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Melissa Barnett, OD, FAAO, FSLS, FBCLA

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Melissa Barnett, OD, FAAO, FSLS, FBCLA Melissa Barnett, OD, FAAO, FSLS, FBCLA University of California, Davis Eye Center ABB Ocusoft Acculens Paragon Bioteck Alden Optical Percept Alcon Science Based Health Allergan Scleral Lens Education Society Anthem, INC Shire Bausch + Lomb Sjogren’s Syndrome Foundation Bruder STAPLE program Contamac SynergEyes CooperVision Visioneering Technologies JJVC Vistakon Gas Permeable Lens Institute Scleral lenses are large diameter gas permeable lenses that rest beyond the limits of the cornea and extend onto the sclera. Popular Mechanics, 1948 Made from impression mold of eye Difficult to make Problem with hypoxia www.college-0ptometrists.org First used in late 1800s and early 1900s Manufacturing process now more reproducible Modern scleral lenses . Don Ezekiel, O.D. Ken Pullum, O.D. Perry Rosenthal, M.D. Boston Scleral Lens www.sclerallens.org Corneal ectasias • Primary corneal ectasias . Advanced (notably decentered) keratoconus . Keratoglobus . Pellucid marginal degeneration • Secondary corneal ectasias . Post-LASIK . Post-PRK . Post-RK Corneal transplants Corneal degenerations or Trauma dystrophies Corneal scars . Salzmann’s nodular degeneration . Terrien’s marginal degeneration Persistent epithelial defects Severe dry eyes . Graft versus host disease . Sjögren’s syndrome . Stevens Johnson syndrome . Neurotrophic keratopathy Neurotrophic Keratitis Exposure Keratitis Dry Eye Syndrome Graft vs Host Disease Steven Johnson Syndrome Ocular Cicatricial Pemphigoid Chemical Burns Limbal Stem Cell Failure Sjogren’s Syndrome Persistent Epithelial Defect Inflammatory conditions . Limbal stem cell deficiency . Ocular cicatricial pemphigoid Neovascularization with hybrid lens designs Poor comfort with traditional gas permeable designs High refractive error Corneas with significant edema from reduced endothelial cell count Fuch’s corneal dystrophy Glaucoma? Picot, C, Gauthier, AS, Campolmi, N, Delbosc B J Fr Ophtalmol. 2015 Sep;38(7):615-9. Evaluated the improvement of QOL with scleral lenses in keratoconus or the treatment of astigmatism after penetrating keratoplasty ▪ Retrospective study ▪ Patients failed to adapt to RGP lenses ▪ QOL before and after scleral lens adaptation 47 patients (83 eyes) fit with scleral lenses on one or both eyes 56 eyes with KCN 27 post-keratoplasty eyes NEI-VFQ 25 scores with scleral lenses were significantly higher than those without scleral lenses. Scleral lenses showed significant improvement in quality of life for patients who had failed or are intolerant to conventional rigid gas permeable contact lenses. Scleral lenses are an alternative or a step prior to surgery ©2012 MFMER | slide- 24 63 year old Caucasian male Referred by corneal specialist for a contact lens fitting both eyes Vision not as clear for distance Eyes irritated and dry at the end of the day History of small diameter gas permeable contact lens wear since 1962 OD OS 20/40 PH 20/30 VA 20/25 PH 20/20-2 (with GPs) -6.50+0.50x065 20/60 Refraction -3.75+0.50x095 20/60 45.18 / 54.26 / 045 Pentacam 51.61 / 53.07 / 002 Irregular astigmatism Sim Ks Irregular astigmatism 505 Pachymetry 542 14 mmHg Applanation IOP 15 mmHg @ 1:22pm OD OS 1+ mgd L/L 1+ mgd White and quiet Conjunctiva White and quiet Fleisher Ring Cornea Fleisher Ring paracentral paracentral scarring scarring less than 1mm Deep and Quiet A/C Deep and Quiet 1+ nuclear and Lens 1+ nuclear and cortical sclerosis cortical sclerosis 0.40 C/D 0.30 Normal Macula Normal OD OS Scleral Lenses Scleral Lens Parameters Scleral Lens Optimum Extra Optimum Extra OD 47.25 / -5.75 / 16.6 / OS 48.50 / -5.99 / 16.6 / 13.25 / 14.75 8.6 OZ / 13.25 / 14.75 Sag 4.88 Sag 4.88 20/25+1 VA 20/20-2 SOR pl SOR pl Binocular VA 20/20+1 Good central and Fit Good central and peripheral clearance peripheral clearance No blanching No blanching Foggy vision after 4-5 hours of scleral lens wear Solutions . Treat eyelid disease . Change solutions ▪ Hydrogen peroxide ▪ Add more viscous solution with lens application . On eye surface cleaning X-Ray Vision Specialties, P.C. 2020 Sunnyview Blvd. Anywhere, USA 12345 Tel:(555) 555-5555 Fax: (555) 555-5556 I.M. Awesome, O.D. B. Mypatient, O.D. Name:____________________________________________ Address:_________________________ Date:___________ R 0.9% NaCl Inhalation saline for ophthalmic use Dispense : 1 box (100 count) 3 ml vials Sig: Use as directed with ocular prosthetic device ©2012 MFMER | slide- Refills: _________ ___________________________________________________ 29 NaCl 0.9% Inhalation LacriPure ScleralFil Solution (Menicon) (B+L) No buffers, no preservatives No buffers, no preservatives Contains buffer, no preservatives Off-label FDA approved FDA approved Available in 3 ml or 5 ml vials 5 ml vials 10 ml vials Available in box of 100 vials Available in box of 98 vials Available in box of 30 vials • Potential severe impact • On visual acuity • On convenience • Lenses removal and reapplication is inconvenient • Etiology • Fluid dynamics under a scleral lens • Attracts deposits in the reservoir if the clearance over the limbus is high enough • No tear exchange: debris accumulation over time Mucin debris . Opaque, white, fluffy, small debris Management . Eliminate peripheral edge lift . Tighten peripheral curves Image credit Lynette Johns, OD . Add toric peripheries . Reduce wearing time . Lens removal and reapplication . Clean lens with an enzymatic cleaner or a sodium hypochlorite- potassium bromide-based system . Eliminate preservatives (use hydrogen peroxide based systems) Atopic debris . Association between atopic disease and keratoconus1 . Diluted milk-like fogging Management Image credit Lynette Johns, OD . Lens removal and reapplication . Evaluate lens fitting relationship . Reduce excessive edge lift . Toric peripheries if edge lift is meridional . Topical mast cell stabilizers or “soft” steroids (monitor IOP and rule out infection with steroid use) 1. Harrison RJ, Klouda PT, Easty DL, et al. Association between keratoconus and atopy. Br J Ophthalmol. 1989;73:816-822. Meibomian debris . Semi-transparent debris that appears like olive oil floating on water . May be refractile and a yellowish color Management Image credit Lynette Johns, OD . Carefully evaluate and treat the eyelids for any signs of meibomian gland dysfunction or blepharitis . Reduce excessive tear exchange by altering the peripheral curves . Lens removal and reapplication Insertion Fluid . Adjunctive fluids? ▪ Preservative free artificial tears ▪ Autologous Serum ▪ Antibiotics ▪ What does the future hold Nutrient? Electrolyte rich? Oxygenated? Hypertonic? Credit John Gelles, OD, Review of Optometry, Mangan, Amazon, ContaPharm, Wyss Slide credit John Gelles,OD Symptoms “hazy” or “misty” after 3-4 hours of lens wear Possible causes . Poor wetting . Front surface deposits . Debris in the tear reservoir . Corneal edema Important to ask about rainbows around lights, indicative of microcystic epithelial edema or Sattler’s veil Patients may describe a sensation of heat In severe cases, patients report migraine-like headaches Practitioners should be hypervigilant about corneal edema, especially with corneal transplant patients Dispense flashlight or penlight for hourly “rainbow checks” Evaluate how many hours lens wear before the onset of fogging and/or rainbows If symptoms, remove the lens, clean and reapply immediately If vision is clear on reapplication, the cause is more likely related to the lens / fit than corneal response Example of microcystic corneal edema in a failing graft that is retroilluminated from the reflection off an intraocular implant Image credit Contemporary Scleral Lenses: Theory and Application Status post radial keratotomy both eyes three times Corrected to +5.00 Underwent hyperopic LASIK Wore soft contact lenses from 2000 - 2006 Then infection of incision of left eye Treated for 4 months, healed Now poor best corrected vision OD OS 20/50 VA 20/50-2 (CLs) 40.66/35.83/173 Topography 34.35/33.58/160 -14.00 20/60 Refraction -16.50 20/80 Poor endpoint Poor endpoint 584 Pachymetry 567 15 mmHg IOP 14 mmHg tonopen @ 11:00am OD OS 1+ mgd L/L 1+ mgd White and quiet Conj White and quiet 16 RK scars K 16 RK scars (irregular), no (irregular), no visible visible LASIK flap, LASIK flap, iron lines iron lines along RK along RK incisions, incisions, 2mm 2mm optic zone, optic zone inferior neovascularization Deep and Quiet A/C Deep and Quiet Clear Lens Clear 0.30 C/D 0.30 Normal Macula Normal Normal Peripheral Normal Retina Scleral lens parameters OD scleral lens / 7.11 / -17.75 / 15.4 / 8.0 / sag 4.63 20/25-2 OS scleral lens / 7.14 / -17.00 / 15.4 / 8.0 / sag 4.62 20/20-2 Binocular 20/20-2 Prevalence is much higher among women Aging is a risk factor Sex hormones are key factors Changing hormone levels / decreased androgens are contributory 50 year old Caucasian female Interested in contact lenses for full time wear History of Sjögren’s Syndrome ▪ Diagnosed 3.5 years ago Dry mouth Ocular foreign body sensation Intermittent red eyes anti-Sjögren’-syndrome-related antigen A (anti-SSA/Ro) antibody positivity focal lymphocytic sialadenitis with a focus score of at least 1 foci per 4 mm2 abnormal ocular staining score of at least 5 or a van Bijsterveld score of at least 4 Schimer’s test result of no greater than 5 mm per 5 minutes an unstimulated salivary flow rate of no greater than 0.1 mL per minute anti-SSA/Ro and sialadenitis items . Weight of three Remaining three items . Weight of one Individuals with signs or symptoms of Sjogren’s syndrome (SS) and who have a total score of at least 4 for the above items meet the criteria for primary SS. New studies additional autoantibodies in Sjögren's Syndrome to . Salivary gland protein 1 (SP-1) . Carbonic anhydrase 6 (CA6) . Parotid secretory protein (PSP) Occurred earlier in the course of the disease Antibodies found in 45% of patients meeting the criteria for Sjögren's Syndrome who lacked antibodies to Ro or La SP-1, CA6 and PSP . Useful markers to identify patients with Sjögren's Syndrome at early stages of the disease .
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