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 diame ter 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, resulting 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