scleral lens essentials - hoaecc.org

Scleral Lens EssentialsDisclosures:

AlconBausch + LombContamacCooperVisionJohnson & JohnsonSpecialEyesValley Contax

Matthew J. Lampa, OD, FAAOlampa@pacificu.edu

Scleral Lenses

WhichLens

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 DisplayPower Map

Elevation MapHeight 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

Highest

Lowest

-227 um

+248 um

475microns

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.

N = 87 Patients127 CL Fits

-276um

+379um

+379- 276655

MicronHeight Differential

Patient CB Right Eye

Elevation Map

Patient VY Post Hydrops

Elevation Map

-260um

+430um-200um

Elevation: +430

Depression: -260

Differential = 690um

KeratometryPhotokeratoscopy

Videokeratography

Composite Corneal Topography

3.0 mm 8.0 mm 10.0 mm12.0 mm

Instrument Evolution

KeratometryPhotokeratoscopy

Videokeratography

Composite Corneal Topography

3.0 mm 8.0 mm 10.0 mm12.0 mm

Eaglet

20.0 mm

sMap 3D

22.0 mm

OCT

16.0 mm

Possible Scleral Lens IndicationsIrregular 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 20/4006 months

Post Scleral Lens 20/25

The Re-Birth of Scleral LensesHigh DK (100 DK+)GP lens materialsComputer 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 XO2 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 ShapeNew 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 mm20.0 mm

Tina Graff, Eef van der Worp, Patrick Caroline, Randy Kojima, Mark Andre

Average Angle from 15 to 20mm

T N

Cone Angle Circa 1948Klaus 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. Scleral LandingZone

12 34 23 4

Anatomy of a Scleral Lens

Scleral LensFitting 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 Zone300 to 400 microns of Apical Clearance

Apical Clearance at Dispensing250 microns

Apical Clearance Post 8 Hours150 microns

Tear Lens300 microns

CL Thickness0.35 mm

350 microns

Scleral Lens Setteling

Apical Clearance at Dispensing 410 um

Apical Clearance at 30 Days 270 um140 um of Lens Settling

AB 130 um Left ChangeEye 8 hours

Baseline400 um

8 Hours270 um (130 um)

30 mts.

1 hr.340 um (60 um)

2 hr.

4 hr.

6 hr.

Estimating Tear Film Thickness

Scleral Lens Corneal Settling11 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 8hours (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

SCLSCL

-3.50 DS

Excessive Apical

Clearance

OK?Not OK?

300 um 600um

Zone #2, Peripheral Corneal Clearance Zone (PCCZ)

Peripheral Cornea and

Limbal Clearance

PCCZ Bearing

AdequateClearance

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

StandardLimbal 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 salineand sodium fluorescein

Lens ApplicationThe 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