scl complications and their management - iran lens gostariranlensgostar.com/upload/scl complications...
TRANSCRIPT
![Page 1: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/1.jpg)
SCL & GP Complications and Their
Management
Prepared by: L. Jones PhD FCOptom DipCLP DipOrth FAAO (DipCL) FIACLE & L. Sorbara OD MSc FAAO (Dip C&CL)
Presented by: M. Steenbakkers OD FAAO
![Page 2: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/2.jpg)
Causes of CL Complications
Physical, lens fitting
CL BVP
CL dehydration
Deposits/wettability
Altered blinking
Hypoxia
Mechanical damage
Pre-existing systemic or ocular disease
Environmental factors
Chemical/toxic/allergic
Microbiological
Immunological
Non-compliance
![Page 3: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/3.jpg)
Causes of CL Complications
If CL Related-
Physiological
Mechanical
Toxic/Allergic
Hypoxia
Inflammatory
Microbial/Infectious
![Page 4: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/4.jpg)
Corneal Epithelial Staining
Dehydration
Toxic
Exposure
Mechanical
Hypoxia
![Page 5: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/5.jpg)
SMILE
Prevalence up to 25% of SCL wearing subjects have inferior corneal
staining (Guillon et al, 1990)
majority of severe staining is inferiorly positioned (Schwallie et al, 1997)
Etiology initial lens dehydration
depletion of the postlens tear film
subsequent staining through epithelial desiccation
greatest with
high water content lenses
thinner lenses
low humidity environments
incomplete blinking
![Page 6: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/6.jpg)
SMILE
Symptoms dryness
reduced wearing time
Signs coarse inferior punctate
staining in an arcuate fashion
extends from 4 to 8 o'clock in the lower 1/3 of the cornea
typically 4-5 mm in from the limbus
![Page 7: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/7.jpg)
SMILE
Management Minor
no treatment
Major
ocular lubricants
blinking exercises
locally placed humidifiers
switch to low water content lenses
thicker higher water content lenses
Prognosis variable
inter patient differences
![Page 8: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/8.jpg)
Corneal Epithelial Staining
Dehydration
Toxic
Exposure
Mechanical
Hypoxia
![Page 9: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/9.jpg)
Toxic/Allergic
Sensitivity to preservatives (CL-SLK)
Toxicity to traces of peroxide, high concentrations of preservatives (SPK or pseudodendrites)
Sensitivity to preservative plus bound deposit (CLAPC)
![Page 10: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/10.jpg)
Toxicity Staining Incidence
unknown; small percentage compared with THI & CHX-preserved care regimens
occurs with all preservatives (delayed)
occasionally with enzyme removers
acute with non-neutralized peroxide
Etiology toxic or hypersensitivity reaction to component in care
system
Symptoms occasionally asymptomatic
reduced wearing time
dryness with lenses
stinging on lens insertion
![Page 11: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/11.jpg)
Toxicity Staining
Signs
bulbar/limbal conjunctival hyperaemia
diffuse corneal SPK
palpebral hyperemia
![Page 12: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/12.jpg)
Solution Sensitivity Management
Discontinue lens wear temporarily
Change lens solutions
(especially the preservative)
![Page 13: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/13.jpg)
Lens Associated Superior Limbic
Kerato-Conjunctivitis: Signs
Typically bilateral
Superior bulbar and limbal hyperaemia
Apron of redundant folds of bulbar conjunctiva at superior limbus
Conjunctival chemosis
Infiltrates (grey)
Sub-epithelial haze
SCL wearer
![Page 14: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/14.jpg)
Lens Associated Superior Limbic
Kerato-Conjunctivitis: Signs
Corneal and conjunctival staining
fluorescein/Rose Bengal
Limbal hypertrophy
Palpebral response
papillae/redness
Signs remain well after cessation of wear
Differential diagnosis - SLK of Theodore
![Page 15: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/15.jpg)
CL-SLK
![Page 16: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/16.jpg)
CL-SLK
Management
Distinguish from SLK of Theodore
Discontinue lens wear
Monitor recovery
Lubrication
Change lens design/lens fit
![Page 17: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/17.jpg)
Management
Fit RGP lenses (probably the best option)
Use alternative solutions
Preservative–free
Alternate preservative
Steroid therapy
![Page 18: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/18.jpg)
97200 - 110 S.PPT
•
•
•
• Enlarged papillae
• Roughened appearance
(irregular specular reflection)
Palpebral redness
Tissue oedema
Precursor to CL-Associated
Papillary Conjunctivitis
SIGNS
CONTACT LENS PAPILLARY
CONJUNCTIVITIS
![Page 19: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/19.jpg)
CLAPC
![Page 20: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/20.jpg)
97200 - 112 S.PPT
•
-
-
-
• Lens front surface deposits
- mechanical irritation
- immune response
- drying of lens surface
AETIOLOGY
CONTACT LENS PAPILLARY CONJUNCTIVITIS
![Page 21: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/21.jpg)
97200 - 113 S.PPT
•
•
•
•
• Modify lens wear
• Change lens design
• Frequent lens replacement
• Optimize lens care and maintenance
MANAGEMENT
CONTACT LENS PAPILLARY CONJUNCTIVITIS
![Page 22: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/22.jpg)
97200 - 114 S.PPT
•
•
•
•
• RGP lenses
• Pharmacological therapy
• Patient education
• Complete resolution is unlikely
MANAGEMENT
CONTACT LENS PAPILLARY
CONJUNCTIVITIS
![Page 23: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/23.jpg)
Corneal Epithelial Staining
Dehydration
Toxic
Exposure
Mechanical
Hypoxia
![Page 24: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/24.jpg)
Mechanical or Physical Factors
Lens movement, fitting relationship i.e. exposure staining
Lens rigidity, i.e. SEAL
Physical condition of lens i.e. tears, scratches, deposits i.e. CLAPC
Blinking: completeness, lagophthalmos, lid tonus
![Page 25: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/25.jpg)
SEAL
Prevalence 8% of SCL wearers (Hine et al, 1987)
lower with current lens types ?
Etiology multifactorial
mechanical, hypoxia and dehydration all implicated
mechanical trauma from inflexible lens designs
misalignment between lens and ocular surface at limbus
pressure induced by the top lid produces staining
(Young & Mirejovsky, 1993)
![Page 26: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/26.jpg)
SEAL
A
B
![Page 27: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/27.jpg)
SEAL
Symptoms often none
occasionally FB sensation
occasionally mild irritation upon lens removal
Signs arcuate staining 1mm from the
superior limbus
between 10 o'clock and 2 o'clock.
staining runs parallel to the limbus
0.1- 0.3mm wide and 2-5mm in length
![Page 28: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/28.jpg)
SEAL
Management remove lenses and cease wear for 3-4 days
resolves in > 30% of cases
fit a different BOZR of the same design
fit a thinner, more flexible lens material
fit a lens with a thinner periphery
if problem persists refit with a rigid lens
problem with HDK lenses
![Page 29: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/29.jpg)
Corneal Epithelial Staining
Dehydration
Toxic
Exposure
Mechanical
Hypoxia
![Page 30: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/30.jpg)
Hypoxic Corneal Edema: Chronic
Responses Epithelial
Microcysts
Bullae (Bullous Keratopathy)
Edematous Corneal Formations (ECF)
Microcystic Edema
Stromal
Stromal Thinning
Neovascularisation
Endothelial
Polymegethism
Endothelial Bedewing
Guttatae
![Page 31: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/31.jpg)
Dk/t Required:
NO Edema
Daily Wear 20.0 (Sarver et al, 1981)
24.1 (Holden & Mertz, 1984)
Harvitt & Bonanno, 1999
basal epithelial cells: 23.0
entire corneal thickness: 35.0
Extended Wear 75.0 (O‟Neal et al, 1984)
87.0 (Holden & Mertz, 1984)
Harvitt & Bonanno, 1999
basal epithelial cells: 89.0
entire corneal thickness: 125.0
![Page 32: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/32.jpg)
Stromal Striae
Etiology hypoxia
accumulation of lactic acid in cornea
osmotic shift
fluid enters the cornea
occurs with > 5% corneal edema
number increases with increasing edema
Symptoms none
Signs fine vertically orientated lines in
the posterior stroma
![Page 33: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/33.jpg)
Management increase corneal oxygenation
Prognosis excellent
La Hood & Grant, 1990
Striae Folds
Number % Edema Number % Edema
1 5% 1 8%
5 8% 5 11%
10 11% 10 14%
Stromal Striae
![Page 34: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/34.jpg)
97200 - 72 S.PPT
•
•
•
• Intervention is warranted
• Increase lens Dk/t
• Reduce wearing time
MANAGEMENT
STROMAL STRIAE
![Page 35: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/35.jpg)
97200 - 57 S.PPT
•
-
-
-
•
• Minimize contact lens effects:
- maximize lens Dk/t (priority)
- optimize lens fit (less significant)
- fit siloxane hydrogels
• Decrease lens wear
MANAGEMENT
CORNEAL OEDEMA
t
![Page 36: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/36.jpg)
97200 - 78 S.PPT
•
•
•
•
• Intervention is mandatory
• Significant increase in lens Dk/t t needed
• Very short wearing time
• Refit with siloxane hydrogels, or high -
Dk
RGP lenses
MANAGEMENT
ENDOTHELIAL FOLDS
![Page 37: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/37.jpg)
Limbal Hyperemia
Prevalence 20-50% clinically significant (Pritchard et al, 1996)
very common in all lens types
greatest with SCL
100 % to some degree ?
Etiology hypoxia
hyperemia related to Dk/t (Papas et al, 1995)
mechanical irritation
tight lens
![Page 38: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/38.jpg)
Limbal Hyperemia
Signs engorgement of limbal blood vessels
linked to vascularisation ?
Management optimise lens fit
reduce wear time
increase lens transmissibility
new high Dk SCL materials
![Page 39: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/39.jpg)
Limbal Hyperemia
0
10
20
30
40
50
Base 1 M 2 M 3 M 4 M 5 M 6 M 7 M 8 M 9 M
Me
an
Lim
ba
l H
yp
ere
mia
Time (months)
p=0.000
LDK
HDK
Dumbleton et al, 1998
![Page 40: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/40.jpg)
Endothelial Blebs
Prevalence 100% of neophyte wearers
not in silicone lenses
reduced in adapted wearers
Etiology Endothelial cell edema
acidic pH shift (stromal acidosis) increase in carbonic acid (hypercapnia)
increase in lactic acid (hypoxia)
Bulging of endothelial cells produces an optically empty area
Bonnano & Polse, 1987
![Page 41: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/41.jpg)
‘blebbed’ cell endothelium
stroma
![Page 42: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/42.jpg)
Endothelial Blebs
Symptoms None
Signs Black, non-reflecting
areas within the endothelium
Appear as holes
within 10 mins of insertion
peak after 20-30 mins
subside after 2-3 hours
Zantos & Holden, 1977
![Page 43: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/43.jpg)
97200 - 85 S.PPT
•
•
-
-
• Clinical significance is unclear
• Higher lens Dk/t minimizes:
- the number of blebs
- the magnitude of the response
MANAGEMENT
ENDOTHELIAL BLEBS
![Page 44: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/44.jpg)
unreversed
effect
reversed
effect
converging refractor
(high RI; microcyst)
diverging refractor
(low RI; fluid vacuole)
stroma epithelium
Zantos, 1983
![Page 45: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/45.jpg)
Compromised Epithelium
Anoxia Suboptimal metabolism
Slowed mitosis
Microcysts 15 - 50 m inclusions in the epithelium
sign of chronic hypoxia
appear as scattered dots
take 2-3 months to occur
4-6 months to peak
Vacuoles fluid-filled bubbles
![Page 46: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/46.jpg)
stroma
intra-epithelial sheet
microcysts
microcyst breaking through surface (stains with fluorescein)
growth
epithelium
Zantos, 1981
![Page 47: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/47.jpg)
Microcysts
Marginal retro
illumination
![Page 48: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/48.jpg)
Microcysts
![Page 49: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/49.jpg)
97200 - 280 S.PPT
EPITHELIAL MICROCYSTS AETIOLOGY: EFFECT OF Dk/ t AETIOLOGY: EFFECT OF Dk/ t
Pre - Lens 1M 3M 6M 9M 12M 1Wk 1N
60
50
40
30
20
10
0
Extended wear
Mic
roc
ys
ts
(Mean
)
High Dk/ t
Low Dk/ t
Keay et al., 2000
![Page 50: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/50.jpg)
97200 - 65 S.PPT
•
-
•
•
-
-
•
•
• Careful monitoring - occur in non- lens wearers as well
• If < 10, no action is needed
• Increasing number warrants intervention
- increase lens DK/t t - reduce wearing time
• Rebound effect after lens discontinuation
• Lengthy time to resolve
MANAGEMENT
EPITHELIAL MICROCYSTS
![Page 51: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/51.jpg)
97200-278S.PPT
EPITHELIAL MICROCYSTSAETIOLOGY: ‘REBOUND’
EPITHELIAL MICROCYSTSAETIOLOGY: ‘REBOUND’
Pre-Lens
0
20
40
60
80
100
120
1M 3M 6M 9M 12M 1Wk 1M 3M
Extended wear
Mic
roc
ys
tsLow Dk/t lens (6N EW) High Dk/t lens (30N EW)R
eb
ou
nd
Ch
an
ge
Keay et al., 2000
![Page 52: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/52.jpg)
Microcysts
Management < 30 microcysts
no action required
monitor carefully
> 30 microcysts
cease lens wear (1 month)
change from EW to DW
refit with HDK lenses
Prognosis initial increase in number
slow decrease thereafter
disappear after 3 months (Holden et al, 1985)
![Page 53: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/53.jpg)
Vascularisation
Prevalence 11% of all wearers (Keech et al, 1996)
< 1% of RGP (Levy, 1985)
< 5% of DW SCL (Poggio & Abelsen, 1993)
< 15% of EW SCL (Spoor et al, 1984)
Etiology hypoxia produces stromal edema and softening
vasostimulating agent produces vessel growth
epithelial damage
solution toxicity
infection
![Page 54: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/54.jpg)
Vascularisation
Symptoms none
Signs new vessels in the cornea
superficial
deep stromal (very rare)
![Page 55: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/55.jpg)
Vascularisation
Management If „mild‟
increase lens transmissibility
reduce wearing time
monitor carefully
If „severe‟
refit with high Dk RGP
cease wear permanently
refit with high Dk SCL ?
![Page 56: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/56.jpg)
Vascularisation
0
0.2
0.4
0.6
0.8
1
Base 1 M 2 M 3 M 4 M 5 M 6 M 7 M 8 M 9 M
Me
an
Gra
de
of
Ne
ova
scu
lari
za
tio
n
Time (months)
LDK
HDK
Dumbleton et al, 1998
![Page 57: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/57.jpg)
Vascularisation
Prognosis
vessels empty rapidly
ghost vessels remain (years?)
ghost vessel can refill
![Page 58: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/58.jpg)
97200 - 97 S.PPT
•
•
•
•
•
• Change lens solutions
• Patient education and follow-up
• Optimize fitting characteristics
• Decrease wearing time
• Refit with silicone hydrogel or
RGP lenses
MANAGEMENT
CORNEAL VASCULARIZATION
![Page 59: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/59.jpg)
Polymegethism
Prevalence natural process of ageing
CL accelerate the process
greatest with low Dk lenses (Schoessler, 1983; Schoessler et al, 1984)
Etiology chronic hypoxia produces tissue-acidosis (Bonanno
& Polse, 1987)
acidic shift at endothelium
hypoxia: lactic acid
hypercapnia: carbonic acid
cell fluid balance disturbed
possible structural damage
![Page 60: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/60.jpg)
Polymegethism
Symptoms usually none
may result in "corneal exhaustion syndrome”? (Sweeney, 1992)
Signs ratio of smallest:largest
endothelial cells increases
from 1:5 to 1:20
endothelium includes cells of significantly differing sizes
![Page 61: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/61.jpg)
Polymegethism
Management not reversible
if suggestive of long-term hypoxia alleviate tissue acidosis
refit with high transmissibility lenses
Prognosis poor
very slow recovery (if any)
![Page 62: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/62.jpg)
97200 - 82 S.PPT
•
-
•
•
•
• Preventative strategy
- high Dk/t lenses
• Careful assessment with slit lamp
• Increase lens oxygen transmissibility
• Minimal recovery expected
MANAGEMENT
ENDOTHELIAL POLYMEGETHISM
![Page 63: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/63.jpg)
Inflammatory Responses
AI (asymptomatic infiltrates) Single, anywhere, in anterior stroma, no staining or
anterior chamber reaction or redness
IK (infiltrative keratitis) Peripheral, multiple, slight staining and redness, no
anterior chamber reaction, can be bilateral
AIK (asymptomatic infiltrative keratitis) Peripheral, small, focal, punctate staining, mild to
moderate redness, no anterior chamber reaction, can be bilateral
![Page 64: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/64.jpg)
Inflammation
Toxic, CL-SLK
Allergic, SEI
Sensitivity to Gm –ve endotoxins, CLARE
Sensitivity to Staph (+ve) exotoxins, CLPU
Mechanical stimulus: CL-denatured protein (CLAPC) or adherence of micro-organisms as PA or SA, SEAL?
![Page 65: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/65.jpg)
Inflammation
Inflammation vs Infection ?
clinical diagnosis
![Page 66: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/66.jpg)
“Presumed” Sterile
inflammatory response
peripheral / mid-peripheral lesions
lesions 1-2 mm
circular appearance
mild pain
epithelium - intact or staining
mild epiphora
mild to moderate injection
confined to anterior stroma only
mild (if any) corneal suppuration
minimal AC reaction
Stapleton et al, 1993
Grant et al, 1998
![Page 67: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/67.jpg)
“Presumed” Microbial
infective process
paracentral / central lesions
lesions > 1mm
irregular appearance
pain increasing; may be severe
epithelial defect
intense epiphora
moderate to severe injection
anterior to mid-stromal
severe, progressive corneal suppuration
ac flare and occasional hypopyon Stapleton et al, 1993
Grant et al, 1998
![Page 68: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/68.jpg)
Sterile Infiltrates
Prevalence 1% of non-lens wearers (Sweeney et al, 1996)
higher risk in smokers
2-10% of lens wearers (Gorden & Kracher, 1985; Cutter et al, 1996)
higher with SCL, particularly EW SCL (Josephson & Caffery, 1979; Vajdic et al, 1995: Cutter et al, 1996)
Etiology inflammatory cells migrate from limbal vessels
PMN
inflammatory response to numerous factors
bacteria; closed-eye environment; tight lens
hypoxia; lens deposits; care systems
![Page 69: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/69.jpg)
Sterile Infiltrates
Signs
circular areas of haziness
normally in the limbal area
focal or diffuse
conjunctival hyperemia
![Page 70: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/70.jpg)
Appearance
![Page 71: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/71.jpg)
Infiltrative Keratitis
Symptomatic or asymptomatic
DW, EW & no wear
With or without epithelial staining
Predilection for 4 and 8 o‟clock position
Staph exotoxins ?
![Page 72: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/72.jpg)
97200 - 297 S.PPT
CORNEAL INFILTRATES: SUMMARY
Anterior Stromal Infiltrate
Peripheral/mid - peripheral
Mild - moderate diffuse
infiltration and/or small, focal
infiltrate, several possible
Peripheral
Small, focal
Several, and/or mild to
moderate diffuse infiltration
Peripheral/anywhere
Very small, focal
Single and/or diffuse infiltration
IK
AIK
AI
Neutrophil
(PMN) Lymphocyte
Macrophage
![Page 73: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/73.jpg)
Contact Lens
Associated Red Eye (CLARE)
EW only
Moderately painful eye
Significant generalised hyperaemia & epiphora
typically at night
Multiple limbal infiltrates
no staining
Rapid resolution
Associated with gram –ve bacteria
Holden et al, 1996
Sankaridurg et al, 1996
![Page 74: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/74.jpg)
97200 - 144 S.PPT
•
•
-
-
•
•
• Temporary discontinuation of wear
• Palliative therapy
- saline rinse (sterile)
- lubrication
• Regular lens replacement
• Low toxicity lens care products
MANAGEMENT CLARE CLARE
![Page 75: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/75.jpg)
97200 - 145 S.PPT
• -
-
•
•
-
-
-
•
• Monitor recovery - complete resolution of infiltrates - about 1 - 3 weeks
• Re-start with DW initially
• Caution with continued EW
- optimize fitting - change lens type - change lens care products
• Monitor for recurrence
MANAGEMENT
CLARE
![Page 76: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/76.jpg)
Contact Lens Peripheral Ulcer
(CLPU)
SCL EW only
Focal, circumscribed, round infiltrate
0.1 - 1.5mm diameter
Full thickness loss of epithelium, but Bowmans is intact
epithelial staining
leaves scar
Predilection for under the lid
Due to toxins from staph or other gram +ve colonising lens ?
Willcox et al, 1995
Holden et al, 1999
![Page 77: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/77.jpg)
CLPU
![Page 78: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/78.jpg)
97200 - 149 S.PPT
•
•
•
•
•
• Discontinue lens wear immediately
• Generally, healing is rapid
• Monitor carefully for first 24 hrs
• Prophylaxis
• Resolves with scarring
MANAGEMENT CONTACT LENS PERIPHERAL ULCER
![Page 79: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/79.jpg)
Inflammation - Management
Clear wearer instruction
Eliminate possibility of infection
Remove lens
Refer if necessary/unsure
Treatment
change to DW
lid hygiene measures
avoid wearing EWSCL when unwell
![Page 80: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/80.jpg)
Accompanying staining requires intervention
•lens wear discontinuation
•monitoring
•antibiotic prophylaxis ?
Resolution (clear cornea) necessary before
lens wear continued
MANAGEMENT CORNEAL INFILTRATES
![Page 81: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/81.jpg)
Risk of recurrence
Need to reduce risk
•isolate cause
•change lenses, solutions, care routine
•change wear schedule
•patient re-education
Refit with daily disposables, siloxane hydrogels, or GPs
Use preservative free products
MANAGEMENT CORNEAL INFILTRATES
![Page 82: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/82.jpg)
Microbial/Infectious
Bacterial Ulcers
Fungal Ulcers
Protozoan Ulcers
Viral Infections
Microbial Keratitis
![Page 83: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/83.jpg)
Signs & Symptoms Can Be
Assessed Using:
Biomicroscope
Keratometer/Videokeratoscope
Retinoscope/Refraction
Case History
![Page 84: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/84.jpg)
Keratometry
Clinical Signs:
Lens Flexure (RGP)
Lens Warpage (RGP)
Corneal Distortion (SCL) Related to edema
Thick lenses
Rigidity of materials
![Page 85: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/85.jpg)
Retinoscopy
Clinical Signs:
Poor Optics
Poor Surface Wettability
Power Change
Lens Deposits
Uncorrected Astigmatism
Toric Lens Rotation
BV? Early presbyopia?
Reproducibility, accuracy?
![Page 86: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/86.jpg)
Case History
Symptoms:
CL- Induced Dry Eye
Discomfort Lens Related
Eye Related
Solution Related
Irritation
![Page 87: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/87.jpg)
GP Fitting Complications
![Page 88: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/88.jpg)
“3&9” Staining
Prevalence
50-80% of daily wear RGP lens wearers (Lowther, 1982; Barr, 1985)
10% clinically significant (Ghormley et al, 1990)
![Page 89: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/89.jpg)
“3&9” Staining
Aetiology
Drying of the peripheral cornea in association with an unstable tear film
Causes are multifactorial
poor peripheral lens fit
inadequate blinking
poor lens wettability
abnormal tear composition
![Page 90: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/90.jpg)
“3&9” Staining
Symptoms
Dry, gritty, irritable eyes and reduced wearing
time
Signs
Conjunctival hyperaemia along the horizontal meridian in conjunction with epithelial punctate staining at the four and eight o'clock positions
Extreme cases may develop a pseudopterygium, vascularised limbal keratitis or dellen
![Page 91: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/91.jpg)
“3&9” Staining Management
If insignificant corneal astigmatism exists
increase the diameter, reduce the edge clearance, reduce the thickness profile and reduce the edge thickness
If significant corneal astigmatism exists
fit a fully back surface toric with a large overall diameter and minimal edge clearance
All cases may benefit from blinking exercises and artificial lubricants
In severe cases the final resort may be to refit with a soft lens
![Page 92: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/92.jpg)
RGP Lens Binding
Prevalence
more prevalent in RGP EW
50% on eye opening (Swarbrick & Holden, 1989)
as high as 80% (Zabkiewicz et al, 1987; Lin et al, 1989)
can occur with DW RGP
![Page 93: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/93.jpg)
RGP Lens Binding
Etiology 1 proposed patient related factors
corneal astigmatism; eyelid pressure; corneal thickness;
ocular rigidity; peripheral topography; tear film characteristics
2 proposed lens related factors
lens diameter ; peripheral curve design; specific gravity
edge clearance; flexibility; lens thickness
most likely (Swarbrick, 1988)
lens is pushed down onto the cornea at night by the upper lid
post lens tear film is eliminated
highly viscous mucous layer acts as an adhesive
lens is literally "glued" to the cornea
![Page 94: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/94.jpg)
RGP Lens Binding
Symptoms none
possible complaints re lens removal (difficult)
occasional spectacle blur following removal
Signs immobile, decentred lens
indentation ring remains when the lens is removed
No lens in place !!
![Page 95: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/95.jpg)
![Page 96: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/96.jpg)
RGP Lens Binding
Management increase lens movement
smaller
increased edge clearance
flatter or steeper BOZR ?
change to daily wear RGP's
change to FRP RGP‟s (Woods & Efron, 1996)
refit with soft lenses
Prognosis variable
inter-patient differences
![Page 97: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/97.jpg)
High Riding RGP
![Page 98: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/98.jpg)
High Riding Lenses
Patient factors
tight lids
displaced corneal apex
high WRT corneal cyl
Lens factors
centrally too flat
too large
too much axial edge clearance
too thick mid-periphery
could be due to being high minus lens
![Page 99: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/99.jpg)
High Riding Lenses
Patient factors tight lids
refit with smaller/bigger lens
refit with SCL
displaced corneal apex refit with bigger RGP
refit with SCL
high WRT corneal cyl refit with smaller spherical RGP
refit with bigger BS toric RGP
![Page 100: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/100.jpg)
High Riding Lenses
Lens factors centrally too flat
Steepen BOZR
too large refit with smaller diameter RGP
too much axial edge clearance reduce AEL of lens
too thick mid-periphery lenticulate to reduce thickness profile
reduce centre thickness ?
![Page 101: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/101.jpg)
Dimple Veil
Prevalence unknown
predominantly rigid lens wearers
very rarely SCL wearers
Etiology not “true” staining
trapped air bubbles
poor fitting relationship between cornea and lens
usually observed in
steep central fitting lenses
high riding lenses in cases of high WTR astigmatism
![Page 102: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/102.jpg)
Dimple Veil
Symptoms
none
Signs
small indentations in the corneal epithelium
appearance similar to the surface of a golf ball
![Page 103: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/103.jpg)
![Page 104: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/104.jpg)
Dimple Veil
Management fit a flatter BOZR
reduce the edge clearance
reduce the overall size
control the thickness profile
to reduce the high riding position
change to a toric back surface lens
with a highly astigmatic cornea
Prognosis excellent
![Page 105: SCL Complications and Their Management - Iran Lens Gostariranlensgostar.com/upload/SCL Complications and Their Management.pdf · SCL & GP Complications and Their Management Prepared](https://reader030.vdocuments.net/reader030/viewer/2022021723/5c97e56209d3f2720a8d107f/html5/thumbnails/105.jpg)
The End!