Scleral Lenses Scleral Lens Design

1/14/16 How Do I Use
Scleral Lenses in My
Practice?
Fitting Full Scleral Lenses Melissa Barnett, OD, FAAO, FSLS
University of California, Davis
Eye Center
Disclosures
Acculens
Alden Optical
Alcon
Allergan
Bausch + Lomb
CooperVision
Novabay
Gas Permeable Lens Institute (GPLI)
Paragon Bioteck
Scleral Lens Education Society
Vistakon
Zeiss
Scleral Lenses
!  First used in late 1800s and early 1900s
!  Manufacturing process now more reproducible
!  Modern scleral lenses
!  Don Ezekiel, O.D.
!  Ken Pullum, O.D.
!  Perry Rosenthal, M.D. Boston Scleral Lens
www.sclerallens.org
Scleral Lens Design
1 1/14/16 Which are do you feel has the greatest
potential for growth in the next 12 months?
Scleral lenses: a literature review.
Scleral lenses: a literature review.
! 
! 
!  Eye Contact Lens 2015 Jan;41(1):3-11
!  Schornack MM
!  Case reviews published after 1983 identified major
indications for scleral lenses and visual and functional
outcomes of scleral lens wear.
!  899 references were identified
!  Statistically significant improvements in
!  Visual acuity
!  Vision-related quality of life
!  Ocular surface disease
!  184 directly related to scleral lenses.
!  ★ Indications for scleral lens wear are well-established
!  Most articles published before 1983 presented lens
!  Current and future research
!  Physiologic impact of scleral lens wear on the ocular
!  Comprehensive review of current and historical
literature on scleral lenses.
design and fabrication techniques or indications for
scleral lenses.
surface
!  Use of technology to improve scleral lens vision and fit,
and
!  Impact of scleral lenses on quality of life
Complications and fitting challenges
associated with scleral contact lenses:
A review.
!  Contact Lens Anterior Eye 2015 Sep 1
!  Walker MK, Bergmanson JP, Miller WL, et al.
!  Complications and fitting limitations of modern scleral
lens
!  Literature review
Complications and fitting challenges
associated with scleral contact lenses:
A review.
!  Reports of infection with scleral lenses
!  Often seen in severely compromised corneas
!  Hypoxic and inflammatory complications are rarely reported
!  Somewhat complex relationship of a scleral lens on the eye
can create fitting and removal challenges
!  Anomalies unique to scleral lens wear
!  Conjunctival prolapse
!  Epithelial bogging
!  Midday fogging
!  Limbal bearing
2 1/14/16 How large should a scleral lens be?
Mini-scleral vs. Full scleral
Typically 1416.5mm
!  Mini-scleral
Limiting factors
• 
• 
• 
• 
• 
• 
• 
14.3 OAD
18.2 OAD
Oxygen permeability
Corneal physiology
Conjunctiva anatomy
Scleral anatomy
Ease of fit /
troubleshooting
Patient handling
Complications
!  Supported by conjunctiva and tear layer (water bed)
!  Less clearance
!  First 16.5mm of sclera is spherical
More than
18mm
!  Full Scleral
!  Supported by conjunctiva
!  Sclera beyond 16.5mm has more toricity due to muscle
insertions
http://www.clspectrum.com/articleviewer.aspx
Lens Diameter
Corneal Diameter
!  Practitioner preference
!  Pd ruler
!  May be able to alter the diameter within the same
!  Topography
lens design
!  If the diameter is changed significantly, may need a
different lens design
!  Pentacam
!  Slit lamp reticle
Clearance
Corneal topography
!  Determines corneal diameter or HVID
!  Clearance is a key advantage of scleral lenses
!  Information about location of corneal apex
!  Sagittal height is adjusted to increase or
!  Determines sagittal height of the cornea
decrease clearance
!  Increasing the sagittal height increases the
clearance or vault of the lens
!  Different terminology is used rather than flat
and steep
3 1/14/16 Sagi,al Depth Excessive Sagittal Depth – Bubbles Centrally
!  Sagittal depth is the measurement from the
flat plane to the highest point of a concave
surface
!  If sagittal depth is too high, leads to central
bubbles
!  If sagittal depth is too low, leads to excessive
Excessive mid-peripheral clearance - bubbles in
mid-peripheral / limbal zone
central touch and bubbles in sclera
4.20 S
Sagittal Height
!  Measurement between the geometric center of the
cornea and the intersection of a specified chord
length
Eye Shape and Scleral Lenses
Contact Lens Spectrum April 2013
!  Randy Kojima, Patrick Caroline, Tina Graff, Beth Kinoshita, OD, Lori
Copilevitz, OD, Roxanne Achong-Coan, OD, Eef van der Worp, PhD;
Matthew Lampa, OD, Kelvin So, OD, Mark Andre
Comparison of the sagittal height
differences between
normal and keratoconic eyes from
corneal apex to a 10.0mm chord.
Mean sagittal difference = 217μm.
!  Average sagittal height from 10mm to 15mm for all
eyes is approximately 2,000 μm (Kojima CLS
2013) Sagittal height difference between
the normal and
eyes at a chord of 10mm to
15.0mm. Mean sagittal height
difference = 22μm.
Sagittal Height
!  Sagittal height of 10mm chord = 2,000μm
!  Desired vault of 300μm centrally
!  15mm diagnostic lens = should be 4,300µm
Sagittal Height
!  Luigina Sorbara, Jyotsna Maramb, Katrin Muellerc
!  Use of the Visante™ OCT to measure the sagittal depth and
scleral shape of keratoconus compared to normal corneae:
Pilot study
!  J Optom.2013;6:141-6
!  (2,000µm + 2,000µm + 300µm for vault =
4,300µm)
!  Larger diameter lens – increase sagittal height
(need to cover larger area of eye surface)
4 1/14/16 Sagittal Height
Clearance
!  Sagittal depth and corneal-scleral junction angle measurements in
the steepest meridian at HVID or 15mm
!  Significantly different in normals and patients with keratoconus.
!  Cornea useful as comparison and a reference
!  Average corneal thickness
!  Central = 530 microns
!  Peripheral = 650 microns
!  Central lens thickness can also be used as a
reference
!  A thin optic section with white light (both with
and without fluorescein) is helpful to evaluate
clearance
Measurements of Anterior
Segment Depth
Measurements of Anterior
Segment Depth
!  Optical coherence tomography (OCT)
!  OCT
!  Scheimpflug imaging
!  Used at follow up appointments
!  Obtain objective measurements of the depth of the
!  Gives precise measurements of the tear reservoir
!  Limitations - only out to about 15mm
!  No need to remove lens on eye prior to
cornea and sclera
!  Images allow visualization of the contour of the
and edge contour to the sclera
measurements
cornea and sclera
!  Aids in selection of initial fitting set
Bridge Over The Cornea and Limbus
51.00 D
46.00 D
Picture courtesy of Bruce Baldwin, OD, FAAO, FSLS
Picture courtesy of Bruce Baldwin, OD, FAAO, FSLS
5 1/14/16 Clearance
!  Allow scleral lenses time to settle and “sink”
into conjunctiva
!  Wait at least 30 minutes before evaluating a
lens on the eye
!  Keep in mind that lenses may settle more with
Clearance
!  Limbal clearance also important
!  Stem cells are located at the limbus
!  Stem cells form new epithelial cells for the
entire cornea
time
Limbal Clearance
!  The lens should not rest on the limbus, but
to have some degree of limbal clearance
Corneal Shape
!  Determine apex (location and height) of cornea to
select a lens
!  Standard geometry lens – corneal apex within
central 4mm of the cornea
!  Reverse geometry lens – corneal apex outside the
central 4mm, some post PK grafts or peripheral
elevations (Salzmann’s)
Materials
!  High Dk materials
!  Thicker than small diameter GP lenses
!  Often 0.4mm to 0.6mm which reduces Dk / t
!  Plasma treatment to improve wettability
6 1/14/16 Useful Resource
!  Scleral lens education society video
!  Scleral Contact Lens Insertion, Removal,
Troubleshooting and Lens Care
!  http://www.sclerallens.org/how-use-scleral-lenses
Joe, 40 year old Caucasian Male
!  History of lattice corneal dystrophy both eyes
!  Diagnosed age 2
!  Family history of lattice corneal dystrophy –
father
!  Has not worn contact lenses for 5 years
!  Previously tried RGPs and hybrid contact lenses
!  Blurry vision for distance with glasses
!  Hard to read computer and near
Joe, 40 year old Caucasian Male
!  Ocular history
!  PTK OU
!  PKP and AK OS
!  PCIOL OS S/P YAG OS
!  Glaucoma suspect
Lattice Corneal Dystrophy Type 1
!  Lattice corneal dystrophy type 1
!  (AKA Biber-Haab-Dimmer dystrophy)
!  No systemic manifestations
!  Autosomal dominant
!  Ocular medications
!  Non-preserved artificial tears as needed
!  Fluorometholone 1% and ketorolac 0.5% daily in
both eyes
Lattice Corneal Dystrophy Type 1
Lattice Corneal Dystrophy Type 1
!  Caused by mutations in the TGFBI gene
!  Variable in appearance
!  TGFBI gene provides instructions for making proteins in
!  Classic 'glass-like' filamentous lesions
the cornea.
!  TGFBI protein is part of the extracellular matrix
!  Plays a role in the attachment of cells to one another
(cell adhesion) and cell movement (migration).
!  The TGFBI gene mutations involved in lattice corneal
dystrophy type I change amino acids in the TGFBI protein.
!  Mutated TGFBI proteins abnormally clump together and
form amyloid deposits.
!  Deposits may change over time
!  Progress from round, ovoid and white, or small, filamentous,
and refractile anterior stromal lesions to nodular, threadlike,
and thicker linear lesions that extend into deep stroma
!  Typically limbus is not involved
!  Clear spaces between lesions in beginning stages
!  Over time, spaces opacify and take on a ground glass
appearance.
!  Signs most often appear in early childhood and become more
prominent into the 2nd and 3rd decades.
!  Unclear how the changes caused by the gene mutations
induce the protein to form deposits.
7 1/14/16 Lattice Corneal Dystrophy Type 1
•  Symptoms (begin in the 2nd or 3rd decades of life)
!  Surface erosions
!  Irregular astigmatism
!  Vision loss
•  Signs
!  Recurrent corneal erosions
•  Treatment
Lattice Corneal Dystrophy Type
II and III
!  Lattice corneal dystrophy type II
!  (AKA Finnish Familial Amyloidosis, Meretoja syndrome,
Amyloidosis V, Familial amyloidotic polyneuropathy IV)
!  Autosomal dominant inheritance of the Gelsolin gene on 9q34
!  Associated with manifestations of systemic amyloidosis due
to accumulation of gelsolin
!  Associated conditions include cutis laxa and ataxia
!  Penetrating or lamellar keratoplasty (may not be needed
until 4th decade)
!  Recurrence may occur in grafts but present differently
than primary lesions
!  Lattice corneal dystrophy type type III
!  Onset at age 70 to 90 years
!  Not associated with systemic amyloidosis
Lattice Literature
!  Seitz B, Lisch W. Stage-related therapy of corneal
dystrophies. Dev Ophthalmol. 2011;48:116-53.
!  Dinh, R., Rapuano, C. J., Cohen, E. J., Laibson, P. R.
Recurrence of corneal dystrophy after excimer laser
phototherapeutic keratectomy. Ophthalmology 106:
1490-1497, 1999.
!  Klintworth GK, Bao W, Afshari NA. Two mutations in
Joe
OD
OS
20/60-2 PH 20/30
VA
(uncorrected)
42.50 / 43.70 / 146
Irregular
astigmatism
central and inferior
Pentacam
Sim Ks
971
Pachymetry
668
10 mmHg
Applanation
IOP @
3:13pm
11 mmHg
the TGFBI (BIGH3) gene associated with lattice
corneal dystrophy in an extensively studied family.
Invest Ophthalmol Vis Sci. 2004 May;45(5):1382-8.
CF @ 6 feet PH
20/200
43.40 / 44.50 / 050
Temporal steepening
and
irregular astigmatism
OD
OD
OS
2+ mgd,
telangectasia
L/L
2+ mgd,
telangectasia
White and quiet
Conjunctiva
White and quiet
3+ lattice
corneal
dystrophy, 2+
central clouding,
reduced tear
meniscus,
no PEK
Cornea
Post Penetrating
Keratoplasty
intact
No PEK
Deep and Quiet
A/C
Deep and Quiet
1+ nuclear and
cortical sclerosis
Lens
PC IOL stable
0.40
C/D
0.30
Normal
Macula
Normal
OS
Initial Diagnostic
Scleral Lenses
Europa
46.00D / -2.00 /
16.0mm
Sag 4.66
Parameters
Europa
48.00D / -3.00 /
16.0
Sag 4.85
Good central and
peripheral
clearance
No blanching
Fit
Inadequate limbal
clearance
New diagnostic
lens
Europa
48.00D / -3.00 /
18.0mm
Sag 5.64
Fit
Good but minimal
central clearance
(want increase 80
microns)
Clearing graft
No blanching
SOR
-0.50 20/20-1
-2.00 20/25+2
8 1/14/16 OD
OS
OD
Initial Scleral
Lenses Ordered
Europa
46.00D / -4.00 /
16.0mm
Sag 4.66
Parameters
OS
Scleral Lens
Dispense
Europa
48.00D / -3.50 /
18.0mm / 9.5
Sag 4.80
Europa
46.00D / -4.00 /
16.0mm
Sag 4.66
Parameters
Europa
48.00D / -3.50 /
18.0mm / 9.5
Sag 5.80
20/20-2 SOR
+0.25 NI
VA
20/15-1 SOR pl
Good central and
peripheral
clearance
No blanching
Fit
Good central and
peripheral clearance
Clearing graft
completely
No blanching
Accepts +1.50 at
Near
OD
Follow Up
OS
Europa
46.00D / -4.00 /
16.0mm
Sag 4.66
Parameters
Europa
48.00D / -3.50 /
18.0mm / 9.5
Sag 5.80
20/25-1
SOR +0.25 to
+0.50 20/25+2
VA
20/20 SOR pl
Good central and
peripheral
clearance
No blanching
Bubble superior
temporal
Fit
Good central and
peripheral clearance
Clearing graft
completely
Far peripheral
blanching
Impression of
bubble on cornea
Anterior segment
without lenses
1+ peripheral
microcystic edema
New lenses (# 2)
Europa
46.00D / -3.63 /
16.0mm
Sag 4.66
Parameters
Europa
48.00D / -3.50 /
18.2mm / 9.7 /
10.5 / 13.25
Sag 5.80
OD
OS
Follow Up after
Scleral Lens
Dispense (#2)
Europa
46.00D / -3.63 /
16.0mm
Sag 4.66
Parameters
Europa
48.00D / -3.50 /
18.2mm / 9.7 /
10.5 / 13.25
Sag 5.80
20/20-1 SOR pl to
+0.25 NI
VA
20/20-1 SOR pl
Good central and
peripheral
clearance
No blanching
No bubbles
Fit
Good central and
peripheral clearance
Clearing graft
completely
No blanching
No PEK, no MCE
Anterior segment
without lenses
No PEK, no MCE
571
Pachymetry
721
9 1/14/16 OCT to Assess Scleral Lens Fit
OCT of Scleral Lens Fit
!  OCT provides information in relation to the sclera
1. Central vault – amount varies
2. Limbal clearance – amount varies
!  Important to have clearance
!  Excessive clearance !conjunctival prolapse and hypoxia
3. OCT useful to determine if toric landing curves
would improve a scleral lens fit.
OCT to Asses Landing Zone
and Edge Profiles
OCT to Assess Landing Zone
and Edge Profiles
!  Flat edge with edge lift on OCT
!  Leads to debris accumulation under the lens
!  Leads to fogging of the vision
!  Tight edge
!  Scleral lens impression or digging in to the scleral
conjunctiva
!  Discomfort and redness over time
TIGHT
Picture from Critical Measurements to Improve Scleral Lens Fitting
Jason Jedlicka, OD and Greg DeNaeyer, OD
Contact Lens Spectrum, September 2015
Keratoconus
!  63 year old Caucasian male
!  Referred by corneal specialist for a contact lens
fitting both eyes
!  Vision not as clear for distance
!  Eyes irritated and dry at the end of the day
!  History of small diameter gas permeable contact
lens wear since 1962
©2012 MFMER | slide-­‐59 10 1/14/16 OS
OD
20/40 PH 20/30
OD
VA
(with GPs)
20/25 PH 20/20-2
1+ mgd
L/L
1+ mgd
-6.50+0.50x065
20/60
Refraction
White and quiet
Conjunctiva
White and quiet
45.18 / 54.26 /
045
Irregular astigmatism
Pentacam
Sim Ks
-3.75+0.50x095
20/60
51.61 / 53.07 / 002
Irregular
astigmatism
Cornea
Fleisher Ring
paracentral
scarring less
than 1mm
Deep and Quiet
A/C
Deep and Quiet
1+ nuclear and
cortical sclerosis
Lens
1+ nuclear and
cortical sclerosis
0.40
C/D
0.30
Normal
Macula
Normal
Pachymetry
14 mmHg
Applanation IOP
@ 1:22pm
15 mmHg
OD
OS
Scleral Lenses
Jupiter (Essilor)
Optimum Extra
OD 47.25 / -5.75 /
16.6 / 13.25 / 14.75
Sag 4.88
20/25+1
SOR pl
Parameters
Jupiter (Essilor)
Optimum Extra
OS 48.50 / -5.99 /
16.6 / 8.6 OZ /
13.25 / 14.75
Sag 4.88
VA
20/20-2
SOR pl
Binocular VA
20/20+1
Good central and
peripheral clearance
No blanching
Fleisher
Ring
paracentral
scarring
OS
Fit
Good central and
peripheral clearance
No blanching
Keratoconus Follow up
!  Foggy vision after 4-5 hours of scleral lens wear
!  Meibonitis treated with eyelid hygiene, doxycyline 100
mg po, Azasite, dietary changes, Restasis
!  Additional treatments
!  Avenova eyelid cleaner
!  Ocusoft eyelid cleaner
!  Solutions – Clear Care, non-preserved 0.9% sodium
chloride inhalation solution with two drops of nonpreserved Celluvisc
X-­‐Ray Vision Specialties, P.C. 2020 Sunnyview Blvd. Anywhere, USA 12345 Tel:(555) 555-­‐5555 Fax: (555) 555-­‐5556 I.M. Awesome, O.D. B. Mypatient, O.D. Name:____________________________________________ Address:_________________________ Date:___________ R 0.9% NaCl Inhalation saline for ophthalmic use Dispense : 1 box (100 count) 3 ml vials Sig: Use as directed with ocular prosthetic device Refills: _________ ___________________________________________________ Keratoconus Follow up
!  Fogging improved!
!  Successfully wearing lenses for 5 years
!  VA
©2012 MFMER | slide-­‐64 Quality of Life in Patients
with KCN
!  Vision related quality of life in patients with keratoconus.
!  Kurna, Aydin, Altun, Gencaga, Akkaya, Sengor
!  J Ophthalmol 2014; April.
!  OD 20/20-1
!  OS 20/20-2
!  Binoc 20/15+2
!  National Eye Institute Visual Function Questionnaire-25 (NEIVFQ-25)
!  30 patients with keratoconus
!  20 RGP wearers
!  10 non-contact lens wearers
!  30 healthy patients (control group)
11 1/14/16 QOL KCN
QOL KCN
!  Evaluated high and low contrast visual acuity
!  Mean K values
!  Each subject completed the NEI-VFQ-25
!  Contact lens wearers had better BCVA compared with
noncontact lens wearers (P = 0.028).
!  Patients with low visual acuity in the better eye
!  Worse distance vision, social functioning, mental health,
and role difficulties.
!  All subscales of NEI-VFQ-25 lower in KCN patients.
!  Especially
!  General vision
!  Ocular pain
!  Near vision
!  Vision-specific mental health
!  Vision-specific role difficulties
!  Peripheral vision
Quality of Life in Patients
Wearing Scleral Lenses
!  Picot, C, Gauthier, AS, Campolmi, N, Delbosc B
!  J Fr Ophtalmol. 2015 Sep;38(7):615-9.
!  Evaluated the improvement of QOL with scleral
lenses in keratoconus or the treatment of
astigmatism after penetrating keratoplasty
!  Retrospective study
!  Patients failed to adapt to RGP lenses
!  QOL before and after scleral lens adaptation
!  Patients with low visual acuity in the worse eye
!  Lower general health scores
!  ★ Vision related quality of life worse in patients with KCN
!  Success with contact lenses and maintaining better
visual acuity may improve vision related quality of life.
Quality of Life in Patients
Wearing Scleral Lenses
!  47 patients (83 eyes) fitted with scleral lenses on one or both eyes
!  56 eyes with KCN
!  27 post-keratoplasty eyes
!  NEI-VFQ 25 scores with scleral lenses were significantly higher
than those without scleral lenses.
!  Scleral lenses showed significant improvement in quality of life for
patients who had failed or are intolerant to conventional rigid gas
permeable contact lenses.
!  Scleral lenses are an alternative or a step prior to surgery
NKCF
N ATIONAL K ERATOCONUS F OUNDATION
Resources for patients with
keratooconus
PROVIDES
INFORMATION AND SUPPORT TO THE
KERATOCONUS PATIENT COMMUNITY
•  Informational Booklets in English and Spanish
•  KC-Link an Email based support group
•  Comprehensive website: www.NKCF.org
•  Toll Free Information: 800 521-2524
kc-link list
[email protected]
Visit the NKCF in booth #1910
12 1/14/16 Charles, 73 year old Caucasian Male
Charles, 73 year old Caucasian Male
!  Presented for evaluation for a corneal transplant
!  Negative medical history
!  No systemic medications
!  History of cataract surgery both eyes
!  History of congenital ptosis left eye
!  Ocular medications
!  History of eyelid cancer right eye eyelid S/P excision
!  Restasis bid OU
!  Then chronic exposure keratitis and mechanical trauma
!  Pred forte qid OS
from the irregular eyelid
!  Ocuflox qid OS
!  Infections OD > OS
!  Bandage contact lens OD
!  Corneal scars OD > OS
OD
OD
OS
20/150
VA
(glasses)
20/25
48.49 / 39.20 /
103
Pentacam
Sim Ks
-2.25+3.25x070
20/100
Refraction
-0.25+0.75x075
20/25
15 mmHg
IOP
tonopen @
1:16pm
18 mmHg
45.92 / 43.77/
041
Upper eyelid
notching (S/P
excision), 1+
mgd
OS
L/L
1+ mgd
clear
Conj
clear
corneal scar
from 11:00 to
5:00 with
extension into
visual axis
Neovascularizati
on extending
into visual axis
Cornea
small inferior
nasal corneal
scar with
neovascularizati
on
small circular
temporal
corneal scar
Deep and Quiet
A/C
Deep and Quiet
PC IOL stable
Lens
PC IOL stable
0.30
C/D
0.30
Normal
Macula
Normal
Normal
Peripheral Retina
Normal
OD
OD
Initial Scleral
Lens Dispense
Initial Scleral
Lens Fitting
Parameters
Maxim
41.00D / plano /
16.5mm / 9.5mm
Sag 4.63
Fit
Excessive central and
peripheral clearance
Far peripheral
blanching
SOR
+2.25 20/40-2
Scleral Lens
Ordered
Maxim
41.00D / +2.25 /
16.5mm / 9.5mm
Sag 4.59 flatter PCs
Parameters
Maxim
41.00D / +2.25 /
16.5mm / 9.5mm
Sag 4.59 flatter PCs
VA
20/40-2
SOR
plano
Fit
Good central and
peripheral clearance
Nasal and temporal
peripheral blanching
13 1/14/16 OD
Initial Follow
Up
OD
Scleral Lens #2
Dispense
Vision
Good
Comfort
Good
Bright lights and sunlight not
bothersome
Uses lubricant ointment at
night
(no bandage lens at night)
VA
20/40-2
SOR
+0.50 20/30+2
Fit
Slightly excessive central
clearance
Nasal far peripheral blanching
Auto Ks over
lens
44.25/42.50/085
New Scleral
Lens Ordered
(#2)
Maxim
40.50D / +3.25 / 16.5mm /
9.5mm CT = 0.40
Sag 4.55 flatter PCs
Parameters
Maxim
40.50D / +3.25 /
16.5mm / 9.5mm CT =
0.40
Sag 4.55 flatter PCs
Vision
Good
Comfort
Good
VA
20/40+1
SOR
plano
Fit
Good central and
peripheral clearance
Nasal far peripheral
blanching
2 years later still wearing the scleral lens with success
Continues to use lubricant ointment at night
Old Train and retrain
application and
removal
Other Considerations
New Replace plunger
Old plunger may be
leaving residue on lens
surface
Training Challenges
!  Age
!  Living alone
!  Dexterity
!  Systemic health status
14 1/14/16 Training Challenges
Sea Green Lens Inserter
!  Dalsey Adaptives
!  Green LED light helps center the scleral lens for
insertion
!  Stand hold plungers and lenses securely prior to
insertion
Sea Green Lens Inserter
!  Helps for unsteady hands
!  Helps for those who need to hold lids open with
both hands
EZi Scleral Lens Applicator
O Ring
!  One finger lens insertion
!  #8
!  Lens self-positioning
!  3/8 inch x 9/16 inch x 3/32 inch wall
!  Less air entrapment
!  Available at any hardware store
!  http://ezibyqcase.com/
15 1/14/16 OD
Angel, 46 year old female
!  Status post radial keratotomy both eyes three times
!  Corrected to +5.00
!  Underwent hyperopic LASIK
!  Wore soft contact lenses from 2000 - 2006
OS
20/50
VA
(CLs)
20/50-2
40.66/35.83/173
Topography
34.35/33.58/160
-14.00 20/60
Poor endpoint
Refraction
-16.50 20/80
Poor endpoint
584
Pachymetry
567
15 mmHg
IOP
tonopen @
11:00am
14 mmHg
!  Then infection of incision of left eye
!  Treated for 4 months, healed
!  Now poor best corrected vision
OD
OS
1+ mgd
L/L
1+ mgd
White and quiet
Conj
White and quiet
16 RK scars
(irregular), no
visible LASIK
flap, iron lines
along RK
incisions, 2mm
optic zone
K
16 RK scars
(irregular), no
visible LASIK flap,
iron lines along RK
incisions, 2mm
optic zone, inferior
neovascularization
Deep and Quiet
A/C
Deep and Quiet
Clear
Lens
Clear
0.30
C/D
0.30
Normal
Macula
Normal
Normal
Peripheral
Retina
Normal
Scleral Lenses
!  Scleral lens parameters
!  OD Maxim / 7.11 / -17.75 / 15.4 / 8.0 / sag 4.63
20/25-2
!  OS Maxim / 7.14 / -17.00 / 15.4 / 8.0 / sag 4.62
20/20-2
Binocular 20/20-2
“My vision is amazing! I am now able to see everything. Thank you.”
16 1/14/16 Salzmann’s Nodular
Degeneration
Salzmann’s Nodular
Degeneration
!  Signs
!  Signs
!  Superficial elevated lesions
!  Confocal microscopy
!  Bluish-white
!  Peripheral cornea
!  Lesions composed of dense,
irregularly arranged collagen
tissue with hyalinization between
epithelium and Bowman’s layer
or beyond
Salzmann’s Nodular
Degeneration
!  Lesions are elongated basal epithelial cells and
activated keratocytes
!  Particularly in the anterior stroma near the nodules
!  Spectral domain OCT imaging
!  Fibrous intraepitheialial nodules with significant
overlying epithelial thinning
Salzmann’s Nodular
Degeneration
!  Symptoms
!  Rare condition
!  Irritation
!  Non-inflammatory
!  Dryness
!  Slowly progressive
!  Foreign body sensation
!  Degenerative condition
!  Decreased vision
!  More common in women
!  Average age of presentation is 59 years
Salzmann’s Nodular
Degeneration
Salzmann’s Nodular
Degeneration
!  Treatment
!  Surgical Treatment
!  Lubrication (more viscous eyedrops)
!  Manual removal
!  Topical corticosteroids
!  Phototherapeutic keratectomy (PTK)
!  Topical NSAIDs
!  Topical cycylosporine A for long-term management
!  With or without Mitomycin C
!  Mitomycin C prevents formation of corneal haze and /or
scarring.
!  Lamellar or penetrating keratoplasty
17 1/14/16 PTK
PTK
!  PTK treatment for anterior dystrophies
!  Large spot size laser is used – central ablation of 6.5-7.0mm
!  May blend out to 10mm of peripheral ablation
!  Clear anterior corneal opacities
!  Treatment is centered on the visual axis
!  Stabilize the corneal epithelium
!  Topical anesthetic instilled
!  PTK has been approved to treat the anterior one-
!  Either mechanical epithelial debridement or central, trans-
third of the cornea.
epithelial ablation can be performed
!  If the corneal surface is irregular, saline or methylcellulose
can be used in order to smooth out surface irregularities
prior to ablation
!  Ablation depth varies due to the type of treatment and
purpose of treatment
Supportive Literature
Denise, 41 year old Caucasian Female
!  Maharana PK, Sharma N, Das S, et al. Salzmann's Nodular Degeneration.
!  History of Salzmann’s nodular degeneration both eyes
!  Chiu GB, Bach D, Theophanous C. Prosthetic Replacement of the Ocular
!  History of soft and gas permeable contact lens wear
Ocular Surface 2015 Oct 10.
Surface Ecosystem (PROSE) scleral lens for Salzmann's nodular
degeneration. Saudi J Ophthalmol. 2014 Jul;28(3):203-6.
!  Has not worn contact lenses for 5 years
!  Das S, Link B, Seitz B. Salzmann's nodular degeneration of the cornea: a
!  Blurry vision for distance with glasses
!  Hamada S, Darrad K, McDonnell PJ. Salzmann's nodular corneal
!  History of dry eyes
review and case series. Cornea. 2005 Oct;24(7):772-7.
degeneration (SNCD): clinical findings, risk factors, prognosis and the role of
previous contact lens wear. Cont Lens Anterior Eye. 2011 Aug;34(4):173-8.
!  Linke S, Kugu C, Richard G, et al. An in vivo confocal microscopic analysis of
Salzmann's nodular degeneration: pre- and post-surgical intervention. Acta
Ophthalmol. 2009 Mar;87(2):233-4.
OD
!  Uses non-preserved artificial tears as needed
!  Uses fluorometholone 1% and ketorolac 0.5% daily in
both eyes
OS
OD
20/30-2
VA
(corrected)
20/40-2
1+ mgd
L/L
1+ mgd
-6.75+6.25x123
20/30-2
Refraction
-8.50+6.25x059
20/20-2
1+ diffuse
injection
Conj
clear
Corneal
Topography
Sim Ks
Scattered
elevated
Salzmann’s
nodules 12:00
to 4:00 and
7:00 to 12:00
Cornea
42.56 / 30.74 /
156
irregular
astigmatism
Elevated
Salzmann’s
nodules
peripherally
mid-peripheral
Iron line
No PEK
IOP
icare @
11:16am
17 mmHg
Deep and Quiet
A/C
Deep and Quiet
Clear
Lens
Clear
34.90 / 25.40 /
027
irregular
astigmatism
16 mmHg
OS
No PEK
C/D
Normal
Macula
Normal
Normal
Peripheral Retina
Normal
18 1/14/16 OD
OS
OD
Initial Scleral
Lenses
Jupiter
44.00D /
17.6mm /
9.0mm OZD /
-7.75
Parameters
Jupiter
44.25D /
18.2mm /
9.0mm / -6.50
20/20-2
VA
20/20+2
Good central
and peripheral
clearance
Lens cleared all
nodules
Fit
Good central
and peripheral
clearance
Lens cleared all
nodules
OD
OS
S/P superficial
keratectomy
2:00 and 7:00
32.20 / 42.20 /
130.1
High irregular
astigmatism
New Pentacam
(Oculus)
Sim Ks
27.1 / 46.1 /
48.2 High
irregular
astigmatism
OS
Scleral Lens
Refit
Zenlens Oblate
37.5D /
16.0mm /
9.0mm / -1.00D
Sag 4.700
Parameters
Zenlens Oblate
37.5D /
16.0mm /
9.0mm /
+0.50D Sag
4.700
20/20
VA
20/20+1
Near
J2
Good central
and peripheral
clearance
Lens cleared all
nodules
Fit
Good central
and peripheral
clearance
Lens cleared all
nodules
Denise
Intraocular Pressure After 2 Hours of
Small-Diameter Scleral Lens Wear
!  “Extreme improvement” with ocular dryness
!  Eye Contact Lens. 2015 Dec 1.
!  Eyes no longer sensitive to light
!  Intraocular Pressure After 2 Hours of Small-Diameter
Scleral Lens Wear.
!  Eyes no longer watery
!  Nau CB, Schornack MM, McLaren JW, Sit AJ
!  Good vision
!  Can scleral lenses elevate intraocular pressure due to
!  Lenses very comfortable
!  Stable for three years
compression of episcleral veins or deformation of tissue
in the Schlemm's canal beneath the landing zone of
scleral lenses?
19 1/14/16 Intraocular Pressure After 2 Hours of
Small-Diameter Scleral Lens Wear
Pneumatonometry
!  Pneumatonometer uses a pneumatic sensor
(consists of a piston floating on an air bearing)
!  29 patients
!  15mm diameter Jupiter scleral lens on one eye
(study eye)
!  IOP measured in both eyes by pneumatonometry
!  Filtered air is pumped into the piston and travels
through a 5 mm diameter fenestrated membrane at
one end
!  Membrane placed against the cornea
!  Balance between the flow of air from the machine
!  IOP measured central cornea
!  IOP measured peripherally on sclera
IOP After 2 Hours of SmallDiameter Scleral Lens Wear
!  Scleral lens worn for 2 hours
!  IOP remeasured
!  Immediately after lens placement
!  At 1 hour of lens wear
!  At 2 hours of lens wear
!  Immediately after lens removal
!  IOP after lens removal was compared (using paired t tests)
with
!  IOP before placing the lens
!  IOP in the control eye
and resistance to flow from the cornea affect the
movement of the piston.
!  Movement is used to calculate IOP
IOP After 2 Hours of SmallDiameter Scleral Lens Wear
!  Immediately after scleral lens removal
!  Mean central IOP in study eye no different from mean
central IOP in control eye (or in the same eye) before
lens wear
!  No differences in IOP measured peripherally at 2
hours of lens wear
!  Conclusion
!  Scleral lens wear of a 15mm scleral lens for 2 hours
does not increase IOP in healthy eyes
Thank You!
Please feel free to contact me with any questions
Melissa Barnett, OD, FAAO, FSLS
[email protected]
20