Fitting Keratoconus and Other Complicated Corneas

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1 Fitting Keratoconus and Other Complicated Corneas Christine W Sindt OD FAAO Professor, Clinical Ophthalmology Director, Contact Lens Service University of Iowa

2 Disclosure Consultant: ALCON Vision Care Allergan Novabay Pharmaceuticals President/ Inventor EyePrint Prosthetics

3 Scleral Lens Indications Optical Correction Ocular Protection Ocular Comfort Keratoconus Pellucid marginal degeneration Post LASIK ectasia Post Radial Keratometry Corneal Transplants High Myopia / Hyperopia Aphakia Neurotrophic Keratitis Ocular Surface Disease (Dry Eye) Graft vs Host Disease Steven Johnson Syndrome Ocular Cicatricial Pemphigoid Chemical Burns Stem Cell Failure Pinguecula Pterygium Scarring Scleral Patch Graft Adverse Environment Rosacea Limbal stem cell disease

4 What Determines The Right Lens Design? Vision? Oxygen? Disease State? Ocular Geometry? Physiological Response?

5 Vision Issues

6 Watch the Posterior Elevation! If > 100 microns posterior backbowing, vision will be compromised Reduced visual acuity Increased aberrations Worse with large pupils

7 Higher Order Aberrations Front surface correction Ideal for Keratoconus with clear cornea and back surface cornea bowing Caution with: Cataracts Corneal scarring

8 Decentered Optics Standard Optics Reverse Geometry Decentered Optics

9 Oxygen Issues

10 Clinical Signs of Corneal Hypoxia Corneal Edema Corneal Staining Neovascularization Conjunctival Injection Refractive Error Shift >-0.50D Endothelial changes polymegathism pleomorphism decreased cell density

11 Oxygen Transmission Lens and Tears Contact Lens and Anterior Eye Volume 35, Issue 6, December 2012, Pages Predicting estimates of oxygen transmissibility for scleral lenses Langis Michaud, Eef van der Worp, Daniel Brazeau, Richard Warde, Claude J. Giasson

12 Scleral Lens and Endothelial Endothelial cell count of less than Cells 800 cells/mm2 is where the problems may arise (Sindt 2010a), and endothelial cell counts <1,000 cells/mm2 should be handled with extra care and should not be fitted with scleral lenses to avoid edema. Eef van der Worp, A Guide to Scleral Lens Fitting (2 ed.) Exhaust other options first:

13 Epithelial Stress Reduction of epithelial adhesions Decreased hemidesmosome synthesis Hypoxia-induced intracellular calcium

14 Epithelial Stress

15 Striae and Folds Striae 3.6-6% swelling Folds 10-15% swelling Haze Gross separation of collagen fibers Full thickness cornea

16 Ocular Geometry

17 The Limbus is Not Round

18 Hyperbolic Paraboloid

19 Photo: Dr Tom Arnold Nasal Limbus

20 Inferior limbus

21

22 Lenses designed to fit specific populations Regular scleral lens designs lead to temporal decentration and nasal touch Regular onefit design Asian onefit design

23 Landing Area It takes about 3mm of landing not to sink in But then more concerned about toric peripheries 13.6mm 15.0mm 18.2mm

24 Unexpected Geometry

25 Physiological Responses

26 Superficial Pannus Limbal Stem Cell Deficiency

27 Conjunctival Chalasis (under the lens)

28 Corneal Haze

29 Herpes Simplex Virus

30

31 Toric Peripheries

32 Could this affect uveal scleral outflow? Increased inflammatory events Tight lens syndrome Compression Factors

33 Impression Rings

34 Limbal Inflammation Go: Larger Flatter Toric Possible uveal sclera compression: Check IOP Photos: Ed Boshnick

35 Heeling

36 Toeing

37 Debris Under the Lens

38 Disease States

39 Evaluating a Bleb or Patch Graft

40 Blebs The Bad Scleral lenses will erode tubes (Erosion/Thinning)

41 Only elevation specific technology can create extra vault specifically over SPG s and Blebs

42 Blebitis

43 GVHD Sjogren Syndrome Ocular Cicatricial Pemphigoid Severe dry Eye

44 Episodes of Inflammation Flare

45 Inflammatory/ Fibrotic lids

46 Granulomas

47 Symblepharon

48 Over Vaulting the Limbus

49 Always Suspect Carcinoma

50 Post Surgical Corneas PKP LASIK RK Artificial Cornea

51 Artificial Corneas

52 Wound Gape

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