2/22/2016. Disclosures. A look in the past. A look in the past. The Basics of Scleral Lens Fitting - It's as Easy as 1, 2, 3

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The Basics of Scleral Lens Fitting - It's as Easy as 1, 2, 3 Melissa Barnett, OD,

Optical Alcon Allergan Bausch + Lomb CooperVision JJVC Vistakon Novabay Gas Permeable

Zeiss Scleral lenses are large diameter gas permeable lenses that rest beyond the

A look in the past The concept of optically neutralizing the cornea with an enclosed

1508. A look in the past Thomas Young was the first to experiment visual correction

1 The Basics of Scleral Lens Fitting - It's as Easy as 1, 2, 3 Melissa Barnett, OD, FAAO, FSLS University of California, Davis Eye Center Disclosures Acculens Alden Optical Alcon Allergan Bausch + Lomb CooperVision JJVC Vistakon Novabay Gas Permeable Lens Institute (GPLI) Paragon Bioteck Scleral Lens Education Society STAPLE program Zeiss Scleral lenses are large diameter gas permeable lenses that rest beyond the limits of the cornea and extend onto the sclera. A look in the past The concept of optically neutralizing the cornea with an enclosed liquid reservoir over the eye s surface was first proposed by Leonardo da Vinci in A look in the past Thomas Young was the first to experiment visual correction through a glass tube filled with water His inspiration came from René Descartes theoretical work T.Young R. Descartes Popular Mechanics, 1948, 1

2 Scleral Lenses First used in late 1800s and early 1900s Manufacturing process now more reproducible Modern scleral lenses Don Ezekiel, O.D. Ken Pullum, O.D. Perry Rosenthal, M.D. Boston Scleral Lens Scleral Lens Design Scleral Lens: Indications Scleral Lens: Indications Corneal ectasias Primary corneal ectasias Advanced (notably decentered) keratoconus Keratoglobus Pellucid marginal degeneration Secondary corneal ectasias Post-LASIK Post-PRK Post-RK Corneal transplants Trauma Corneal scars Corneal degenerations or dystrophies Salzmann s nodular degeneration Terrien s marginal degeneration 2

$High refractive error Corneas$ with significant edema from

3 Scleral Lens: Indications Persistent epithelial defects Scleral Lens: Indications Severe dry eyes Graft versus host disease Sjögren s syndrome Stevens Johnson syndrome Neurotrophic keratopathy Scleral Lens: Indications Scleral lenses: Contraindications Inflammatory conditions Limbal stem cell deficiency Ocular cicatricial pemphigoid Neovascularization with hybrid lens designs Poor comfort with traditional gas permeable designs High refractive error Corneas with significant edema from reduced endothelial cell count Which are do you feel has the greatest potential for growth in the next 12 months? 3

and historical literature on scleral lenses.

articles published before 1983 Lens design and fabrication techniques Or scleral

lenses Visual and functional outcomes of scleral lens wear Statistically

surface disease Indications for scleral lens wear are well-established Current

Use of technology to improve scleral lens vision and fit Impact of scleral lenses

5mm Mini-scleral Supported by conjunctiva and tear layer (water bed) Less

5mm of sclera is spherical More than 18mm Full Scleral Supported by conjunctiva

5mm has more toricity due to muscle insertions How large should a scleral lens be?

Scleral anatomy Ease of fit / troubleshooting Patient handling Complications 14.

4 Scleral lenses: a literature review. Eye Contact Lens 2015 Jan;41(1):3-11 Schornack MM Comprhensive review of current and historical literature on scleral lenses. 899 references were identified 184 directly related to scleral lenses Most articles published before 1983 Lens design and fabrication techniques Or scleral lens indications Scleral lenses: a literature review. Case reviews published after 1983 Major indications for scleral lenses Visual and functional outcomes of scleral lens wear Statistically significant improvements in Visual acuity Vision-related quality of life Ocular surface disease Indications for scleral lens wear are well-established Current and future research Physiologic impact of scleral lens wear on the ocular surface Use of technology to improve scleral lens vision and fit Impact of scleral lenses on quality of life Mini-scleral vs. Full scleral Typically mm Mini-scleral Supported by conjunctiva and tear layer (water bed) Less clearance First 16.5mm of sclera is spherical More than 18mm Full Scleral Supported by conjunctiva Sclera beyond 16.5mm has more toricity due to muscle insertions How large should a scleral lens be? Limiting factors Oxygen permeability Corneal physiology Conjunctiva anatomy Scleral anatomy Ease of fit / troubleshooting Patient handling Complications 14.3 OAD 18.2 OAD Lens Diameter Practitioner preference May be able to alter the diameter within the same lens design If the diameter is changed significantly, may need a different lens design Pd ruler Topography Pentacam Slit lamp reticle Corneal Diameter 4

Overall Diameter 1 Bridge over the Cornea (and Limbus) Too small

scleral lenses Sagittal height is adjusted to increase or

clearance or vault of the lens Different terminology is used

and a reference Average corneal thickness Central = 530 microns

as a reference Clearance Allow scleral lenses time to settle and

a lens on the eye Keep in mind that lenses may settle more with

5 Overall Diameter 1 Bridge over the Cornea (and Limbus) Too small Inadequate coverage Leads to discomfort Optimal Lens centered and > 1.5mm beyond limbus Clearance Clearance is a key advantage of scleral lenses Sagittal height is adjusted to increase or decrease clearance Increasing the sagittal height increases the clearance or vault of the lens Different terminology is used rather than flat and steep Clearance Cornea useful as comparison and a reference Average corneal thickness Central = 530 microns Peripheral = 650 microns Central lens thickness can also be used as a reference Clearance Allow scleral lenses time to settle and sink into conjunctiva Wait at least 30 minutes before evaluating a lens on the eye Keep in mind that lenses may settle more with time Clearance Limbal clearance also important Stem cells are located at the limbus Stem cells form new epithelial cells for the entire cornea 5

6 Limbal Clearance Clearance A thin optic section with white light (both with and without fluorescein) is helpful to evaluate clearance White Light High Mag Central Clearance 50 Microns 150 Microns 300 Microns Tear Layer on front surface of lens Corneal Thickness Lens CT =.35mm 350 microns OK if large scleral You can order final lens thinner Central Clearance Apical Clearance (AC) Approx= to lens CT AC=350 1:1 ratio 500 Microns 600 Microns Photos courtesy of Base curve changes can increase VAULT (Clearance, Fluid Chamber) OCT With Corresponding Slit Images Greg DeNaeyer, OD 6

Sagittal Depth Sagittal depth is the measurement from the flat plane to the

central bubbles If sagittal depth is too low, leads to excessive central

Excessive mid-peripheral clearance - bubbles in mid-peripheral / limbal zone

and the intersection of a specified chord length Average sagittal height from

(24-28%) 4 marked/tangential (2.5-7%) 5 concave/convex (0-0.5%) Average Conj.

7 Sagittal Depth Sagittal depth is the measurement from the flat plane to the highest point of a concave surface If sagittal depth is too high, leads to central bubbles If sagittal depth is too low, leads to excessive central touch and bubbles in sclera Excessive Sagittal Depth Bubbles Centrally Excessive mid-peripheral clearance - bubbles in mid-peripheral / limbal zone 4.20 S Sagittal Height Measurement between the geometric center of the cornea and the intersection of a specified chord length Average sagittal height from 10mm to 15mm for all eyes is approximately 2,000μm (Kojima CLS 2013) Scleral Anatomy Conjunctival shape dictates which lens to fit Corneal-Scleral-Profile 1 gradual/convex (8-23%) 2 gradual/tangential (42-56%) 3 marked/convex (24-28%) 4 marked/tangential (2.5-7%) 5 concave/convex (0-0.5%) Average Conj. 15mm Toricity: 2D Average 38.3 Average Conj. 20mm Toricity: 5D Average 39.8 T N T N 7

Scleral lens fitting- smap3d Scleral lens fitting- smap3d Eye Shape and

Caroline, Tina Graff, Beth Kinoshita, OD, Lori Copilevitz, OD, Roxanne

Andre Sagittal height difference between the normal and keratoconic eyes at a

Comparison of the sagittal height differences between normal and keratoconic

Sagittal Height Sagittal height of 10mm chord = 2,000μm Desired vault of 300μm

for vault = 4,300µm) Larger diameter lens increase sagittal height (need to

Maramb, Katrin Muellerc Use of the Visante OCT to measure the sagittal depth

8 Scleral lens fitting- smap3d Scleral lens fitting- smap3d Eye Shape and Scleral Lenses Contact Lens Spectrum 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 Sagittal height difference between the normal and keratoconic eyes at a chord of 10mm to 15.0mm. Mean sagittal height difference = 22μm. Comparison of the sagittal height differences between normal and keratoconic eyes from corneal apex to a 10.0mm chord. Mean sagittal difference = 217μm. Sagittal Height Sagittal height of 10mm chord = 2,000μm Desired vault of 300μm centrally 15mm diagnostic lens = should be 4,300µm (2,000µm + 2,000µm + 300µm for vault = 4,300µm) Larger diameter lens increase sagittal height (need to cover larger area of eye surface) Sagittal Height Luigina Sorbara, Jyotsna Maramb, Katrin Muellerc Use of the Visante OCT to measure the sagittal depth and scleral shape of keratoconus compared to normal corneae: Pilot study J Optom.2013;6:141-6 Sagittal Height Sagittal depth and corneal-scleral junction angle measurements in the steepest meridian at HVID or 15mm Significantly different in normals and patients with keratoconus. 8

Corneal topography Corneal Shape Determines corneal diameter or HVID Information

apex (location and height) of cornea to select a lens Standard geometry lens corneal

central 4mm, some post PK grafts or peripheral elevations (Salzmann s) Measurements

Obtain objective measurements of the depth of the cornea and sclera Limitations -

sclera Aids in selection of initial fitting set Measurements of Anterior Segment

reservoir and edge contour to the sclera No need to remove lens on eye prior to

9 Corneal topography Corneal Shape Determines corneal diameter or HVID Information about location of corneal apex Determines sagittal height of the cornea Determine apex (location and height) of cornea to select a lens Standard geometry lens corneal apex within central 4mm of the cornea Reverse geometry lens corneal apex outside the central 4mm, some post PK grafts or peripheral elevations (Salzmann s) Measurements of Anterior Segment Depth Optical coherence tomography (OCT) Scheimpflug imaging Obtain objective measurements of the depth of the cornea and sclera Limitations - only out to about 15mm Images allow visualization of the contour of the cornea and sclera Aids in selection of initial fitting set Measurements of Anterior Segment Depth OCT Used at follow up appointments Gives precise measurements of the tear reservoir and edge contour to the sclera No need to remove lens on eye prior to measurements Image courtesy of Stephanie Woo, OD, FAAO, FSLS Image courtesy of Stephanie Woo, OD, FAAO, FSLS 9

FAAO, FSLS Image courtesy of Bruce Baldwin,

The lens and the eye seem to be of similar

Compression Blanching of the conjunctival

the scleral lens peripheral curve Typically

10 51.00 D D Images courtesy of Stephanie Woo, OD, FAAO, FSLS Image courtesy of Bruce Baldwin, OD, FAAO, FSLS Fitting Scleral GP lenses 2- Stick the Landing MID-PERIPHERAL CENTER LIMBAL PERIPHERAL LANDING Scleral Alignment The lens and the eye seem to be of similar shape and Lens edge contours the eye evenly Compression Blanching of the conjunctival vessels as a result of excessive bearing of the scleral lens peripheral curve Typically will not result in staining, but may rebound hyperemia may be present after removal Can occur at the outer edge of the lens or at the inner aspect of the landing zone 10

11 Conjunctival Blanching due to Compression Edge Lift Conjunctival Impingement Lens edge pinches conjunctiva Negative pressure builds behind scleral lens with blink Take it Up a Notch How to Notch 1. Measure the size (both height and width) of the conjunctival abnormality using a slit beam. 2. Measure the height and width of the conjunctival abnormality while the scleral lens is on the eye. 3. Mark the scleral lens with a permanent (e.g., Sharpie) or dry erase marker while the lens is on the eye. 4. Measure the tracing on the lens after removing it from the eye. 5. Call the laboratory consultant to discuss the plan and send the lens to the laboratory. MicroVault Pictures courtesy of Shelley I. Cutler OD, FAAO, Scleral Lens Associates, Inc, Philadelphia, PA 11

$3 Over-refraction Over-refraction and$ Solutions Special considerations

Resources Scleral lens education society

12 3 Over-refraction Over-refraction and Handing Insertion removal training Solutions Special considerations Materials High Dk materials Thicker than small diameter GP lenses Often 0.4mm to 0.6mm which reduces Dk / t Plasma treatment to improve wettability Useful Resources Scleral lens education society video Scleral Contact Lens Insertion, Removal, Troubleshooting and Lens Care Old New Train and retrain application and removal Replace plunger Old plunger may be leaving residue on lens surface 12

0.9% NACL prescription example X-Ray Vision

Anywhere, USA 12345 Tel:(555) 555-5555 Fax:

Mypatient, O.D. Name: Address: Date: R 0.

Dispense : 1 box (100 count) 3 ml vials Sig:

Refills: LacriPure Disinfection Unit-dose,

application solution Approved for rinsing

and GP lenses No buffers or preservatives

98-vial box for a 7 week supply Menicon Progent

13 0.9% NACL prescription example X-Ray Vision Specialties, P.C Sunnyview Blvd. Anywhere, USA Tel:(555) Fax: (555) I.M. Awesome, O.D. B. Mypatient, O.D. Name: Address: Date: R 0.9% NaCl Inhalation saline for ophthalmic use Dispense : 1 box (100 count) 3 ml vials Sig: Use as directed with ocular prosthetic device Refills: LacriPure Disinfection Unit-dose, non-preserved saline Approved as a scleral lens application solution Approved for rinsing contact lenses and lens cases Used with soft and GP lenses No buffers or preservatives Packaged in 5ml unit-dose vials Packaged in 98-vial box for a 7 week supply Menicon Progent 2-component cleaner with sodium hypochlorite and potassium bromide Removes deposits, bacteria, fungus, molds and yeasts. 30 minutes Warning! Do not store lenses in saline due to risk of microbial keratitis 13

14 Other Considerations Age Living alone Dexterity Systemic health status Training Challenges Training Challenges Sea Green Lens Inserter Dalsey Adaptives Green LED light helps center the scleral lens for insertion Stand hold plungers and lenses securely prior to insertion Sea Green Lens Inserter Helps for unsteady hands Helps for those who need to hold lids open with both hands 14

EZi Scleral Lens Applicator One finger lens insertion Lens self-positioning Less air entrapment O Ring #8 3/8 inch x 9/16 inch x 3/32 inch wall Available at any hardware store

com/ Joe, 40 year old Caucasian Male History of lattice corneal dystrophy both eyes Diagnosed age 2 Family history of lattice corneal dystrophy father Has not worn contact lenses

PTK OU PKP and AK OS PC IOL OS S/P YAG OS Glaucoma suspect Ocular medications Non-preserved artificial tears as needed Fluorometholone 1% and ketorolac 0.

manifestations Autosomal dominant Caused by mutations in the TGFBI gene TGFBI gene provides instructions for making proteins in the cornea.

15 EZi Scleral Lens Applicator One finger lens insertion Lens self-positioning Less air entrapment O Ring #8 3/8 inch x 9/16 inch x 3/32 inch wall Available at any hardware store Joe, 40 year old Caucasian Male History of lattice corneal dystrophy both eyes Diagnosed age 2 Family history of lattice corneal dystrophy father Has not worn contact lenses for 5 years Previously tried RGPs and hybrid contact lenses Blurry vision for distance with glasses Hard to read computer and near Joe, 40 year old Caucasian Male Ocular history PTK OU PKP and AK OS PC IOL OS S/P YAG OS Glaucoma suspect Ocular medications Non-preserved artificial tears as needed Fluorometholone 1% and ketorolac 0.5% daily in both eyes Lattice Corneal Dystrophy Type 1 Lattice Corneal Dystrophy Type 1 Lattice corneal dystrophy type 1 (AKA Biber-Haab-Dimmer dystrophy) No systemic manifestations Autosomal dominant Caused by mutations in the TGFBI gene TGFBI gene provides instructions for making proteins in the cornea. TGFBI protein is part of the extracellular matrix Plays a role in the attachment of cells to one another (cell adhesion) and cell movement (migration). The TGFBI gene mutations involved in lattice corneal dystrophy type I change amino acids in the TGFBI protein. Mutated TGFBI proteins abnormally clump together and form amyloid deposits. Unclear how the changes caused by the gene mutations induce the protein to form deposits. 15

$or small, filamentous, and refractile anterior stromal lesions to nodular, threadlike, and thicker linear lesions that extend into deep stroma Typically limbus is not involved Clear spaces between$

16 Lattice Corneal Dystrophy Type 1 Lattice Corneal Dystrophy Type 1 Variable in appearance Classic 'glass-like' filamentous lesions Deposits may change over time Progress from round, ovoid and white, or small, filamentous, and refractile anterior stromal lesions to nodular, threadlike, and thicker linear lesions that extend into deep stroma Typically limbus is not involved Clear spaces between lesions in beginning stages Over time, spaces opacify and take on a ground glass appearance. Signs most often appear in early childhood and become more prominent into the 2nd and 3rd decades. Symptoms (begin in the 2nd or 3rd decades of life) Surface erosions Irregular astigmatism Vision loss Signs Recurrent corneal erosions Treatment Penetrating or lamellar keratoplasty (may not be needed until 4 th decade) Recurrence may occur in grafts but present differently than primary lesions Lattice Corneal Dystrophy Type II and III Lattice corneal dystrophy type II (AKA Finnish Familial Amyloidosis, Meretoja syndrome, Amyloidosis V, Familial amyloidotic polyneuropathy IV) Autosomal dominant inheritance of the Gelsolin gene on 9q34 Associated with manifestations of systemic amyloidosis due to accumulation of gelsolin Associated conditions include cutis laxa and ataxia OD 20/60-2 PH 20/30 VA (uncorrected) / / 146 Irregular astigmatism central and inferior Joe Pentacam Sim Ks OS 6 feet PH 20/ / / 050 Temporal steepening and irregular astigmatism 971 Pachymetry 668 Lattice corneal dystrophy type type III Onset at age 70 to 90 years Not associated with systemic amyloidosis 10 mmhg Applanation 3:13pm 11 mmhg OD 2+ mgd, telangectasia L/L OS 2+ mgd, telangectasia White and quiet Conjunctiva White and quiet 3+ lattice corneal dystrophy, 2+ central clouding, reduced tear meniscus, no PEK Cornea Post Penetrating Keratoplasty intact No PEK Deep and Quiet A/C Deep and Quiet 1+ nuclear and cortical sclerosis Lens PC IOL stable 0.40 C/D 0.30 Normal Macula Normal OD 46.00D / / 16.0mm Sag 4.66 Good central and peripheral clearance No blanching Initial Diagnostic Scleral Lenses Parameters Fit New diagnostic lens Fit OS 48.00D / / 16.0mm Sag 4.85 Inadequate limbal clearance 48.00D / / 18.0mm Sag 5.64 Good but minimal central clearance (want increase 80 microns) Clearing graft No blanching /25+2 SOR /

OD OS OD OS 46.00D / -4.00 / 16.0mm Sag 4.66 Initial Scleral Lenses Ordered Parameters 48.00D / -3.50 / 18.0mm / 9.5 Sag 4.80 46.00D / -4.00 / 16.0mm Sag 4.66 Scleral Lens Dispense Parameters 48.

50 at Near Good central and peripheral clearance Clearing graft completely No blanching OD Follow Up OS 46.00D / -4.00 / 16.0mm Sag 4.66 20/25-1 SOR +0.25 to +0.

66 Parameters VA Fit Anterior segment without lenses New lenses (# 2) Parameters 48.00D / -3.50 / 18.0mm / 9.5 Sag 5.

5 / 13.25 Sag 5.80 OD 46.00D / -3.63 / 16.0mm Sag 4.66 20/20-1 SOR pl to +0.

17 OD OS OD OS 46.00D / / 16.0mm Sag 4.66 Initial Scleral Lenses Ordered Parameters 48.00D / / 18.0mm / 9.5 Sag D / / 16.0mm Sag 4.66 Scleral Lens Dispense Parameters 48.00D / / 18.0mm / 9.5 Sag /20-2 SOR NI VA 20/15-1 SOR pl Good central and peripheral clearance No blanching Fit Accepts at Near Good central and peripheral clearance Clearing graft completely No blanching OD Follow Up OS 46.00D / / 16.0mm Sag /25-1 SOR to /25+2 Good central and peripheral clearance No blanching Bubble superior temporal Impression of bubble on cornea 46.00D / / 16.0mm Sag 4.66 Parameters VA Fit Anterior segment without lenses New lenses (# 2) Parameters 48.00D / / 18.0mm / 9.5 Sag /20 SOR pl Good central and peripheral clearance Clearing graft completely Far peripheral blanching 1+ peripheral microcystic edema 48.00D / / 18.2mm / 9.7 / 10.5 / Sag 5.80 OD 46.00D / / 16.0mm Sag /20-1 SOR pl to NI Good central and peripheral clearance No blanching No bubbles No PEK, no MCE Follow Up after Scleral Lens Dispense (#2) Parameters VA Fit Anterior segment without lenses OS 48.00D / / 18.2mm / 9.7 / 10.5 / Sag /20-1 SOR pl Good central and peripheral clearance Clearing graft completely No blanching No PEK, no MCE 571 Pachymetry

OCT of Scleral Lens Fit OCT to Assess Scleral Lens Fit OCT provides

Limbal clearance amount varies Important to have clearance Excessive

OCT useful to determine if toric landing curves would improve a scleral lens

OCT Leads to debris accumulation under the lens Leads to fogging of the

conjunctiva Discomfort and redness over time OCT to Assess Landing Zone and

Lens Fitting Jason Jedlicka, OD and Greg DeNaeyer, OD Contact Lens Spectrum,

specialist for a contact lens fitting both eyes Vision not as clear for

18 OCT of Scleral Lens Fit OCT to Assess Scleral Lens Fit OCT provides information in relation to the sclera 1. Central vault amount varies 2. Limbal clearance amount varies Important to have clearance Excessive clearance conjunctival prolapse and hypoxia 3. OCT useful to determine if toric landing curves would improve a scleral lens fit. OCT to Asses Landing Zone and Edge Profiles Flat edge with edge lift on OCT Leads to debris accumulation under the lens Leads to fogging of the vision Tight edge Scleral lens impression or digging in to the scleral conjunctiva Discomfort and redness over time OCT to Assess Landing Zone and Edge Profiles TIGHT Picture from Critical Measurements to Improve Scleral Lens Fitting Jason Jedlicka, OD and Greg DeNaeyer, OD Contact Lens Spectrum, September 2015 Keratoconus 63 year old Caucasian male Referred by corneal specialist for a contact lens fitting both eyes Vision not as clear for distance Eyes irritated and dry at the end of the day History of small diameter gas permeable contact lens wear since MFMER slide

X-Ray Vision Specialties, P.C. 2020 Sunnyview Blvd. Anywhere, USA 12345 Tel:(555) 555-5555 Fax: (555) 555-5556 I.M. Awesome, O.D. B. Mypatient, O.

$device Refills: 2/22/2016 OD 20/40 PH 20/30 VA (with GPs) OS 20/25 PH 20/20-2 -6.50+0.50x065 20/60 Refraction -3.75+0.$ 50x095 20/60 45.18 / 54.26 / 045 Pentacam 51.61 / 53.

White and quiet Fleisher Ring paracentral scarring Cornea Fleisher Ring paracentral scarring less than 1mm Deep and Quiet A/C Deep

40 C/D 0.30 Normal Macula Normal OD Jupiter (Essilor) Optimum Extra OD 47.25 / -5.75 / 16.6 / 13.25 / 14.75 Sag 4.

OS 48.50 / -5.99 / 16.6 / 8.6 OZ / 13.25 / 14.75 Sag 4.

after 4-5 hours of scleral lens wear Meibonitis treated with eyelid hygiene, doxycyline 100 mg po, Azasite, dietary changes,

9% sodium chloride inhalation solution with two drops of non-preserved Celluvisc R 2012 MFMER slide-112 Keratoconus Follow up

19 X-Ray Vision Specialties, P.C Sunnyview Blvd. Anywhere, USA Tel:(555) Fax: (555) I.M. Awesome, O.D. B. Mypatient, O.D. Name: Address: Date: 0.9% NaCl Inhalation saline for ophthalmic use Dispense : 1 box (100 count) 3 ml vials Sig: Use as directed with ocular prosthetic device Refills: 2/22/2016 OD 20/40 PH 20/30 VA (with GPs) OS 20/25 PH 20/ x065 20/60 Refraction x095 20/ / / 045 Pentacam / / 002 Irregular astigmatism Sim Ks Irregular astigmatism 505 Pachymetry 542 OD OS 1+ mgd L/L 1+ mgd White and quiet Conjunctiva White and quiet Fleisher Ring paracentral scarring Cornea Fleisher Ring paracentral scarring less than 1mm Deep and Quiet A/C Deep and Quiet 14 mmhg Applanation 1:22pm 15 mmhg 1+ nuclear and cortical sclerosis Lens 1+ nuclear and cortical sclerosis 0.40 C/D 0.30 Normal Macula Normal OD Jupiter (Essilor) Optimum Extra OD / / 16.6 / / Sag /25+1 SOR pl Good central and peripheral clearance No blanching Scleral Lenses Parameters OS Jupiter (Essilor) Optimum Extra OS / / 16.6 / 8.6 OZ / / Sag 4.88 VA 20/20-2 SOR pl Binocular VA 20/20+1 Fit Good central and peripheral clearance No blanching Keratoconus Follow up Foggy vision after 4-5 hours of scleral lens wear Meibonitis treated with eyelid hygiene, doxycyline 100 mg po, Azasite, dietary changes, Restasis Additional treatments Avenova eyelid cleaner Ocusoft eyelid cleaner Solutions Clear Care, non-preserved 0.9% sodium chloride inhalation solution with two drops of non-preserved Celluvisc R 2012 MFMER slide-112 Keratoconus Follow up Fogging improved! Successfully wearing lenses for 5 years VA OD 20/20-1 OS 20/20-2 Binoc 20/15+2 Quality of Life in Patients with KCN Vision related quality of life in patients with keratoconus. Kurna, Aydin, Altun, Gencaga, Akkaya, Sengor J Ophthalmol 2014; April. National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) 30 patients with keratoconus 20 RGP wearers 10 non-contact lens wearers 30 healthy patients (control group) 19

QOL KCN Contact lens wearers had better BCVA compared with noncontact lens wearers (P = 0.028).

Patients with low visual acuity in the worse eye Lower general health scores Vision related quality of life worse in patients with KCN Success with contact lenses and maintaining better visual acuity

Evaluated the improvement of QOL with scleral lenses in keratoconus or the treatment of astigmatism after penetrating keratoplasty Retrospective study Patients failed to adapt to RGP lenses QOL

eyes NEI-VFQ 25 scores with scleral lenses were significantly higher than those without scleral lenses.

20 QOL KCN Contact lens wearers had better BCVA compared with noncontact lens wearers (P = 0.028). Patients with low visual acuity in the better eye Worse distance vision, social functioning, mental health, and role difficulties. Patients with low visual acuity in the worse eye Lower general health scores Vision related quality of life worse in patients with KCN Success with contact lenses and maintaining better visual acuity may improve vision related quality of life. Quality of Life in Patients Wearing Scleral Lenses Picot, C, Gauthier, AS, Campolmi, N, Delbosc B J Fr Ophtalmol Sep;38(7): Evaluated the improvement of QOL with scleral lenses in keratoconus or the treatment of astigmatism after penetrating keratoplasty Retrospective study Patients failed to adapt to RGP lenses QOL before and after scleral lens adaptation Quality of Life in Patients Wearing Scleral Lenses 47 patients (83 eyes) fitted with scleral lenses on one or both eyes 56 eyes with KCN 27 post-keratoplasty eyes NEI-VFQ 25 scores with scleral lenses were significantly higher than those without scleral lenses. Scleral lenses showed significant improvement in quality of life for patients who had failed or are intolerant to conventional rigid gas permeable contact lenses. Scleral lenses are an alternative or a step prior to surgery NKCF NATIONAL KERATOCONUS FOUNDATION PROVIDES INFORMATION AND SUPPORT TO THE KERATOCONUS PATIENT COMMUNITY Informational Booklets in English and Spanish KC-Link an based support group Comprehensive website: Toll Free Information: Resources for patients with keratooconus Thank You! kc-link list kc-link@listserve.com Please feel free to contact me with any questions Melissa Barnett, OD, FAAO, FSLS drbarnett@ucdavis.edu 20

Scleral Lens Essentials

Scleral Lens Essentials Disclosures: Alcon Bausch + Lomb Contamac CooperVision Johnson & Johnson SpecialEyes Valley Contax Matthew J. Lampa, OD, FAAO lampa@pacificu.edu Scleral Lenses Which Lens Modality???