9/24/2014
That’s a BIG lens!!
Scleral Contact Lenses
MOA Convention 10.4.2014 Chris DeRose, OD
Average Corneal Size matters diameter = 11.5mm Average RGP lens = 9.5 mm
Soft Contact lens = 14.0 to 14.5mm
Mini‐scleral lens = 15.0 to 18.0mm
Scleral lens = 18.0 to 24.0mm
RGP Soft Contact Lens
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What makes Sclerals Scleral Lens different?
Rest on the sclera (don’t touch the cornea) Vault over the cornea Tear Reservoir between the contact lens and the eye Insertion and removal process
So What? Advantages
Who is a good patient for scleral lenses? No corneal touch = no chance of worsening scar progression Corneal irregularity Corneal scarring or post trauma No corneal contact and less movement = less Keratoconus awareness (kinda) S/P refractive surgery Tear reservoir can be therapeutic Advanced dry eye or incomplete lid closure (exposure) S/P Corneal transplant Better VA (sometimes dramatic) Extreme astigmatism Easier to compensate for crazy corneal shapes Cosmetic (albinism, trauma, aniridia)
Resurgence Messed Up Corneas
Increased O2 permeability of new lens materials New digital manufacturing processes
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Vault
Can we fix this cornea Corneal Topography with scleral lens? (normal)
Corneal Topography Corneal Topography (astigmatism) (Keratoconus)
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Corneal Topography Fitting (?)
Must be fit Fitting diagnostically Alignment with sclera No bearing on limbus Based on sagittal height Little to no movement Must settle for 30 minutes No conjunctival impingement Spherical over‐refraction
Vault Reduction Therapeutic Sclerals
Tear Reservoir promotes healing in Ocular Surface Disease Sjogren’s Stevens Johnson Syndrome Graft vs Host Ocular cicatricial pemphigoid Neurotrophic corneal disease Exophthalmos Ectropion Eyelid Coloboma
Start Steep Minimal Vault Touch
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Insertion and Removal Insertion and Removal
Insertion and Removal Insertion and Removal
Fill the lens with non‐preserved saline Must break the negative pressure underneath Place lens on formed "tripod" (thumb, index, and the lens middle finger) or use scleral cup Manual method – Using fingers, guide eyelid margin under the bottom Position face parallel to a horizontal plane, typically edge of the lens. This will break suction and allow lens the table/mirror and open eyelids wide using to come out opposite hand. Plunger method – Insert lens edge into lower cul‐de‐sac while pushing Place the plunger on bottom portion of lens the lens onto cornea NEVER place the plunger centrally on lens –may result in corneal damage
Insertion and Removal
Use anesthetic for initial lens dispense Study: Reduces long term drop outs by 75%
Patients may be intimidated by size of lens and handling –Doc presentation is the key
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Complications Complications
Complications Contact Lens Optics Sagittal height Increased sagittal height steepens corneal‐lens fit
Systemic Conditions that Cosmetic Sclerals Affect CLs Diabetes Collagen Vascular Disorders Pregnancy Birth Control Thyroid Eye Disease Allergy Anti‐histamine use
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Cosmetic Sclerals Hollywood Sclerals
Hollywood Sclerals Why fit scleral lenses?
Differentiate your practice Incredibly grateful patients = more referrals Full scope of professional practice More referrals from Ophthalmology/cornea
Case Case
Patient AW ‐ 55 year old Male + Severe Keratoconus OD > OS Has been wearing Rose K lenses OU for many years Lenses have begun to spontaneously eject VA cCLs: OD 20/40‐ OS 20/40 BVA with specs: 20/400 OD, OS
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Case Case
Slit lamp: Refit to scleral lens –diameter 18.0 mm Central corneal scarring OD > OS BVA cCL: OD 20/30 OS 20/30+ Significant apical thinning OU 2‐3+ central SPK OU 16 hours of comfortable wearing time Refit to SynergEyes Ultrahealth hybrid CL No corneal contact on central scarring Poor comfort and limited wear time Significant protein build‐up on lenses
Case References
ES, Barr JT, Szczotka‐Flynn LB. Keratoconus. In: Clinical Manual of Contact Lenses.
Bennett and Henry, Wolters Kluwer, 4th ed. 2014; Chapter 1: 518–577.
DeNaeyer G, Breece R. Fitting techniques for a scleral lens design. Contact Lens Spectrum. 2009; 1: 34–37.
DeNaeyer G. Scleral contact lens fitting. Contact Lens Spectrum. 2010; 6: 20–25.
DeNaeyer G, Jedlicka J, Schornack MM. Scleral Lenses. In: Clinical Manual of Contact Lenses.
Bennett and Henry, Wolters Kluwer, 4th ed. 2014; Chapter 21: 609‐647.
Eggink FAGJ, Nuijts RMMA. Revival of the scleral contact lens. Cataract & Refractive Surgery Today Europe. 2007; 9: 56–7
Jacobs DS. Update on scleral lenses. Current Opinion in Ophthalmology. 2008; 19: 298–301
Kalwerisky K, Davies B, Mihora L, et al. Boston Ocular Surface Prosthesis in the management in severe periorbital thermal injuries: a case series of 10 patients. Ophthalmology. 2012; 119: 516‐521.
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