This is My Patient s Condition: Can Scleral Lenses Help? Alan Kwok, OD, FAAO, FSLS Karen G. Carrasquillo, OD, PhD, FAAO, FSLS
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1 This is My Patient s Condition: Can Scleral Lenses Help? Alan Kwok, OD, FAAO, FSLS 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: Salaried employees of BostonSight No proprietary interest in BostonSight PROSE treatment or BostonSight Scleral
3 Broad Indications Irregular Corneas Ocular Surface Disease 3 Innovation Education
4
5 Disease Etiology Concomitant Diseases Patient s emotional state Think BIG picture It s NOT just about the piece of plastic!
6 LONGSTANDING PENETRATING KERATOPLASTY
7 Penetrating keratoplasty - Older grafts are more vulnerable to hypoxia and suction with scleral lens wear
8 Endothelial cell counts decrease Typical endothelial counts range from cells/mm 2 Cell counts decrease with: - Age of patient - Age of graft 8
9 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 Microcystic Edema (our view in) Sattler s Veil (pt s view out) 9 Lamber, Klyce, The Origins of Sattler s Veil Am J Ophthalmol 1981 Jan 91 (1): 51-6
10 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 10
11 Fitting Strategies Decrease Hypoxic Stress Studies by Meng Lin, OD, PhD show that Dk/t of material have more an effect of corneal metabolism (hypoxia) and saw no effects on corneal metabolism (hypoxia) with different amounts of lens clearance. - High Dk material Ex. XO 2 with Dk Thin center thickness Design Strategies to Decrease Suction 11 - Large diameters - Fenestrations - Channels
12 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 12
13 Strategies: Large and Loose PROSE Device #1: - Vault: 4.9, BC: 8.2, Power: -0.50, Diameter: Wearing times of 2 hours before haze, rainbows and epithelial edema PROSE Device #2: - Vault: 5.1, BC: 8.2, Power: -0.50, Diameter: No haze, rainbows or edema after 9 hours of wear 13
14 Strategies: Large and Loose 14
15 Fitting Strategies Fenestrations in Optic Zone Goal to decrease hypoxia and suction Some keys to fitting: - Apical touch - Bubble management Size Placement 15
16 Fitting Strategies 16
17 Strategies: Decrease Suction Channels - Radial grooves in device to disrupt the seal of the device on the globe - Encourages fluid ventilation 17
18 Strategies: Decrease Suction Channels - Radial grooves in device to disrupt the seal of the device on the globe - Encourages fluid ventilation 18
19 FUCHS DYSTROPHY
20 Fuchs Endothelial cells die off Onset ~30-40 yo, manifests ~50 yo Women > Men Family Hx increases risk 2 Stages Blur decreases over time Blur remains all day 20
21 Case 54 yo female Hx Fuchs OU, s/p PK OD (2003) Failed RGPs OD H/O SCL wear (torics) last 10 yrs BCVA 20/100 PH 20/40 OD; 20/50- PH 20/40 OS Referred goal: improve BCVA 21
22
23
24 Improves to 20/20
25 Glaucoma Patients Dry eye and Glaucoma Glaucoma meds can aggravate ocular surface - BAK is main culprit Alphagan-P Travatan-Z - Preservative free options Zioptan Lumigan Cosopt PF Ocudose 25
26 Glaucoma Patients MIGS - Minimally Invasive Glaucoma Surgery 26 Image courtesy of R. Caywood OD, S. Omidghaemi OD, Review of Optometry July 2018
27 Glaucoma Patients - Case 61 year old male Pellucid Marginal degeneration POAG H/o dermatitis on eye lids Ocular Meds: - Simbrinza - Travatan - Vyzulta 27
28 Glaucoma Patients - Case MIGS OU 5/2018 Discontinuation of drops (Simbrinza, Travatan, Vyzulta) Prolensa QD OS Reports improvement in vision Reduction in dermatitis 28
29 Advanced Glaucoma patients 1. Tube shunts associated with glaucoma drainage devices a. Insertion at limbus b. Ahmed valve higher profile elitemotorperformance.co.uk 29
30 Advanced Glaucoma patients 1. Tube shunts associated with glaucoma drainage devices a. Previous scleral lens use may dictate tube entry b. Recommend Pars Plana entry as opposed to anterior chamber entry to avoid erosion of tube c. Additional benefit of not compromising corneal endothelium stage.abbottmedicaloptics.com 30
31 Fitting over Tube Case 1 75 year old Asian male Neurotrophic keratopathy H/O longstanding diabetes s/p CE, aphakia OU (40 years ago) Advanced POAG s/p Ahmed valve OU (2-3 years ago) 31
32 Fitting over Tube Case 1 Recent history of corneal surface breakdown - 2 neurotrophic ulcers in the past 6 weeks Entering corrected acuities: - OD 20/125 - OS 20/150 32
33 Fitting over Tube Case 1 33
34 Fitting over Tube Case 1 34
35 Fitting over Tube Case 1 35
36 Fitting over Tube Case 1 36
37 Fitting over Tube Case 1 37
38 Fitting over Tube Case 1 Initially limited wearing time to 2-3 hours Monitored before and after with fluorescein and lissamine staining Wearing times up to 12 hr/day IOP s stable: 11 mmhg OD, 11 mmhg OS 38
39 Fitting over Tube Case 1 39
40 Fitting over Tube Case 1 40
41 Fitting over tube Case 2 65 year old female Exposure keratitis h/o lagophthalmos from blepharoplasty OU for congenital ptosis Pseudoexfoliation glaucoma h/o CME OU h/o persistent epithelial defect OS s/p Ahmed tube shunt infero-temporal OS Entering corrected acuities 20/40 OD, 20/80 OS 41
42 Fitting over tube Case year old female Exposure keratitis OU Fit into PROSE device with goal of supporting surface, heal PED, improve vision 7.9 BC / D / 20.0 mm OS Moderate awareness, 20/25- OS Erosion over tube prompted discontinuation of device wear per glaucoma specialist s instruction
43 Fitting over tube Case year old female Exposure keratitis OU Fit into PROSE device with goal of supporting surface, heal PED, improve vision 7.9 BC / D / 20.0 mm OS Moderate awareness, 20/25- OS Erosion over tube prompted discontinuation of device wear per glaucoma specialist s instruction
44 Fitting over tube Case 2 Refit into flatter lens with deeper channel No impingement at edge No conjunctival staining 44
45 Fitting over tube Case 3 67 year old WM h/o Stevens-Johnson Syndrome PROSE devices since 2008 Ahmed tube with supero-temporal tube 2017 Thickened conj confluent with symblepharon 45
46 Fitting over tube Case 3 Fit with smaller diameter with notch Trace staining upon removal 46
47 Fitting over bleb Case 1 84 year old Caucasian female Keratoconus, Dry Eye Syndrome, POAG OU h/o corneal gas permeable lens intolerance OS Corneal GP lens OD, PROSE device OS 47
48 Fitting over bleb Case 1 Fit with PROSE device 2008 BCVA 20/30 OS Combined cataract and filtering bleb surgery OS
49 Fitting over bleb Case 1 Fit with PROSE device 2008 BCVA 20/30 OS Combined cataract and filtering bleb surgery OS 2009 Continued to wear device OS Large diameter 23.0 mm 49
50 Fitting over bleb Case 1 Corrected VA: 20/30 IOPs before surgery: mmhg IOPs after surgery: 8-11 mmhg VFs: stable with no progression of defects after bleb surgery 50
51 Fitting over bleb Case 2 72 year old make with PKP h/o Fuch s Dystrophy Glaucoma with superior bleb OD Initially fit with scleral - Impingement on bleb - Fit deemed unacceptable by glaucoma surgeon 51
52 Fitting over bleb Case 2 Refit into PROSE Small diameter with notch - Unstable with intrusion of bubbles - NaFl Staining at edge of bleb on removal 52
53 Fitting over bleb Case 2 Refit into PROSE Large diameter to vault over PD Conjunctival congestion with PD wear 53
54 Fitting over bleb No easy answers for complex patients who have multiple issues Each needs to be evaluated on it s on merit and 54
55 PATIENT S EMOTIONAL/PSYCHOLOGICAL STATE
56 Pediatric patients Carrasquillo, KG. (2017) Pediatric Scleral Lenses in Pediatrics. Contemporary Scleral Lenses: Theory and Application, Ed : Barnett, M. and Johns, L Trauma Anxiety Pain 56
57 Case 4yo Hispanic female (lives in Uruguay) Hx SJS (Phenobarbital - Seizures) OS>OD Hx AMT 1 yr prior OS Distichiasis, Keratinization, Entropion, Haze, Neovascularization, Keratitis 57
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59 Trial Only able to apply in right eye Used 16mm lens BCVA 20/80 +2, NVA J5 ~8 (LEA Cards) Seen for 2 weeks in clinic A/R After ~14 A/R sessions with parents - Able to apply unreliably - Unable to remove (patient wouldn t cooperate too anxious) 59
60 Allow ample time on your schedule Establish rapport/trust Even then, patients may not be ready Try again in 6 months/1 yr 60
61 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18
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