A 5 Step Program. A 5 Step Program. A 5 step program. A 5 step Program 2/7/2018. A 5 Step Program Lens Settling Evidence.

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1 Lens Vault Settling evidence Lens Settling Evidence Lens Settling Evidence Optom Vis Sci Dec;91(12):1462- A comparison of the short-term settling of three scleral lens designs. Kauffman MJ1, Gilmartin CA, Bennett ES, Bassi CJ. The purpose of this study was to quantify the mean total settling and mean rates of settling for three scleral lens designs: Onefit P&A (Blanchard Contact Lens, Inc), Mini Scleral Design (msd) (Blanchard Contact Lens, Inc), and Jupiter (Visionary Optics) lenses settled a total of 113.7, 133.7, and 88.1 μm, Settling rates were greatest shortly after insertion. Larger lenses were estimated to be settled by 8 hours The Perfect Vault Review based on evidence Be comfortable with SLE assessment Know the thickness of the CL being used Shoot for a max of 400um Maximize lens Dk and minimize vault for best 02 permeability A 5 step Program 3. Conjunctival assessment / landing zone Assessment A 5 step program 3. Conunctival Assessment / Landing Zone assessment Pearls: don t let a little compression scare you Listen and let the eye fit the lens Scleras are OFTEN TORIC!!!!! 1

2 5 Step Program Tight, Loose, or perfect? 5 Step Program Edge profiles all the same or different? 5 Step Program Tear Exchange - We do NOT want tear exchange 5 Step Program Tear exchange / fogging Is the eye Round or something different? Observational study 1997 Topographical analysis, 2012 (Kojima, Caroline) The next frontier of Scleral lens fitting Scleral topography measurements Eaglet Scleral Topographer $ smap3d $$ EyePrintPro $$$$ 2

3 A 5 step program 4. Over refraction -Pearls do everything you can to avoid cyl, (min of 1D, 2 Va lines) -don t push it initially if you can get 20/25 or 20/50 leave it be - if possible use loose lenses, be quick and dirty initially Over refraction studies 5. Recheck steps 2-4, vault, and conjunctival assessment, order a first lens 3

4 Sceral lens Basic Anatomy Base Curve Most lenses are 3 lens curve system Limbal Zone Curve / Reverse curve Scleral Landing Zone Making basic adjustments Sceral lens Basic Anatomy Central Touch --- More Vault! Steepen the Roof (steeper BC) Base Curve Limbal Zone Curve / Reverse curve Scleral Landing Zone Central Touch Raise Da Roof! Base Curve Limbal Zone Curve / Reverse curve Scleral Landing Zone Sceral lens Basic Anatomy Being a Doctor Compression / Impingement Flatten SLZ- Base Curve Limbal Zone Curve / Reverse curve Scleral Landing Zone 4

5 Bubbles Troubleshooting Pearls All about the angle PF Refresh / oasys tears for bowl If you can get it in w/o bubbles For an experienced fitter not a problem If appearing after insertion, SLZ problem Troubleshooting Lens awareness / discomfort Pearls Check vault Most often SLZ issue Consider Toric Periphery if pt can point to irritation Don t forget about DES, bullae and Corneal edema! (over 800cells ) Troubleshooting Troubleshooting Inferior lens displacement Most common displacement inf and temporal Pearls Do nothing!!! Thin the lens Reduce the vault/sag Tighten periphery (if possible) Consider toric periphery Fogging of the tear prism after wear Pearls Set expectations (4 hours) Check for TF communication (toric periphery Try PF Tears Sicker eyes (pkps/severe DES /GVHD) Sclerals and Dry Eye Possible Treatment many case studies What about the overlying tear film? Sclerals and Dry Eye Possible Treatment many case studies What about the overlying tear film? 5

6 Sclerals and Dry Eye Carracedo et al (2015) evaluated 26 patients with keratoconus and an average age of years. The scleral lenses were the ICD 16.5 design with an overall diameter of 16.5 mm clearance thickness between 300 µm and 400 µm. Researchers recorded the Schirmer s test, tear break-up time, matrix metalloproteinase 9 concentration, osmolarity, diadenosine tetraphosphate (ApA) concentration and the Ocular Surface Disease Index (OSDI) questionnaire before and after patients wore the scleral lens for 8 hours. Mean scleral lens sag was 4,310 µm, with no significant sag difference between the two groups. OSDI scores were significantly lower after wearing the lens in both groups. Osmolarity and ApA concentration lowered, and MMP-9 rose after wearing scleral lenses in both groups. Sclerals and Dry Eye When I do a Dry Eye/Ocular Surface Workup What is Included in my Dry Eye Workup (initial visit or follow up ) Subjective BLUR/FLUCTUATING VISION ITCH BURN FBS TEAR REDNESS TIRED Dry eye workup Objective FLUCTUATION REFRACTION INJECTION MEDS AUTO-IMMUNE CONDITIONS OVER AGE OF 50 MALES OVER AGE OF 45 FEMALE ROSACEA POOR MEIBUM KERATINIZED GREY LINE DRY EYE CENTER WORKUP NaFl stain Lissamine Stain Tear prism eval Meibomian gland eval Grey Line Eval Meibum expression eval TBUT Schirmer with anesthetic Osmolarity Inflammadry External Photos/Video Dry Eye Treatment Personal Treatment Protocol (Level 2 and Above) Follow up in 2 weeks or 2 months 6

7 SJO TESTING Follow up Inflammation reduced (symptoms persist) Inflammation Reduced (symptoms improved) Evaporative Signs / Symptoms Persist Evaporative Signs and Symptoms Reduced Plugs D/c lotemax Increase WCs 4x/day D/c lotemax Continue lotemax Return in 4 months Discuss Mibo/Lflow Return in 4 months Return in 1-4 months Return 4 months Personal Treatment Protocol Fitting Pearls and Practice Builders 1. Treat the Ocular Surface Before a lens touches the eye! Symptoms/signs Worsen, no improvement 4 Month follow up Symptoms improve 2. The Deom Gaurantee Get the lens on the eye!! 3. Don t Let impingement Scare you 4. Don t Let a little touch Scare you 5. Let the eye fit the lens 6. Set the expectations and use terms like journey, together, and success be positive! 7. Store your lenses dry but keep one or two lenses in solution better refraction 8. Squeegee method (C/O MCO Contact lens Department) Scleral Contact lens Prokera /ambiodry Lipiflow /mibiflow Regular 4 6 month follow ups Expert Fitting Indications and alterations Abnormal Scleral Topography 7

8 Expert Fitting Indications and alterations Ocular healing Expert Fitting Indications and alterations Eye lid Abnormalitie Expert Fitting Indications and alterations Cosmesis Expert Fitting Indications and alterations Regular Eyes Expert Fitting Indications and alterations Iris Abnormalities Expert Fitting Troubleshooting Fogging 8

9 Expert Fitting Troubleshooting Conjunctival chalasis / billowing Expert fitting Troubleshooting Non wetting surfaces Expert Fitting Purchases Topography Unit Options Expert fitting purchases Dry Eye Analysis Expert Fitting purchases Spectral microscopy 9

10 Cases if we have time 75 Year old Kcone w/ CGPs 75 Year old Kcone w/ CGPs Cases if we have time 10

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12 15.8 mm Custom Stable 20/20 vision OU for about 4 hours and mild pinching temporally and fogging of the lens about 15 minutes after insertion Flourescein Dye disappearance test ME: Sir, I know that you have been told your entire life that your corneal scar caused your right eye to be very poor, but would you allow me to quickly place a contact lens on your eye to see if I can improve your vision? 91 Y/O Man: Sure, Kid Resultant Vision OD 20/40 with 16.8 Custom Stable Lens OS 20/40 uncorrected Improved ptosis OD approx 1 mm Normal Eye Helpful resources Gpli website great free webinars on scleral lens practice and billing and coding Manufacturers websites ie. Scleral lens society website Boston- great short videos Join Facebook group scleral lens fitters 12

13 Thank you Wet Lab Pennsylvania Optometric Association Dr. Kislan and Hazleton Eye Specialists staff Kurt R First KCN patient cried in my chair and I caught the bug Valley Contax OBJECTIVES 1. observe I and R, evaluation, and fitting suggestions 2. Break into groups of 3 to 4 docs - I and R (everyone should have a lens on) - Evaluate lens - Utilize technology and Biomicroscope 3.Try the MiboThermoflo Wet Lab 13