contact lenses - eyeness€¦ · optics and physiology whatever contact lens you fit, always...
TRANSCRIPT
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Dr. M i c h a e l B a e r t s c h iPhD (Biomedicine), MSc.Optom. et M.med.Education, FAAO, FEAOO
eyeness ag, Bern / Switzerland
Contact LensesSwiss Eye Week 2020
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eyeness AG
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eyeness Team
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www.eyeness.ch/downloads
D o w n l o a d
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DisclosuresStudien für: Consulting Mandate:
Abbott Falco Kontaktlinsen
Alcon Vision Care Haag Streit Diagnostics
Bausch&Lomb RaayonNova
Contamac Vistakon (Johnson&Johnson)
Cooper Vision
Falco Kontaktlinsen
Haag Streit Diagnostics
Sensimed AG (Triggerfish)
Tissot Medical Research
Vistakon (Johnson&Johnson)
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Goals
• Understand the basics of contact lenses.
• Know their differentiations and frequency of CL wearers,
understand the specific optics and physiology, distinguish
wearing modalities, know the fields of applications and the
fitting basics, discuss the importance of hygiene and lens
care, differentiate complications and how to avoid them
and take a look into novelties.
• Have Fun with Contacts !
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History and Demography
Leonardo da Vinci, 1508 and Rene Descartes 1637
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(Glass) Scleral Lenses / Shells
Over All Diameter
OAD 20-24 mm
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(Soft) Hydrogel Lenses
Otto Wichterle, Prague 1961
Patent sold to Bausch&Lomb 1968
Over All Diameter OAD 13-15 mm, Water content 25-85%
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(Hard) gas permeable Lenses
Over All Diameters between 8 mm to 18 mm, no water
Invented after WW II (1945), High-tech today
10,2 mm 9,3 mm 8,3 mm
11,2 mm 13,0 mm 16,0 mm
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Movement, centration and stabilization
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Demography
Contact lenses
1/3 vs 2/3
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CL Market (Alcon Data, 2015)
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Optics and Physiology
Whatever contact lens you fit,
always respect the physiology
and the safety of the eye !
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Spheric Calculations
• As a rule of thumb: 0.1mm radius difference results in a power change of 0.5dpto If the lens is chosen 0.1mm steeper than the cornea you have to
increase the amount of minus with -0.5dpt
o If the lens is chosen 0.1mm flatter than the cornea you have to decrease the amount of minus with +0.5dpt
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Aniseikonia between CL and glasses
Myopic Px profit the most from CL regarding less retinal image size
reduction, respectively image size magnification.
Hyperopic Px profit the most from CL regarding aesthetics.
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Visual acuity comparison
Myopic Px profit the most of CL regarding VA
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Visual field comparison
Both Px groups profit from CL regarding VF
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Accommodation
• Hyperopic Px with contact lenses needs to accommodate less
(more accommodation success A0) for a given distance.
• Myopic Px with contact lenses needs to accommodate more.
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Convergence
• Myopic Px with contact lenses needs to
converge more (less comfortable) compared
to a correction with spectacles for a given
distance.
• Hyperopic Px needs to converge less with
contact lenses.
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Example Distance Myopia
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Example Reading Myopia
comfortReading Target
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Regarding Presbyopia and CL
Due to accommodation and convergence disadvantages, myopic
Px are more difficult to correct with CL than with glasses.
But they always profit from better optics (less aberrations).
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Higher Order Aberrations
K.Gumus et al The Impact of the Boston Ocular Surface
Prosthesis on wavefront Higher-Order Aberrations, Am J
Ophthalmol 2011;151:682–690
The corrective rates of higher-
order aberrations are about
70-90% with (hard) scleral
lenses in place !
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CL Materials: Physics and Physiology
Differentiate important physical properties :
• Oxygen Permeability
• Hardness (Shore), Resistance
• Stiffness (Flex Modulus)
• Wettability (Wetting angle)
• Silicone, Fluor, Water content
• Refractive Index
• UV Filter
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Oxygen Permeability Dk
26 42
56
86
110 118 121 125
138 147
156 160 163 175
0
20
40
60
80
100
120
140
160
180
200
etafilcon A omafilcon Filcon II 3 somofilcon A balafilcon A Narafilcon A senofilcon A enfilcon A lotrafilcon B senofilcon A delefilcon A comfilcon A samfilcon A lotrafilcon A
Sauerstoffdurchlässigkeit Dk/t
DW
EW
CW
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Hardness, Resistance
Scratches and Edgedefects
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Wettability, Silicone, Water, Fluor
Deposits (Lipids and Proteins)
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Contact Lens Manufacturing
Understand manufacturing steps:
- Calculation
- Preparation
- Back Geometry
- Over All Diameter
- Front Geometry and Power
- Finish
- Quality Check
Disposable lenses (daily, weekly, monthly)
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CL Laboratories
Calculation and Preparation
Infrastructure
Cutting and lathingFinish and Quality Check
FALCO, Switzerland
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Calculation and Preparation
Finish and Quality CheckCalculation and Preparation
GELFLEX, Perth / Australia
CL Laboratories
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Contact Lens Design
Distinguish different Backcurve Designs
• spherical
• Multi-curve
• aspheric
• toric
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Sphere versus Asphere
„ “
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KK: Steiler Apex mit hoher Abflachung
zur Peripherie hin
Numeric Eccentricity nE
r1
r2
r2 > r1
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Numeric Eccentricity nE – Rule of Thumb
Numerical Eccentricity / peripheral flattening
0.1 = 0.02 mm -> Elliptic
0.2 = 0.05 mm
0.3 = 0.10 mm -> 0.1 mm
0.4 = 0.16 mm -> 0.2 mm
0.5 = 0.23 mm
0.6 = 0.35 mm -> 0.3 mm
0.8 = 0.55 mm
1.0 = 0.80 mm -> Parabolic (Keratoconus)
1.2 = 1.20 mm -> Hyperbolic (Keratoconus)
1.5 = 2.00 mm
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Spherical Design
0.0
0.0 0.0
0.0
BC = r2/0
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Multi curve Design
0.0
0.0 0.0
0.0
BC = r2/0
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Aspherical Design
BC = r2/0
0.0
0.0 0.0
0.0
0.4
0.4
0.4
0.4
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Toric Design
0.0
0.0 0.0
0.0
BC = r2/0
BC = r2/1
0.6 0.6
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Lens Design
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Fitting Technics,Ocular Topography and
Fluorescein
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Technique Oculus
• 22’000 measuring pointso Nose and forehead make shadows and reduce the
amount of measure points
o Only about the central 8mm diameter are really measured
o Accuracy +/-0.1D
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Diagnostic Software (Mapping)
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Diagnostic Software (Fourier)
• Fourier Analysiso Mathematical separation of the topographic map into
individual components
o Optical aberration (spherical component, decentration or decentration with spherical component, regular astigmatism, irregularities or irregularities with spherical component)
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Diagnostic Software (Fourier)
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3D ImagesRegular Astigmatism
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3D Images
Irregular Astigmatism
post Trauma
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3D ImagesPseudo Keratoconus (high riding contact lens)
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3D Images
Keratoconus
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3D Images
Keratoplasty
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3D Images
LASIK / Orthokerathology
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3D Images
Pellucid marginal Degeneration
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Scheimpflug Technology
• Slit illumination creating a cross-sectional image of the anterior chambero True elevation data rather than curvature values
o Measurement of anterior and posterior surface, center of cornea really measured
o Independent of tear layer quality
o Detection of opacities in cornea and cristalline lens
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Scheimpflug Technology
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Diagnostic Software
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Diagnostic Software (Mapping)
• Topography and elevation data of anterior and
posterior corneal surface
– Keratoconus detection (very early due to the posterior
surface evaluation) and classification
– Advanced topographical calculation due to refractive
surgery
– Comparative displays for progression control and
follow-up
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Diagnostic Software (Pachy & Topo)
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Diagnostic Software (Holladay Report)
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Diagnostic Software (Belin/Ambrosio)
• Sagittal and tangential mapping shows similar
results and no evidence of abnormality
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OCT Technology
• Optical Coherence Tomography (OCT)o Mapping and Keratoconus detection software already
available
o Resolution between 5μm - 60 μm
o Maximum of four scans, to date
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OCT Technology
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• OCT and contact lenses
o Measurement coverage up to 16.00mm and include
Sclera/Conjunctiva data
o Simplify scleral lens fitting process
o Allows in-situ validation of any contact lens, even
Hydrogel’s
OCT Technology
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OCT Technology
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OCT Technology
Toric Soft Lens Fit Analysis
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Fitting procedure
1. Anamnese and History taking
2. Perform Slitlamp observation and Topography measurement
3. Check central and peripheral corneal astigmatism
4. Check ametropia and total eye astigmatism
5. Define wearing modality
6. Choose your ideal fitting strategy (Physiology and Optic)
7. Define the ideal material, lens geometry and over all diameter OAD
8. Check centration, rotation (stabilization axes) and vertical movement
9. Define Lens Care regime
10. Organize regular CL and Eye Checks
11. Send final report to Ophthalmologist
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CL Fitting Software
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CL Fitting Software
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Fitting Software Oculus
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Fitting Software
• “Real Life” peripheral Astigmatism
– The lens rocks around flat meridian
– High or Low Riding lens as a consequence
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Final Fitting Result
• Perfect centration
• Outstanding comfort
• Fluorescein pattern:
typical pooling in steep
mid-periphery and alignment fit in periphery
• Markings of flat meridian
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Rigid Lens Fluorescein PatternsProducts (Small molecular / Large molecular NaFl)
Small
Large
RGP, screening Soft lenses
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Rigid Lens Fluorescein PatternsTechnical approach (Kobalt Filter, Yellow (Wratten) Filter)
Kobalt Filter
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Rigid Lens Fluorescein Patterns
Wratten
Yellow Filter 12
Mobile Alternatives
LED hand held
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Rigid Lens Fluorescein PatternsApplication / Installation of NaFl
Install only a small (!) drop of NaFl, diluted with NaCl
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Characteristics: Diameter
Tear exchange
Oxygen
Movement
Price (standard lenses)
Comfort
Stabilization
Safety
Less dust (foreign body)
Handling
Small lenses :
Large lenses (intra-limbal):
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Characteristics: Diameter
Very large lenses :
(“Miniscleral” or Scleral)
Comfort
Stabilization
Less dust (foreign body)
Protection
Visual acuity !
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Contact Lenses for Astigmatism
Available for Soft and Hard GP Lenses up to +/- 20dpt cyl
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Contact Lenses for Irregular CorneasDue to :
Contact lens use (Deformation, unaceptable fit, Pseudo Keratoconus)
Trauma (Physical, chemical)
Infections (Microorganism)
Degeneration (Keratoconus, Marginal Deg., Salzmann, Band Deg,...)
Dystrophy (EBM Dystrophy, Mapdot-fingerprint, Meesmann,
Fuch’s, bullous Epitheldys., Granular, Lattice, ….)
Systemic (e.g. Lyell Syndrom)
Post surgery (PKP, lamellar Keratoplasty, Trabecelectomy / Filtering bleb)
Refractive surgery (RK, PRK, LASIK/LASEK, SMILE…)
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Typical Topographies
Keratoconus Pellucid marginal
or Terrien Degeneration
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Optical Axes
Center of Pupil
Apex caudal
decentered
Keratoconus
Scars and
folds(Vogt Striae
or Haab
Lines)
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Quadrant-specific Design
1.6 1.6
1.4
0.0
cross sectional view
Spherical optic zone with quadrant specific
periphery for best physiological fit and
maximized visual acuity.
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Quadrant-specific Design
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Penetrating Keratoplasty
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Cross section view Comparison
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Typical Topographies
Keratoplasty
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Case Keratoplasty
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Case Keratoplasty
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Case Keratoplasty
Multicurve, reverse geometry with 2 fenestration holes
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Quadrant specific Keratoplasty CL
• New Geometry (Falco Switzerland) for tilted grafts– Quadrant specific geometry with tilted reverse geometry
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Advantages
• Perfect centrationo Vaulting entire Cornea and Limbus
o The lens rests only at the Scleral Zone
• Simplyfied Fittingo Sclerals are fitted by Sagittal Depth rather than BC
or K readings
• Outstanding Optic Resultso Flatter BC and bigger Optical Zone Diameter
Scleral Lenses
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Scleral Fitting TechnicCentral Area - Fluorescein Pattern
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Scleral Fitting TechnicThe entire fit, centration and stabilization of the whole CL lays on the conjunctiva/sclera
- OAD 15 - 18mm
- Extreme high Dk
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Contact Lenses for Presbyopia
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Translating bifocal Systems
© by Bach Optik
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Multifocal, Simultaneous DC
© by Bach Optik
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Soft and disposable Contact Lenses• Distance or Near central optic zone, with
progressive or degressive power changes
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Translational Soft (BYO Royal™)
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The Future is Now!
Segmented-Simultaneous Design (Falco Kontaktlinsen Switzerland)
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Contact Lenses for Children
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Reasons for CL for Children
Myopia Aphakia
Anisometropia
Hyperopia
Astigmatism
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Children and eye glassesChildren loves eye glasses ? (Hyperopia +8.0 dpt)
At least their parents believe and unfortunately some eye “experts” as well !
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Children and contact lensesChildren loves contact lenses ! (Hyperopia +9.0 dpt)
This is what the children believes and their contact lens specialists !
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Children and contact lenses
The two most common reasons today are :
- Myopia Management - Aphakia
- Special soft and „hard“ GP contact lenses are suitable for children.
- Well tolerated and at least as safe as for adults.
- Hygiene and regular CL/eye checks are evident.
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Contact Lenses for Therapy• Pain reduction
• Protection against environmental factors
• dirt, mechanical friction, evaporation of tear film
• Improving the epithelial healing process
• Stabilization and modulatio of corneal surface
• Improvement of VA
• Optical Rehabilitation
• Cosmetic Rehabilitation
• (carrier for pharmacologic drugs)
• Improvement of overall comfort, vision and safety !
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Method
Fitting of therapeutic and refractive effective soft or hard bandage
contact lenses as ocular surface protection layer.
Without contact lens
With protecting contact lens
OCT image of anterior ocular segment
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Materials
• Hydrogel (“old style”)
• Traditional (BG 80%, Benz-G)
• Disposable (Daily, Monthly)
• Silicone Hydrogel (new style)
• Disposable (Daily, Bi-weekly, Monthly)
• Gas Permeable (Hard) Specialty CL and Scleral Lenses
• Hybrid Lenses (Hard GP center, Soft skirt)
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Main Material for Clinic
•Past…:
• Hydrogel with H2O content
•…Present:
• Silicone Hydrogel !
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O2-Permeability of Silicone Hydrogel CL
Conv. Hydro
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Excellent Resultse.g. Px with Epidermolysis Bullosa
- Eliminate pain
- Stabilize Epithelium
- Reduce inflammation
- Increase or restore vision
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Epithelial basement membrane Dystrophies EBMD :(Cogan or Map-Dot-Fingerprint)
- Eliminate Discomfort
- Increase physiological
and optical/visual
Stabilization
Excellent Results
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Clinical Case: EBMD
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Clinical Case: EBMD
B.H., m, 59 y/o
Since 6/2010:
Biofinity sph / Biofinity Toric
Vacc: OD 0.9 , OS 0.8
Constant wear 1 week, cleaning, changes every 4 weeks.
Rewetting drops as needed.
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Conclusion
Short term prognosis :
• Therapeutic bandage contact lenses are useful to protect the
compromised cornea from negative environmental influences.
• They are helpful to protect the patient from discomfort and
pain.
• They are usable as a drug deposit with care.
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Intermediate and long term prognosis :
• Therapeutic bandage contact lenses are useful to protect the long term dystrophic cornea from negatives environmental influences.
• They help to remodel the irregular cornea for better vision.
• They help to protect the patient from discomfort and pain.
They make patients happy!
Conclusion
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Contact Lenses for OrthokeratologyHistory: Dr. J. Ball 1850 developed eye cup it spring mounted mallet to pound the cornea flat through the closed eye
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History
With CL initially reported 1960 by Jessen (Old)*o Spherical lens, daily wear, PMMA (Dk = 0)
1997 Mountford introduced new Design (accelerated Ortho-K)
o 4-5 Zones Reverse Geometry, Overnight wear, extrem high Dk >100
*Please: Don‘t mix up old and new Ortho-K
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How it works• Change in epithelial thickness
o 4 weeks in Cats results in 8.4microns reduction, results in -4.0D of Ortho-K effect !
• Munnerlyn Formula (tissue displacement)o Optical Zone Diameter2 x refractive Error / 3
o e.g. -5.0D correction with Treatment Zone of 3.0mm (tangential mapping) results in 15microns Epithelium displacement
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• Central epithelial thinning o Focal cell compression (Wing and Basal cells) rather than cell migration
or loss of cell layers
o Microvilli and Desmosomes unaffected
• Midperipheral epithelial/stromal thickeningo Increased surface (squamous) cell and nucleus sizeo After 24h: Stromal +2.5% / Epithelial +16.89%o No classical stromal Edema, more likely increased cell retention!
Histology in Ortho-K
• Endothelium o No changes at all
• Anterior Radii vs posterior Radiio Ortho-K alters the anterior corneal shape rather than the posterior
radius of the corneal curvature and the anterior chamber depth
o There is no overall “corneal bending”
Tsukiyama, Eye & Contact Lens 34(1): 17–20, 2008
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• Pediatric and Geriatric Patients
• Therapeutic Indications
• Extreme High Altitude Climbers
Contact lenses for Continuous wear
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Indication for continuous wear
• Bandage contact lens after surgery or injury
• Therapeutic use in cornea disorders• EBMD (Map-dot-fingerprint dystrophy) and recurrent corneal erosion
• Epidermolysis Bullosa
• Elagophthalmus
• Incomplete lid closure during sleep
Post LASIK: Pre-Therapy CL With Therapy CL
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Products OverviewPurevision
(Toric, multi)
Night&Day(Children)
AirOptix(Toric, multi)
Oasys(Toric, multi)
Biofinity(Toric, multi)
DK/t 110 175 138 154 160
H2O 36% 24% 33% 40% 48%
Radius 8.60 8.40 / 8.60 8.60 8.40 8.60 (8.7)
Ø 14.00 13.80 14.2 14.0014.00
(14.50)
Diopter +6.0 / -12.0 +6.0 / -10.0 +6.0 / -10.0+6.0 /
-12.0
+10.0 /
-10.0
Cylinder
-0.75
-1.25
-1.75
-2.25
*******
-0.75
-1.25
-1.75
-2.25
-0.75
-1.25
-1.75
-2.25
-0.75
to
-5.75
CW 30 days 30 days 7 days 7 days 30 days
Replace 1 month 1 month 1 month 1 week 1 month
Modulus 1.50 1.52 1.2 0.72 0.75
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Risk factors for infiltrative event
Szczotka-Flynn L. et al.: Predictive Factors for Corneal Infiltrates with Continuous Wear of Silicone Hydrogel
Contact Lenses; Arch Ophthalmol. 2007;125:488-492
Extended or continuous wear is not for
everybody and deserves special care !
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Complications
• Evaporation / Dehydration
• Lack of Oxygen
• Microbial Inflammations or
Infections
• Chemical contamination
• Allergies
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1
2
Complications
Superior Epithelial Arcurat Lesion SEAL Gigantopapillary Conjunctivitis GPC
vs
Follicle (FoCoSi)
Contact Lens induced acute red Eye CLARE
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Complications CLPC
Differential diagnosis Papillae versus Follicle
Naumann
Pathologie
des Auges
1980;
12:252
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Complications
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Contact Lens related Peripher Ulcus (CLPU)
“CLPU is an inflammatory reaction of the cornea that is
characterized in its active stage by focal excavation of the
epithelium, infiltration, and necrosis of the anterior stroma.
However, Bowman’s layer is intact”Holden BA, Reddy MK, Sankaridurg PR, et al. The histopathology of contact lens induced peripheral corneal ulcer. Invest Ophthalmol Vis Sci 1997;38:s201.
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Microbial (infectious) Keratitis
“MK is an infection of the cornea by microbes that is
characterized by excavation of the corneal epithelium,
Bowman’s layer, and stroma with infiltration and necrosis
of the tissue.”Cokington CD, Hyndiuk RA. Bacterial keratitis. In: Tabbara KF, Hyndiuk RA (eds): Infection of the Eye. 2nd ed. Little, Brown & Co, 1996.
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Differential Dx: CLPU vs MK
Active phase: CLPU Fluo „negativ“ MK Fluo strong positive
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1
3
Complications
Chronic Red Eye (Ideology ?)
Bacterial Blepharitis due to chronic MGD
=>
Intense Lidcare, warm compresses, Omega-3 substitution
Final result
after 6 months
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Predisposing factors for adverse events
Blepharitis and Meibomian Gland Dysfunction (MGD)
Picture: www.healtarena.org
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Hygiene and
Safety:
Important
Informations for
CL wearers
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Contact Lens Care
Soft Peroxid Hard GPAll-in-One
Rinsing (NaCl 0.9%)
Cleaning
Desinfection
& Storage
Specials (De-Protein)
Always Rub & Rinse with All-in-One products !
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Contact Lens Care
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Conclusion and Discussion
Contact lenses are offering a high amount of
technical and physiological possibilities to correct
nearly every kind of ametropia.
They offer an acceptable safety level for all ages, but
fitting and communication has to be age related.
Contact lenses are much more than just “another
kind of glasses”.
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