Scleral Contact Lenses Simplified

1/12/2015
Disclosure
Scleral Contact Lenses Simplified
Alcon, Inc. Vision Care Speaker
Chandra V. Mickles, O.D., M.S., F.A.A.O.
Patient
46 year old male presented for
scleral lens fit
Penetrating
Keratoplasty
(PK)
Corneal Transplant (PK) +17D of Astigmatism!
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1/12/2015
The Big Picture
Scleral Lenses
Simplified
•
What are Sclerals?
•
When to Fit ?
•
How to Fit?
•
What is a Good Fit?
•
Where do I fit in?
The Big Picture
The Big Six
Where do I fit in?
•
Why should you care?
•
When to Fit ?
•
How to Fit?
•
What is a Good Fit?
•
Where do I fit in?
Your role as a paraoptometric
1.
2.
3.
4.
5.
6.
Insurance
Ancillary Testing
Insertion and Removal
Care and Handling
Ordering
Troubleshooting patient concerns
“My doc doesn’t fit
these lenses”
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1/12/2015
Why Should You Care?
Why Should You Care?
Sclerals, Sclerals, Sclerals!
Likely patients will come in wearing
these lenses
“The Annual Growth for large diameter lenses since 2006 is
50%.”
Paraoptometrics have an integral
role in providing quality eye care
and patient satisfaction
“It is the single largest growth category we have seen in gas
permeable contact lenses.”
Valuable skill for marketing
yourself for optometric and
ophthalmologic practices
David Bland, Direct of Global GP and Custom Soft Lens
Business for Bausch + Lomb, Egnnet Es. GP lens Update.
Contact Lens Spectrum, October, 2012
What are Sclerals?
Large Diameter Gas permeable Lenses
What are Sclerals?
Corneal Gas permeable
Scleral lens
Traditional GP
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What are Sclerals?
What are Sclerals?
LARGE
SMALL
Larger
LARGE
Mini-Scleral and Scleral
Corneo-Scleral and Semi-Scleral
VS
Land on
sclera
• Land on
or just
outside
limbus
• Easier to
handle
13.5
Corneal Gas permeable
Scleral lens
Land on cornea
Land on scleral
15.0
18.2
Sindt, CW. “Basics of Scleral Lens
Fitting and Design.” Contact Lens
Spectrum. October 2008
What are Sclerals?
What’s the Big Hype?
Necessity for Sclerals
Scleral Lens Categories
3
Name
Diameter (mm)
Corneo-Scleral
12.5 to 13.5
Semi-Scleral
13.6 to 14.9
Mini-Scleral
15.0 to 18.0
Scleral
18.1 to 25
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WHY Sclerals?
Necessity for Larger Designs
More comfortable, less lid-lens edge interaction
+
Provide a better fit and vision for the most challenging cases
WHEN TO FIT?
When to Fit? Irregular Corneas
Primary Corneal Ectasia
• Keratoconus
• Post-refractive Surgery
• Keratoglobus
• Corneal transplants
• Pellucid Marginal
Degeneration
When to Fit?: Irregular Corneas
Post-Surgical
Others
• Trauma
THE HARD TO FIT EYES!
Normal/Regular Cornea
Irregular Cornea
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When to Fit? Irregular Corneas
Steepening is not central
When to Fit? Irregular Corneas
Red / Warm colors
= Steep/More Curved
Advanced Keratoconus
Scarred Cornea from Trauma
Topography
Corneal GP
Scleral lens
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When to Fit? Irregular Corneas
Cornea
Lens
Topography
Our Corneal Transplant patient
When to Fit? Irregular Corneas
When to Fit? Ocular Surface Disease
Cases of Severe Dry Eye Syndrome
Sjogren’s Syndrome
……..and others
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1/12/2015
When To Fit? Ocular Surface Disease
When to Fit? Ocular Surface Disease?
Effective Dry Eye Treatment: Creates a long-lasting moist environment
due to retention of a lubricating reservoir that can nurture the ocular surface throughout the
day
Conventional treatment, artificial tears, provide only temporary dry eye relief due to limited
ocular contact
2
WebMD. 2013 How to Use Eye Drops. Retrieved from
http://www.webmd.boots.com/eye-health/guide/instilling-eyedrops-properly
Sclerals: We fill the bowl of the lens with preservative free artificial tears or saline
When to Fit?: Even Normal Corneas!
When to Fit?: Even Normal Corneas!
Gas Permeable provides vision that surpasses soft
particularly for high Rx’s
(high astigmatism and high spherical)
More comfortable, less lid-lens edge interaction
Provides crisp vision of gas permeable lens and comfort of a soft lens
Provides crisp vision of gas permeable lens and comfort of a soft lens
Soft lens
Scleral GP Lens
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How to Fit: 3 Step Approach
1. Select the Diameter
HOW TO FIT
2. Select the Sagittal Depth
3. Evaluate the Fit
Step 1: Diameter
Step 1: Diameter
Scleral Lens Categories
3
Name
Diameter (mm)
Corneo-Scleral
12.5 to 13.5
Semi-Scleral
13.6 to 14.9
Mini-Scleral
15.0 to 18.0
Scleral
18.1 to 25
ALL OF THESE SETS , HOW DO YOU CHOOSE?
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1/12/2015
Step 1: Diameter
Step 1: Diameter
Many manufacturers will often give recommendations based off
The Horizontal Visible Iris Diameter (HVID)
Lens exceeds HVID by at least
1.0 mm in each meridian, and
limbal area is properly vaulted
TIP
Many patients can be fit with a MINISCLERAL
START WITH LENS in the 15 Range for Optimal Success
EASY STEP : Most Sets come in 1 diameter
Especially the irregular patients, the more irregular
the larger you will need
If you have more than 1 Scleral Lens set, start with set in 14 or 15 range
Step 2: Sagittal Depth
Step 2: Sagittal Depth
Measurement from a flat plane at a given diameter to the highest
point of a concave surface (degree of corneal elevation)
Why not use Base Curves?
Scleral lens
↑
Sag
Depth
Some designs still reference as base curves
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Step 2. Sagittal Depth
Each design will
give you guidelines
of where to start
STEP 2: Sagittal Depth
Fine tuning/save chair time
i.e. Select a base curve from diagnostic
set approximately one diopter steeper
than the mean K
OR
Our patient
Select the sag 4.4 for K readings
between 42-55D
For our patient start a little higher sagittal depth or
steeper BC than recommended
Our patient
K 44.00/50.00
Step 3: Evaluate The Fit
Step 1: Select Miniscleral Design
(works on many patients)
Blanchard MSD
Corneal Zone
Limbal Zone Scleral Zone/Edge
Step 2: Guidelines state 4.4 SAG
Look at Profile: Start with 4.6
SAG instead
Inward to Outward
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Step 3: Evaluate the Fit
Step 3: Evaluate the Fit
Corneal and Limbal Zone
Goal to clear the cornea
Denoted by the amount of microns of clearance
Cobalt Blue Light
Vault the entire cornea and clear the limbus
• Fluorescein dye -Green = lens clears /doesn't touch cornea.
• Black= lens doesn’t clear the cornea
• Stagnant Bubble= Too high centrally
Step 3: Evaluate the Fit
Goal to clear the cornea
Step 3: Evaluate the Fit
Goal to clear the cornea
Denoted by the amount of microns of clearance
Not Enough
Sagittal Depth of lens
Larger number 4.6 instead of 4.4
Initial Sag was 4.4
Sagittal Depth of lens
Lower number 4.2 instead of 4.4
Not Enough
Too much
Too much
Different manufacturers use different terms but
in general this is what you are doing
Base cure numbers are opposite
If needed to steepen go from B.C. 8.4 to 8.3
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Step 3: Evaluate the Fit
Step 3: Evaluate the Fit
Corneal and Limbal Zone
WHAT IS WRONG HERE?
White light
Solution?
Increase Sagittal Depth
Step 3: Evaluate the Fit
Corneal and Limbal Zone
Depends on manufacturer
Corneal and Limbal Zone
White light
Normal Cornea Thickness is 540
microns
Goal:
Compare cornea thickness to
fluid layer
Cornea
+/OR compare lens thickness to
fluid layer
Recommended Clearance depens on lens size
Larger lens, more clearance
Step 3: Evaluate the Fit
Narrow beam to a small slit to observe the
fluid reservoir highlighted with fluorescein
(Green) in order to estimate vault (comparing
the reservoir with the known thickness of the
lens or thickness of cornea).
Fit Recommendations
Typical Recommendations
Vaults the cornea
Approximately 150 to 400 microns at the
corneal apex
How do you determine how much is enough?
Fluid Layer
1/2 to 2/3 cornea thickness
for normal cornea
1/2 of 540= 270
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1/12/2015
Step 3: Evaluate The Fit
Corneal Zone
Flluid Layer
Cornea
Lens
Inadequate corneal clearance
Alternative: Compare Fluid Layer to Lens thickness
Step 3: Evaluate The Fit
Corneal and Limbal Zone
Good corneal clearance
Step 3: Evaluate Fit
Lens
Limbal Zone
Corneal apical clearance 225 microns
Inadequate
Fluid layer
Ideal
Cornea
Limbal clearance varies per manufacturer: Typically 40 to 100 microns
OCT: More accurate
SD OCT OD (Optovue, Inc., Fremont, CA)
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Step 3: Evaluate Fit
Step 3: Evaluate the Fit
and Edge
Edge
Bubble
You want to the lens to align with sclera
Not impinge on it or drag the vessels
Blanching
Excessive Bearing
Ideal
SD-OCT OD, nasal conjunctival alignment
Too much edge lift
Too loose at edge
Mag Up to see the blanching or impingement of the vessels
No conjunctival blanching
(Optovue, Inc., Fremont, CA)
Step 3: Evaluate the Fit
Step 3: Evaluate the Fit
Scleral Zone and Edge
Scleral Zone and Edge
Blanching
Excessive Bearing
Flatten periphery
Blanching
Bubble
Too much edge lift
Steepen Periphery
Place FL on conjunctiva to see if it is picked up under the lens
Courtesy of Blanchard, Inc.
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1/12/2015
Step 3: Evaluate the Fit
Fitting: 3 Step Approach
What About Movement??
1. Select the diameter
2. Sagittal Depth (B.C.)
3. Evaluate the Fit
Scleral lenses typically do not move much
Movement can actually can cause patient discomfort
However, be certain to check for tear exchange
Determine the Power and VA
The Big Picture
BEST FIT
A.
What are Sclerals?
•
When to Fit ?
•
How to Fit?
•
What is a Good Fit?
•
Where do I fit in?
C.
B.
.
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1/12/2015
The Big Picture
•
What are Sclerals?
•
When to Fit ?
•
How to Fit?
•
What is a Good Fit?
•
Where do you fit in?
Where Do You Fit in?
The Big Six
Where do You Fit in?
Your role as a paraoptometric
1.
2.
3.
4.
5.
6.
Insurance and scheduling
Ancillary Testing
Insertion and Removal
Care and Handling
Ordering
Troubleshooting patient concerns
Where Do You Fit In?: Insurance
Some vision and medical insurance
plans will cover for these lenses.
eg. VSP
Can be considered as medically
necessary contact lenses for
Keratoconus
Be aware of what is covered for the
plans at your office.
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1/12/2015
Where Do You Fit In?: Insurance
Vision Service Plan (VSP)
Keratoconus (371.60, 371.61, 743.41, 743.42)
Irregular Astigmatism (367.22)
Cornea Transplant (V42.5)
Qualify as Medically Necessary
Where do You Fit in? Scheduling
Action
Don’t forget to explain the fitting
process
On average: 3 visits
1. 1-hour diagnostic fitting
2. 1-hour dispensing visit
which includes I&R
3. 30-60 minutes follow up visit
&
Result
Eliminates patient frustration
Where Do You Fit In?: Insurance
V codes
For Schedule use either HCPS
V2530 or V2531
•
*V2530 for Corneoscleral
lenses (13.5-15.00
Diameter)
• Use V2531 for Scleral
Lenses (15.0-20.00
Diameter)
Visual Necessary Maximums
V2530
$499
V2531
$987
VSP
Where do You Fit in? Ancillary Testing
Key Tests
1. Pretest: Topography
2. Imaging: Anterior segment OCT
Ultimately improves success
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1/12/2015
Where do You Fit in? Ancillary Testing
Where do You Fit in? Pretesting & Imaging
Key Tests
Key Tests
1. Pretesting: Topography
1. Pretesting: Topography
• Aid in diagnosis and
progression of corneal
disease
• Contact Lens Fitting
Do’s
Ask doctor’s preferred scale and type of map
The type of scale and map are important for assisting in the diagnosis and
appropriate contact lens selection
There are various names of scales and types of maps
Where Do You Fit In? Looking At The
Scales
Topography
Max
Red
• Red is Max
• Green is middle
• Blue is Min
Where do You Fit in? Ancillary Testing
Absolute
•
•
Min
Topography
Scales
Diopter range attempts to cover the
entire power spectrum commonly
seen in practice
9D to 101.50D
Autosize
Adapted to the range of powers on
individual cornea
In this case 34D to 44D
Blue
Standard, names vary with instrument
Adjusted, Relative, names vary with instrument
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1/12/2015
Scales: Why is Does this Matter?
Is This the Same Eye?
Where Do You Fit In? : Ancillary Testing
Topography
Type of Maps
Axial (sagittal) and Tangential
Assessment of the Curvature(Shape) of Eye
Absolute Scale
Larger steps may cause important information
to be smoothed over
Auto Scale
Smaller steps may exaggerate
non-pathologic changes
True Pathology will show up on absolute scale
Where Do I Fit in? Pretesting and Imaging
Select the appropriate
scale and map requested
Key to successful diagnosing and
fitting of scleral lenses
Where Do I Fit In? Ancillary Testing
OCT imaging
Various instruments offer anterior segment imaging useful in
assessing the fit of scleral lenses
Gives excellent guidance of lens clearance above the cornea
Visante (Carl Zeiss, Meditec)
Pentacam (Oculus)
RTVue (Optuvue)
Cirrus (Carl Zeis, Meditec)
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1/12/2015
Where Do I Fit In? Pretesting and Imaging
Where Do I Fit In? Insertion & Removal
OCT imaging
Often docs will request views of lens over apex of the cornea
Lens
Supplies Needed
Preservative
Free saline
Tear Layer
Cornea
Clearance of Mini-scleral lens on Sjogren’s Syndrome Patient
I and R Made Easy
Tripod Method
DMV INSERTER METHOD
Suction Cup
DMV Remover
Where Do I Fit In? I&R
For evaluation of fit only
Instill fluorescein strip
into bowl of the lens
What is wrong here?
A Key to Success with Sclerals
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1/12/2015
Where Do I Fit In? I&R
Tips for common challenges:
•
Goals:
Tips for common challenges:
Goals:
Allow lens to settle 20 minutes
(15 to 30 minutes)
Assessing fit accurately
Enough liquid remaining in bowl
Fill the bowl of lens excessively
•
Nose pointed to the floor
Tell patients to tuck chin into chest
•
Don’t let go of the suction cup to first!
Where Do I Fit In? I&R
Lens clearance decreases over time
Prevention of insertion bubbles
Likely to settle 40 microns
70-90 microns during entire day
Once lens is securely on
let go of lids slowly
then let go of the insertion device
Where Do I Fit In? Care & Handling
Insertion solution
Where Do I Fit In? Care & Handling
Care Systems
Educate patients on their options
Rx: 0.9% Sodium Chloride Inhalation Sol’n
. 3mal Tray of 100
Preservative Free Artificial Tears
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1/12/2015
Where Do I Fit In? Care & Handling
Starter Kits
Where Do I Fit In? Ordering
Labs
Essilor
www.Gpli.info/labs
Dallas
• Assist doctor in creating starter kits
1. handout on I&R, care and handling, +
places to purchase to supplies
2. preservative saline and starter solution
3. Inserter and remover
Blanchard
NH
Metro Optics
Dallas
• Prepackaged kits are now available
Truform
• Patients really appreciate these resources
materials when new to sclerals
Where Do I Fit In? Ordering
Order Form
San Antonio
Bedford
Where Do I Fit In? Ordering
What is this Plasma Treatment all about??
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1/12/2015
Where Do I Fit in? Ordering
Plasma Treatment
WHAT WE DON’T WANT
Where do I Fit In? Ordering
PLASMA TREATMENT
WHAT WE WANT
Poor Wettability: “Lens doesn’t wet well”
• Surface of lens is sterilized
• Removes polish residues
Results:
Extremely clean and wettable surface
Reduces wetting angle
Improved initial comfort
Untreated Lens
Treated Lens
Where Do I Fit In? Ordering
Policies
Where Do I Fit In?
Troubleshooting Patient Concerns
Common Concerns
“ My vision gets foggy or blurry”
Be aware of exchange and return policies
Warranties
They Change!
“Red ring when I remove the lens”
“ I keep getting bubbles in the lens”
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1/12/2015
Where Do I Fit In?
Troubleshooting Patient Concerns
Where Do I Fit In?
Troubleshooting Patient Concerns
Foggy/ Hazy Vision
Hazy Vision
Resevoir Debris
Deposits
Trapped debris that accumulates
in the resevoir of the lens
Have patients thorough wash fingertips and reinstruct on cleaning
Common: 30-50% of wearers
Not and easy fix
Fix: Remove lens 1x or 2x
a day rinse and refill with fresh saline
Where Do I Fit In?
Troubleshooting Patient Concerns
Application error
Fix: Application training
Where Do I Fit In?
Troubleshooting Patient Concerns
Red Ring
• Re-instruct on application and removal
Remove using plunger near edge
NOT center
• Recheck for tight fight
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Thinking Outside the Box
Large Diameter: What’s New?
Sclerals
Large Diameters
Designs with
Presbyopic Correction
Multifocals
Newest Designs
(Primary Center-Near)
Monovision
SO2Clear Progressive
(Art Optical/Dakota Sciences/ MetroOptics)
Piggyback
Digiform (Truform Optics)
Our Scleral Presbyopes
would like to see at near too!
AVT Scleral Multifocal
(Advance Vision Technologies) Center-Distance
Blanchard Multifocal
(Center-Near)
C-RAY GP Multifocal (Unilens Vision, Inc.)
Exact Add Powers in 0.25D steps
Large Diameter: What’s New
So Comfortable!:
Sclerals Options now for Normal Corneas
Large Diameter: Thinking Outside the Box
Onefit P+A- Not So Normal Application
The Onefit P+A (Blanchard) of a
Sjogren’s Syndrome Patient
The Onefit Prolate
+Astigmatism
(Blanchard)
Improved Dry Eye Symptoms and Signs
with ease of handling
Easy 3- step, inside-out, fitting
approach
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1/12/2015
Large Diameter: What Else is New?
The Big Picture
Blanchard
• When to Fit ?
• How to Fit?
• What is a Good Fit?
• Where do I fit in?
Newest
Remember Our Patient
Corneal Transplant
Remember my technician….
17D! Of Astigmatism
With Glasses best corrected to 20/30 with poor quality vision
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1/12/2015
BEST GOAL: HAPPY PATIENTS!
GOALS
•
Sclerals
When to Fit ?
Transplant, High Astigmatism
•
How to Fit?
Diameter 15.8, Sag Depth 4.6
1. Diameter 2. Sag Depth 3. Evaluate
•
What is a Good Fit?
Good Fit with 20/20! Vision
•
Where do I fit in?
I& R, Care and Handling was all successful,
Scleral Lenses provided exceptional quality vision and comfort
Enhancing the patients’ quality of life!
Insurance Coverage
•
Resources
Resources
Gas Permeable Contact Lens Institute
CONCLUSION
• Scleral lens designs are an invaluable tool for
successfully fitting corneas
http://www.gpli.info
A Guide to Scleral Lens Fitting
Commons. Pacificu.edu/mon/4/
Boston® Product Guide
fit-boston.com
• Paroptometric technicians should become
familiar with this design so they can help
patients achieve quality vision
Blanchard Contact Lenses Beyond the Limbus Educational Sessions
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