9/24/2014

That’s a BIG !!

Scleral Contact

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

1 9/24/2014

What makes Sclerals Scleral Lens different?

Rest on the (don’t touch the ) Vault over the cornea Tear Reservoir between the contact lens and the 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 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 Easier to compensate for crazy corneal shapes Cosmetic (albinism, trauma, )

Resurgence Messed Up

Increased O2 permeability of new lens materials New digital manufacturing processes

2 9/24/2014

Vault

Can we fix this cornea Corneal Topography with scleral lens? (normal)

Corneal Topography Corneal Topography (astigmatism) (Keratoconus)

3 9/24/2014

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‐

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

Start Steep Minimal Vault Touch

4 9/24/2014

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 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

5 9/24/2014

Complications Complications

Complications Contact Lens Sagittal height Increased sagittal height steepens corneal‐lens fit

Systemic Conditions that Cosmetic Sclerals Affect CLs Vascular Disorders Pregnancy Birth Control Thyroid Allergy Anti‐histamine use

6 9/24/2014

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

7 9/24/2014

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 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. & 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.

8