FOUR ACES IN YOUR HAND: HOW CAN YOU LOSE?

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Feb 22, 2017 - Scleral Lens Education Society (Board member, T). PROS & CONS- RGP. PROS. ▻ Optics. ▻ Handling. ▻ Cost. ▻ Easy to fit. CONS. ▻ They ...
2017‐02‐22

FOUR ACES IN YOUR HAND: HOW CAN YOU LOSE? Dr Langis Michaud OD FAAO FSLS FBCLA Professor



Honorarium received as a speaker (S) or a consultant (C), as a research fund (R) or travel grant (T)from the following organizations



Allergan (S,C)



Alcon



Bausch & Lomb (S,C,T)



Cooper Vision (S)



Johnson & Johnson Vision Care (R,T)



Blanchard Labs (S,C,R,T)



Sanofi (S,R,T)



Synergeyes (S,T)



Scleral Lens Education Society (Board member, T)

(S,R)

DISCLOSURE

PROS

CONS



Optics



They HURT



Handling



THEY HURT

Cost





THEY HURT



Easy to fit

Except overnight





THEY HURT



THEY HURT



Must be worn with piggy back



THEY HURT



You can lose them in a blink

PROS &

CONS- RGP

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PROS 

CONS

Comfortable – THEY DO NOT HURT



Fully customizable



Easy to handle



Wide variety of parameters

PROS &



Cost



Not so predictable



Oxygen delivery



Limited applications



May be cumbersome (10 peripheries)

CONS – CUSTOM SOFT

Piggy backs Initial comfort Visual acuity

SCLERALS √

Long term comfort

√ RGP can decenter

Stable, better v.a.

Clinical application

Fewer

Fully customizable

Fitting /Learning curve

Easier

Longer

Cumbersome

Lenses < 15 mm are preferable

Handling Designs (toric)

Front

Front

Designs (MF)

N/A

Better outcome

Higher /less

Lower / More

Cost /convenience

SCLERALS VS PIGGY BACKS

SMALL RGPs Initial comfort



Long term comfort Visual acuity Corneal astigmatism (spherical lens)

SCLERALS √

=

=

Up to 3 D 3-9 o’clock stg ?

Up to 3.5 D No corneal stg

Fitting /Learning curve

Easier

Longer

Handling

Easier

Lenses < 15 mm are preferable

Designs (toric) Designs (MF)

Front/ bi-toric

Front

Corneal warpage

Lens is stable Better outcome for high ametropia

SCLERALS VS SMALL RGPS

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2017‐02‐22



KC , 26 y.o. PhD student 

Former RGP wearer



Underwent CXL 

Referred to be fitted in CL



No lens wear x 12 wks



Rx OD -6.75 -3.25 x 35 20/40

OS -4.50 -4.50 x 115 20/30



Complaints: poor vision at all distances



Assessment 

Moderate KC 

Steepest K : 49.00 D



Corneal thinnest point: 475 um



Striae and Vogt’s

CR 1



KERATOCONUS REFRACTION



CROSS-LINKING INDICATIONS

CLINICAL PEARLS



RGP lenses 

KC design



Fitted according to manufacturer’s recommendation 



2D steeper than average than K

Outcome 

Lenses well centred, expected fluo pattern



VA 20/25 OD 20 /25 OS 20/20 OU



Issues with inferior edge lift



Resolved with quadrant specific pc and piggy back

TRIAL 1

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Not able to wear more than a few hours /day. 

Does not want to sustain lens wear



Hates to wear 2 types of lenses



Once worn: exceptional visual acuity, stable



Options post CXL 

Sclerals:



Glasses: reduced VA



Custom Soft Lens : ??



does not want to handle

DISCOMFORT, OTHER OPTIONS



Custom soft lens



Quadrant specific adjustment



Parameters 

BC 8.6 / 14.5



Peripheries A1-2/ 30-215 standard A3-4 /260-315 steep 2



Pwer OD -6.00 -2.75 x 45 (WTR rotation) OS -4.00 -4.00 x 120 (5 deg)



VA OD 20/25 OS 20/20-2 OU 20/20



Patient relatively comfortable (feels lens movement) and happy



At Follow-up, reported good comfort and VA – No issues with ocular health over time





Limited wearing time – provided with glasses

TRIAL 2 – F/U



Keratoconus vs normo-tensive glaucoma



Keratoconus vs sleep apnea

CLINICAL PEARLS

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Corneal diameter is #1 factor to fit soft lenses



20% of the patients are showing > or < cornea



We need custom soft lenses….. If possible disposable!



However 

Not a go-to-lens for a majority of patients (variable rate of success)



Once used 

Fitted flatter than soft lenses (tear exchange)



Do not lose time if 2nd trial is not conclusive (toric especially)

CLINICAL APPLICATIONS: SOFT CUSTOM LENSES



Corneal hypoxia



Epithelial fragility post cross linking



Compliance





Lens replacement rate



Extended lens wear / Extended-wear

Long-term comfort 

Thick lens, deposits, etc.

POTENTIAL OCCURENCE



Cold chemical with rub and rinse step



Hydrogene Peroxide 

KC vs atopy

CARE REGIMEN

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2017‐02‐22

 Y.L.,

46 Y/O, Asian contact lens wearer

 Visual

needs



Computer and near work mostly (> 10Hr / day)



High myopia and astigmatism



Complaints about near + intermediate visual acuity

 Refraction 

OD -7.00 -1.00 x 20

20/20



OS -7.50 -1.00 x 160

20/20



Add +1.25

CASE NO. 2



Tried soft lens MF 



Did not see well at all distances

Tried monovision 

Not able to adapt, especially during computer work



Fitted with 2-weeks SiHy disposable lenses 

Needs UV protection – outdoor activities



CLD – episodic



Unstable VA : windy conditions

CASE HISTORY

 Slit

lamp



(-) Blepharitis or MGD



(-) Cornea SPK



(+) Conjunctival hyperemia,1+



TBUT 9 sec OU



Tear meniscus = 0.15 mm (Oculus keratograph)



Pupil size: 5.5 mm

 DES

Syndrome – Reduced aqueous production (or Mixed)



Near tasks reduces blink rate (Computer / Smartphone / Near)



Environmental conditions (air conditionning, rugs, dust, etc)



(-) Allergies or Systemic contributors (medication, topical drugs, health issues )

CASE NO. 2 – FACTORS IN PLAY

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2017‐02‐22



Treat and manage episodic eye dryness



Address refractive issues 

Astigmatism and presbyopia



Needs a toric design if astig >0.75D

MANAGEMENT

DIAGNOSIS OF DED Rule Out

Evaluate Symptoms Tear quality Tear volume Anterior segment

Acuity SLE with attention to MGD TBUT Tissue integrity

Medicamentosa Blepharitis Conditions that mimic DED

Primarily Aqueous Deficient DED

Primarily Evaporative DED Follow-up Appointment • • • •

Systemic disease (incl. allergy)

Follow-up Appointment • • • • •

Acuity Tear volume SLE TBUT Tissue integrity

MGD = meibomiam gland dysfunction; SLE = slit lamp examination; TBUT = tear break-up time

Screening, Diagnosis and Management of Dry Eye Disease: Practical Guidelines for Canadian Optometrists, Canadian Journal of Optometry (CJO), 2014 (in press)

OVERVIEW OF MANAGEMENT OF EPISODIC DED Lubrication

• The main stay of therapy across the full spectrum of DED • Lipid based in case of MGD

Ocular Considerations

• Hot compresses (DIE x 2-3 wks; then 2-3X /wks) • Lid hygiene +shampoo • Modifications to contact lens wear

Non-ocular Considerations

• Environmental modification (humidity, air movement, screen use) • Alcohol use • Smoking • Hormonal status • Sleep apnea

Screening, Diagnosis and Management of Dry Eye Disease: Practical Guidelines for Canadian Optometrists, Canadian Journal of Optometry (CJO), 2014 (in press)

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Once the ocular surface is restored and tear film stabilized



Eye dryness: DD/ hypergel / MF/ UV protection



Astigmatism:



Eye Dryness and astigmatism : Sclerals

RGPs, hybrids

CONTACT LENS OPTIONS

MF souples Eye dryness

RGP- régulier

RGP sclérales

Hybrides

Monovision

X

X















X

Astigmatisme

X

Unstable







X

Centration (vs pupil)

Vs design

X

Needs translation





X

Lid aperture

X

X



Plan B

Plan A

X

Handling

X

X







X

Comfort











Visual needs (3D)

Hypergel DD /UV

MF souples Toriques

Plan B: Smaller scleral ( DHA)



Lipid-based tears



Oral / topical combo medication (?)

Long term 

Cyclosporine (off label)

MANAGEMENT

CYCLOSPORINE AND LID MARGIN DISEASE ? 

Off-label use



Lid margin disease associated with increased inflammatory markers on the ocular surface



Studies show … 

Decreased viscosity of



Increased TBUT



Increased Schirmer scores



Resolution of lid telangiectasia



Improved symptoms



Better efficacy at three-month follow-up than Tobradex

gland secretions

4 1

BE AWARE : ROSACEA

A CHRONIC INFLAMMATORY DISORDER

AFFECTED AREAS Subtype Subtype Subtype Subtype

CLASSIFICATIO N (4 subtypes)

1: Facial redness (erythematotelangiectatic rosacea) – flushing and persistent redness, visible blood vessels may also appear 2: Bumps and pimples (papulopustular rosacea) – persistent facial redness with bumps or pimples, often seen following or with subtype 1 3: Skin thickening (phymatous rosacea) – skin thickening and enlargement, usually around the nose 4: Ocular irritation (ocular rosacea) – watery or bloodshot appearance, irritation, burning or stinging

Subtypes: http://www.rosacea.org/sites/default/files/images/faces_of_rosacea.gif

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HYPERGEL: IDEAL FOR ROSACEA Material generated with a surface acting as a dehydration barrier

Tensioactive monomer (poloxamère 407) concentration is higher at the material surface level, which becomes a permanent characteristic of the material. This is why Hypergel mimics the lipid layer of the eye and helps to maintain lens structure and hydration.,3,8

.

Hyfrophilic molecules of polyvinylpyrollidone (PVP) adheres to the macromere and can adsorb up to 40% of their molecular weight in water

[ 43 ]

Combination of molecules and macromeres leads to 98% hydration retention along the day6



Contact lens options 

Ocular surface treatment first done



Scleral lenses considered to improve symptoms 

Vision



Eye dryness (CLD)



Contamination /exposure to pathogens (operating room)



Use of oblate designs to minimize minus power

IN THIS CASE



A spherical surface has a Q value of 0



Cornea is a parabola with a periphery flatter than the centre 

Q is negative (-0.25)



Induces spherical aberrations



Added to the crystalline lens Q (-0,25 in young; 0 in older)

PROLATE VS OBLATE

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2017‐02‐22

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

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

NEW CLINICAL APPLICATIONS



Outcome 



Visual issues resolved (due to larger optic zone) 

OBLATE



Multifocal scleral lenses

Eye dryness resolved after treatment and CL refit 

No more CLD

OUTCOME

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Scleral lenses for normal corneas



Oblate profiles vs prolate surfaces

CLINICAL PEARLS

Identifying a need





Vision



Comfort

Educate the patient about the technology





Benefits



Limits



Handling



Cost

Convenience





Handling



Care regimen

WHAT DOES IT NEED TO SWITCH PATIENTS FROM SOFT TO SCLERAL LENSES





COMFORT 

Never touch the cornea



No lens to lid interaction / no lens movement



Constant hydration of the ocular surface



Optimal landing on the conjunctiva



No lens dehydration

VISION 

Larger optic zone (8-9 mm)



Full compensation of corneal irregularity



Better centration



Reduced HOA



Gas permeable material optics



Optimal fluid layer thickness required



No lens dehydration

SCLERAL LENSES CAN HELP

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2017‐02‐22





High refractive errors 

Larger optic zone: less high order aberrations



Centration



Physiological issues associated with RGPs (3-9 o’clock, corneal warpage, etc.)



Improved overall visual acuity

Astigmatism 

No rotation and no visual fluctuation



Larger optic zone



A spehrical scleral can compensate up to 3.5 D of corneal astigmatism



No dehydration with time

POTENTIAL CLINICAL APPLICATIONS FOR NORMAL CORNEAS





Sports /outdoors activities 

UV protection



No exposition to dust, particules, foreign body as for small RGPs



Corneal protection

Allergy /Challenging environement 

Reduced exposition to allergen



RGP materials compatible with concurrent use of topical meds

POTENTIAL CLINICAL APPLICATIONS

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Presbyopia 

Stable lens



Full compensation for astigmatism



Friendlier for the presbyopic eye environment (dryness, tear film stability, etc.)



Compensation for corneal irregularities

Symptomatic patients 

Contact lens induced Dry Eye



No preservative agent / solution toxicity

POTENTIAL CLINICAL APPLICATIONS





FOUR ACES IN YOUR HAND 

Custom soft lenses



RGPs /piggy back



Hybrids



Sclerals

How can you lose ?

CONCLUSION

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