Scleral Lens Essentials

Transcription

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

2 Scleral Lenses

3 Which Lens Modality???

4 Bausch + Lomb

5 Some eyes can not be optimally fitted with corneal lenses

6 Because they result in fluorescene patterns that look like this!

7 Is There a Way to Predetermine the Success of a Corneal GP Lens?

8 To Avoid This

9 Curvature versus Elevation Axial Display Power Map Elevation Map Height Map

10 Axial Display Elevation Display

11 Corneal Elevation Differences and the Initial Selection of Corneal and Scleral Contact Lens Frank Zheng OD, Patrick Caroline FAAO, Randy Kojima FAAO, Beth Kinoshita OD FAAO, Mark Andre FAAO, Matthew Lampa OD FAAO Pacific University College of Optometry, Forest Grove, Oregon Elevation Display Map +248 um -227 um Highest 475 microns Lowest

12 N = 87 Patients 127 CL Fits Less than 350um Greater than 350um Patients with 350um or less of corneal elevation difference (along the greatest meridian of change) have an 88.2% chance of success with a corneal GP lens.

13 +379um Micron Height Differential -276um

14 Patient CB Right Eye

15 Elevation Map

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17 Patient VY Post Hydrops

18 Elevation Map -200um +430um Elevation: um Depression: -260 Differential = 690um

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21 Instrument Evolution Composite Corneal Topography Keratometry Photokeratoscopy Videokeratography 3.0 mm 8.0 mm 10.0 mm 12.0 mm

22 Composite Corneal Topography Keratometry Photokeratoscopy Videokeratography 3.0 mm 8.0 mm 10.0 mm 12.0 mm OCT Eaglet smap 3D 16.0 mm 20.0 mm 22.0 mm

23 Possible Scleral Lens Indications Irregular Astigmatism Keratoconus Pellucid Marginal Degeneration Post Corneal Trauma Post keratoplasty Post K-Pro Post Refractive Surgery RK, PRK and LASIK Post HSV and HZV Athletes GP stability (rocking) issues

24 ) Pathologic Ocular Surface Disease Chemical Burns Ocular Pemphigoid Stevens-Johnson Syndrome Symblepharon formation Graft vs Host Disease Persistent Epithelial Defect Exposure Keratitis Neurotrophic Keratopathy Severe Dry Eye Sjogren s Syndrome, Filamentary Keratitis Limbal Stem Cell Deficiency

25 Scleral Lens Indications Ocular Surface Disease Corneal Irregularity Ectasia/Scar/Post Surgery

26 Ocular Surface Disease Pre-Scleral 2 Months Post Scleral

27 SJS 20/400 6 months Post Scleral Lens 20/25

28 The Re-Birth of Scleral Lenses High DK (100 DK+) GP lens materials Computer assisted manufacturing techniques Advanced in our understanding of scleral shape Increasing knowledge related to the management of unique scleral lens complications

29 Average 8.5

30 High DK Scleral Materials Menicon Z DK = 163 B & L, Boston XO 2 DK = 141 Contamac, Optimum Extreme DK = 125 B & L, Boston XO DK = 100 Paragon HDS 100 DK = 100 Contamac, Optimum Extra DK = 100 Lagado, Tyro -97 DK = 97

31 Traditional Corneal / Scleral Shape

32 Scleral Shape New Understandings

33 Scleral Angle Measured at 15.0 & 20.0 mm 15.0 mm 20.0 mm Tina Graff, Eef van der Worp, Patrick Caroline, Randy Kojima

34 Corneal/Scleral Angle 10 to 15 mm 10.0 mm 15.0 mm Tina Graff, Eef van der Worp, Patrick Caroline, Randy Kojima

35 Average Angle from 10 to 15mm T N

36 Scleral Angles at 15.0 & 20.0 mm 15.0 mm 20.0 mm Tina Graff, Eef van der Worp, Patrick Caroline, Randy Kojima, Mark Andre

37 Average Angle from 15 to 20mm T N

38 Cone Angle Circa 1948 Klaus Pfortner Argentina

39 Corneal Vaulting Properties Of Scleral Lenses

40 Scleral Lens Fitting Objectives 1. Central Vault Zone (250 to 400 microns) 2. Peripheral Lift Zone 3. Limbal Lift Zone Scleral Landing Zone

41 Anatomy of a Scleral Lens

42 Scleral Lens Fitting by Sagittal Height 3,800 4,000 4,200 4,400 4,800

43 Zone #1, Central Clearance Zone (CCC)

44 What is the Appropriate Central Corneal Clearance???

45 Central Clearance Zone 300 to 400 microns of Apical Clearance

46 Apical Clearance at Dispensing 250 microns Apical Clearance Post 8 Hours 150 microns

47 Tear Lens 300 microns CL Thickness 0.35 mm 350 microns

48 Scleral Lens Setteling

49 Apical Clearance at Dispensing 410 um Apical Clearance at 30 Days 270 um 140 um of Lens Settling

50 AB Left Eye Baseline 400 um 130 um Change 8 hours 30 mts. 4 hr. 1 hr. 340 um (60 um) 6 hr. 2 hr. 8 Hours 270 um (130 um)

51 Estimating Tear Film Thickness

52 Scleral Lens Corneal Settling 11 subjects, 22 eyes At lens application and 8 hours post lens wear Average apical clearance on application: 393um Average apical clearance after 8 hours: 265um Average drop in sag between insertion and 8 hours (22 eyes): 127um

53 Lens Settling 15 Subjects 96 microns following 8 hours of lens wear. 70 to 180 micron range. 146 microns following one month.

54 Right Axial Left Axial Right Elevation Left Elevation

55 -3.50 DS SCL SCL

56 Excessive 300 um 600um Apical Clearance OK? Not OK?

57 Zone #2, Peripheral Corneal Clearance Zone (PCCZ)

58 Peripheral Cornea and PCCZ Bearing Limbal Clearance Adequate Clearance

59 Appropriate Limbal Clearance Inadequate Limbal Clearance

60 Inadequate Peripheral Corneal Clearance

61 Dispensing 4 hrs. Post Dispensing

62 Diagnostic Lens Final Lens

63 Changing the PCCZ Peripheral Corneal Clearance Zone Plus changes (+) = more depth Minus changes (-) = less depth 1 degree steps = 25 microns sag change

64 Temporal Nasal

65 Temporal Nasal

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67 Left Eye

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70 Zone #3, Limbal Clearance Zone (LCZ)

71 White Light Cobalt Light Limbus

72 Limbal Clearance Zone

73 Standard Limbal Clearance Zone +5 Degree In the Limbal Clearance Zone

74 Changing the LCZ Limbal Clearance Zone Plus changes (+) = more depth Minus changes (-) = less depth 1 degree steps = 25 microns sag change

75 Bulging Graft 42.3 Sag 5,

76 Horizontal Meridian

77 Keratoglobus 50.5 Sag 5,

78 Zone #4, Scleral Landing Zone (SLZ)

79 Scleral Landing Zone Evaluation Dispensing Post 4 hours

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90 Standard Edge Greater Lift Design

91 Conjunctivial Compression

92 Scleral Lens Fitting by Sagittal Height

93 Lens Application Preservative-free saline and sodium fluorescein

94 Lens Application The patient looks down.they hold their lower lid practitioner the upper & the lens is applied.

95 Preservative Free Saline Options (in the USA) The unit dosed 5 or 10 ml Inhalation PF saline % Sodium Chloride Solution by Rx only The 12 OZ aerosol saline Simply Saline by Arm and Hammer OTC The 4 OZ bottle Purilens Plus Ultra PF Saline from Purilens OTC

96 LacriPure Saline from Menicon

97 Application Bubble

98 Re-Application

99 Apical Clearance = 350 microns

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101 Conjunctivial Blood Vessels

102 Over-refraction