Baldwin.AFOS.Denver.2014.HO 1
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1 Disclosures: Alden Optical Honoraria, Consultant Essilor Honoraria, Consultant Scleral Lens Education Society Past President No financial interests OBJECTIVES Brief introduction to scleral lens fit principles Polymethylmethacrylate (PMMA), in the early 1900 s Made from impression mold of eye Difficult to make Problem with hypoxia Case presentations illustrating some fit principles and complications Lens Type Description Definition of Bearing Area Corneal Corneo-scleral Scleral Mini-Scleral Lens is up to 6mm larger than HVID Large Scleral Lens is more than 6mm larger than HVID Lens rests entirely on the cornea Lens rests partly on the cornea, partly on the sclera Lens rests entirely on the sclera Scleral Contact Lens Fitting Principles 18.2mm 9.0mm Baldwin.AF.Denver.2014.HO 1
2 SCLERAL LENS DESIGN Companies have proprietary lens designs Example: Five Curve Lens Base Curve (BC), 8.2mm Width Corneal Curve = BC + 0.4, 2mm W Limbal Curve = 9.0, 1mm W Scleral Curve (Landing) =12.25, 1.5mm W Edge Curve = 14.5, 0.5mm W FITTING SCLERAL LENSES IS AS EASY AS Bridge over the cornea 1. Bridge Over The Cornea and Limbus Base curve changes can increase VAULT (CLEARANCE, FLUID CHAMBER, SAG) 5100 D 4600 D Greg DeNaeyer, OD Baldwin.AF.Denver.2014.HO 2
3 Horizontal AS OCT With Corresponding Slit Images Design and fit philosophies SAG AS-OCT and the Specialty Contact Lens Bruce Baldwin, OD, PhD, Sarah Moyer, CRA, OCT-C. April Good Limbal Clearance 2 Landing Aligned with Sclera 2. Landing not too flat or steep Baldwin.AF.Denver.2014.HO 3
4 18.2mm, 4700, -650, 20/20- Landing aligns with sclera 3. Adequate tear exchange 3. Adequate Tear Flow Under the Lens Severe Dry Eye-GVHD Punctal Cautery Lynette Johns, OD Punctal Occlusion Baldwin.AF.Denver.2014.HO 4
5 20/50 20/30 RGP SCL Recurrent corneal abrasions, even with piggyback 24F UNC Soccer, Keratoconus, Piggyback OU Note chronically inflamed pingueculae OD Small scleral caused more pinguecula inflamation Pinguecula notch 15.6 mm OD Upper lid Refit to 18.6 OD Upper lid 12 mm RGP Piggyback mm 20/ /25 Baldwin.AF.Denver.2014.HO 5
6 19 M, MVA Mirror glass, corneal lac, open globe VA: LP Sutures in place Sutures removed July 21, , 4400, -775 CL VA:?? Lac repair Reposition uvea VA: LP July 26, 2011 Aspirate cat Sulcus IOL VA 20/200 Baldwin.AF.Denver.2014.HO 6
7 AC OCT, horizontal, above lac Good Landing AC OCT, vertical, through lac 50yo Male Keratoconus, GPC, blepharitis, dermatitis trichiasis, chronic red eye, RGP OU Referred for poor fit, redness, pain, blur Mechanic/truck driver, BVA OD 20/100 Mhx: Asthma, COPD, obesity, sleep apnea, chronic rhinitis, HTN, immune disorder, depression, recurrent pneumonia Meds: Advair, albuterol inhaler, Flonase, allopurinol, azithromycin, Celexa, Tramadol, chlorthalidone, CPAP Initial exam: flat low riding 9mm RGPs Severe keratoconus OD with light central scarring, RGP VA 20/100 Moderate severe keratoconus, 20/40 Scleral lens trials: BVA OD 20/100, needs 20/40 for truck driver license Fit and ordered for : XO, 18.2, 5300 (6.37), , steep P PK OD 03/30/2012, interrupted + running Running removed after 105 days Dsp scleral OD at 55 days PO Using same parameters except P curves Tighter P curves for excess debris Consult for PK OD Baldwin.AF.Denver.2014.HO 7
8 Initial OD lens, May 2012, 42 days PO XO, 18.2, 4800 (7.03), 7.43/2.0, 9.0/1.0, 12.25/1.5, 14.5/.5 20/30 regained truck driver lic Hygiene a big problem Gave box of surgical gloves OD Aug 2012, 154 days PO OD Mar 2013, 343 days PO Note chamber debris Aug 2012 XO, 18.2, 4800 (7.03), 7.43/2.0, 9.0/1.0, 11.75/1.5, 14.0/.5 42 OD Graft Healing Days PO May 2012 Aug Aug 2012 Baldwin.AF.Denver.2014.HO 8
9 Mar 2013 When pinguecula inflamed, edge lift and debris. Considered notch. Refit to toric P. Khodadoust line Good! 09/18/2012 Endothelial rejection 11/02/2012 Rejection resolved 12/04/2012 Epi/subepi rejection 10 days on PF QID Rejection resolved SEIs 02/01/2013 Epi rejection returns 05/17/2013 Endo rejection returns Graft Rejection History Management Acute: Prednisolone Acetate hourly, with taper Glaucoma drops for steroid response Currently maintained on Fuorometholone one drop daily Dorzolamide three times daily Baldwin.AF.Denver.2014.HO 9
10 67M, Trauma with skull/brain damage Exposure keratopathy OD x 25+ years Lateral tarrsorrhapy OD Poor risk for PKP Corneal thinning to about 200 microns BSCVA: OD 20/100 CF (RD, XT) 15.6, (7.11), -3.75, 20/ (7.11) (6.89) Original 15.6, (6.89), -5.25, 20/60+ First remake Extremely happy with vision, and grateful Before wear Hemiplegia, wife inserts lens for husband Celluvisc reduced insertion bubble problem After two months of wear March 2014 Baldwin.AF.Denver.2014.HO 10
11 49M, Post LASIK Keratectasia , (7.18), /25 OD 18.2, (7.18), /20 Note less tear exchange OD Jan 23, 2009 C/O Irritation Note small abrasion Superior touch and lack of tear flow superior. (Arrows) Lens needs refit with greater vault OD Apr 9, 2009 Pt called from airport with two day hx of severe pain and photophobia. Treatment: Cycloplege, antibiotic, start steroid after first two days. Pt scheduled to fly across country and told to remove the right cl during flight. Baldwin.AF.Denver.2014.HO 11
12 Jul 20, 2009:, 4D Reverse Geometry 19.0, 7.63, 6.99/2.0, 20/20 Larger lens vaults well over limbus. OD Apr 15, 2009 One week f/u. Symptom free. Small infiltrate scar. Larger, reverse geometry lens vaults over limbus. Evaluate edge profile for Adequate limbal vault 51F, RK BSCVA 20/25 OU but dry eye, poor contrast, and extreme spectacle blur from hybrid lens Note small decentered OZ Baldwin.AF.Denver.2014.HO 12
13 Refit to scleral lens but developed corneal edema from poor fit C/O: halos around lights, spec blur 18.2, (5000), 6.75,6.62, D reverse Note microcystic corneal edema Horizontal Note touch anterior to limbus Vertical So how do we redesign For more limbal vault? Different companies have different design and fit techniques ICD ABB Concise Essilor Valley Contax Modify limbal curve ACCU Lens Maxim Custom changes at BFS or partner clinic Diameter change Optic zone size AVT AVT RC Sagital depth Diameter Landing curve Tru-Form Digiform 18 Limbal curve markings Blanchard Sagital depth Limbal curve MSD Essilor & Visionary Jupiter Custom Dia, BC, CC Baldwin.AF.Denver.2014.HO 13
14 Trial Prolate 5200 sag OR , (4800), 7.03/ True 3D reverse Alden Zenlens Trial Oblate 5100 sag OR Larger True 3D reverse 18.6, 3D reverse, 20/20 OU 12+ hrs wear time, no spectacle blur Original Remake Note limbal clearance Original Remake 45F, Keratoconus >>OD OD 20/20, Hybrid Flat/tight Unilateral keratoconus Horizontal Vertical Baldwin.AF.Denver.2014.HO 14
15 Wearing 15.6, 56.00, , 20/20 Refit to larger lens with more vault. Mailed to pt but she continued to wear this lens for six months Developed hydrops, BVA CF Touch at Cone Refit of scleral lens after hydrops, 20/25 Conjunctiva under the lens Cause Conjunctival chalasis Suction under the lens Decentered lens Too much limbal clearance Remedy Conj resection Ignore Refit Conjunctival entrapment Conj entrapment Baldwin.AF.Denver.2014.HO 15
16 Conjunctival Entrapment Redness Irritation 30 yo F, Keratoconus OD RGP intolerant OD for 1 yr Referred for PK RGP VA OD 20/100 RGP VA 20/40, flat fit Only wanted scleral for OD OD 20/30- XO, 18.2, 5500 (6.3), -1162, Std P Scleral RGP Scleral Lens for ptosis control 20/40 RGP Flat 9mm RGP, refit 18.2mm scleral Scleral Scleral Baldwin.AF.Denver.2014.HO 16
17 Developed red, painful chemical keratitis Rxed this Scleral contact lens usage in patients with complex blepharoptosis. Shah-Desai SD, Aslam SA, Pullum K, Beaconsfield M, Rose GE. Ophthal Plast Reconstr Surg Mar-Apr;27(2):95-8. Got this 69yo M, Lamellar Ichthyosis AR inheritance Severe exposure keratopathy Pain Scarring Poor vision Multiple skin grafts to lids No normal skin left Options? Scleral lens full time for two years???s Baldwin.AF.Denver.2014.HO 17
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