GPS Guide to Advanced Scleral Lens Fitting

Transcription

1 GPS Guide to Advanced Scleral Lens Fitting Clark Y. Chang, OD, MSA, MSc, FAAO Melissa Barnett, OD, FAAO, FSLS The Cornea and Laser Eye Institute - Center for Keratoconus University of California, Davis Eye Clinic Financial Disclosures Dr. Chang Dr. Barnett Alden Optical Allergan Oasis Medical SynergEyes Acculens Alcon Allergan Bausch + Lomb Coopervision JJVC Vistakon Novabay Paragon Bioteck STAPLE Program Visionary Optics Zeiss Let s Start from the Very Beginning Early 1900s Made from impression mold of eye Difficult to make PMMA: Problems with hypoxia 0ptometrists.org 1

2 Fast Forward to A New Nomenclature Lens Type Corneal Corneo-Scleral Scleral Description Mini-Scleral Up to 6mm > HVID Large Scleral More than 6 mm > HVID Adopted from Nomenclature introduced by Scleral Lens Education Society (June 2013). Definition of Bearing Area Lens Rests Entirely On Cornea Lens Rests Partly on Cornea & Partly on Sclera Lens Rests Entirely on Sclera Relative Contraindication Corneas with significant edema from reduced endothelial cell count Potential Indications: A Growing List Severe dry eyes Graft versus host disease Sjögren s syndrome Stevens Johnson syndrome Neurotrophic keratopathy 2

3 Potential Indications: A Growing List Inflammatory conditions Limbal stem cell deficiency Ocular cicatricial pemphigoid Persistent sterile epi-defects LSCD Familial dysautonomia Neurotrophic keratopathy Exposure keratopathy Lens-related neovascularization Potential Indications: A Growing List Corneal ectasias Primary corneal ectasias Advanced (notably decentered) keratoconus Keratoglobus Pellucid marginal degeneration Secondary corneal ectasias Post-LASIK Post-PRK Post-RK Potential Indications: A Growing List Corneal transplants Trauma Corneal scars Corneal degenerations or dystrophies Salzmann s nodular degeneration Terrien s marginal degeneration 3

4 Potential Considerations Before We Start Eye Shape and Scleral Lenses (CLS, April 2013): Randy Kojima, Patrick Caroline, Tina Graff, Beth Kinoshita, OD, Lori Copilevitz, OD, Roxanne Achong-Coan, OD, Eef van der Worp, PhD; Matthew Lampa, OD, Kelvin So, OD, Mark Andre Comparison of SAG (Sagittal Height) differences between normal and keratoconic eyes from corneal apex to a 10.0mm chord: Mean SAG difference = 217μm SAG difference between the normal and keratoconic eyes at a chord of 10mm to 15.0mm: Mean SAG difference = 22μm Potential Considerations Before We Start Doesn t Sagittal Depth Affect Vision? Sonsino J, Mathe DS. Central vault in dry eye patients successfully wearing scleral lens. Optom Vis Sci Sep;90(9):e Clearance 100 µm 125 µm 150 µm 200 µm 250 µm 300 µm 350 µm 400 µm Lens Dk Recommendations on Expected Clearance? 4

5 Fitting Inside-Out Minimally sustainable clearance extending beyond limbus within a semi-sealed system Appropriate SAG height differs Settling Time HVID Conj. Biomechanics Lens Design/Haptic Ocular Dx Elevation Profile Fitting Inside-Out : Let s Find Our Center SAG estimation after proper settling (± NaFL) Optic Section (~45 ) OCT Design variables Patient variables Bauer A, Lotoczky J. Let s Settle This Once and For All: A Comparison of Scleral Lens Settling. GSLS Poster. Jan Josh Lotoczky, OD; Chad Rosen, OD; Craig W. Norman, FCLSA (Vision Research Institute, Michigan College of Optometry) Fitting Inside-Out : Going Out On A Limb 5

6 Fitting Inside-Out : Stick Your Landing Langis Michaud O.D., M.SC. FAAO Finishing Touches: Patience, My Young Jedi Visual Considerations Lens Flexure Central/Peripheral thickness Residual Cyl Spec Rx Front Toric (Stabilizing Mechanisms) Subjective feedback Tear lens thickness & coverage SAG height OZ & Limbal Zone Posterior Haptic Customizations Follow Up: Don t Rush The Take-Off! Hx Tolerance Lens Handling and Care Vision Sph- or Sph-Cyl OR Residual HOA (or Related Sx) SLE Centration Inside-Out Evaluation Media clarity of Ant-/Post-lens Metabolic Exchange Scleral Obstacles 6

7 Follow Up: Houston, We Have Lift Off! Cornea & Limbus Bearing Hypoxia Bulbar Conjunctiva & Sclera Rebound hyperemia Impingement Compression Conjunctival prolapse NaFL Eval. Patient techniques Lens settling characteristics The Hitchhiker s Guide To Troubleshooting Lens Handling Poor Vision Hyperemia Discomfort/Pain Troubleshooting Guide: Insertion/Air Bubbles Insertion Bubbles: Avoid Aerosol PF Saline ( More is better ) Increase viscosity ($$!) 7

8 Troubleshooting Guide: Insertion/Air Bubbles Troubleshooting Guide: Insertion/Air Bubbles Assistive insertion devices overcoming dexterity Troubleshooting Guide: Insertion/Air Bubbles Assistive insertion devices Overcoming dexterity O Ring #8 3/8 inch x 9/16 inch x 3/32 inch wall Available at any hardware store 8

9 Troubleshooting Guide: Insertion/Air Bubbles Summary on Insertion/Bubbles Re-education on Lens I/R Vary lens application saline SAG adjustment (If needed) BOZ Diameter Haptic customizations Back Bi-Toric PC Back Quad-Specific PC Impression molding Corneo-scleral profiler Troubleshooting Guide: Removal Re-education on Lens I/R Pre-removal Wetting DMV Lid message Modify SAG: Reduce (+) & (-) Forces Posterior Haptic Circumferential (360) Meridian Quad-specific BC/lens geometry Optical Residual Cyl/HOA Presbyopia Lens & Connecting Medium Chamber Bubble/Debris Surface Deposit Ant Seg Anatomy Scotopic Pupil Rotational Asymmetry Timing of symptom! 9

10 Poor or Blurry vision (Cont ) Residual Cyl R/O Lens Flexure Spec vs Front Toric Back Toric, Or Other stabilizing mechanism Front Asphericity/FSE 1 Wavefront-Guided Optic 1. Hussoin T, Le HG, Carrasquillo KG, Johns L, Rosenthal P, Jacobs DS. The effect of optic asphericity on visual rehabilitation of corneal ectasia with a prosthetic device. Eye Contact Lens Sep;38(5):300-5 Poor or Blurry vision (Cont ) Presbyopia OTC vs Mono vs Multifocal A Case in Point: Nicole 50 year old Caucasian female Interested in contact lenses for full time wear History of Sjögren s Syndrome Diagnosed 2.5 years ago Dry mouth Ocular foreign body sensation Intermittent red eyes Stephen Byrnes, O.D., FAAO A Case in Point (Cont ) Medical history Sjögren s Syndrome Medications: Plaquenil 200 mg bid po (x 2.5 years) Ocular history Dry eyes Cyclosporine 0.05% bid OU PF-Artificial tears PRN (3x in past week) Visine PRN (2x in past week) Family history Mother rheumatoid arthritis 10

11 OD 20/20 VA (glasses) / / 106 Pentacam Sim Ks OS 20/ / / /20 Refraction / Pachymetry mmhg IOP 3:42pm 18 mmhg OD 2+ mgd, irregular lid margins Trace hyperemia, 2+ NaF stain nasal and temp 1+ nasal and temp LG stain Trace inferior PEK Trace endopigment inferior paracentrally L/L Conj Cornea OS 2+ mgd, irregular lid margins Trace hyperemia, 3+ NaF stain nasal and temp 3+ nasal and temp LG stain 3+ inferior PEK at 6:00 and 3:00 Trace endopigment inferior paracentrally Deep and Quiet A/C Deep and Quiet Clear Lens Clear 0.15 C/D 0.15 Normal Macula Normal Normal Peripheral Retina Normal OD Comfort SL Aspheric Multifocal / / Comfort SL Aspheric Multifocal / / 16.4 / 9.2 Flattter PCs Sag 4.55 Parameters OS Comfort SL Center Progressive multifocal / / 16.4 / 9.2 Flatter PCs Sag /20-2 J2 VA Binoc 20/15+1 J1 20/20 J1 Plano SOR Plano Good central apical clearance Good peripheral fit No blanching Fit Good central apical clearance Good peripheral fit No blanching 11

12 Poor or Blurry vision(cont ) Progressive Foggy Vision Retrolental Debris Sebum, Mucous, and Atopic Debris Conj. epithelial cell sloughing? Tx underlying causes Lens application saline PF Viscosity PC customizations Scleral toricity alignment BC adjustment? Poor or Blurry vision(cont ) Progressive Foggy Vision Non-wetting/Deposit Plasma treatment Alcohol-based surfactant system Enzyme cleaners Mid-day cleaning Frequent rewetting Tx OSD! Lynette Johns, O.D., FAAO R/O Hypoxia Gradual, late onset blur Relatively rare but serious 12

13 Image Courtesy of Ocular Dynamics A Case of Exposure Keratitis Observe debris deposition that is adherent to anterior lens surface within the exposure zone. Patient will still need to supplement with lubrication over scleral lens devices. Johns, L. Fitting Scleral Lenses for Ocular Surface Disease. Contact Lens Spectrum, July [Last accessed on August 29, 2015] Poor or Blurry vision (Cont ) Ant Seg Anatomy Rotational Asymmetry PC misalignment Sudden Onset Blur Eye rubbing & Movt Push-Up Test (± NaFL) Haptic/PC customizations Diameter? Back-Toric PC Corneo-Scleral profiler Impression Molding Lynette Johns, O.D., FAAO 13

14 Courtesy, Greg Denaeyer, O.D., FAAO/SMap3D Poor or Blurry vision (Cont ) Ocular Anatomy Night time disturbances Multifocal expectations OZ Vs Pupils Corneal hypoxia HVID vs. Limbal zone Adjust chamber size Dk/t vs Tear CT Tear mixing Haptic toricity Frequent CL breaks OD OS 1+ mgd L/L 1+ mgd White and quiet Conj White and quiet 16 RK scars (irregular), no visible LASIK flap, iron lines along RK incisions, 2mm optic zone K 16 RK scars (irregular), no visible LASIK flap, iron lines along RK incisions, 2mm optic zone, inferior neovascularization Deep and Quiet A/C Deep and Quiet Clear Lens Clear 0.30 C/D 0.30 Normal Macula Normal Normal Peripheral Retina Normal 14

15 Troubleshooting Guide: Hyperemia Conjunctival Redness At Insertion Insertion skills Lens defects or switching Solution sensitivity Haptic compression or lift Verify toric markers Troubleshooting Guide: Hyperemia Conj. Redness (Cont ) Rebound hyperemia Removal skills Corneal bearing Haptic impingement Haptic/PC customizations Adjust SAG & design geometry Troubleshooting Guide: Hyperemia Conj. Redness (Cont ) Few Hrs - end of day Gradual Onset Solution Toxicity Conj Prolapse Monitor if benign Resolve upon removal Pseudo-Pannus & noninflammatory SAG adjustment R/O flexure 15

16 Troubleshooting Guide: Hyperemia Conj. Redness (Cont ) Few Hrs - end of day Ocular surface desiccations (DED/KCS ) Diffuse corneal/conj staining Treat underlying causes! Tear film imblanace Adjust insertion saline Adjust diameter & haptic angles Scleral toricity Controlled tear exchange Troubleshooting Guide: Hyperemia Conj. Redness (Cont ) Few Hrs - end of day Scleral obstacles Pinguecula/Pterygium Symblepharon Filtering Bleb Patch graft May monitor if (-) Pain, VA, Neo, or other complications Haptic customizations Vary lens diameter Troubleshooting Guide: Hyperemia Challenges of major scleral obstacles Hyperemia ± air bubbles ± decrease comfort Customized technologies for Haptic and OZ 16

17 Troubleshooting Guide: Let s Take It up a Notch A Protocol for Notch Measurement Measure target dimensions (height/width) via slit beam Repeat dimension measurement with scleral lens on eye Trace outline on the lens with a permanent (e.g., Sharpie) or dry erase marker Photodocumentation can be helpful prior to removal After lens removal, measure the tracing on the lens Call the laboratory consultant to discuss the plan and send the lens with marking to laboratory. Troubleshooting Guide: Hyperemia A Scleral Obstacle Course: Pinguecula Case of 46 Y/O, M. Hx: Burn injury to ocular surface and adnexa. Postsympblehparonlysis and buccal mucous membrane graft, OS. Presentation: Limbal cell deficiency with Neo. Entry BCVA is 20/200 Sindt, C. EyePrintPRO Fitting After Buccal Mucosa Graft. Scientific Poster, Global Specialty Lens Symposium. Las Vegas, Nevada. January

18 Troubleshooting Guide: Pain/Discomfort Insertion bubble(s) Sudden onset, ~2-4 after insertion Non-vision threatening bubbles & limited Movt Re-educate insertion skills More is better Saline Viscosity Adjust SAG height in affected zone(s) Troubleshooting Guide: Pain/Discomfort Excessive Corneal bearing Can onset at insertion and gradually worsen Adjust SAG height Central Vault Transition Zone geometry Adjust chamber width OZ Transition Zone(s) Troubleshooting Guide: Pain/Discomfort Solution Toxicity Corneal & Conj staining NaFL pattern in lens 18

19 Troubleshooting Guide: Pain/Discomfort If Excessive Conj. bearing (pending biomechanics) Impingement Compression Troubleshooting Guide: Pain/Discomfort Excessive Conj Bearing Conj- or lens-settling characteristics over time Adjust central SAG height Adjust haptic SAG & Width Rotational Asymmetry or Scleral obstacles Haptic customizations Asymmetrical haptic SAG Scleral profiler (smap3d) Impression molding (EyePrint) Troubleshooting Guide: Pain/Discomfort Projector Camera 1 Camera 2 Corneo-Scleral Profiler: SMap3D TM Structured light 3D-Imaging 2 cameras + 1 light source gives 3 independent triangulation 19

20 Troubleshooting Guide: Pain/Discomfort Stabilization Mechanisms for Front Toric Scleral Troubleshooting Guide: A Mixed Bag Microbial Keratitis: A risk for both soft lenses and scleral devices Lynette Johns, O.D., FAAO cchang@salus.edu.com drbarnett@ucdavis.edu Thank you 20