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CUSTOM CONTACT LENSES

Presbyopia Patient Looking For Alternative To Eyeglasses

Sharing a case we recently worked on with custom soft lenses.

50 year old female was looking for an alternative to glasses that would also allow her to see up close and far. She reported that she first wore glasses when she was in 1st grade and has a history of high astigmatism. During our exam, we found that she had limbal to limbal corneal astigmatism and her manifest Rx was :

Right eye: Plano-3.00×016 (20/20)
Left eye: +1.75x-4.25×165 (20/20)

Based on our findings, we felt that she would benefit from several different lens options between monovision or multifocal GP lenses, hybrids, sclerals, or custom softs. Due to her history of previous soft contact lens wear and finances at this time, the patient opted for a custom soft contact lens.

We fit her into monovision Specialeyes in both eyes. Specialeyes is a company that makes custom soft contact lenses. This will work much better for patients with higher amounts of astigmatism, compared to traditional soft contact lenses. The patient reported good comfort and was excited to be able to see her cell phone without any glasses on! She was able to achieve binocular 20/20 distance and 20/20 near!

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Patient switched into a custom scleral lens design after failing in a traditional scleral lens

We have been working with a 25 yo male with h/o keratoconus OS>>OD s/p CXL. He found us online looking to see if he can improve his vision with scleral lenses. His vision with his glasses was 20/30 in the right eye and 20/400 in the left eye. He was also having problems with night vision.

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Despite multiple changes, there was still excessive seepage into the 12:00 and 6:00 position, indicating a large amount of scleral toricity.

He was first fitted into the ZenLens and was able to achieve 20/20 vision in the right eye and 20/30 vision in the left eye with significant improvement in his night vision. Unfortunately, he was experiencing significant redness nasally and temporally. After several designs of increasing the haptics and vaulting over the pinguiculas, he continued to experience injection after an hour of wear. Due to the limitations of non-custom scleral lens designs, we recommended a custom Latitude lens in order to reduce the redness. When we have to make alterations to the lens design more than 2 times, we will often times switch designs completely.

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We refit him into a custom scleral lens, which fits his eye much better than the traditional scleral lens.

After imaging him with the sMap3D, we found that he had a scleral toricity of almost 400 in both eyes! The average scleral toricity is about 150-170 which can help explain the nasal and temporal redness he was experiencing with the previous scleral lens.
With the Latitude lens his redness significantly improved, only noticing a mild amount at the end of the night. In addition to the improved fit, he was able to achieve 20/15 vision in the right eye and 20/20 vision in the left! We are so thrilled that he is doing so well!

Live demonstration of an EyePrint Prosthetic

In this video, join Dr. Stephanie Woo for a live demonstration of the EyePrint Prosthetic on a real patient.

This patient suffers from poor vision as a result of prior eye surgery. She had radial keratotomy surgery (also known as RK surgery) in the early 1990’s. This surgery was a popular option for patients looking to eliminate their glasses or contact lenses.

Watch EyePrint Demo

RK surgery involved the surgeon making small cuts onto the cornea in a spoke-like pattern, hence the name “radial.” Making the incisions allowed the cornea to reshape and become flatter in the center. This changed the shape of the eye, which reduced the need for glasses or contact lenses.

Most RK patients saw well for many years, but as time has progressed, there have been many issues.

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RK scarring in the cornea

RK patients suffer from blurry vision, distorted vision, ghosted vision, shadow-y vision, double vision, and other visual complications.

This patient also has a corneal transplant. This was due to the enormous amount of scar tissue in the center of the cornea.

Due to her very irregular cornea, we decided to fit her into an EyePrint Prosthetic.

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The Eyeprint procedure is painless and take less than 3 minutes

Step-by-step instructions:

  • First, the tip is placed at the edge of the impression material and locked into place.

  • Next the trigger is squeezed, which allows 2 separate materials to combine in the chamber of the tip.

  • The mixed materials are placed into a small plastic tray.

  • We wait for 40 seconds for the material to set.

  • Then, the patient looks at their fixation target.

  • Quickly, the impression is inserted under the upper eyelid and then the lower eyelid. This is the most important part. You must get the lids out of the way.

  • Let go.

  • The patient continues to look at their fixation target for about 90 more seconds so the material can set.

  • Then, the impression is removed.

  • After, we proceed with a diagnostic scleral lens fitting to determine what power to add into the EyePrint.

Watch EyePrint Pro Demo

After several impressions are obtained, we send them to the EyePrint lab in Colorado. Next, the lab uses a 3-D scanner and captures over 3 million data points using information from the impression. This information is then used to design a perfectly custom scleral lens. The lens is then fabricated in the lab and then shipped to us for dispensing.

When the EyePrint arrives, we will call the patient and schedule her for a scleral lens dispense.

We were able to achieve 20/20 vision with the EyePrint with this patient. Looking forward to seeing how her next visits go!

Next: Does Insurance Cover Scleral Lenses?

What Are Custom Scleral Lenses?

The sMap is such a cool instrument, and it tells us a lot of information.

Normal topographers map the corneal surface only, and give little (if any) data about the shape of the sclera. Since scleral lenses rest on the white part of the eye (the sclera), it makes sense that a scleral topographer could help improve our scleral lens fits. Scleral topographers are expensive, which is why most eye doctors do not offer this technology in their office. It would only make sense for clinics that are fitting scleral lenses at a high level to invest in this equipment.

This particular patient has severe keratoconus in the right eye (K max of over 70 diopters). He complains that a traditional scleral lens does not fit his eye perfectly and he has issues with redness and irritation. With the slit lamp, we observe a small area of elevation inferiorly and a slight area of increased elevation nasally. The nasal elevation is a result of a small pinguecula.

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Corneal topography showing a keratoconus patient

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A small pinguecula on the sclera can cause issues with a scleral lens fitting.

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A small area of elevation is seen on the sclera (white part of the eye) . This was easily detected with the sMap.

The sMap images take 3 D images of all areas of the eye, and the information is used to create a custom fit scleral lens. We instill a drop of sodium fluorescein and have the patient look up, down, and straight ahead. Then, the sMap software stitches the images together to give us a 3D image of the shape of the sclera.

Notice how the 3:00 and 6:00 position are slightly "warmer" colors compared the the rest of the sclera. This is due to the elevation of the pinguecula nasally and the small area of elevation inferiorly.

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sMap images of a patient looking up, down and straight ahead.

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Notice the 3:00 position and the 6:00 position have more of a teal and yellow color compared to the other colors on the map.

This information will be used to create a custom scleral lens, which should vault over those areas perfectly. This results in an extremely accurate scleral lens fit.

So grateful to have this special technology in our office!

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The end result is a beautiful scleral lens fit

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The scleral lens fit is perfect.

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Damage to Eye from a Burning Building

Super interesting case from Dr. Schorr from New Eyes!

We saw a 19 year old boy for a consultation today. He suffered a trauma from going into a burning building and when he opened the door, the door flew open and the padlock hit him in the right eye. According to the patient, he left the burning building but then his boss told him to go back in. When he went back in, he opened the door, and (probably due to backdraft), the door slammed into the right side of his face and the padlock went right into his eye. He was a child when this all happened.

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Large, dense corneal scar which goes right through the center of his eye.

He had a globe perforation to his eye that had to be repaired quickly.

His crystalline lens could not be saved, so he is aphakic in that eye. He has severe corneal scarring. There is also a dense amount of scar tissue that attaches the posterior cornea to the anterior iris. You can see in the OCT image below that the back side of the cornea attaches to the front side of the iris.

He also has an artificial pupil and iris defect both nasally and inferior nasal.

His main goal of today’s visit was to see if a specialty lens could improve his vision. He sees count fingers at 4 feet and complains of diplopia in the right eye.

When I looked at his eye, I had little hope that any vision improvement would be possible, due to the severe scar tissue and lack of a normal entrance pupil.

We tried on a diagnostic Europa scleral lens to see if any vision improvement was possible and with a +8.00 over refraction, he could achieve 20/50 and he stated his double vision was gone.

Due to the ocular condition, he must be eccentrically viewing out of his artificial pupil inferiorly. We are going to attempt a scleral lens for him to see if it helps improve his vision, diplopia and balance. Stay tuned for updates!

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This image shows us that the back side of his cornea is attached to the iris

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The topography of the right eye shows irregularity

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We placed a diagnostic Europa scleral lens on his eye and he could see 20/50!

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Prosthetic Contact Lens

Prosthetic Contact Lens – A cool case sent over from Dr. Irene Voo!

A 73 year old white male was kindly referred to us for a prosthetic contact lens consultation.

He has a history of several retinal issues such as branch retinal vein occlusions and epiretinal membranes. He also has artificial lenses in each eye from cataract surgery.

His main complaint is that his vision is very blurry, distorted, double, and issues with glare on the right eye. His right eye is best correct to 20/200 and he complains of shadows, distortion and double vision. His left eye best corrected is 20/32.

Many times, patients that cannot see well out of one eye have a very hard time. This is because with both eyes open, the brain tries to overlay the image detected from each eye. This can result is visual confusion and other symptoms such as dizziness, nausea, feeling off balance, light sensitivity, issues with glare, blurred vision, double vision, visual discomfort and more.

He is so bothered by the distortion in the right eye that he wears a patch over his right eye to improve his visual comfort. He also wears a pair of glasses which were specially made by Dr. Quinton where the right lens is black and the left lens is clear. This also helps so that less light enters his eye.

We think he would be an excellent candidate for a prosthetic contact lens! We color matched his eye today using the Orion Fitting Set from ABB specialty lenses. The first photo was a good match but a bit too blue. The second photo was a different mix of colors and looks like a better match. We used Underprint #3, followed by CB3, and then #52-V to get this result.

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The first color match appeared a bit too blue.

With the Orion fitting set, you stack different colors until you get a good match.
We ordered the lens today to be completely blacked out on the underside of the contact lens so that no light will enter his eye. He should feel much more comfortable with the lens on his eye. We will post photos of his dispense soon!

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The second color match appears to be a better match.

Major thanks to Dr. Kramer for always helping us with prosthetic lenses and to Dede from ABB for your expert help.

What is scleral topography?

The sMap is such a cool instrument, and it tells us a lot of information.

Normal topographers map the corneal surface only, and give little (if any) data about the shape of the sclera. Since scleral lenses rest on the white part of the eye (the sclera), it makes sense that a scleral topographer could help improve our scleral lens fits.

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The sMap takes a series of 3D images to help create a custom scleral lens

Scleral topographers are able to map the white part of the eye, called the sclera. This is important because this is the area that the scleral lens lands on. It would make sense that using a scleral topographer would give us important information about the shape of the entire eye, not just the cornea.

This particular patient has severe keratoconus in the right eye (K max of over 70 diopters). He complains that a traditional scleral lens does not fit his eye perfectly and he has issues with redness and irritation. With the slit lamp, we observe a small area of elevation inferiorly and a slight area of increased elevation nasally. The nasal elevation is a result of a small pinguecula.

The sMap images take 3 D images of all areas of the eye, and the information is used to create a custom fit scleral lens. Notice how the 3:00 and 6:00 position are slightly “warmer” colors compared the the rest of the sclera. This is due to the elevation of the pinguecula nasally and the small area of elevation inferiorly.

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The sMap generates a scleral topography to show us areas of elevation

This information will be used to create a custom scleral lens, which should vault over those areas perfectly. This results in an extremely accurate scleral lens fit.

Good candidates for custom scleral lenses include patients with extreme eye conditions, such as severe keratoconus, graft-vs-host disease, sjogren’s syndrome, extreme dry eye, glaucoma patients, and patients who have difficulty with their current scleral lenses.

We have been able to help thousands of scleral lens patients with this incredible technology.

So grateful to have this special technology in our office! Book an appointment with our office to see if you would be a good candidate for the sMap!

Custom Scleral Lenses Help Physician to See Better

We had the pleasure of seeing our patient back for a Latitude custom scleral lens dispense today.

This patient had LASIK surgery years ago, and he had monovision correction. This means that one eye is corrected for distance and one eye is corrected for near. In his case, the right eye was corrected for distance and the left eye was corrected for near.

He was successful for many years, and he was able to function glasses-free.

He was seen by his primary care ophthalmologist, Dr. Paul Casey, for his annual exam a few months ago. Dr. Casey had discovered that this patient developed some highly irregular astigmatism in both eyes, likely due to the LASIK surgery.

Even though the vision was still quite good (around 20/25 both far and near), Dr. Casey wanted him to see me for an evaluation due to a desire to improve vision quality.

This patient saw us for a consultation in February 2021 and he stated that although he saw clearly, some of the images were a bit distorted, and he had a bit of ghosting at night.

When we viewed his topography, we could see why the vision became more distorted at night time. As the pupil increases in size, he starts to see into the midperipheral cornea, which is more distorted in shape.

We also found that he had more than 7 diopters of cylinder in the left eye. Both eyes exhibited irregular topography images.

Dr. Casey has been repeating the topography scans every 3 months and for the past year, the patient has been completely stable.

We decided to put a diagnostic scleral lens on for fun, just to see if it would improve his vision.

With the Europa scleral lens on each eye and an over-refraction, the patient could see 20/20 in each eye and, most importantly, he noticed a huge improvement in the overall QUALITY of vision. This is important because even if someone can technically see 20/20, that does not mean that they have good vision. If the vision is distorted, blurred, has haloes, or glare, it can be very disturbing to the patient. Since he was so happy with the improvement in the quality of vision, we decided to proceed with a scleral lens fitting.

Due to the highly irregular curvature of each cornea, we decided to proceed with a custom scleral lens design, called the Latitude scleral lens. We took 3D images of the eye with the sMap machine, and the laboratory designed a pair of custom scleral lenses for him.

At the dispense, visit, he noticed the vision was very good. He was seeing 20/20 at far and 20/20 at near. The OCT images showed that there was a bit of shallow clearance, but we dispensed the lenses and followed up with him one week later.

At the one week follow up, Dr. Wong noticed that the clearance was a bit too shallow superiorly. Although the patient loved his new vision, we had to re-design his lenses for safety purposes. He also mentioned that when he removes his lenses, they are really stuck on his eye and they feel like champagne bottles popping off his eye. This is not normal and usually means the fit needs to be modified.

Today, we saw him for another Latitude dispense. The lab made some minor adjustments to the lenses to increase the fluid layer underneath the scleral lenses to help improve the fit and help with lens removal.

He mentioned the new lenses were even more comfortable than the old lenses, and we were very happy that the new lenses showed more central and midperipheral clearance.

We feel very honored to have worked with such an amazing patient! Scleral lenses are so rewarding, and it is an honor to be a part of their journey to better vision.

Keratoconus patient fit into custom scleral lens

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A nice patient was seen today for a specialty contact lens consultation. He was diagnosed with keratoconus 2 years ago at the age of 34 years old. He wore focus daily soft lenses for years, but 2 years ago, he noticed some changes in his vision, which led his optometrist to perform a topography. The topography revealed keratoconus OD>OS.

He gets Pentacam images every 3 months, and his corneas are both very stable, which is why he has not had corneal cross linking.

He was then fit into different scleral lenses which didn’t feel right (comfort wise) and the most recent lenses made him feel “wonky.” His main complaint was that his eyes suffer from ghosting, especially at night. With the current scleral lens, the ghosting is still apparent sometimes when the lens decenters.

We decided to perform a few tests and see for ourselves.

His scleral topography is interesting because the more elevated areas are at more of an oblique axis, which might explain why the traditional scleral lenses did not fit perfectly. With a diagnostic Europa lens, he still noticed some ghosting and accepted cylinder in his over-refraction. I performed an over topography to check for flexure, and it appears that it is possible that the lens shape could be contributing to the residual cylinder.

After analyzing all of the image, Sabrina from Visionary Optics helped me design a new lens for him. We decided to keep any cylinder out of the first pair, because that will make things more challenging if we need to alter the fit or Rx later. We are going to increase the optic zone to 9.0 mm to help with the ghosting as well. I am hoping that by order the custom Latitude scleral lens, the lens will center much better and will help to decrease or eliminate the ghosting.

Looking forward to his dispense. Thanks to the sMap team for their help with this fun case!

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Topography right eye

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Contact lenses for high astigmatism

We saw our Latitude scleral lens patient today for his dispense and insertion/removal training.

He is a 35 year old white male and he has regular astigmatism, but a large amount (over 5 diopters in the left eye). He’s tried many different contact lenses in the past, but he complains that they don’t seem to fit correctly and the vision also seems sub-optimal. Patients with large amounts of astigmatism often see better with more custom lenses, due to the fact that standard soft contact lenses have limited parameters and availability. Most standard soft contact lenses can go up to 2.75 diopters of astigmatism. If you have more than this, the options become more limited. I always recommend more custom contact lenses for patients with higher amounts of cylinder.

After reviewing the images of his eye together and explaining pros and cons of different lens types, we decided to try the Latitude custom scleral lens. The reason we selected this option is because it is very stable on the eye, so the the optics are likely to be superior to his soft contact lenses. When you have a large amount of astigmatism, it is very important that contact lens centers on the eye and remains stable. If there is any sort of rotation of the contact lens, the vision could be affected. This is why patients with large amounts of astigmatism usually see better with a more custom lens, such as a scleral lens.

The lenses fit very well on both eyes and he can see 20/20 in the right eye and 20/30 in the left eye. He did take a small over refraction on each eye, which improved his vision to 20/20 in the left eye. The lenses move slightly with blink, but I never change the lens fit at the dispense, because the lens fitting relationship could be changed within a week or so.

He is coming back in a few weeks for a follow up visit, and we will reassess his vision and the fit of the lens at that time. He is also going to be one of our patients at the Global Specialty Lens Symposium workshop, so if you are attending the workshop, we will be able to see the progression of his interesting case! Thank you Visionary Optics for the Latitude scleral lenses – we can’t wait to see how he does over the next few weeks and also at the workshop!