Scleral lenses presentation final (1)

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Innovations in Managing Complex Irregular Corneas, presented by Fernando Auza, OD
Visionary Ophthalmology
Lecture Series 11th
Feb 20th 2011

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Scleral lenses presentation final (1)

  1. 1. Managing Complex Irregular Corneas with Scleral Contact Lenses Fernando Auza, O.D. Visionary Ophthalmology Lecture Series 11 February 20, 2011
  2. 2. Scleral Lenses Beyond the Borders <ul><li>Large diameter contact lenses that have their resting point beyond the corneal borders </li></ul><ul><li>Believed to be among the best vision correction intervention among contact lenses for irregular corneas </li></ul><ul><li>Decrease the risk for corneal scarring. </li></ul>
  3. 3. Terminology Alternative Names Diameter Bearing Tear Reservoir Corneal 8.0 to 12.5mm Cornea No Tear Reservoir Corneo-Scleral Corneal-Limbal Semi-Scleral Limbal 12.5 to 15.omm Cornea and Sclera Limited tear reservoir Full Sleral Haptic Miniscleral 15.0-18.0 Large Scleral 18.0 – 25.0 Sclera Tear reservoir directly related to size of haptic
  4. 4. Indications <ul><li>Vision improvement </li></ul><ul><li>Corneal protection </li></ul><ul><li>Cosmesis </li></ul>
  5. 5. 1. Vision Improvement – Main indication <ul><li>Primary corneal ectasias - largest segment </li></ul><ul><ul><li>Keratoconus </li></ul></ul><ul><ul><li>Keratoglobus </li></ul></ul><ul><ul><li>Pellucid Marginal Degeneration </li></ul></ul><ul><li>Secondary corneal ectasias/Post-surgical corneas </li></ul><ul><ul><li>Post-LASIK and post-PRK </li></ul></ul><ul><ul><li>Corneal grafts </li></ul></ul><ul><ul><li>Irregular corneas due to trauma </li></ul></ul>
  6. 6. 2. Corneal Protection <ul><li>Severe ocular surface disease </li></ul><ul><ul><li>Sjogren’s syndrome </li></ul></ul><ul><ul><li>Persistent epithelial corneal defects </li></ul></ul><ul><ul><li>Steven’s Johnson Syndrome </li></ul></ul><ul><ul><li>Graft Versus Host Disease </li></ul></ul><ul><ul><li>Cicatricial pemphogoid </li></ul></ul><ul><ul><li>Neurotrophic Ulcers </li></ul></ul><ul><li>Incomplete lid closure </li></ul><ul><ul><li>Eyelid coloboma </li></ul></ul><ul><ul><li>Exophthalmus </li></ul></ul><ul><ul><li>Ectropion </li></ul></ul><ul><ul><li>Nerve palsies </li></ul></ul>
  7. 7. 3. Cosmesis <ul><li>Hand painted scleral lenses </li></ul><ul><ul><li>Aniridia </li></ul></ul><ul><ul><li>Albinism </li></ul></ul><ul><ul><li>Nanophthalmus </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>
  8. 8. Scleral Lenses Vs Regular GP’s <ul><li>Scleral lenses are very comfortable </li></ul><ul><li>Reduce risk of scaring -CLEK study determined risk factors for corneal scaring in Keratoconus </li></ul><ul><ul><li>Corneal curvature > 52.00D </li></ul></ul><ul><ul><li>Contact lens wear </li></ul></ul><ul><ul><li>Marked corneal staining </li></ul></ul><ul><ul><li>Patient age less than 20 years </li></ul></ul><ul><li>Scleral lenses have large optical Zones and center better than corneal GP’s </li></ul>
  9. 9. Scleral lenses and Surgery <ul><li>The National Keratoconus Foundation estimated that 15-20% of keratoconus patient will eventually undergo surgery </li></ul><ul><li>Many post-PK patients still need CL’s to restore vision </li></ul><ul><li>A study by Smiddy et al (1988) found that 69 percent of patient who were referred for keratoplasty could be succesfully fitted with contact lenses prolonging the need for surgery </li></ul><ul><ul><li>Keratoconus. Contact lens or keratoplasty? Ophthalmology. 1988 Apr;95(4):487-92. </li></ul></ul><ul><ul><li>Evaluate all contact lens options including scleral lenses before considering surgery </li></ul></ul>
  10. 10. Keratoconus. Contact lens or keratoplasty? Ophthalmology. 1988 Apr;95(4):487-92. <ul><li>190 eyes with keratoconus, all referred for keratoplasty after CL’s had no longer been successfull </li></ul><ul><li>25(13%) could not be fitted </li></ul><ul><li>165(87%) - successfully fitted </li></ul><ul><li>51(31% of 165) -PK after an average of 38.4 months of CL wear </li></ul><ul><li>114(69%)- no PK over an average follow up time of 63 months </li></ul>
  11. 11. Anterior Ocular Anatomy <ul><li>Average corneal diameter of 11.8mm </li></ul><ul><li>24mm -the maximum diameter a scleral lens can have </li></ul>7.5mm 7.0mm 5.5mm 6.5mm
  12. 12. Limbal and Anterior Scleral Shape <ul><li>Corneo-limbal-scleral transition is often tangential rather than curved </li></ul>
  13. 13. Limbal profiles <ul><li>Two most commonly occuring limbal profiles </li></ul><ul><ul><li>Profile 2 (gradual-tangential) followed by profile 3 (marked –convex) </li></ul></ul><ul><ul><li>Die Kontaklinse by Rott-Muff (2001) </li></ul></ul>Daniel Meier/die Kontaktlinse
  14. 14. Limbal profiles <ul><li>Study of 46 eyes concluded an even distribution of gradual vs. marked transitions </li></ul><ul><ul><li>Van der Worp E, (2010b) Exploring Beyond the Corneal Borders, Contact Lens Spectrum; 6, 26-32 </li></ul></ul>Contact Lens Spectrum, June 2010
  15. 15. Limbal and Scleral Angles; the Scleral Shape Study <ul><li>96 eyes normal eyes </li></ul><ul><li>OCT measurements in eight directions </li></ul><ul><li>Concluded: </li></ul><ul><ul><li>Corneal-limbal zone – straigh in most cases </li></ul></ul><ul><ul><li>Anterior scleral shape – tangential in most cases </li></ul></ul><ul><ul><li>Within limbal zone – difference in angles are small (on average 1.8 degrees or 108microns) </li></ul></ul><ul><ul><li>Within scleral zone – difference in angles larger (on average by 6.6 degrees or 400microns) </li></ul></ul>
  16. 16. Simmulated Scleral Topography based on the Scleral Shape Study
  17. 17. Scleral Lens Design <ul><li>The optic zone </li></ul><ul><li>The transitional zone </li></ul><ul><li>The landing zone </li></ul>Contact Lens Spectrum; Dec. 2009
  18. 18. The Haptic/Landing Zone <ul><li>Area in touch with anterior ocular surface </li></ul><ul><li>Ideally mimics the shape of the sclera </li></ul><ul><li>Some designs specify landing zone radius of curvature , others as landing angles . </li></ul><ul><li>Size of landing zone can be increased to improve comfort and stability </li></ul>
  19. 19. Fitting Spherical Scleral Lenses – Four Step Approach <ul><li>Chose diameter </li></ul><ul><li>Establish central and limbal clearance </li></ul><ul><li>Landing zone alignment </li></ul><ul><li>Adequate edge lift </li></ul>
  20. 20. Chosing the Diameter <ul><li>Depends on anterior ocular sagittal height </li></ul><ul><li>Factors affecting sagittal height evaluate: </li></ul><ul><ul><li>Corneal curvature </li></ul></ul><ul><ul><li>Asphericity </li></ul></ul><ul><ul><li>HVID </li></ul></ul><ul><ul><li>Shape of anterior sclera – difficult do evalluate </li></ul></ul><ul><li>Common diameter used in the US is 15-18mm </li></ul>
  21. 21. Optical/Clearance Zone Diameter <ul><li>Optical zone important to provide good optical outcome and corneal clearance </li></ul><ul><li>Clearance zone = optical zone + transition zone </li></ul><ul><ul><li>Usually 0.2mm larger than HVID </li></ul></ul><ul><li>Size depends on lens designs </li></ul><ul><li>Can be altered to improve corneal and limbal clearance </li></ul>
  22. 22. Clearance <ul><li>Up to 600 microns of corneal clearance can be easily achieved if needed centraly </li></ul><ul><li>Large or small sagittal height should be used instead of steep or flat </li></ul><ul><li>Minimum of 100microns is the desired at any place </li></ul><ul><li>Sagittal depth differs with the condition </li></ul><ul><ul><li>Ectasia needs less than post-corneal grafts </li></ul></ul><ul><ul><li>Ocular surface disease management requires large sagittal height </li></ul></ul>
  23. 23. Evaluating corneal clearance <ul><li>Start with low sagittal height and gradually increase height to desired clearance </li></ul><ul><li>A green fluorescein pattern will be visible. </li></ul><ul><li>Use a thin optical section with brightest illumination setting at a 45 degree angle </li></ul><ul><li>If CCT known, compare corneal thickness to tear layer thickness to estimate clearance </li></ul><ul><li>If CCT not know, assume a 530micron cornea and compare to the slit </li></ul>
  24. 24. <ul><li>LS11 InmagesLS slit scan.AVI </li></ul>
  25. 25. Evaluating Central Corneal Clearance 50microns 250microns 500microns
  26. 26. Evaluating peripheral corneal clearance <ul><li>Ideally no touch and limbal clearance should be obtained </li></ul><ul><li>If clearance is < 20microns, clinician may not be able to indentify underlying fluorescein band – look for staining </li></ul>Trace limbal touch Limbal clearance
  27. 27. Limbal Clearance <ul><li>Avoid mechanical pressure in the limbal area </li></ul><ul><li>If good central clearance achieved but limbal clearance is absent change the limbal clearance zone </li></ul><ul><ul><li>Flattening BC – reduces pressure </li></ul></ul><ul><ul><li>Change transition zone angle </li></ul></ul><ul><ul><li>Increase OZ diameter </li></ul></ul>
  28. 28. Landing Zone Fit <ul><li>Aligning the periphery of the lens with the scleral shape </li></ul><ul><li>A ring of bearing on the inner part of the landing zone indicates a flat landing zone </li></ul><ul><li>A ring of bearing on the outer part of the landing zone indicates a steep landing zone </li></ul><ul><li>Increasing the size of the landing zone relieves pressure if needed </li></ul>
  29. 29. Lens Edge Lift <ul><li>Assess lens edge lift after 30 minutes of lens installation during fitting process </li></ul><ul><li>Also assess lens edge after 3-4 hours of lens wear </li></ul><ul><li>Two easy methods </li></ul><ul><ul><li>Push-in method (video) </li></ul></ul><ul><ul><li>Remove lens and evaluate surface with fluorescein staining </li></ul></ul>
  30. 30. <ul><li>LS11 InmagesLS edge lift.AVI </li></ul>
  31. 31. Conjunctival Impingement Courtesy of Cristine Sindt, OD, FAAO
  32. 32. Conjunctival Blanching
  33. 33. JC, 16y/o male presents for CEE <ul><li>Patient interested in contact lenses </li></ul><ul><li>Plays football and lacrosse </li></ul><ul><li>MR </li></ul><ul><ul><li>OD: -1.00-3.75x005 20/20 </li></ul></ul><ul><ul><li>OS: -0.25-2.25x003 20/20 </li></ul></ul><ul><li>Keratometry </li></ul><ul><ul><li>OD: 40.9/44.8@095 </li></ul></ul><ul><ul><li>OS: 41.3/44.7@090 </li></ul></ul><ul><li>HVID: 12.0mm </li></ul>
  34. 35. Soft Contact Lens Trial <ul><li>Freq 55 Toric/8.4 </li></ul><ul><ul><li>OD: -1.00-3.75x180 20/25 Slow </li></ul></ul><ul><ul><li>OS: Plano-2.25x180 20/20-2 </li></ul></ul><ul><ul><li>Excessive movement >3mm, unstable rotation OU </li></ul></ul><ul><ul><li>Unstable VA </li></ul></ul><ul><li>Soft Lens Toric </li></ul><ul><ul><li>OD: -1.50-2.75x180 20/20-2 </li></ul></ul><ul><ul><li>OS: Plano – 2.25x180 20/20-2 </li></ul></ul><ul><ul><li>Unstable rotation and Vision </li></ul></ul>
  35. 36. Discussed Regular GP’s and Scleral Lenses <ul><li>Jupiter 15.6 </li></ul><ul><ul><li>OD: 7.11/-9.00/15.6mm/Standard periphery </li></ul></ul><ul><ul><ul><li>Great fit, 20/20 </li></ul></ul></ul><ul><ul><li>OS: 7.18/-8.00/15.6mm/12.75 Int.Zone/14.25 Peripheral zone - 20/25 – unstable </li></ul></ul><ul><ul><ul><li>Overall corneal and limbal clearance </li></ul></ul></ul><ul><ul><ul><li>Loose peripheral fit and excessive edge lift </li></ul></ul></ul><ul><ul><ul><li>Excessive movement and unstable vision </li></ul></ul></ul><ul><ul><li>OS: 7.18/-8.00/15.6/12.25Int.Zone/13.75 peripheral zone – 20//20 (Stable) </li></ul></ul>
  36. 37. ID, 43y/o female presents for corneal evaluation <ul><li>Blurry vision with Specs and unable to wear CL’s </li></ul><ul><li>OcHx: Keratoconus OU, s/p PK OU 20 years ago </li></ul><ul><li>MR; OD: -13.75+3.00x117 20/70 </li></ul><ul><li> OS: -10.00+500x046 20/100 </li></ul><ul><li>Dx: </li></ul><ul><ul><li>S/P PK OU </li></ul></ul><ul><ul><li>Recurrent Keratoconus </li></ul></ul><ul><li>Plan: </li></ul><ul><ul><li>PK OS </li></ul></ul><ul><ul><li>Contact Lens OD </li></ul></ul>
  37. 39. <ul><li>Rose K2 IC 5.82/11.20mm </li></ul><ul><li>Lens flat centrally </li></ul><ul><li>Manufacture unable to produce a steeper curve </li></ul>
  38. 40. <ul><li>Jupiter 16.0 /6.25mm/54.00D/-9.50 </li></ul><ul><li>20/25+ </li></ul><ul><li>Central Touch/Good limbal clearance/ loose peripheral fit (Video) </li></ul><ul><li>Ordered </li></ul><ul><ul><li>Jupiter 16.0/6.25/-12.25/ 9.0 OZ/Steeper tertiary curves (raise SH by 110microns) </li></ul></ul><ul><ul><li>Obtained 100microns of central clearance, limbal clearance and adequate scleral landing </li></ul></ul><ul><ul><li>VA 20/20-1 </li></ul></ul><ul><ul><li>WT:10hrs/day comfortably </li></ul></ul>
  39. 41. LB, 28y/o female <ul><li>Blurry vision OU, spectacles do not help. </li></ul><ul><li>OcHx: RK OU and LASIK OU four times </li></ul><ul><li>VAsc: OD 20/80 OS:20/80 </li></ul><ul><li>MR: </li></ul><ul><ul><li>OD -5.50+500x175 20/70-1 </li></ul></ul><ul><ul><li>OS:-150+2.25x005 20/60-2 </li></ul></ul><ul><li>Cornea has 6 radial and 6 radial incisions OU </li></ul>
  40. 44. <ul><li>OD: RSS 9.92/7.67/10.5 </li></ul><ul><li>OS: RSS 9.62/7.67/10.5 </li></ul><ul><li>Both lenses decentered up and temporal </li></ul><ul><li>Poor vision and excessive inferior lift </li></ul>
  41. 45. OD:Jupiter 15.6/7.18/-7.00 OR -17.00 20/30 453microns 300microns 6.5mm OS: 7.03/-8.00/15.6 OR -24.00 20/50
  42. 46. Ordered <ul><li>OD: Jupiter 7.03/16.6/-14.75/8.6OZ/Steeper Transition zone </li></ul><ul><li>OS: Jupiter 7.50/16.6/-5.00/8.6 OZ/Steeper transition zone </li></ul><ul><li>Larger diameter and steeper transition zone will raise sagittal depth corneal periphery keeping same corneal clearance </li></ul>
  43. 47. <ul><li>Scleral lenses can help delay surgery </li></ul><ul><li>Most difficult corneas can be successfully fitted with scleral lenses </li></ul><ul><li>http://commons.pacificu.edu/mono/4/ </li></ul><ul><li>Thank you! </li></ul>

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