleral lens over an 8 hour period?

12 Subject SM Tear Exchange Study #1 1. A scleral lens was placed on the right eye of 3 subjects, using fluorescein dissolved into PF saline as the application solution. 2. Subjects wore the lens for 8 hours and photography was performed at 30 min, 1, 2, 4, 6, and 8 hrs. 2. Anterior segment OCT was performed at each Right Eye Baseline Left Eye time point to monitor lens settling. 30 mts. 1 hr. 2 hr. 4 hr. 6 hr 8 hr.

SM Right Eye

Baseline Post 8 hrs.

Apical Clearance Apical Clearance 420 um 250 um

SM Right Eye 8 hr. Post-Fitting SM 170 um Right Baseline Change Eye420 um 8 hours

30 mts. 4 hr.

1 hr. 320 um (100 um) 6 hr.

8 Hours 2 hr. 250 um (170 um)

13 SM 130 um Subject AB

Left Baseline Change Eye340 um 8 hours

30 mts. 4 hr.

Right Eye Baseline Left Eye 1 hr. 30 mts. 270 um (70 um) 6 hr. 1 hr. 2 hr. 4 hr. 8 Hours 6 hr 2 hr. 210 um (130 um) 8 hr.

AB Right Eye Baseline Post 8 hrs

Apical Clearance Apical Clearance 370 um 220 um (170 um)

AB Left Eye 8 hr. Post-Fitting

14 AB 150 um AB 130 um

Right Baseline Change Left Baseline Change Eye370 um 8 hours Eye400 um 8 hours

30 mts. 4 hr. 30 mts. 4 hr.

1 hr. 1 hr. 320 um (50 um) 6 hr. 340 um (60 um) 6 hr.

8 Hours 8 Hours 2 hr. 220 um (150 um) 2 hr. 270 um (130 um)

Subject CY

Right Eye Baseline Left Eye 30 mts. 1 hr. 2 hr. 4 hr. 6 hr 8 hr.

CY Right Eye CY Right Eye 8 hr. Post-Fitting Baseline Post 8 hrs

Apical Clearance Apical Clearance 420 um 310 um (110 um)

15 CY 110 um CY 110 um

Right Baseline Change Left Baseline Change Eye420 um 8 hours Eye420 um 8 hours

30 mts. 4 hr. 30 mts. 4 hr.

1 hr. 1 hr. 380 (40 um) 6 hr. 380 um (40 um) 6 hr.

8 Hours 8 Hours 2 hr. 310 (110 um) 2 hr. 310 um (110 um)

CY Right and Left Eyes Tear Exchange Study #2 Pre-Fitting RT Post 8 Hours RT 1. Scleral lenses filled with clear PF saline were place onto one eye of three subjects and photographed with white and cobalt blue light. 2. Following 30 minutes of lens “settling”, PF fluorescein drops were instilled onto the superior bulbar conjunctiva every 20 minutes for 8 hours (total 23 drops). 3. At 8 hours the amount of fluorescein present beneath the lens was photographed and 525 um 525 um subjectively compared to the baseline images. Right Eye Left Eye Anterior segment OCT was performed at baseline Difference, 0 um Increase Difference, 3 um Decrease and at 8 hours to monitor lens settling. Corneal Swelling = 0.0% Corneal Swelling = 0.00%

16 Complications With Scleral Lenses Scleral Lens Deposit

Lid Reactions Hydrogen Peroxide Lens Disinfection

17 Dalsey Adaptives LLC Lens Storage Cases Springfield, Massachusetts

ClearCare Case Dalsey Adaptives 8.0 to 18.0 mm 8.0 to 24.0 mm

Progent Large Diameter Case DMV GP Lenses 11.0 to 23.0 mm

Dalsey Adaptives LLC Dalsey Adaptives LLC Springfield, Massachusetts Springfield, Massachusetts

18 The EZ Eye Scleral Lens Applicator Right Eye (Q-Case Inc.)

Left Eye

Right Eye Intracorneal Hemorrhages with Removal

Left Eye

Conjunctival Impingement Conjunctival Impingement

19 Conjunctival Impingement Conjunctival Impingement

Scleral Lens Deposit Poor Surface Wetting

Surface Deposits Non-Wetting

20 Pre-Cleaning

PPtost-Cleani ng

Epithelial “Bogging” Epithelial “Bogging”

1 week post-fitting

2 months post-fitting

Conjunctival Conjunctival Prolapse Prolapse OK ? Not OK?

21 Conjunctival Prolapse Transient Conjunctival Prolapse

Conjunctival Prolaps

Conjunctival Prolapse

22 Conjunctival Prolapse Axial Display Elevation Display

Prolapse Conjunctival Conjunctival Prolapse Prolapse

Recessed Prolapse

Axial Display Elevation Display

Conjunctival Prolapse

Scleral Lens Application Solutions PH = 7 PH = 5 Opaque Substance

Scleral Lens

23 Patient Patient CK KR Baseline Baseline

4 hours 4 hours

Little or No Significant Tear Clouding Tear Clouding 8 hours 8 hours

The Human Tear Film Tear Reservoir Proteins Mucous Layer Proteins* • Mucopolysaccharide • Lysozyme • glycoproteins • Lipocalin • N-Ac-glucosamines • IgA • sialic acid • Lactoferrin • fucose *Mann and Tighe 2007 • mannose • Galactose Lipid Layer Aqueous Layer • Wax esters • water 98% • Cholesterol esters Goblet Cells • solids 2% • Fatty acids • Inorganics • Free cholesterol • cations • Triacylglycerol • Anions (TAG) • Organics • OAHFA • glucose • Urea

Tear Reservoir Proteins Tear Reservoir Lipids 1600

1400

1200 Turbid Clear 1000

800

es per 12.5ul sample sample 12.5ul es per 600 d

400

200 # of pepti # of 0

in -1 C r in r n n B in r o e to o o - e r n e rs t p i i t e li m o e g g in o f a y u r e e r s c z c p c r r b p n o re re C C lo o a o le c tr ip s p G n ir g L y n ib i a a ly to L i c ig a m g c u h h - a m d ic c c m L u r a a 2 lb in e 1 p - a a p M in m h a a t ly p h m c o l k lp ru la P a G a e o - I - S r g c P I in Z Clear Sample Turbid Sample Proteins

24 Tear Reservoir Lipids: Cholesterol Managing the Fog 400 Alter lens design to decrease excess clearance 350

300

250

ol (ug/ml) ol 200 r Fog Sampl es 150 Clear Samples

Choleste 100

50

0 C1 C2 C3 C4 F1 F2 F3 F4 F5 Tear Reservoir Samples

Managing the Fog Scleral Lens Application Alter lens design to decrease excess clearance

Pinguecula

25 Pinguecula Right Eye: 14.5mm Scleral Lens

Impingement of Pinguecula Pinguecula

Pinguecula Large Diameter Pinguecula Large Diameter

26 Preservative Free Tears Lens Application

• Sterile • Preservative Free • pH Balanced

Solution Reaction Application Bubbles

Edge Lift Mucus in Reservoir

27 Mid-Peripheral (Limbal) Clearance Mid-Peripheral (Limbal) Clearance

Limbal Edema Scleral Lens Fenestration

Fenestration

Fenestrations Conjunctival Impingement

28 Low Angle Sag ClCalcul ltiation

Corneal/Scleral Sag = 2,000 High Corneal Sag = 1,727 Angle Corneal Clearance = 400 Total Sag = 4,127

29 Superior Vertical Sag Right Eye 33.7 3,660 um 95 microns at 13.0 mm

H vs V Difference = 170 microns

Horizontal Sag 0i0 microns 0i0 microns 3,490 um Temp Nasal 34.4 36.5

Inferior 156 microns 39.7 at 15.0 mm

Subject ML… 0.62 D. WTR

30 In the US Complications Related to Soft 37.6 million CL Wearers Lens Induced Corneal Hypoxia 3.2 million Begin (New Fits) 2.8 million Depart (DC CL’s) Reason Comfort 42% Presbyopia 18% Expense 17% Acuity 15% Complications 8% Total 100%

Current Silicone Hydrogel Lenses

ACUVUE ADVANCED B&L PUREVISION CIBA NIGHT & DAY COOPERVISION Oxygen Permeability AVAIRA

125 2 wk DW DW, FW & 30 day CW Dk 60 Dk 140 DW or 30 day CW 2 wk DW Dk 101 Dk 100

ACUVUE OASYS COOPERVISION BIOFINITY CIBA O2 OPTICS (Air Optix)

2 wk DW or 6 Night EW 30 DW or 6 Night EW 2 wk DW or 6 Night EW Dk 103 Dk 128 Dk 110

31 Epithelial Microcysts Polymegethism

Limbal Hyperemia Pre & Post S/H SCL Increased blood flow at the limbus, results in dilatation and distention of the vessels.

Neovascularization

32 Limbal Epithelial Hypertrophy LEH: Treatment

The condition resolves in 3 to 5 days after discontinuing lens wear

Inferior SPK Staph Hypersensitivity

Nocturnal Lagopthalmus Lens Removal Abrasion

33 Superior Epithelial Arcuate Epithelial Splitting: Subjective Lesion (SEAL) • Patients relatively asymptomatic – slight FB sensation • Usually found during routine CL examination

Epithelial Splitting Epithelial Split

Epithelial Split Silicone Hydrogel Properties

34 The Average Eyelid

•Blinks per Minute 12.55 •Blinks per Year 4,397,520 •Distance Traveled per Blink 8.5 mm •Distance Traveled per Year 46.5 miles

Giant Papillary Conjunctivitis

Antigen on Immune a CL Response

Vasculature Changes

Basophils & Mast CCllells Accumulate

Histamine Release

Mechanical GPC GPC from Ocular Prosthesis

35 CLPC: Treatment Mucin Balls: Subjective • Rule out mechanical GPC Cause no discomfort, vision loss or ocular • Manage lens deposits health concerns ‐ More frequent lens replacement (Daily Disp.) ‐ Enzyme cleaners • Change to a preservative‐free lens care system • Artificial tears • Pharmacologic intervention (mast call stabilizer) • Topical steroids • Consider GPs

Life Beneath a Contact Lens

Infiltrative Keratitis

Solution Sensitivities Contact Lens Peripheral Ulcers CLPU

36 CLPU: Subjective CLPU: Objective • Focal elevated infiltrate • Discomfort • No lid edema – moderate to severe • Unilateral – FB sensation • No A/C reaction – slight irritation • Peripheral or – asymptomatic mid-peripheral • Slight redness • Full thickness epithelial loss with • Tearing PMN infiltration into underlying stroma.

CLPU CLPU: Treatment Non-infectious inflammatory reaction to G+ Exotoxins (S. aureus) colonizing on the lens • Artificial tears??? surface. Cultures…sterile with rare bacteria. • Anti-infective agent – 4th generation • CllCycloplege • Steroids after re- epithelialization? • Monitor closely

Bull’s Eye Scarring

CLPU vs Microbial Keratitis Contact Lens Peripheral Ulcer (CLPU) Compared with microbial keratitis: – Peripheral location – Regularity of lesion – Absence of photophobia – No visual involvement – No AC reaction – Rapid resolution (2 to 3 days)

37 Microbial Keratitis Microbial Keratitis

Focal defect or – Bacteria (Pseudomonas, excavation of the Serratia, Staph, Strep) sub-epithelial corneal surface – Protozoan (Acanthamoeba)

Produced by – Fungal (Aspergillus, Candida, sloughing of necrotic Fusarium) inflammatory tissue (loss of stromal substance) – Viral

Microbial Keratitis: Subjective Microbial Keratitis

Symptoms may be mild to severe Acute inflammatory infiltrate of the epithelium and stroma Patient may experience in the presence of infectious – Pain microorganisms – Photophobia – Tearing Infection of the corneal surface – Blepharospasm cannot occur without initial – Red Eye bacterial attachment or binding – Floaters to epithelial cells – AM lid crusting The normal cornea binding – Purulent discharge few, if any, bacteria; therefore, spontaneous infection is rare

Microbial Keratitis With Microbial Keratitis: Objective Traditional EW • Infiltrate • With traditional EW the – Central or paracentral, sometimes peripheral epithelium becomes – Large, irregular, focal >1mm edematous – Satellite lesions common • Increased attachment of – Anterior stromal to full thickness microorganisms to the – Corneal Edema epithelium – Full thickness epithelial loss • Compromised epithelium – Anterior chamber reaction unable to defend against – Lid edema microbial invasion – Severe bulbar & limbal redness – Unilateral – Hypopyon

38 Risk Factors Extended Wear • Trauma • 1989 Schein & Poggio (N Engl J Med) data suggest MK: • Ocular Surface Disease • Smoking – 3x to 8x greater – 1/500 in EW (low Dk) risk – 1/2500 in DW (5x less risk) • Age – young / old at higher • 1999 Cheng (Lancet) – Planned Replacement risk – 1/500 or 20 per 10,000 EW • High Ametropias (> +/- – 1/2857 or 3.5 per 10,000 DW 5.00D) • Frequent replacement did not minimize • Male gender complications • Swimming • What about Silicone Hydrogels? • Illness

Extended Wear LASIK • 2005 Schein, McNally et al. (Ophthalmology) • Vision loss of two or more lines – The incidence of loss of visual acuity due to MK – 0.5 to 1.4% of individuals during the intra- among users of SiHy contact lenses was low operative and early post-operative • 0.3 to 3.6 per 10,000 – 1 per 2500 late post-operative • 2005 Morgg,an, Efron, et al ((p)Br. J. of Ophth.) • Primarily from post surgical ectasia – Higher incidence of SK in EW compared with DW • Comparing Risk – EW in SiHy carry 5x less – “…equivalent to the risk following 20 years of risk of SK EW hydrogel wear where lenses are used for • 2007 Keay, Stapleton, et al 6 nights continuously or silicone hydrogel contact lens use where lenses are used for 30 (Eye & CL) nights continuously.” (Stapleton et al OVS 2007) – Principal risk factor of MK is EW

Bacterial Keratitis Protozoa Keratitis • Pseudomonas • Appear dendritic or patchy stromal infiltrates − One of the most common isolates • Symptoms disproportionate to signs in CL related MK − Liquefactive necrosis • Risk factors − perforation in 48 hours – CL wear – 85% of cases − Semi-opaque ground glass • 3 per 100,000 / year vs. appearance • 1 per 1,000,000 • Intact epithelium – Injuries from vegetative matter − Corynebacterium diphtheriae – Hot tub exposure − Listeria − Haemophilus • Treatment • Treatment – Brolene 1% q1h, Neosporin q1h, Chlorhexadine 0.02% − Culture q1h, and oral itraconazole 100-200mg − Broad spectrum antibiotic – PKP

39 Acanthameoeba Keratitis Fungal Keratitis Thermography • Large white infiltrate with fluffy or branching margins • Significant edema • Fusarium Found in soil, vegetation & water • RRttbkecent outbreaks Lens care products • High risk of loss of BCVA • Treatment (No Steroids) Natamycin 5% and/or Amphotericin B 0.15% q1h around the clock, oral Itracanozol 200-400mg loading dose followed by 100-200mg QD, and cycloplege

Viral Keratitis Microbial Keratitis • Simplex (HSV-1) − course punctate staining • Treatment Options − linear branching w/ terminal – Progressively worsens without treatment end bulbs – D/C CL wear immediately − geographic appearance − pseudodendrite (epithelial – Corneal scrapings & antimicrobial therapy healing) • Which therapeutics? − TtTreatment – Referral to cornea specialist if in visual axis anti-viral: Vira-A ung, Viroptic 1% 9x/day, acyclovir 200-400mg 5x/day • Zoster (HHV-3) − no terminal end bulb on pseudodendrites (raised mucous plaques) − Treatment lubrication, topical steroid, cycloplege, acyclovir 800mg 5x/day (consider Famvir 500mg TID or Valaciclovir 1000mg TID)

Wearing Modality & Material Summary of CL Associated Serious & Significant Events • Daily Disposable • Rare – Benefits • Absolute risk has remained constant for DW • Convenience, No CL storage case and EW SCL • Decrease deposit formation • Occurrence – Decrease in incidence severity of MK – 1 in 10,000 fGfor GP – 3-4 in 10,000 for DW SCL • Silicone Hydrogel – 10-20 in 10,000 for EW SCL – Benefits • Vision loss with CL related MK • Increase oxygen permeability – 0.3 to 3.6 in 10,000 – Equal risk but wearing SiHy for longer • Sterile keratitis – 1% to 7% of SCL wearers periods of overnight wear (continuous wear) ♦Principle risk factor for MK is overnight wear♦ • Other factors contributing to complications

40 As eyecare practitioners we sometimes Understanding Soft Contact take for granted the incredible healing Lens Complications ability of the cornea.

Heal quickly, with new, smooth, optically clear cells

BUT !!!

41