Scleral Lenses and Anterior Segment Disorders

Transcription

1 Scleral Lenses and Anterior Segment Disorders Learning to see the BIG picture Karen G. Carrasquillo, OD, PhD, FAAO, FSLS Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Disclosure Statement: Nothing to disclose

3 Indications Ocular Surface Disease DRY EYE SYNDROME Ocular chronic GVHD Sjögren s syndrome History of refractive surgery (LASIK, PKP) Rheumatoid arthritis After radiation LIMBAL STEM CELL DEFICIENCY Stevens-Johnson syndrome (SJS) Aniridia Cicatricial conjunctivitis/ocular cicatricial pemphigoid Chemical/thermal injury EPIDERMAL OCULAR DISORDERS Goldenhar syndrome Ectodermal dysplasia Atopy Epidermolysis bullosa 3 NEUROTROPHIC KERATITIS Herpes zoster (shingles) Herpes simplex (ocular herpes) Familial dysautonomia Trigeminal nerve dysfunction Moebius syndrome After surgery CORNEAL EXPOSURE / LAGOPHTHALMOS Anatomic Paralytic - Acoustic neuroma

4 Indications Distorted Corneal Surface DEGENERATIONS Keratoconus Keratoglobus Pellucid marginal degeneration Terrien s marginal degeneration Salzmann s nodular degeneration Ehlers-Danlos syndrome AFTER SURGERY Cornea transplant (PK, PKP) Radial keratotomy (RK) Photorefractive keratectomy (PRK) Phototherapeutic keratectomy (PTK) Epikeratophakia LASIK Open globe injury DYSTROPHIES Cogan s dystrophy Bowman s dystrophy Granular corneal dystrophy Lattice corneal dystrophy Meesmann s corneal dystrophy 4 CORNEAL SCARRING After infection After trauma

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6 Disease Etiology Concomitant Diseases Think BIG picture It s NOT just about the piece of plastic!

7 Effects of Mechanical Triggers Tight lens fits Suction Hypoxia Compression

8 Discern when is time for medical management Treat with topical steroids Change topical medications Discontinue topical medications Titrate levels of systemic vs local immunosuppression Proper IOP management

9 55 yo male KCN OU Case Longstanding Hx GPs intolerant Hx of? Infection OS 3 mos prior to consultation +Haze, striae OU, nodule OS UCVA 20/100 OD BCVA 20/40 OS (GP) Improve BCVA to 20/25 OU 9

10 During A/R training We check cornea/ocular surface pre and post A/R Post A/R - We notice bullae over scar/opacity OD at end of day Next day pre A/R we notice? Epi Defect Bullae rupture? Rx E-mycin ung QHS OD, RTC next day for eval Book cornea consult with corneal specialist 10

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12 Plan Suspected HSV Stromal Disciform Keratitis Immunosuppress locally provoke dendrite formation to confirm Dx Cont E-mycin ung HS Add PF QD OD (just a whisper of steroid) RTC 3 days 12

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15 Rx Valtrex (resume) 500mg BID po Cont PD QD OD Ok to d/c E-mycin ung HS Plan 1.5 wks s/p They don t call it the big masquerader for nothing! AGAIN go back to basics.good Medical History Big picture! 15

16 Case 76 yo female SJS unknown trigger, 1981 Benign iris tumor, s/p iridectomy 1957 PROSE treatment 1997 s/p CE OD with pupil enlargement OD 2007 s/p CE, PCIOL OS 2008 H/O Thyroid Cancer and Melanoma (right shoulder) H/O pannus/conjunctivalization OU baseline BCVA OD fluctuates between 20/25-20/40 BCVA OS originally 20/40-20/50 range Followed as GLC suspect 16

17 OD OS

18 2014 GLC Dx Topical Meds: Ketorolac 0.5% BID OU, Lotemax ung QHS OS, Simbrinza 1% 1 gtt BID OU Evaluation in 2015 Worsening of pannus OS, mild MCE/epitheliopathy OS BCVA decreased to 20/80-20/100 range 18

19 What to do? Are scleral lenses still viable? Is the scleral lens making it worse? Is it hypoxia, SHOULD WE DECREASE THE SAG?? MAKE THE LENS THINNER? Already in XO 2, CT 0.25mm 19

20 Glaucoma Meds Preservatives - can often cause toxic reaction at ocular surface Most common BAK Activates inflammatory mediators/cytokines Direct damage to corneal and conjunctival epithelium Due to persistence of BAK in cell membranes, toxicity often is delayed and prolonged.

21 Use of BAK has negative effects under normal and dry eye conditions Increased inflammation Reduced number goblet cells

22 Plan D/C Acular, Switch Simbrinza to preservative free Zioptan monitor IOP Maintain LTX ung at QHS OS BCVA 20/60-20/80 22

23 Case 42 yo male NTK, DES, Neovascular GLC, OD>>OS Dorzolamide OU QAM Istalol BID OD Combigan OU QAM IOP typically ~17-18mmgH OU With PROSE devices, BCVA 20/20 OU 23

24 OS

25 BCVA OD decreased to 20/50 range Is it the fit? Are scleral lenses still viable/helpful? Do we jump and modify the fit? Focus on clearance??? 25

26 7 albino rabbits exposed to high IOP, 15min-4hrs 15-30min minimal change 1-2 hrs corneal opacification 3-4 hrs stromal and epi edema, many areas bare of endothelium showing cells with ballooning surfaces and ruptures. CONCLUSIONS Endo cells are sensitive to IOP elevation Injury to the active pump system due to morphological damage is responsible for the resultant corneal edema

27 IOP under control Required tube shunts Scleral lens wear dictated entry Pars Plans entry Cont to wears scleral lenses successfully Communicate with referring and comanaging doctors ECD is less than normal grp

28 Case 44 yo Male H/O KCN with h/o hybrid lens wear. Tight fitting OU Referred to be refit into a more physiologic lens/device. Initial presentation Active K neo with associated haze from leaky vessels.

29 Baseline Kwok, A. and Carrasquillo, K.G. (2018) What Makes a Scleral Lens Fit Physiological? A Case Report J. Ophthalmol. Clin. Res. 5(41), 1-5.

30 Estimated clearance (using lens CT as reference) OD: ~ um OS: 500um

31 2 months after

32 2 years after

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34 Even when there s a theoretical model that predicts that central clearance should be 150um to avoid hypoxic effects (Michaud et. al. (2012) Predicting estimates of oxygen transmissibility for scleral lenses. Contact Lens Ant Eye, 35, ) Majority of recent clinical studies find levels of hypoxia well within range of physiological edema that develops overnight (4%) and in most cases is less than 2% Vincent et. al. (2016) No clinically significant edema after 8 hours of mini-scleral lens wear Median central clearance of ~350um. They report findings suggest that the amount of central clearance or postlens tear layer thickness does not contribute significantly to corneal hypoxia, in the wearing schedule studied, in healthy subjects. Kim et. al. (2018) Looked at 2 variables Lens Clearance Dk/t system Minimal impact in edema with increased lens clearance Measured amounts of edema between 1-1.5% MAIN factor playing role = Dk/t system

35 Case

36 10/15/2008

37 11/18/2008

38 11/25/2008

39 Conclusions Scleral lens can help in a wide variety of anterior segment disorders Good understanding of disease etiology is KEY for success Is crucial to always think medically.is not always about the fit or the piece of plastic! Important to think about the scleral lens fit as a whole and not focus or hyper focus on just certain aspects of fit

40 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18