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???
Bausch + Lomb
Some eyes can not be optimally fitted with corneal lenses
Because they result in fluorescene patterns that look like this!
Is There a Way to Predetermine the Success of a Corneal GP Lens?
To Avoid This
Curvature versus Elevation Axial Display Power Map Elevation Map Height Map
Axial Display Elevation Display
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
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.
+379um +379-276 655 Micron Height Differential -276um
Patient CB Right Eye
Elevation Map
Patient VY Post Hydrops
Elevation Map -200um +430um Elevation: +430-260um Depression: -260 Differential = 690um
Instrument Evolution Composite Corneal Topography Keratometry Photokeratoscopy Videokeratography 3.0 mm 8.0 mm 10.0 mm 12.0 mm
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
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
) 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
Scleral Lens Indications Ocular Surface Disease Corneal Irregularity Ectasia/Scar/Post Surgery
Ocular Surface Disease Pre-Scleral 2 Months Post Scleral
SJS 20/400 6 months Post Scleral Lens 20/25
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
Average 8.5
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
Traditional Corneal / Scleral Shape
Scleral Shape New Understandings
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
Corneal/Scleral Angle 10 to 15 mm 10.0 mm 15.0 mm Tina Graff, Eef van der Worp, Patrick Caroline, Randy Kojima
Average Angle from 10 to 15mm T N
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
Average Angle from 15 to 20mm T N
Cone Angle Circa 1948 Klaus Pfortner Argentina
Corneal Vaulting Properties Of Scleral Lenses
Scleral Lens Fitting Objectives 1. Central Vault Zone (250 to 400 microns) 2. Peripheral Lift Zone 3. Limbal Lift Zone 4 3 2 1 2 3 4 4. Scleral Landing Zone
Anatomy of a Scleral Lens
Scleral Lens Fitting by Sagittal Height 3,800 4,000 4,200 4,400 4,800
Zone #1, Central Clearance Zone (CCC)
What is the Appropriate Central Corneal Clearance???
Central Clearance Zone 300 to 400 microns of Apical Clearance
Apical Clearance at Dispensing 250 microns Apical Clearance Post 8 Hours 150 microns
Tear Lens 300 microns CL Thickness 0.35 mm 350 microns
Scleral Lens Setteling
Apical Clearance at Dispensing 410 um Apical Clearance at 30 Days 270 um 140 um of Lens Settling
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)
Estimating Tear Film Thickness
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
Lens Settling 15 Subjects 96 microns following 8 hours of lens wear. 70 to 180 micron range. 146 microns following one month.
Right Axial Left Axial Right Elevation Left Elevation
-3.50 DS SCL SCL
Excessive 300 um 600um Apical Clearance OK? Not OK?
Zone #2, Peripheral Corneal Clearance Zone (PCCZ)
Peripheral Cornea and PCCZ Bearing Limbal Clearance Adequate Clearance
Appropriate Limbal Clearance Inadequate Limbal Clearance
Inadequate Peripheral Corneal Clearance
Dispensing 4 hrs. Post Dispensing
Diagnostic Lens Final Lens
Changing the PCCZ Peripheral Corneal Clearance Zone Plus changes (+) = more depth Minus changes (-) = less depth 1 degree steps = 25 microns sag change
Temporal Nasal
Temporal Nasal
Left Eye
Zone #3, Limbal Clearance Zone (LCZ)
White Light Cobalt Light Limbus
Limbal Clearance Zone
Standard Limbal Clearance Zone +5 Degree In the Limbal Clearance Zone
Changing the LCZ Limbal Clearance Zone Plus changes (+) = more depth Minus changes (-) = less depth 1 degree steps = 25 microns sag change
Bulging Graft 42.3 Sag 5,330 47.7
Horizontal Meridian
Keratoglobus 50.5 Sag 5,690 49.4
Zone #4, Scleral Landing Zone (SLZ)
Scleral Landing Zone Evaluation Dispensing Post 4 hours
Standard Edge Greater Lift Design
Conjunctivial Compression
Scleral Lens Fitting by Sagittal Height
Lens Application Preservative-free saline and sodium fluorescein
Lens Application The patient looks down.they hold their lower lid practitioner the upper & the lens is applied.
Preservative Free Saline Options (in the USA) The unit dosed 5 or 10 ml Inhalation PF saline... 0.9% 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
LacriPure Saline from Menicon
Application Bubble
Re-Application
Apical Clearance = 350 microns
Conjunctivial Blood Vessels
Over-refraction