Everything Therapeutic: Houston

Transcription

1 Presents Everything Therapeutic: Houston CourseMaster Bruce Onofrey, RPh, OD, FAAO Program Location University of Houston College of Optometry Health District: Health 1 Building 4901 Calhoun Road, Houston, Texas Program Agenda Saturday, June 9, :00 am to 8:00 am Registration, Continental Breakfast, & Visit Exhibits Lectures presented by Andrew Gurwood, OD and Marc Myers, OD 8:00 am to 9:45 am Ocular Urgencies and Emergencies COPE ID# GO CEE Available 9:45 am to 10:15 am Break & Visit Exhibits 10:15 am to 12:00 pm Periocular Malignancies COPE ID# SD CEE Available 12:00 pm to 1:00 pm Lunch & Visit Exhibits 2 DT 2 DT Lectures presented by Sheila Morrison, OD, MS 1:00 pm to 1:50 pm Scleral Lens 101 COPE ID# CL 1 GEN 1:50 pm to 2:45 pm Incorporating Myopia Control Into Clinical Practice COPE ID# GO 1 GEN 2:45 pm to 3:15 pm Break & Visit Exhibits 3:15 pm to 4:05 pm Orthokeratology for all Ages COPE ID# CL 1 GEN 4:05 pm to 5:00 pm Understanding Corneal Topography and Beyond COPE ID# PD 1 DT

2 Andrew S. Gurwood, O.D., F.A.A.O. Marc D. Myers, O.D., F.A.A.O. Andrew S. Gurwood, OD, FAAO, Dipl. Professor of Optometry, PCO at Salus University Attending Staff, AEMC Dept. Ophthalmology Alcon B&L Optos Marc D. Myers, OD, FAAO Senior Staff Optometrist, Coatesville VAMC Adjunct Clinical Staff and Faculty, PCO at Salus University Alcon Allergan B&L Ciba Vision Cooper Vision J & J Novartis 1

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6 Complete blood count (CBC) Fasting blood sugar (FBS) Glycosylated hemoglobin A1c Angiotensin converting enzyme (ACE) HLA B27 Gallium scan Tissue biopsy Fluorescent treponemal antibody absorption test (FTA Abs) MHA TP RPR Erythrocyte sedimentation rate (ESR) C reactive protein (CRP) Rheumatoid factor (RF) Thyroid function tests TSH, T3, T4 Titers Lyme Toxoplasmosis Purified protein derivative (PPD) Inter gamma release assay (QuantiFeron) Antinuclear antibody ( ANA) Sacro illiac joint films Chest X Ray (CXR) Neuroimaging MRI CT 5

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8 Projectile Kile, J., Chen, S. Contusion injuries and their ocular effects. Clin Exp Optom 2001; 84(1):

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17 Prokera TM technology Toxic conjunctivitis Prokera TM technology 16

18 Toxic conjunctivitis Toxic conjunctivitis 17

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34 Periocular Malignancies Marc D. Myers, O.D., F.A.A.O. Andrew S. Gurwood, O.D., F.A.A.O., Dipl. COPE disclaimer Dr. Gurwood and Dr. Myers have no financial interest to disclose. United States United Kingdom Most More common than half form of all of new cancer cancers in the are United skin cancers States 1 out of 5 people Over will 3 million develop new some cases form of skin of skin cancer cancer each during year their lifetime South Africa International Agency for Research on Cancer Australia New Zealand cancer in the us.html 1

35 Risk factors Primary skin malignancies Basal cell carcinoma Squamous cell carcinoma Sebaceous cell carcinoma Malignant melanoma 2

36 A B C D E Rule Asymmetry Border irregularity Color is mottled, not uniform Diameter of the lesion ( > 6 mm.) Elevation of the lesion Basal Cell Carcinoma LL > medial canthus > UL > lateral canthus Lesions tend to be slow growing Low incidence of METS 99% are adequately cured Five clinical types of BCC 1. Nodulo ulcerative 2. Sclerosing ( morpheaform ) 3. Pigmented 4. Fibroepithelioma 5. Superficial 3

37 Squamous Cell Carcinoma 4

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39 Sebaceous Cell Carcinoma METS: Highly metastatic. Must be considered lethal!! (+) METS 50% to 67% five year mortality rate. ( ) METS up to 15% five year mortality rate. Sebaceous Cell Carcinoma Malignant Melanoma Melanoma Most Accounts important is for a darkly 2 % to pigmented finding 3 % of eyelid in regards malignancies to prognosis is 16 mole the Staging or Almost 14 depth tumor. exclusive of Scheme: the to lesion Caucasians (depth of 1 mm is key). Symptoms Stage a I bleeding localized or ulcerated primary disease 12 sore. More Lesions associated involving with the chronic lid margin UV exposure seem to have a Signs 10 Stage a pigmented, II biopsy superficial proven ormets to regional worse nodular 20% 8of prognosis. lesion patients that lymph may are nodes be younger sessile than 40 years old or pedunculated. Most Prognosis 6 common is much skin CA worse in Caucasians in Stages 25 II 29 and y/o III A pigmented Stage III eyelid biopsy lesion proven is 10 times METS to distant 4 more 5 Incidence year likely mortality to is be increasing lymph a pigmented rate: nodes worldwide BCC 1 node viscera involved 55% than MM. 2 40% Incidence of 0 MM are is doubling non pigmented every 2 4 decade nodes 72% > 4 nodes % Rate/100,000 6

40 Treatment Options Making the appropriate referral Dermatologist Oculoplastic or plastic surgeon General ophthalmologist Diagnostic testing Incisional, excisional or punch biopsy Biopsy with lipid stain 7

41 Punch Biopsy Excisional Biopsy Treatment modalities Surgical excision using Mohs micrographic surgical technique, modified Mohs, or frozen section biopsy Electrodessication and curettage Radiation therapy Cryotherapy Chemotherapy Newer treatment options including photo dynamic therapy (PDT) and interferon 8

42 RADIATION THERAPY Generally not the primary treatment of choice Used as an adjunct to surgery Certain carcinoma may be radio resistant Complications may include skin atrophy or necrosis, madarosis, entropion, ectropion, dry eyes, cataract, corneal ulcers, secondary carcinoma of irradiated areas (usually SCC in sun exposed areas in patients under 40). Once treatment is performed, surgery is frequently ineffective. 9

43 RADIATION THERAPY Second largest cure rate (after MMS). Only a 12% recurrence rate (overall). 90% cure rate with BCC. Best as adjunct with SCC and Sebaceous cell carcinoma. Role as primary treatment of MM being reevaluated. CRYOTHERAPY Use of liquid nitrogen spray More useful outside of the periocular area Considered a non specific treatment Generally not a primary treatment Useful when surgery can not be tolerated Report of 98% cure rate with small SCC CRYOTHERAPY Complications from treatment Motor dysfunction of lid Sensory abnormality Pigmentation or hypopigmentation Indistinct tumor margins Tissue contracture causing lid notching, symblepharon formation, ectropion, or entropion Contraindications 10

44 CHEMOTHERAPY Used locally (topical or injectable) or systemically 5 fluorouracil, cis platinum, doxorubicin Not a primary treatment for periocular lesions Topical treatment of multiple superficial BCC Systemic treatment of tumors unresponsive to surgery SCC adjunct to treatment of regional or distant metastasis when no other treatment is available Zigler M, American Journal of Clinical Dermatology; 05/06/2009. PHOTODYNAMIC THERAPY Photochemotherapy with non ionizing radiation to destroy malignant cells Photosensitizer given 96 hours prior to treatment Argon dye laser applied to tumor Beneficial in treating superficial BCC Low morbidity, mild edema, mild pain Not a primary treatment More effective with non melanotic tumors INTERFERONS Low molecular weight glycoproteins Injected intralesionally Mixed results thus far with non melanotic cases Treatment has not included periocular tumors 11

45 TOPICAL THERAPY PATIENT EDUCATION Review early warning signs of suspicious lesions. Skin cancer prevention. Limit exposure to strong sunlight. Keep infants out of the sun completely. Sunburn on children are the most hazardous. Regular use of sunscreen with at least a 15 SPF. SPF > 30 when outdoors for prolonged time period. SPF > 35 with known history of sun sensitivity. Reapply sunscreens frequently and liberally. Wear protective clothing when exposed to sun. Seek medical attention for severe sunburns. INFORMATION ON LINE

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47 Lecture Outline Submission: Everything Therapeutic Saturday June 9, minutes COPE Category: CL Scleral Lens 101 Speaker: Sheila D. Morrison, OD, MS, FSLS Course Learning Objectives 1. To provide instruction on application, removal, and handling of scleral contact lenses, including troubleshooting tips. 2. To demonstrate application, removal, and assessment of a scleral lens on an eye. 3. To describe the use of typical equipment (ie corneal topography, biomicroscopy) to evaluate a scleral lens on the eye, and to review advanced technology to evaluate scleral lenses. 4. To provide an overview of ordering and adding special features to a scleral lens. 5. Practitioners should feel comfortable with the initial scleral lens fitting process after viewing this course. Course Description This course is designed to instruct practitioners on basic to advanced techniques to handle and assess a scleral lens in practice. The course will begin with an overview of diagnostic lens selection and presentation of the scleral lens modality to patients. It will then cover application, removal and handling of the scleral lens, and will also outline the evaluation of the lenses using corneal topography and biomicroscopy. The rationale for understanding each patient s unique scleral shape will be discussed, as will advantages and disadvantages of different methodologies for measuring scleral/conjunctival shape. A brief orientation to nomenclature will also be provided to assist practitioners in communication with labs. Course Outline: 1. Scleral lens Introduction a. Diagnostic sets vs. Empirical fitting b. Fitting sets and the features that are described i. The scleral lens 1. Small-diameter scleral lens: lens is up to 6mm larger than HVID, somewhat limited tear reservoir 2. Large-diameter scleral lens: lens is greater than 6mm larger than HVID, almost unlimited tear reservoir capacity ii. Scleral lens zones

48 1. Optic zone, transition zone, intermediate zone, landing zone iii. Scleral lens terminology 1. Overall diameter, total sagittal depth, base curve iv. Front surface versus back surface 1. Front surface a. Power (toric versus sphere) i. Is optical 2. Back surface a. Shape (toric versus sphere back haptic) i. Not optical c. Presenting the idea of scleral lenses to a patient 2. Scleral lens Handling a. GP scleral lens preparation (with video clips) i. Storing the lens ii. Cleaning the lens iii. Conditioning the lens b. GP scleral lens application (with video clips) i. Importance of proper hygiene and cleaning hands, eyelids, etc ii. Correct application tools including DMV, application solutions, and mirror 1. Scleral lens application solutions a. Must be preservative free b. Sterile saline is the most common i. Vials 1. ScleralFill (B&L) 2. Lacripure (Menicon) 3. Addipack (generic) ii. Bottles 1. Ourilens (generic) c. Other options for scleral lens application solutions i. Preservative free artificial tears ii. Autologous serum

49 iii. Overview of techniques to apply a lens on another, and to apply a lens to self iv. Use of fluorescein v. Troubleshooting application difficulties 1. Application bubble 2. Patient looking all around versus right down center of the lens vi. Tools for use with patients who have difficulty applying scleral lenses c. GP scleral lens removal (with video clips) i. Proper removal technique and discussion of suction properties of lenses, including proper use of removal tools 1. Small DMV 2. Scleral depression at lens edge ii. Live instruction on removal from a patient and from self iii. Troubleshooting removal difficulties d. GP scleral lens deep cleaning i. Proper cleaners to be used with SGPs. 1. Hydrogen peroxide cleaning 2. Enzyme cleaners ii. Cleaning techniques and solutions specific to SGPs. 3. Scleral lens Evaluation a. Understanding scleral images i. White light ii. Blue light iii. OCT b. Biomicroscopy i. Start with wide blue light for overall view ii. Use white light optic section iii. Be mindful of inferior temporal decentration to account for differences in thickness of tear lens iv. Compare known lens thickness to tear lens to evaluate (not to cornea which varies in thickness anatomically) v. Used to evaluate apical clearance, limbal clearance and landing zone fit.

50 1. Limbal clearance/apical clearance a. Aim for 300um at application b. Lens will settle approximately 150um 2. Scleral landing zone a. Comparison of a well-aligned lens versus blanching/impingement/compression vi. Should also be used to evaluate NaFl characteristics beneath the lens, and staining patterns after lens removal. vii. Advanced techniques to look at excess edge lift and tear exchange. c. OCT i. Used to assess clearance and peripheral fitting relationships of the lens on the eye. ii. Can also be used to evaluate the shape characteristics of the eye (ie scleral shape) and to follow corneal thickness changes. 4. Scleral Lens Advanced Technologies a. Corneal Topography i. Used prior to fitting to determine corneal irregularity and follow progression of disease not commonly needed for diagnostic lens selection. ii. Topography and/or OCT should be used to follow corneal thickness changed after initiation of SGP wear. b. Specular Microscopy i. Used to follow integrity of the endothelium during lens wear, and to predict hypoxic response of the eye to scleral lenses. c. Scleral Mapping Techniques i. Newer technologies such as scleral maps can be used to evaluate the shape of the sclera. 5. Order Protocol and Special Features of GP scleral lenses a. Proper parameters to specify when ordering scleral lenses i. Bascurve ii. Sag iii. Power iv. Edge modifications

51 v. Location of toric back haptic markers should always be noted and communicated to the lab vi. material b. Proper information to convey to consultants and benefits of consultation services with scleral lens ordering c. Special features such as toric curve ordering, special coatings and treatments, and material decision-making. i. Use toric back haptic as a lock-and-key to place toric front surface optics, and notches/microvaults ii. Hydra-peg iii. Impact of dk 1. Higher dk is often less wettable 2. Higher dk provides greatest oxygen permeability 6. Conclusion a. How to make scleral lenses work in your practice and how to incorporate them into your daily practice.

52 Lecture Outline Submission: Everything Therapeutic Saturday June 9, minutes COPE Category: GO Course Description: Incorporating Myopia Control Into Clinical Practice Sheila D. Morrison, OD, MS, FSLS Tel: This course is designed to educate the general optometrist on myopia control, and introduce current theories and treatment options. It will cover the implementation of basic myopia control into clinical practice and discuss medico legal information and standards of care. Course Objectives: 1. To educate the general optometrist on myopia control. 2. To provide an overview of the treatment options for myopia control. 3. To discuss ways to implement myopia control into clinical practice. Outline: I. History of myopia control a. Theory of myopia control i. Peripheral myopic defocus reduces signal for eye growth. ii. Peripheral hyperopic defocus induces signal for eye growth iii. Natural optics of spectacles vs. contact lenses vs. bifocal contact lenses. b. Overview of treatments for myopia control. i. Refractive: spectacles, contact lenses ii. Therapeutic: treatment with drugs (atropine, pirenzipine) iii. Other treatments light therapy? iv. Investigative studies II. Contact lenses for myopia control a. Orthokeratology lenses vs. soft multifocal lenses i. Generally equally effective b. Several designs of multifocal contact lenses choosing center distance with peripheral plus is generally most accepted i. Custom soft options also exist with decentered optic c. Selecting power of central distance and peripheral plus push plus d. How to determine final power i. BCVA need to be 20/20? ii. Consider affect of multifocality of sports performance, driving, etc. III. Orthokeratology for myopia control a. Naturally sets up area of central distance with mid peripheral plus power

53 b. Fitting ortho K on myopes special myopia control designs i. New designs may offer greater protection against myopia progression ii. Higher prescription options are available in custom lenses c. Works best for low myopes with low amounts of astigmatism i. Consider lifestyle and parental involvement as well. ii. Families with children already in treatment may be more likely to have success in small children IV. Implementing myopia control into your practice a. Selecting candidates for myopia control i. Who is a good candidate? ii. What ages are appropriate for treatment? Too young? Too high? iii. Setting up patient expectations: low vs. high myopes iv. How to determine treatment modality b. Parent s questions about Myopia Control i. Should I be concerned that my child s eye is growing 1. Retinal complications 2. Optic nerve complications ii. What is the best option for my child 1. ~Equally effective a. Corneal reshaping b. Soft multifocal lens designs 2. Atropine and bifocal treatment iii. How does it work? 1. Peripheral defocus iv. Is myopia control guaranteed to work? 1. There are no guarantees as some children will progress but the research shows that the progression will be slowed (or halted) by about 40 50% v. Is the treatment safe? 1. There is a small risk associated with all contact lens wearers compared to spectacles 2. Many studies have shown low risk 3. Compliance with care and solutions is essential vi. Will my insurance cover the costs? 1. Not likely, open spending account may vii. How long will my child need to use the treatment that is suggested? 1. Late teens viii. When will my child s eye stop getting worse? 1. Late teens or early 20 s ix. Do we need new lenses every year? More frequently? 1. We recommend annually 2. May last longer than a year dependent on care c. Use of equipment what is needed to implement? i. Exam Lane ii. Autorefractor, accommodative control iii. Corneal Topography

54 iv. Axial length scan (gold standard) v. pharmaceuticals d. Determining the cost of treatment i. Sample flow chart with cost for services and materials ii. Challenges with billing for myopia control 1. Cash pay is better than a la carte 2. Global fees versus independent test charges e. Patient follow up and treatment plan changes accordingly. i. How much progression is expected? 1. Case by case, difficult to predict ii. Managing doctor expectations vs. patient expectations f. Targeting marketing to patient populations g. Legal considerations i. Myopia control treatment is always off label use of FDA approved medical devices and products ii. Caution with advertising. Can not advertise specific treatments for myopia control

55 Lecture Outline Submission: Everything Therapeutic Saturday June 9, minutes COPE Category: CL Orthokeratology for all Ages Sheila D. Morrison, OD, MS, FSLS Tel: Course Learning Objectives After participating in this course participants should: 1. Be oriented to global use of corneal gas permeable lenses and understand the growing interest in orthokeratology (corneal refractive therapy) lenses. 2. Understand the positive vision related quality of life factors that may be attributed to the use of orthokeratology lenses. 3. Recognize that patients of all ages may be fit successfully with orthokeratology lenses and understand the benefits and challenges of fitting different age groups. 4. Review the history of orthokeratology in myopia control and modern knowledge of orthokeratology as a myopia control treatment strategy 5. Become familiar with the basics of orthokeratology lens fitting and with the pertinent clinical measurements necessary to fit and design orthokeratology lenses 6. Become familiar with the technical equipment and tools necessary to implement orthokeratology fitting in clinical practice 7. Review the exam flow and recommended exam flow and follow up schedule for orthokeratology patients Course Description This course is designed to instruct practitioners on basic orthokeratology fitting and provide an overview of the benefit of offering orthokeratology services in clinical practice. The course will begin with an overview of the use of orthokeratology lenses in pediatric and adult populations. It will then briefly outline the use of the lenses in myopia control. A tutorial for basic orthokeratology will be provided, including pertinent equipment needs and billing and coding considerations to implement orthokeratology services into clinical practice. A review of the exam flow and recommended followup schedule for orthokeratology patients will be provided. Course Outline: 1. Orthokeratology Introduction a. Definition

56 i. Historically known as the temporary reduction of myopia via corneal reshaping GP contact lenses worn during sleep ii. Aka corneal reshaping therapy, sleep shaping lenses b. Why fit orthokeratology lenses i. Freedom from glasses during the day ii. Ocular surface dryness with other lenses iii. Myopia control iv. Cost and lifestyle considerations 2. Positive impact on vision-related quality of life a. Clarity of vision at distance and near b. Less activity restriction c. Greater self-image/confidence d. Elimination of Daytime contact lens wear symptoms (dryness, itching, discomfort) e. Less glare than LASIK 3. Who is a good candidate for orthokeratology a. Why fit children b. Why fit adults c. FDA approved criteria i. Myopia up to -6.00D ii. Astigmatism up to -1.75D iii. No age limitation d. Off-label fitting for higher myopia and hyperopia e. Patients to avoid i. Against the rule astigmatism ii. Limbus-to-limbus astigmatism 1. Dual axis may be helpful iii. Lenticular astigmatism 1. Located inside the eye, cannot easily correct on the cornea iv. Ocular conditions that contraindicate contact lens wear 4. History and roots in myopia control a. Not a new technology

57 b. Early lenses were flat corneal GP lenses; modern lenses are reverse geopmetry curved lenses i. Overview of modern orthokeratology lens design 1. Reverse geometry 2. 3 versus 4 curve geometry 3. pulling and pushing forces beneath the lens 5. Efficacy a. 90% achieve 20/25 or better b. equally effective in children and adults c. effect is reversible i. refraction recovers 5-7 days ii. topography recovers 3-8 weeks iii. lasts most waking hours 6. Safety a. Safe when used as directed b. Swarbrick et al: the Risk of Microbial keratitis with overnight corneal reshaping lenses i. Risk is similar to that with other overnight lens modalities c. Lim YM and Xie P. The safety of orthokeratology a systematic review i. Low risk 7. Equipment needs a. Slit lamp b. Contact lens station c. Corneal topography d. Refractive lane 8. Fitting techniques a. Find a system that fits your practice. Choose the design that works best for you and become an expert in that design b. Diagnostic fitting sets i. Still requires topographical maps c. Software-based, empirical design i. Need

58 1. Refractive error 2. HVID 3. Keratometry 9. Proper fitting characteristics a. Lens is dispensible if i. 4mm treatment zone ii. lands well iii. bullseye pattern iv. centered v. adequate edge lift b. Lens is not dispensible if i. Small or no treatment zone ii. Decentered lens iii. Minimal edge lift or tight periphery 10. Recommended follow-up schedule a. Next day as early as possible in the morning b. One week c. One month d. 3-6 months 11. Recommended testing for follow-up visits a. Unaided visual acuity b. Refraction with BCVA c. Slit-lamp examination d. Corneal topography e. Record time of visit i. Time lenses were worn ii. Time lenses were taken off f. Inspect lenses g. History of cleaning and conditioning solutions 12. Difference display maps in corneal topography to measure treatment a. Always compare baseline to follow-up

59 b. Axial power maps c. Tangential curvature maps

60 Lecture Outline Submission: Everything Therapeutic Saturday June 9, minutes COPE Category: Understanding Corneal Topography and Beyond Sheila D. Morrison, OD, MS, FSLS Tel: Course Learning Objectives After participating in this course participants should: 1. Be oriented to corneal topography and modern scleral mapping tools, including the primary measures of ocular surface topography 2. Be oriented to methods and equipment for measurement of corneal shape 3. Become familiar with the basics of choosing the right map for patients and understand the data associated with these maps 4. Review basic uses and interpretation of corneal topography for contact lens design and anterior segment disease management 5. Review the roadmap to contact lens design based on ocular surface geography 6. Review corneal topography clinical considerations for capturing and optimizing images 7. Be oriented to modern scleral mapping tools which measure the ocular surface beyond the limbus Course Description This course is designed to instruct practitioners on basic to advanced corneal topography. The course will begin with an overview of corneal and scleral topographers. It will then cover selection of topographical maps and interpretation of topographical data. Basic uses of corneal topography for contact lens design and anterior segment disease management will be outlined. A review of clinical considerations for capturing and optimizing images will be provided, as well as an orientation to scleral mapping tools to image the topography of the eye beyond the limbus. Course Outline: 1. Topography Introduction a. Definition b. Why use corneal topography i. Diagnosis ii. Documentation/monitoring of anterior segment disease iii. Contact lens design

61 1. Corneal GP, orthokeratology, custom soft 2. Determination of best lens modality iv. Pre and post operative v. Tear analysis c. Corneal versus scleral anatomy and geography 2. Measurement of corneal shape a. Keratometry i. Central 6%, assumes reference sphere b. Corneal topography 1. Placido disc systems 2. Slit scanning 3. Scheimpflug Imaging 4. Interferometry 5. Projection profilometry 3. Data Interpretation a. Color Scale Settings b. Measurements c. Oblate versus prolate i. Oblate: flatter in center and steeper in periphery 1. LASIK, RK, corneal graft, orthokeratology ii. Prolate: steeper in center and flatter in periphery 1. normal cornea, keratoconus d. Defining Maps i. Axial map ii. Tangential map iii. Refractive power map iv. Elevation map e. Displays i. Single view ii. Multi-view iii. Difference display maps

62 1. Used in orthokeratology fitting or disease progression analysis f. Classifying Corneal Astigmatism g. Ectatic Disease Classification i. Keratoconus ii. Pellucid Marginal Degeneration iii. keratoglobus iv. Post-refractive ectasia h. Understanding Indices i. Eccentricity ii. Shape factor iii. I-S index 4. Roadmap to Contact Lens Design a. Using elevation maps to determine most approproate lens modality b. Using topography software to design contact lenses and order from laboratory c. Simulated fluorescein patterns 5. Topography Considerations: Capturing the Image a. Small versus large pupil b. Image clarity c. Quality of the tear film d. Ring distortion e. Lids and lashes f. Single versus multiple captures 6. Introduction to lens design beyond the limbus a. Scleral lenses have become mainstream modality i. Irregular cornea, ocular surface, high prescription, normal eye b. Understanding scleral/conjunctival shape is essential to fit scleral lenses i. Modern lens design affords multi complex curves c. Curves of the anterior eye are asymmetrical i. Corneo scleral junctions vary individually ii. Need to measure to get best understanding iii. Inter eye differences exist

63 7. Introduction to lens design beyond the limbus a. Scleral lenses have become mainstream modality i. Irregular cornea, ocular surface, high prescription, normal eye b. Understanding scleral/conjunctival shape is essential to fit scleral lenses i. Modern lens design affords multi complex curves c. Curves of the anterior eye are asymmetrical i. Corneo scleral junctions vary individually ii. Need to measure to get best understanding iii. Inter eye differences exist 8. Scleral/conjunctival mapping tools a. Determination of sagittal height and asymmetries i. OCT ii. Topographic Maps iii. Profilometry