ADVANCED CLINICAL APPLICATIONS AND TROUBLESHOOTING IN SCLERAL LENSES Langis Michaud, OD Jason Jedlicka, OD Disclosures Langis Honorarium and research grants Alcon Cooper Allergan Bausch*Lomb Johnson * Johnson Blanchard Labs Shire Santen Jason Consultant to Bausch and Lomb SVP Honorarium: Oculus Allergan Advanced Applications and Troubleshooting Front surface wetting Fogging / Debris in the Tear Reservoir Dealing with conjunctival landmarks Conjunctival prolapse 1
FRONT SURFACE WETTING ISSUES Managing Scleral Lens Surface Issues Impact is mainly on vision, not comfort Anterior surface deposits Causes Anterior segment pathological conditions Blepharitis Rosacea Atopic condition Poor tear film chemistry Especially in severe eye dryness Oily substances Mascara, make-up, soap Lens material reduced wettability Photo: L.Michaud Drying of the lens surface ultimately allows deposits to form Photo: M.Lipson 2
1. Treat ocular surface issues Lid hygiene Omega 3s Medication 2. Stabilize tear film Dry eye management Lubrication Medication Management Managing Scleral Lens Surface Issues Monitor for changes to the Lid Wiper Management 3. Select material with low wetting angle Plasma treated lenses Hydra Peg as an option 4. Customize care regimen Alcohol based cleaner Hydrogen Peroxide Enzyme treatment including Progent Pre and post Hydra Peg Sindt, C. Rev. Contact Lenses 04/2015 3
Hydra Peg Is a 90% water surface polymer that creates a mucinlike hydrophilic surface to the contact lens Active ingredient: polyethylene glycol (PEG) Caroline P. GSLS poster. 2016 Management 5. Patient education Ask patients about hand soaps, lotions, makeup and eye creams. Change hand soap to either contact lens hand soap or acne treatment hand soap without lotion additives. Apply makeup, facial moisturizers after lenses are applied. 6. On eye management Moisten a cotton swab or removal plunger with solution and clean the surface on-eye. Managing Scleral Lens Surface Issues How does putting a liquid reservoir over the corneal surface impact the feedback mechanism to the brain that governs basal tear production? After 15 minutes in a scleral lens 4
Managing Scleral Lens Surface Issues Remember that wearing a scleral lens increases the surface area of the ocular surface that is exposed by increasing the palpebral aperture Puts increased demand on the tear layer Managing Scleral Lens Surface Issues Using a drop of lubricant on a lens tool or a cotton tip applicator and rubbing the lens surface while on eye can also help when removing the lens is not practical Adding conditioner to the lens applicator at the time of insertion may also help with initial non-wetting issues FOGGING / DEBRIS IN THE TEAR RESERVOIR 5
Fogging / Debris Debris is a common problem that can impact vision Usually takes a few hours to get bothersome for most patients Can be seen at slit lamp at follow up Left lens no complaints Symptomoatic fogging / debris 6
What is it? Maria Walker, OD, published findings in October 2014 of 5 subjects with post lens tear fogging vs. 4 subject without post lens tear fogging Proteins and mucins were the same in each group Lipids were significantly elevated in the post lens tear reservoir in 4 of the 5 subjects with fogging Pacific Uni ersit Where is it coming from? 7
After 2 minutes After 4 Minutes no manipulation After 4 minutes 8
Debris Debris will follow path of tear exchange / fluorescein when applied Most commonly channels under the lens superior / temporal, but can come from anywhere there is a loose fitting relationship Can be improved by steepening the landing zone in the meridian that the debris is migrating in from Debris Manage with notch, microvault, or EyePrint Pro 9
Tight Lens Related Fogging?? Or is it just tight in one meridian and loose in the other? How do we get rid of it? Optimize lens fit to eliminate lens movement and tear exchange Use of toricity in the landing zone of scleral lenses what % of your fits are in toric haptics? Increasing lens toricity eliminates / Significantly reduces fogging 10
DEALING WITH CONJUNCTIVAL LANDMARKS Conjunctival Landmarks Some patients have abnormal conjunctival or scleral issues such as pinguecula or blebs Conjunctival Landmarks These can be dealt with several ways: Go smaller if feasible Go larger is shallow enough and close enough to the limbus Notch the lens Microvault EyePrint 11
Lens Notches Notch Size Needs to be wide enough to not constrict obstacle Form semi-sealed fit with no movement Too deep or wide of a notch can cause bubbles Better with smaller diameter lenses Watch IOP in blebs carefully Lens Notches When Ordering Measure depth and width Pictures always help lab Consider keeping a notched trial in office Conjunctival Landmarks 12
MicroVaults Microvault measurements Microvault needs to be roughly 5 degrees inferior to the horizontal meridian or at axis 175 Microvault: 3.0 mm wide Located at axis 175 Peak at lens edge 250 microns max elevation 13
Lens with Microvault CONJUNCTIVAL PROLAPSE Conjunctival Prolapse 14
Why Prolapse? Conjunctival Prolapse Benign? Managing Prolapse? Many claim there is no reason to try to resolve it Conjunctiva can become adhered to limbus over time and create vascularization Reduce limbal clearance if possible, move to toric / quadrant specific design if and when available, or monitor 15
Lens selection To avoid troubles.. + Determining Lens Diameter Factors to Consider HVID corneal diameter Ocular health Type of cornea/ocular surface Endothelial cell layer status Potential troubleshooting issues Handling Risk/benefits ratio + + 16
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+ Customized scleral lenses + Oblate scleral lenses Goal: To reduce central clearance when found excessive Clinical applications: oblate corneas Post Lasik /RK Post-graft Design: central curve is made flatter while the fit over the limbus and at the edge remains the same Flatter central curve generates less negative power + 17
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New clinical applications To lower minus power of scleral lenses Prolate Corneas Keratoconus Irregular corneas To reduce induced lens HOA and spherical aberrations of the eye To improve presbyopic correction Reduced minification Effective more add power Seeing through a -25D + Eye Print Pro + 18