scleral lenses for irregular corneas and osd scleral.pdf · ventilated scleral lens – 1986 “a...
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Karen G. Carrasquillo, OD, PhD, FAAO, FSLS, FBCLA
Innovation | Education
Scleral Lenses, Irregular Corneas and Ocular Surface Disease
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• VP of Clinical and Professional Affairs, BostonSight
• Adjunct Clinical Faculty• New England College Of
Optometry
• Adjunct Clinical Faculty• MCPHS University School of
Optometry
• Advisory Board Member• Gas Permeable Lens Institute
• Fellow Scleral Lens Education Society
• Fellow of the British Contact Lens Association
Disclosure
Karen G. Carrasquillo, O.D., Ph.D., FAAO, FSLS and all doctors of the BostonSight are salaried, full-time employees of a 501(c)3 non-profit organization.
• Neither Dr. Carrasquillo nor any of the BostonSight providers have proprietary interest in BostonSight PROSE treatment or BostonSight SCLERAL
• www.bostonsight.org
Brief History
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Earliest descriptions of CL – published late 1800s
Scleral Shells 19-21mm made out of blown or ground glass - 1889
Impression molding –1930s
Translation of Mueller, Fick, and Kalt’s work -
published in 1980s
Ezekiel publishes first description of gas
permeable scleral lens –1983
Rosenthal develops Fluid-Ventilated scleral lens –
1986
“A recent search of scleral lens designs included on the Gas Permeable Lens Institute’s website yielded a list of 17 manufacturers currently offering 41 different scleral lens designs”
From: Schornack, M. (2014) Scleral Lenses: A Literature Review, Eye and Contact Lens, (41) N1 3-11
Terminology
• Intralimbal
• Corneoscleral
• Miniscleral
• Scleral
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Scleral Lenses
• Diameter varies between 17.0 to 23.0+
• Vaults over the cornea
• Bearing of lens completely on sclera
Scleral Lenses
Scleral Lens Features
• Avoids all contact with the cornea• Fluid reservoir• Modern high Dk materials• Rests entirely on the conjunctival
tissue overlying sclera
Scleral Lens Examples
• BostonSight SCLERAL• Jupiter• TruForm• Europa• Custom Stable • EyePrint PRO
Indications for Scleral Lens Use
• Correct irregular astigmatism• Dry eye symptom relief• Protection of ocular surface• Maintenance and support of the
ocular surface
Scleral Lens Evaluation/Assessment
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• Measure central clearance first
- With and without NaFl
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Vault
Identify the front and back surface of the lens with an optic section
Vault
Make sure there is no corneal contact (unless you are fitting a corneosclerallens)
Confirm both the front and back surface reflex of the lens
Insert the lens with Fluorescein and look for narrowing of vault or contact
Vault Diameter•Selection may be arbitrary•May be multifactorial•Fitting set parameters
•Palbebral fissure size•Patient apprehension/
cooperation•Anatomical Obstacles
Diameter
Anatomical Obstacle: Pinguecula
Working Inside Out
• Then monitoring the limbus
Superiorly
Inferiorly
Nasally
Most likely to be problematic Temporally
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Working Inside Out
• Edge Lift
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Excessive Edge Lift
Note the air meniscus
Working Inside Out
• Compression
• Blanching
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Mid-Haptic Compression
Compression and Impingement Working Inside Out
• Impingement
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ImpingementHaptic Evaluation
•Goal is haptic alignment to sclera•Things to avoid
•Excessive Edge Lift•Compression 360°
•Monitor for Toricity
Toricity
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Working Inside Out
• Hooding/Conjunctival Prolapse
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Large diameter vs. Small diameter
• Large bearing area on sclera to support higher corneal clearances
- Distributes weight over a larger area
- Easier to clear the limbal area
- Provides more coverage in dry eye conditions
• Smaller diameters may minimize toricity
- May have to fit under symblephera
- Lower corneal clearance
- Smaller eyes or difficult applications
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Evaluation after settling
Allow lenses to settle
Smaller lenses settle more than larger lenses
More critical in corneal scleral lenses
3 hours settling
- At least 20 minutes
End of day appointments
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Caroline, P, Andre, M. (2012) “Scleral Lens Settling”, Contact Lens Spectrum
Effect of settling over time
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EVIDENCED-BASE/DATA-DRIVEN DESIGN
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Contraindications and Non-candidates
Determined on a case by case basis
Ankyloblepharon
Symblepharon too close to the limbus
Glaucoma tube shunts – tricky
Glaucoma Blebs
Entering with corneal edema
Unique fits Graft Failure: Fenestration
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Training Challenges Training Challenges
Application and Removal
• Supplies
Cleaning and Disinfection
Saline Solutions
SCLERAL LENS INDICATIONS
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Irregular Astigmatism Correction
Keratoconus
Pellucid Marginal
Degeneration
Post Penetrating Keratoplasty
Post Refractive Surgery
Keratoglobus
Keratoglobus
Apex Thinning
Keratoconus Pellucid Marginal Degeneration
Apex
Thinning
Baseline
Cressey, A., Jacobs, D.S., and Carrasquillo, K.G. (2012) Management of vascularized limbal keratitis (VLK) with prosthetic replacement of the ocular surface system. Eye and Contact Lens 38(2):137-40
6 mos s/p PROSE 6 mos s/p PROSE 2 yrs s/p PROSE 4 yrs s/p PROSE 2 yrs s/p PROSE
Complications
• Scarring
• Hydrops
• High Order Aberrations
• Rupture
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Hydrops
50.8/ 58.9 @ 143
August 2004
66.5/ 73.4 @ 122
December 2007
31.0/ 39.2 @ 172
August 2009
Signs and symptoms of graft edema
• Complications of older grafts
- Microcystic Epithelial Edema
- Hazy Vision
- Sattler’s veil:
• rainbows around light sources from corneal edema
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Microcystic Edema(our view in)
Sattler’s Veil(pt’s view out)
Endothelial cell counts decrease
• Typical endothelial counts range from 2400 – 3200 cells/mm2
• Cell counts decrease with:
- Age of patient
- Age of graft
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Failing Grafts and Scleral lenses
• Etiology
- Hypoxia
• Epithelial edema resulting from oxygen deprivation
- Suction with Sclerals
• Suction increases with wearing time
• Both poor epithelial cell junctions and low endothelial reserve may be contributory to edema
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Fitting Strategies
• Decrease Hypoxic Stress
- High Dk material
• XO2 with Dk 141
- Thin center thickness
• Design Strategies to Decrease Suction
- Large diameters
- Fenestrations
- Channels
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Case
• 52 year old female s/p PKP (OD 1998, OS 1991) secondary to keratoconus
• Presented to clinic having been fit with scleral lenses in the past for vision OU
- Intolerant; required frequent removal and re-insertion throughout the day secondary to discomfort
• Trial BostonSight® PROSE devices
- Appreciated comfort and VA (20/20 OD, 20/20 OS)
• Proceeded to start treatment
• During treatment reported hazy vision and rainbows around lights
- Corroborated by objective observation of epithelial edema
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PROSE Strategies: Large and Loose
• PROSE Device #1:
- Vault: 4.9, BC: 8.2, Power: -0.50, Diameter: 18.5
- Wearing times of 2 hours before haze, rainbows and epithelial edema
• PROSE Device #2:
- Vault: 5.1, BC: 8.2, Power: -0.50, Diameter: 20.5
- No haze, rainbows or edema after 9 hours of wear
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PROSE Strategies: Large and Loose
• Goal to decrease hypoxia and suction
• Some keys to fitting:
- Apical touch
- Bubble management
• Size
• Placement
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Fitting Strategies – Fenestrations in Optic Zone Fitting Strategies
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PROSE Strategies: Decrease Suction
• Channels
- Radial grooves in device to disrupt the seal of the device on the globe
- Encourages fluid ventilation
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PROSE Strategies: Decrease Suction
• Channels
- Radial grooves in device to disrupt the seal of the device on the globe
- Encourages fluid ventilation
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Systemic Associations with Ectasia conditions
Down’s SyndromeAtopyConnective Tissue Disorders
Ocular Surface
The ocular surface• cornea • conjunctiva• lacrimal glands• tear film• lid margins
from Gipson, Joyce, ZieskeSmolin and Thorf’s, The Cornea, 2005
Ocular Surface Disease
• Corneal Stem Cell Deficiencies• Severe Dry Eye• Anesthetic Corneas• Exposure• Diseases of the Epidermis
Dry Eye Syndrome
Exposure Keratoconjunctivitis
Neurotrophic Keratopathy
Limbal Stem Cell Deficiency
Ocular Exposure
OS pre-lens OS 4.5 hours lens wear
GVHD
OD pre-lens OS pre-lens
OD 6 hours lens wear OS 6 hours lens wear
Stem Cell Deficiencies
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CORNEAL STEM CELL DEFICIENCIES
• Stevens-Johnson Syndrome
• Ocular Pemphigoid
• Chemical/Thermal Injuries
• Aniridia
• Radiation Keratopathy
Stevens-Johnson Syndrome
Trichiasis & Distichiasis
Stevens-Johnson Syndrome
Conjunctivalization
Stevens-Johnson Syndrome
Keratinization
Stevens-Johnson Syndrome
June 2007 November 2007
SEVERE STEVENS
JOHNSON SYNDROME
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Neurotrophic Keratopathy
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Neurotrophic Keratopathy - A degenerative corneal condition resulting from impaired corneal sensation
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Poor healing
Decreased reflex blinking//tearing
Ulceration
Infection
Corneal melting
Perforation
Permanent vision loss
NEUROTROPHIC CORNEAS
Goals of Treatment
• Protection
• Lubrication
• Re-epithelialization
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Neurotrophic Keratopathy - Etiology varies (and is often multi-factorial)
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HSAN Type III (Familial DysautonomiaRiley Day Syndrome)
HZO
CNV and CNVII neuropathys/p resection of acoustic neuroma
Congenital
Familial Dysautonomia
HSAN
Acquired
HSV
Multiple surgeries
Medicamentosa
Neurological – HZO
Neurosurgical -Meningioma, Acoustic Neuroma, Trigeminal Ablation
Systemic – DM, Sjorgrens
Re-epithelialization of Persistent Epithelial Defects
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Exposure Keratopathy
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Exposure Keratoconjunctivitis
• Result of any condition that causes abnormal lid function or reduction in the natural blink reflex
• Most commonly associated with cases of orbital disease or cranial nerve palsy
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Causes of Ocular Surface Exposure
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Congenital Lagophthalmos
Craniofacial Trauma
Craniofacial Abnormalities
Cranial Nerve Palsy
• Acoustic neuroma
• Bell palsy
• CPEO
• Möbius syndrome
• Stroke
Infectious
Nocturnal Lagophthalmos
Orbital disease
• Graves’ disease
• Orbital tumors
Post-operative
• Botox
• Blepharoplasty
• LASIK
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Chronic Exposure
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Congenital Craniofacial Abnormality
Facial Nerve Palsy (s/p acoustic neuroma resection)
Chronic Exposure Treatment Options
Depends on underlying cause
May Include
- Aggressive Lubrication
- Punctal Occlusion
- Lid Weights
- Contact Lenses (Soft or Scleral)
- Amniotic Membrane
- Surgical Correction of Lid Function
- Tarsorrhaphy
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Complications from Chronic Exposure
• Corneal scarring
• Corneal neovascularization
• Epithelial Breakdown
• Stromal thinning
• Ulceration
• Perforation
Bad Blepharoplasty
Bad Blepharoplasty Chronic Exposure: Case 1
• 34 yo female Crouzon’s Syndrome
• Arnold Chiari Malformation
• Blepharoplasty OD
• Entropion repair OS
• s/p mucus membrane grafting OU
• Strabismus surgery OU
• Tarsorrhaphy OU –successful OD
• Failed lid weight OS
• 20/20 OD
• 20/80 OS96
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2017
H/O epithelial breakdown 2’ chronic exposure
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2009
CASE 2
• 36 yo (at the time) male soldier
• Sustained severe burns from an improvised explosive device (IED) 11 months prior to referral
• Despite multiple reconstructive surgeries chronic exposure keratopathy OU from cicatricial lagophthalmos
• OS – Corneal thinning and irregularity – 80% tarsorrhaphy to protect surface
• OD – Pt reported Sx of dryness and photophobia
• UCVA OD 20/25 20/80 OS
• PROSE Tx OD Only
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SymptomsUCVA
BCVA20/25
20/15No PAINPHOTOPHOBIA
Managed effectively A/R despite using only one hand
VAULT - CENTRALLY
What about central clearance?
Vault
• Relationship to corneal surface oxygen tension
1. Certainly less oxygen at K surface with higher vaults
• Compan et. al. 2016, Giasson, et. al. 2017
2. But doesn’t necessarily correlate with negative corneal sequelae
• Berkeley studies (UC Berkeley Clinical Research Center) don’t show a correlation between increased vault and corneal swelling
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Case #1a
• 45 year old WF• h/o RK, AK OU 1993• Salzmann Nodules removal 2009
• PROSE treatment: 2011• Vault in lenses ~ 500 um
Case #1a
2011 2017
Case #2
• Fit originally February 25, 2008
PROSE Device OD
BC: 7.90 mm
Power -1.50 D
Diam: 22.0 mm
Vault: > 500 um
PROSE device OS
BC: 7.90 mm
Power: -1.25 D
Diam: 22.0 mm
Vault: > 500 um
Diameter and Vault
• Smaller diameter certainly needs a lower vault
- Small haptic landing area cannot sustain higher vaults
- Generally smaller diameters result in a closed system, more suction
- More suction occurs in smaller diameters with less fluid exchange requiring a lower vault
• Large diameter affords more flexibility:
- Inherent toricity will result in more fluid exchange
- Can have wider range of vault
Vault
• Relationship between vault and corneal physiology needs to be established
• Even when there’s evidence that higher vault results in lower oxygen tension levels at the cornea, there may not be a direct correlation to negative effects on corneal physiology
• More studies needed
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PEDIATRIC CORNEA
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Kendra Phillis, OD, Dan Brocks, MD, and Karen G. Carrasquillo, OD, PhD, FAAO, FSLS, FBCLA
Use of PROSE treatment for traumatic lid
ptosis in a pediatric patient: Case Report
Submitted to OVS, Jan 2020
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Medically Necessary Scleral Lenses
Is it always about the piece of plastic?
H/O GVHD post trasplante de células
madres 2016. PROSE since 2017
H/O “steroid response”
At the time ‐ 30mg/d oral prednisone (slow taper)
Cosopt (Dorzolamide/Timolol –without preservatives) 1 gtt BID
OU
Loteprednol ung QHS OR
Prednisolone acetate 1% 1 gtt QID OD
CASE
Graft vs Host Disease
19mm OD/OS
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2 week evaluation
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Without any revisions to the lens!
When everything seems to fail…..
Boston Keratoprosthesis Type I and II
There is always hope…
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Thank you for your attention!
www.bostonsight.org
QUESTIONS?
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