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Keratoconus Contact Lens M T Management

Keratoconus Contact Lens M T Management

1/29/2015

Course Outline Keratoconus 1. Keratoconus treatment options Contact • Overview of medical/surgical options • Crosslinking MtManagement • Intracorneal Ring Segments • Penetrating Keratoplasty

Clark Chang, OD, FAAO • Optical rehabilitation Greg DeNaeyer, OD, FAAO • Mechanisms of action • Fitting outcome and expectations

Course Outline Course Outline

2. selection guidelines 3. Specialty soft lenses • General challenges and complications • candidacies • Classifications of contact lens options • Principles of lens designs • Selection criteria • Clinical fitting evaluations and troubleshooting • Patient characteristics • Patient study case(s) • Clinical findings

Course Outline Course Outline

4. Corneal-GP Lenses 5. Piggyback lenses • Patient candidacies • Patient candidacies • Principles of lens designs • Principles of lens designs • Clinical fitting evaluations and troubleshooting • Clinical fitting evaluations and troubleshooting • Patient study case(s) • Patient study case(s)

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Course Outline Course Outline

6. Hybrid lenses 7. Scleral-GP Lenses • Patient candidacies • Patient candidacies • Principles of lens designs • Principles of lens designs • Clinical fitting evaluations and troubleshooting • Clinical fitting evaluations and troubleshooting • Patient study case(s) • Patient study case(s)

Course Outline Keratoconus 8. Current and future clinical development • Lens care systems Contact Lens • Presbyopic corrections in irregular • Wavefront aberrometry applications MtManagement Clark Chang, OD, FAAO Greg DeNaeyer, OD, FAAO

Objectives Objectives

• Keratoconus- defined • Treatment Options • Ectasia- defined • Contact Lens • Classifications Management • KtKeratoconus • Soft • Forme Fruste • Corneal GP • Post-surgical ectasia • Hybrid/Piggyback • • Scleral • PMD • /Wavefront

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Objectives Keratoconus (KC) • Incidence • Risk Factors • Genetic • Hormonal • Enzymatic dysregulation RGP Soft KC Piggyback • Environmental • Eye rubbing • Trauma • Oxidative stress

Recessed CL System Hybrid Scleral

Keratoconus (KC) Keratoconus (KC) • Diagnosis • External • Topography • Munson’s sign • Pachymetry <500 • Slit lamp • Tomography • Vogt’ s Striae • Aberrometry • Fleischer’s Ring • Apical Thinning • Optical Signs • Apical Scar • Signs • Apical Nodule • Hydrops

Keratoconus (KC) Keratoconus (KC)

• Nipple • Break(s) at Oval Decemet’s allows aqueous infusion into stroma • Monitor until resolution, ~3Mth • Scarring process may flatten corneal curvature

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Keratoconus (KC) Keratoglobus

Spectrum phenotypic expression • Keratoglobus • Global • 75-90% of area involved • Typically congenital and rarely acquired

Pellucid Marginal Post-surgical ectasia Degeneration • Refractive • PMD • Topography • Relatively rare • Slit Lamp • LASIK or PRK • Peripheral apex above inferior • Management thinning • Clear tissue typically intervening apex and limbus

Medical Management Surgical Management

• Corneal Crosslinking • Intracorneal Ring • Riboflavin Segments (ICRS) (photosensitizing agent) • Intacs® + UV exposure results • FDA- HDE 2004 in free radical formation • Improve • Age biomechanical • Diabetes support and VA

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Contact Lens (CL) Surgical Management Management • Corneal Transplant • Corneal Crosslinking • 20% KC • Will crosslinking • > 7000 KC in US (2012) decrease severity to • Penetrating the po in t that we need Keratoplasty- PKP GPs less often? • Deep Anterior Lamellar • Influences to surgical Keratoplasty- DALK management options?

CL Management CL Management

• Higher order aberrations (HOAs) • Lower order aberrations • “Masking” • • Residual • Contact Lens • Hyperopia • Posterior •

CL Management CL Management

• Patient Education • Goals • Specialty contact • Vision • Comfort • Short/Long Term lenses Health • Why • Vision • Cost • Two contact lenses • over contact lenses for BCVA

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CL Management CL Management K Irregularity Contact Lens Device Considerations • Specialty Soft Grade I Irregularity Specialty Soft Lens Design • Gas Permeable Corneal GP or Specialty Corneal GP Grade II Irregularity Specialty Soft Lens or Corneal GP Design • Corneal (ilfiid/VAi)(potential fitting and/or VA compromises) Corneo- • Scleral Mini-Scleral or hybrid Lens • Piggyback Grade III Irregularity Corneo-Scleral Lens (potential fitting difficulties) • Hybrid Mini-Scleral or hybrid Lens Full-Scleral Lens Gade IV Irregularity Mini-Scleral or hybrid Lens (potential fitting difficulty) Full-Scleral Lens Denaeyer G. Managing Irregular Cornea Patients. Contact Lens Spectrum. April 2012.

CL Management- CL Management Specialty Soft • Yamazaki (2006) • 66 KC/80 eyes • Mild to advanced KC • 91% achieved better than 20/40 with a specialty KC soft lens design • Corneal Transplant • Scar • Comfort

Soft Lenses for KC Soft Specialty KC Lenses

• Soft Lenses • Soft Specialty Lenses • Standard designs • Lathe cut • Forme Fruste KC • Extended BC/Power ranges • Spectacle • Increased center thickness Responses • Large OZ to enhance draping • Unable to • Adjustable secondary curve(s) accommodate • Hydrogel vs SiHy HOAs induced by moderate to • Wavefront-Guided correction severe KC

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Soft Specialty KC Lenses Soft Specialty KC Lenses • Enhanced thickness • Base Curve masks mild-moderate • As steep as 4.1mm degree of corneal irregularity • Rx Range • Corneal draping • SPH: Up to ± 30D mechanism available • Cyl: Up to -15.00 D

• Center Thickness • 0.3mm to 0.6mm • Fixed or Variable

Soft Specialty KC Lenses Soft Specialty KC Lenses • Secondary Curves: Independently adjustable • Geometry customizations • Alignment with disproportional eccentricity • Essential to lens performances in KC (De Brab an der e t a l, 2003) • Lenticularization • Improves comfort & Oxygen delivery

Topography without CL Topography over a 0.48mm thick soft KC CL BSCVA = 20/40 BCVA = 20/25

Soft Specialty KC Lenses Soft Specialty KC Lenses

• Wavefront guided soft lenses • Marsack et al. refit patient into wavefront guided soft lenses • VA improved 1.5 lines • HOA reduced 50% • Hurdles • Translation/Rotation Topography and Wavefront over 0.48mm soft KC lens • Neural Adaptation

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Soft Specialty KC Lenses Soft Specialty KC Lenses Soft Contact Lenses for Keratoconus • Material selection Manufacturer Lens • Hydrogel Alden Novakone • Maximize Oxygen Acculens Soft K Advanced Vision Technologies Soft K • Lens Movement Art (distributed from B&L) Kerasoft • Lenticularization Continental S L Continental Cone Gelflex USA Keratoconus Lens Marietta Vision Soflex Soft • SiHy Ocu‐Ease/Optech OCU‐FLEX K SLIC Soft K • Monitor United Contact Lens UCL‐55 XCel Contacts Tricurve Keratoconus • CLPC Visionary Optics Hydrokone • CIE UltraVision CLPL Kerasoft World Vision Perfect Keratoconus

Soft Specialty KC Lenses Soft Specialty KC Lenses

• Empirical Fitting • Initial BC selection • Follow design specific • Diagnostic Fitting formulary • Lens fitting set • Flatter than you think • Manufacturers • Sagittal depth guidelines • 1st diagnostic lens will be your guide.

Soft Specialty KC Lenses Case Example- LM Dynamic Assessment OD • 34 YO female KC • Centration • MR • Comfort • OD -2.50 – 5.75 x 090 20/40 • Movement • OS -2502.50 – 0. 50 x 097 20/20 • 1mm movement • OD OS • Rotation • Previous scleral lens • Prism ballast • OS • Double slab off • Oasys 8.4 -3.00 • Vision • No fluctuation with blinking.

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Case Example- LM Case Example LM • Specialty soft fit OD • Video • During dispense • NaFl Video • Diagnostic Lens • 15.0mm • Dia:15.0mm • BC: 8.5/8.3 • 8.5/8.0 • Power +2.50 -5.75 X 090 • +0.62 -4.50 X 085 20/30 • OR -0.50 +1.50 X 014 • OR +1.00 • Excessive Movement • Fit Evaluation • 8.5/8.0 • Final • +1.62 -4.50 X 085 20/25

Soft Specialty KC Lenses –Take Home • Many new designs available • Wide range of Sph and Cyl Rx available • Fitting requirements differ from regular soft • For some KC patients, specialty soft lenses might be a first option • Typically Mild – Moderate KC • Alternative for those who failed GPs • Realistic expectations for outcome

GP Lenses for KC GP Lenses for KC

• The firm nature of GP allows the underlying tear layer to seamless connect both refractive surfaces

CL + Increasing corneal irregularity often requires an Tear Lens increase in diameter for a successful fit

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GP Lenses for KC Corneal GP Lenses

• Guided by • Small • 8.0mm to 9.0mm • MdiMedium • 9.0mm to 10.0mm • Large • 10.0mm to 11.5mm

Corneal GP Lenses Corneal GP Lenses • Trends in corneal GP • Lens selection • Larger Diameters guided by • Weight distribution • Disease severity • Stability/Position • Cone location • HOA Reduction • Cone area • Aspheric Optics • Elevation • Lens Weight • Eccentricity • Posterior OZ alignment • Ocular adnexa • Spherical Aberration • Handling skill • Asymmetrical PCs • Stability/Position • Comfort

Corneal GP Lenses Corneal GP Lenses • Advantages • Consultation or Empirical fitting • Lens Handling • Diagnostic fitting Recommended!! • Application/Removal • Initial BC selection • Durability • Fitting guide • Cost • Topography/Keratometry • Disadvantages • Irregularity scale • Medium Lens • Adaptation time • Dislodgement • Bracket with NaFL • FB entry • Central Alignment • Non-compliance in • AEL replacement and care • Centration

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Corneal GP Lenses Corneal GP Lenses • Central bearing or Clearance • 3 point touch • Vision • Shared distribution of • Comfort bearing pressure • Corneal Health between the • Corneal bearing center and the • Dynamic tear exchange mid-periphery • 3’ & 9’ staining • Edge impingement • Edge standoff

Corneal GP Lenses Corneal GP Lenses

• Is apical bearing acceptable? • Patient Case: JR • CLS- GP Insights November 2011 OD • 44 year-old Female • Comfort • Mild/Moderate KC • Vision • Topography • Health • SLE • Discussed Options

Corneal GP Lenses Corneal GP Lenses • Patient Case: JR • Patient Case: JR • Bi-aspheric • Front surface toric • Diagnostic lens fit • Ballasted with double slab-off bracketing base curve • Final CL Rx =- 2.00 -1.25 X 015 20/25 selection. • Lens ordered • BC = 7.35mm (46 diopters) • Diameter = 10.4mm • Power = -4.00 20/50 • OR = +2.00 -1.25 X 015

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Corneal GP Lenses Piggybacking Corneal GP • Decentration • Piggyback • Vision • Potential Advantages • Comfort • Comfort • Lens Dislodgement • Corneal Health • Lens Expulsion • Lens Position • VA • Troubleshoot • Potential Disadvantages • Sag depth • Hypoxic concerns • Optical Zone • Handling complexity • Secondary curves • Daily Disposables • Lid Attachment • Consider SiHy • Different Lens Designs • Specialty lathe cut

Piggybacking Corneal GP Piggybacking Corneal GP

• Patient Case: DT OS • Patient Case: DT 2012 • 35 year-old female • RTC in 2012 • mild/moderate KC • Growing intolerance

• 9. 6mm/6. 75(50D) 2009 • Rx: -12.00 20/30

2007 2009 2012

Piggybacking Corneal GP Hybrid Lenses: 1977-2007 • Patient Case: DT • CL options discussed • High molecular NaFL! • Initial Refit, and • Follow-ups • May continue using

same GP design or can • Saturn® lens invented in 1977, and FDA approval in 1984 improve current GP fit • SoftPerm® released in 1986 & expanded parameters in 1989 • Soft lens Rx contributions • Early generations with reported incidences • Cost • Junctional Rippage • Tight & Immobile Lens • Disposable preferred • Reduced Tear Exchange • Hypoxia

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Hybrid Lenses: 2005- Present Hybrid Lenses: 2005- Present

• Redefining hybrid platform • Fitting Parameters: Central and junctional SAG depth • Metabolic requirements: Higher gas diffusion constant • Comfort/Cost/Compliance: Junctional adherence • Comfort: Surface wetting chemistry

CLEK Study: Central (AKA Nipple) ~15-20%

Hybrid Lenses: 2005- Present Hybrid Lenses: 2009- Present

• New Reverse Geometry Designs • Further improved central and junctional Sagittal depth • SiHy skirt available (2013- Present)

Oval ~ 50-60% Globus/PMD ~20%

Hybrid Lenses: 2009- Present Hybrid Lenses: 2009- Present

Image Courtesy of Lens Optical Technology, UZA Post- PRK Ectasia, spCXL

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SoftPerm® Clearkone® UltraHealthTM Hybrid Lenses: 2009- Present Diameter 14.3 mm 14.5 mm 14.5 mm Diameter (GP) 8.0 mm 8.4 mm 8.4 mm dK (GP) 14 100 130 Wetting Angle (GP) N/A 420 340

UV-A Block (GP) N/A 0% 82% UV-B Block (GP) N/A 0% 96.7% Modulus/Mpa (GP) N/A 1150 1314

dK (Soft Skirt) 5.5 9.3 84 Courtesy of Jeff Sonsino, OD, FAAO Wetting Angle N/A N/A 25-350 (SCL) Modulus/Mpa N/A 0.7-0.8 0.5-0.8 (SCL)

Hybrid Lenses: 2009- Present Hybrid Lenses: Case 1

• Reverse Geometry with Hydrogel Skirt • Pt JW, 19 y/o • 77.8% (14/18) success in post-Intacs study (Shin A, Chang C, and Fry K, 2012) • KC OU, post CXL OS

• 83% (N=33 KC) reported good VA and comfort with • OD with good GP Clear kone ® Vs. ha bitual CL (C arrace do G e t a l, 2014) tltolerance • HCVA improved ≥1 line in most of habitual GP wearers • Pachymetry values remained constant thru 1-Mth study period • OS GP dislodges and Piggyback OS still • Significant higher scores in NEI-VFQ 25 despite comparable VA outcome as habitual GPs (Heshemi H et al, 2014) does not reach full • Ocular • Vision Specific Mental Health time wear as OD GP • General Vision • Distance Activitities • Total Score

Hybrid Lenses: Case 1 Hybrid Lenses: Case 1

New hybrid lens with Silicone Hydrogel New hybrid lens with Silicone Hydrogel

UH/250mi/Flat UH/350mi/Flat UH/350mi/Flat

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Hybrid Lenses: Case 1

New hybrid lens with Silicone Hydrogel

UH/300mi/Flat

Scleral Lenses Hybrid Lenses: 2009- Present

Scleral Lenses Scleral Lenses

• Advantages • Centration • Stability • Fitting • Comfort • Disadvantages • Case examples • Application/Removal • Troubleshooting • Reservoir debris • Cost

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Standard Scleral Scleral Lenses Designs • Fitting Philosophy • Diagnostic Lens • Formula • Inside Out • Corneal Zone • 100 to 400 m icrons of corneal vault. • Limbal Zone • Scleral Zone • Haptic alignment

Scleral Lenses Scleral Lenses

• Scleral sag Calculation Method • Dx Lens Application

• Topography sag @ 10mm: • Fill with • Stain the saline with • Scleral sag factor: a fluorescein strip

2000um • Initial apical clearance: 400um

• Required Scleral Lens: 4300um

Patrick Caroline, FAAO, FCLSA, FIOS Randy Kojima, FAAO, FSLS, FIOS Pacific University College of

Scleral Lenses Scleral Lenses

• Assessing lens vault • Assessing lens vault • Comparing the thickness of the scleral lens with the thickness of the reservoir by turning the slit beam at a 45 degree angle

Josh Lotoczky, OD; Chad Rosen, OD; Craig W. Norman, FCLSA (Vision Research Institute, Michigan College of Optometry)

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Scleral Lenses Scleral Lenses

• Assessing lens vault • Assessing lens vault

Josh Lotoczky, OD; Chad Rosen, OD; Craig W. Norman, FCLSA (Vision Research Institute, Michigan College of Optometry)

Scleral Lenses Scleral Lenses

• Be aware of the influences of lens • Bracket the lens fit until the stained settling reservoir is 200 • Scleral lenses rests microns more than the on the spongy desired final vault bulbar • Expect the lens to • Bracket by 2 to 6 D lose up to 200 µm steps (vary with designs)

Scleral Lenses Scleral Lenses

• Haptic Examination • Special KC • Ideally, haptic Considerations section of a scleral lens should align • Keratoglobus evenlthlly on the • Sagitt al d ep th • Without • Steepness is to compression or the outside impingement of the • Large optic zones bulbar conjunctiva • Reverse geometry

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Scleral Lenses Patient SA

• Hydrogen Peroxide • 68 year-old KC OD OD • Saline • s/p surgery OU • New glasses- no help OS • PtitPatient was off ered a PK from an Ophthalmologist. OS • Optometrist unsuccessful with soft contact lens? • Referred for consultation.

Patient SA Patient SA

• New glasses • Lens Options • OD +1.00 -3.50 X 040 20/25 • Specialty Soft • OS +1.50 -2.25 X 072 20/200 • Corneal GP • HbidHybrid • Slit Lamp • Scleral • Cornea clear OU • Advantages • Disadvantages

Patients SA Patient SA

• Scleral 18.0 46 diopter 50 diopter • 9.0 OZ • Reverse geometry designs • CT= 0.49 • Where to start?

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Patient SA Patient SA

• Base Curve= 50 diopters • Daily Wear • Diameter= 18.0mm • Fills with 0.9% • Standard periphery NClNaCl • Power= -5.75 (OR= • Clear Care® +2.50) • Final Power= -3.25 20/30

Patient MM Patient MM

• 47 YO KC • OD • OS • ICRS OU 2009 • MR • OD -6506.50 -1. 00 X 168 20/200 • OS -12.50 sph 20/200 • OD Corneal GP • OS D/C GP

Patient MM Patient MM

• Topos OD • Topos OS • Scleral Lens Fit OD • 16mm • OD Dx Lens • 48D/-3.25 • OR –11.25

• OS Dx Lens • 50D/-4.25 • OR -13.75

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Patient MM Patient MM

OD OS 16mm 16mm 48 diopter 48 diopter -13.25 20/25 -13.25 20/25

Patient DS Patient DS

• 46 YO KC OD OS • MR • OD +1 . 00 -2. 50 X 037 20/40 • OS +1.00 – 2.00 X 111 20/60 • Uncomfortable with GP lenses

Patient DS Patient DS

• OD Topo • OD HVID OS OS

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Patient DS Patient DS

OD 16mm 50 diopter -4.25 OR -5.50

Patient DS Patient DS OD 50 • 16.5mm • OD • BC= 49 diopters • Power -8.50 • OS • BC= 50 OS 50 OS • Power -9.75 16mm 50 diopter -4.25 OR -5.75

Patient DS Patient LC

• 56 year-old keratoglobus • PK OS

OD 16.5mm 49D/-8.50 20/40 OR +1.00 20/30

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Patient LC Patient LC • Keratoglobus • “Difficulty” with • Generally require a lens hybrid contact with a large OZ and lens reverse geometry profile. • 20/40 (hybrid/specs) • “Monster Kone” • Dia= 20mm • OZ= 10mm • Reverse geometry • 4 peripheral curves

Patient LC Patient LC

BC= 54 BC=56 • 1st diagnostic lens • BC= 52 diopters • Needs more sagittal depth.

Patient LC Patient LC • Dia=20.00mm • BC = 55 diopters • OZ = 10.0mm • 4D of reverse • Power = -20.50 • OR -1.75 • Total sag = 7.68mm • Dispense • Power= -22.25 20/30

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Future- Customization Multifocal Contact rotation: 0.7 deg • KC • BCVA • HOA D dy=1.48 • Lens centration D N D D dx=1.19

Future- Customization

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