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GAS PERMEABLE CONTACT LENS

Patient Looking For New Rx For Her Multifocal Gas Permeable Contact Lenses

Thank you for this fun referral from Dr. Casey at NVision!

63 year old female was looking for a new prescription for her multifocal corneal gas permeable lenses. She has been wearing GP lenses since she was a child and has always found it difficult to find a well-fitting lens that was coupled with great vision. During our testing, we discovered this patient has a moderately high minus prescription with about 4 diopters of limbal to limbal corneal astigmatism in the right eye and almost 5 diopters in the left. Her manifest Rx was OD: -4.25 -6.00 x 179 (20/30+1) and OS: -5.25 -6.00 x 001 (20/40+1). She also wanted to try to eliminate all need for glasses since she has been using OTC readers on top of her habitual multifocal contact lenses for near work.

Since she wanted to stick with corneal GP lenses, we discussed options for adding in near optics. Our patient stated that she had some success with the MF lenses and that she would like to see if an increase in add power would help with near work.

Due to her high amount of with-the-rule- astigmatism, we fit her in Valley Contax bitoric MF corneal GP lenses. We explained that this type of lens should allow for functional vision without OTC readers for about 70% of her daily routine.

After about 15 minutes of settling, her DVA was 20/20-2 OD, 20/20 OS, and 20/15 OU, and her NVA was 20/40-2 OD, 20/20-2 OS, and 20/20 OU. Both OD and OS lenses fit wonderfully with apical alignment, mild midperipheral bearing and moderate edge lift. The patient reported good comfort and vision and was so incredibly ecstatic in the office! She pulled her Kindle out and stated that it was the first time she could see the 12 point font without readers in years!

OD topo

OS topo1

The Use of Scleral Rigid Gas Permeable Contact Lenses in Keratoconus – A Case Report

A special thank you to Judy Tran for developing this amazing case report.

Introduction:

The prevalence of keratoconus (KCN) in the United States is approximately 8.8-229 per 100,000 affecting both men and women equally.1 KCN is a progressive disease resulting in ectasia of the corneal stroma. It is a noninflammatory process that causes a decrease in patient visual acuity (VA) from the changes in corneal shape that leads to an increase in myopia and irregular astigmatism. What causes KCN is still not completely understood but there are studies that show a correlation between the disease and environmental factors such as eye rubbing, a family history of the disease, and atopy. Age, ethnicity, contact lens use, as well as exposure to sunlight are also observed environmental risk factors for KCN. Genetically, there has been some evidence of genes VXX1 and SOD1 being highly associated with the pathogenesis of the condition which is autosomal dominant but can occur in a sporadic pattern.2

There is currently no cure for KCN, however corneal collagen cross-linking (CXL) has been shown to have promising results in slowing the progression of the disease especially in cases involving severe progressive KCN. CXL utilizes riboflavin and a photo-oxidative reaction to increase corneal stiffness by altering the collagen within the corneal tissue. The changes to the collagen consist of increasing the number of covalent bonds and increasing the resistance to enzymatic degradation.3 CXL has been widely used in many countries for managing KCN, but it was only just recently FDA approved in the United States April 2016 and this method of treatment is becoming increasingly popular since its approval. Before the development of CXL, a corneal transplant was the only treatment for KCN but is indicated only when the disease had progressed into more advanced stages. Even after a corneal transplant, patients are still at risk for developing KCN again in the transplanted cornea. Another major complication post corneal transplant is glaucoma. There is a significant risk for the development of glaucoma after a corneal transplant as seen in a study conducted by Zheng et al.4 Depending on the severity of glaucoma, treatment could be lifetime eye drops or even requiring another ocular surgery. Just like KCN, glaucoma is an uncurable condition that can lead to blindness. Even though CXL and corneal transplant are both FDA approved methods for treating KCN, they do not always help with the major side effect of the disease which is reduced vision.

Due to the optics of an irregular cornea often seen in KCN, spectacles often cannot correct the vision. Specialty contact lenses are typically used to help maximize vision. Usually, a corneal rigid gas permeable contact lenses (RGPCL) are often indicated initially but with recent advancements, scleral rigid gas permeable contact lenses (ScCL) have shown to be an excellent, safe, and effective alternative.5 Since the scleral contact lenses do not interact with the cornea, there is a therapeutic benefit to using the larger lens especially in patients with severe dry eye. There is a liquid layer between the ScCL and the cornea which can provide constant hydration to the corneal cells. ScCL are often reserved for more severe KCN but with their material and fitting advancements, it should be an option at any stage of the condition to help patients achieve their best potential VA as well as to delay the possible need for a corneal transplant.6 This case report supports the benefits of using a ScCL for a patient with a moderate and severe KCN. By using a more custom fitted ScCL, the patient was able to reach a VA of 20/20 with optimal comfort and the ScCL could potentially reduce their need for a corneal transplant later in life.

Case description:

Visit 1: The consultation. Patient DB, a 51-year-old Hispanic male, was referred to the Contact Lens Institute of Nevada after completing a comprehensive eye exam at a Sam’s Club Optical in May 2021. The referring optometrist diagnosed the patient with myopia, astigmatism, and bilateral keratoconus with the right eye being more severe than the left. There was no spectacle prescription recommended at this time due to the severity of the KCN. The patient was advised that a specialty contact lens would provide better vision than glasses.

DB’s medical history was unremarkable, the patient had denied any medical diagnosis, medications, and allergies. The patient was unaware of any KCN prior to the eye examination in May 2021. The patient had also denied any other ocular conditions and surgeries.
Entering unaided VA were OD 20/200 and OS 20/25. Anterior segment evaluation revealed corneal central inferior thinning with striae OU. Corneal thinning and striae were mild in OS and significantly worse in OD. Fluorescein dye evaluation revealed mild SPK staining over the cone apex of OD. There were nasal and temporal pingueculas noted OU. The rest of the anterior segment was unremarkable. Posterior health was evaluated via retinal imaging which was unremarkable. There were no signs of glaucoma, macular degeneration, or any retinal disease that could possibly contribute to the patient’s reduced vision.

A KCN pattern was observed in the topometric exam (Figure 1). An OCT and a scleral mapping (sMAP) were performed over DB’s naked eye (Figure 2). The results of the exam are listed in Table 1. Based on the topography and scleral elevation (Figure 3), a Europa diagnostic lens was selected for both eyes and the parameters of the diagnostic lenses are seen in Table 2. The suggested lenses are based on a sagittal depth (Table 1), the sMAP software determines the sagittal depth assuming a chord length of 16mm and incorporating a 300um buffer. The lenses were allowed to settle for approximately 5 minutes before assessing the vision and fit, as well as an auto-refraction/keratometry over the diagnostic lens (Table 3). The over-refraction (Table 3) was determined with the starting point measured with the auto-refractor.

Figure 1: Using the Medmont, corneal topography reveals a KCN pattern in both OD and OS.

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Figure 2: Images of DB’s naked eye with trace sodium fluorescence that was instilled prior. Photos were taken during the slit-lamp examination with the ION Imaging system.

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Figure 3: sMAP scleral elevation of DB’s OD and OS.

Measurements over naked eye OD OS
Pachymetry (OCT) 405um 491um
Keratometry (Topo) 56.43D @ 160°/ 71.61D 43.21D @ 2°/ 46.38D
Corneal Cylinder (Topo) 15.18D 3.17D
Scleral Toricity (sMAP) 214um 270um
Sagittal Depth 4479um 4456um

Table 1: Measurements taken over DB’s naked eyes.

Diagnostic Lens Parameters OD OS
Base Curve 45.00D 46.00D
Sagittal Depth 4560um 4660um
Power -1.50D -2.00D
Overall Diameter 16.0mm 16.0mm
Optic Zone Diameter 0.2mm 0.2mm
Center Thickness 0.4mm 0.4mm
Material HEXA100 HEXA100

Table 2: The Europa Lens made by Visionary Optics were the diagnostic lenses used.

Lens Assessment OD OS
Central Clearance 58um – over apex 388um
Limbal Clearance Present 360° Present 360°
Lens edges Flat 360° Flat 360°
Impingement or Blanching Negative 360° Negative 360°
Auto-refraction +0.25 -2.50×067 -1.50 -1.50×095
Auto-keratometry 43.50D @ 162°/ 43.75D 43.75D @ 161°/ 44.00D
Over-refraction in Phoropter -0.25 -2.50×080 -1.00 -1.75×095
VA with Over-refraction 20/20-2 20/20

Table 3: Fit and vision assessment of the diagnostic Europa Lens on the patient’s eyes.

Due to the DB’s high scleral toricity and high internal cylinder, a custom impression ScCL was recommended for both eyes to maximally optimize visual acuity and fit but other fitting modalities were also discussed to the patient. The patient had opted for the premium custom fit for their right eye, the eye with more severe KCN and the advanced custom fit for their left eye. The premium custom fit uses an impression of the eye, similar to a dental mold, to design a lens with a 3D scanner and utilizes three million data points from the mold (Figure 4). The advanced custom fit uses the scleral mapping scan of the eye, and that special software is able to design a lens from a million data points. Two impressions of the right eye for the custom EyePrint Prosthetic were completed in-office (Figure 5) and the sMAP images that were taken were sent to the Visionary Optics Lab for the advanced custom ScCL fit for the left eye. All images and the over-refraction were sent to both labs for the lens design.

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Figure 4: Front surface and back surface design of the custom EyePrint Prosthetic ScCL for DB’s right eye.

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Figure 5: A visual of how the eye impression is completed for the EyePrint Prosthetic. Note: the patient in the image is not the patient in the case report.

The patient was expected to return to clinic once the ScCL arrive for a training session before being dispensed.

Visit 2: Training and dispense. An EyePrint Prosthetic ScCL was ordered for the right eye and a Latitude ScCL was ordered for the left; lens design parameters are listed in Table 4. The ScCLs were inserted for DB shortly after their arrival (Figure 6). The lens was allowed to settle for approximately 10 minutes before checking VA (Table 5) and assessing the lenses (Table 6). The clearance was determined with an anterior segment OCT (Figure 7), which was checked at the center and limbus of the cornea. Before the training session, an over-refraction was completed with the auto-refraction as the starting point and VA was measured (Table 5). Throughout the over-refraction, the patient reported fluctuating vision with may have been due to the lens settling which affected the reliability of the over-refraction.

Lens Parameters OD (EyePrint Prosthetic) OS (Latitude Scleral Lens)
Base Curve 8.336mm (40.49D) 7.55mm (44.70D)
Sagittal Depth 5788um 5134um
Power +2.75 – 2.38×080 -1.67 -1.75×095
Overall Diameter 18.0mm 16.5mm
Center Thickness 0.527mm 0.30mm
Material Optimum Extra Optimum Extra

Table 4: Custom ScCLs parameters received by the manufactures.

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Figure 6: DB with custom EyePrint Prosthetic on OD and custom Latitude lens on OS.

Vision Assessment OD OS
Entering VA 20-20 20/50
Auto-refraction +1.50 -1.25×022 +0.25 -1.00×136
Auto-keratometry 40.25 @ 078/ 42.00 41.75 @ 069/ 42.50
Over-refraction in Phoropter +0.50 -1.50×120 +1.25 -1.50×126
VA with Over-refraction 20/25+2 20/20-1

Table 5: Vision assessment through custom ScCL.

Lens Assessment OD OS
Centration Centered Centered
Central Clearance 252um – over apex 396um
Limbal Clearance Acceptable 360° Acceptable 360°
Lens edges Flat 360° Mild nasal edge lift
Movement 0.25mm 0.25mm
Lens Marker Location 6:00 7:00
Impingement or Blanching Negative 360° Negative 360°
Conjunctival Prolapse None 11:00 to 1:00

Table 6: Lens assessment of the custom ScCL on DB’s eyes after 10 minutes of settling.

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Figure 7: Anterior segment OCT reveals central clearance of the ScCL on the eyes. Top photo: OD, bottom photo: OS.

After lens evaluation, DB was educated on how to properly insert and remove the scleral lenses by using a DMV to insert and a small plunger to remove. The patient was taught how to clean and store the ScCLs using Tangible Clean Multipurpose Solution and to use sodium chloride preservative-free saline to fill the lens bowl prior to insertion. DB had no difficulties with removing the lenses with the use of the small plunger. They were advised to stick the plunger inferiorly of the lens rather than directly center, this creates an uneven pressure of release for the lens to come off the scleral resting points. There were some difficulties with insertion, DB has deeper set eyes and larger hands, so they found it difficult to maneuver the lens into the eye when they used one hand to open the upper lid and the other hand to hold the lower lid and DMV plunger with the ScCL. The technique that was most comfortable for DB was using one hand to hold the upper and lower lid while the other hand solely guided the DMV and ScCL. A scleral stand was suggested to patient which would essentially act as a third arm allowing the patient to comfortably hold open the eyelids with both hands as the move towards the scleral stand that props up the DMV and ScCL. DB expressed feeling comfortable with insertion without the need of the scleral stand. DB successfully completed training by removing and inserting the ScCL once leaving the clinic with them on, and DB was scheduled to return to the clinic in a week for a follow-up to recheck their visual acuity and the fit. The patient was advised to wear the lenses as much as possible to allow for adaptation.

Visit 3: 1 week follow-up. Case History: DB had worn the ScCL OU for 4 hours prior to the appointment. Average wear time was about 1 to 2 hours, and this was due to their eyes feeling fatigued during wear. There were difficulties with reading and intermediate distance because their eyes felt like the vision was too overwhelming which caused the eyes to feel tired. DB reports seeing better at intermediate distances without ScCL. With lenses, OD vision is much clearer than OS vision. There was mild discomfort with the OS at the appointment but denies and redness from the ScCL. The patient also noted that there were some difficulties with insertion because they could not get their eyes wide enough, but ScCL removal was easy with the use of the small plunger. The fit of the ScCL was reassessed (Figure 8), clearance was determined with the anterior segment OCT (Table 7 and Figure 9), auto-refraction/keratometry was completed, and an over-refraction was measured with the auto-refraction as a starting point (Table 8).

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Figure 8: 1-week follow-up with custom ScCL with Eyeprint Prosthetic for OD and Latitude Lens for OS.

Vision Assessment OD OS
Entering VA 20/20-1 20/50
Auto-refraction +1.25 -1.00×012 +1.25 -2.75×109
Auto-keratometry 40.25 @ 078/ 41.75 41.50 @ 025/115
Over-refraction in Phoropter +0.25DS +0.75 -1.75×135
VA with Over-refraction 20/20-2 20/20-1

Table 7: Vision assessment through custom ScCL at 1 week follow-up.

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Figure 9: Anterior segment OCT after 4 hours of ScCL wear on the eyes at 1-week follow-up. Top photo: OD, bottom photo: OS.

Lens Assessment OD OS
Centration Centered Centered
Central Clearance 222um 340um
Limbal Clearance Acceptable 360° Acceptable 360°
Lens edges Flat 360° Flat 360°
Movement Minimal Minimal
Lens Marker location 6:00 8:00
Impingement or Blanching Negative 360° Negative 360°

Table 8: Lens assessment of custom ScCL after 4 hours of wear.

Since the patient had difficulties with near and intermediate vision, a monovision fit was discussed to maximize acuity at all distances and to improve patient visual comfort. However, with the monovision fit, it was discussed that distance vision may be reduced to compensate for near vision. It was also educated to the patient that with a monovision fit, depth perception will be reduced. A monovision fit was trial framed and DB could not adapt to the vision. The patient opted to best correct distance vision in the ScCL for part-time wear and was educated that an over-the-counter reading spectacle prescription will be necessary to optimize near vision.

The overall fit of the lenses was acceptable, the only modification needed was to change the prescription of the left eye since the patient entering visual acuity was 20/50. A new lens was ordered to adjust the lens prescription incorporating the over-refraction that was determined (Table 7). The patient will continue with the right lens to allow more time to adapt. Another modification that will be considered at the next dispense appointment is possibly making the OD ScCL a smaller diameter for easier insertion. The patient is to return to the clinic for a new OS latitude ScCL dispense when it arrives.

Discussion:

Before the development of the corneal topographer, the only way to diagnose KCN was through slit lamp observed clinical signs, therefore it was often not diagnosed until later stages. Corneal signs such as corneal protrusion, corneal apex thinning, Vogt’s striae, Fleisher’s ring, and possibly corneal scarring typically represent more advanced stages of the condition. In earlier stages of KCN, patient symptoms can include reduced vision due to an increase in myopia and irregular astigmatism, visual distortions, and light sensitivity. Because of the constant changes in vision, patients with KCN may need to frequently change their spectacle correction. Now that the corneal topographer is becoming increasing popular and more readily available, early stages of KCN can be more easily diagnosed with the technology and treatment such as CXL can be implemented sooner to slow down the disease progression, ultimately preserving the patients’ vision.1 A 10-year study conducted by Raiskup et al. showed that CXL treatment was effective in decreasing the progression of the disease as well as stabilizing the cornea long-term ultimately reducing the need for a corneal transplant. By decreasing the progression of the disease by stabilizing the cornea, vision is preserved. CXL provides treatment in early diagnoses especially in adolescents with less complications compared to a corneal transplant.7 The Nordstorm et al. study demonstrated that after a year post CXL treatment in KCN subjects had decreased corneal irregularities and improved vision. There was also no damage or any cell loss to the corneal endothelium. The study demonstrated that CXL treatment for KCN is not only effective in slowing the progression of the disease, that the procedure is also safe.8

In early stages of the disease, a spectacle correction can provide adequate vision, however as the disease progresses, glasses are unable to mask the irregular astigmatism that typically occurs. Corneal RGPCL are common for correcting keratoconus. However, ScCL are becoming increasing popular because of they provide better patient comfort compared to corneal RGPCL. In a study conducted by Levit, Benwell, and Evans, they found that although there was no significant difference in vision or vision quality of life, KCN patients preferred ScCL over corneal RGPCL because of the significant difference in comfort.9 ScCL are typically preferred over corneal RGP because of their design, they rest only on the sclera which allows the lens to vault over the cornea entirely. This minimizes any interaction between the cornea and the contact lenses. ScCL can also help reduced the need of a corneal transplant in patients with severe keratoconus, which was observed in a study by Koppen et al. A majority of subjects with severe KCN had a decreased need for a corneal transplant when they were successfully fitted with a ScCL. Subjects that underwent a corneal transplant even after a ScCL fit was due to their inability to tolerate the lens.6 By fitting KCN patients with ScCL rather than treating with a corneal transplant, this is reduced the complications associated with the surgical procedure such as glaucoma.

A retrospective study by Fuller and Wang assessed the prevalence of ScCL complications such as microbial keratitis, phlyctenulosis, cornea abrasion, contact lens-induced acute red eye, corneal infiltrates, pingueculitis, and hydrops. The complications were observed to be related to poor wetting, poor handling, reservoir fogging, lens intolerance, deposits in the eye, and broken lenses in the eye. Although the adverse effects occurred in a small percentage of subjects in the study, they can still occur with any ScCL, therefore proper ScCL fitting, and patient education is important to reduce the risk of any complications. Other management options for complications were adding a surface treatment to the lens, replacing the lens, and adjusting the wear time. Overall, the study concluded that ScCL for KCN patients are safe and effective.5

Most traditional ScCLs design assume that the sclera is a uniform, spherical shape, however, this is not the case for many individuals. With the use of a sMap3D corneo-scleral topographer, DeNaeyer et al. measured not only the elevation of the cornea, but the elevation of the sclera as well on 140 eyes. They determined that approximately only 5.7% of the eyes had a spherical scleral shape, 28.6% had a regular toricity, and actually 40.7% had asymmetric elevations and depressions. This means that a majority of the population have a non-spherical scleral yet, most practitioners continue to fit scleral lenses empirically with a traditional lens design. Common complications often seen with ScCLs that have a poor landing on the sclera is conjunctival blanching, conjunctival prolapse and can even potentially result in staining of the surface tissues.10 By determining the patient’s scleral shape at the initial visit, it can help potentially decrease fitting chair time and improve patient comfort with the ScCL.

In the case of DB, their stage of KCN was well advanced, especially in their right eye, therefore their reduced vision of 20/200 could not be corrected with glasses. Scleral lenses were selected over a corneal RGP lens for maximum comfort and optimal visual acuity. A more custom fit ScCL was chosen over a traditional fit because of the patients high scleral toricity that was determined initially at the consultation appointment. A well-fitted ScCL was achieved just after one visit and by using a more custom ScCL design, such as the Latitude and EyePrint Prosthetic ScCL, the patient was able to achieve 20/20 vision in the poorer 20/200 seeing eye while maximizing the lens comfort reducing any risk of ScCL complications. Hopefully, by fitting DB in a ScCL it reduces their need for a corneal transplant later.

Conclusion:

Fitting a ScCL can be intimating and has a poor stigma of being difficult and time consuming, requiring a lot of follow-ups and lens adjustments. However, with advancements in corneal imaging and mapping, diagnosing KCN and fitting ScCL is much simpler with less chair time. By gaining the confidence to fit ScCL, the care and services can be provided to KCN patients without the need for an additional referral. ScCL have been shown to be safe and effective for achieving optimal vision for KCN patients even after a couple of months post CXL treatment. By diagnosing KCN in earlier stages, CXL can be implemented to immediately stabilize the cornea before the disease progresses, then with the added ScCL fit, the potential need for a corneal transplant is significantly reduced along with the associated complications with the surgical procedure.

References:

  1. Leucci, M., & Carter, M. (2018). Clinical signs in keratoconus. Optometry Today (London), 58(11), 86.
  2. Hashemi, H., Heydarian, S., Hooshmand, E., Saatchi, M., Yekta, A., Aghamirsalim, M., Valadkhan, M., Mortazavi, M., Hashemi, A. & Khabazkhoob, M. (2020). The Prevalence and Risk Factors for Keratoconus: A Systematic Review and Meta-Analysis. Cornea, 39 (2), 263-270. doi: 10.1097/ICO.0000000000002150.
  3. Vinciguerra, R., Romano, M. R., Camesasca, F. I., Azzolini, C., Trazza, S., Morenghi, E., & Vinciguerra, P. (2013). Corneal cross-linking as a treatment for keratoconus: Four-year morphologic and clinical outcomes with respect to patient age. Ophthalmology (Rochester, Minn.), 120(5), 908-916. https://doi.org/10.1016/j.ophtha.2012.10.023
  4. Zheng, C., Yu, F., Tseng, V. L., Lum, F., & Coleman, A. L. (2018). Risk of glaucoma surgery after corneal transplant surgery in medicare patients.American Journal of Ophthalmology, 192, 104-112. https://doi.org/10.1016/j.ajo.2018.05.004
  5. Fuller, D. G. & Wang, Y. (2020). Safety and Efficacy of Scleral Lenses for Keratoconus. Optometry and Vision Science, 97 (9), 741-748. doi: 10.1097/OPX.0000000000001578.
  6. Koppen, C., Kreps, E. O., Anthonissen, L., Van Hoey, M., Dhubhghaill, S. N., & Vermeulen, L. (2018). Scleral lenses reduce the need for corneal transplants in severe keratoconus.American Journal of Ophthalmology, 185, 43-47. https://doi.org/10.1016/j.ajo.2017.10.022
  7. Raiskup, Frederik, MD, PhD, FEBO, Theuring, A., MD, Pillunat, L. E., MD, & Spoerl, E., PhD. (2015). Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: Ten-year results.Journal of Cataract and Refractive Surgery, 41(1), 41-46. https://doi.org/10.1016/j.jcrs.2014.09.033
  8. Nordström, M., Schiller, M., Fredriksson, A., & Behndig, A. (2017). Refractive improvements and safety with topography-guided corneal crosslinking for keratoconus: 1-year results.British Journal of Ophthalmology, 101(7), 920-925. https://doi.org/10.1136/bjophthalmol-2016-309210
  9. Levit, A., Benwell, M., & Evans, B. J. W. (2020). Randomised controlled trial of corneal vs. scleral rigid gas permeable contact lenses for keratoconus and other ectatic corneal disorders.Contact Lens & Anterior Eye, 43(6), 543-552. https://doi.org/10.1016/j.clae.2019.12.007
  10. DeNaeyer, G., Sanders, D., van der Worp, E., Jedlicka, J., Michaud, L., & Morrison, S. (2017). Qualitative Assessment of Scleral Shape Patterns Using a New Wide Field Ocular Surface Elevation Topographer: The SSSG Study. Journal of Contact Lens Research and Science, 1(1), 12-22. https://doi.org/10.22374/jclrs.v1i1.11

Are Hard Contact Lenses Still Useful?

Are hard contact lenses still useful?

With the invention of scleral lenses, corneal gas permeable lenses may seem like a thing of the past. However, corneal gas permeable lenses still remain a very effective option for many patients.

We have the pleasure of seeing a patient with keratoconus. He was used to wearing a corneal GP lens for keratoconus, and wanted to remain in the same lens modality. His lens was 5 years old, however the fit still looked ok. There were some scratches and deposits on the lens surface, and there was some excessive touch on the apex of the cone.


Patient’s habitual contact lens (unknown parameters)

Based on the topography, we decided to try the Rose K 2 lens. This corneal gas permeable lens is great for patients with nipple cones and oval cones. He falls into the mild/moderate category of keratoconus, so we thought this was a good lens to try first.

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The topography shows a mild/moderate keratoconus with a nipple/central cone

Based on the fitting guide, we chose the base curve that we equal to his average K. The average K was 6.96mm so we selected the 6.9mm lens in the Rose K 2 fitting set.

When we placed the lens on the eye, it looked great! We were super happy with the fit and he was able to see 20/20 in this lens. Usually, we need to try several lenses on to get the perfect fit, but we really lucked out today! The lens was very well centered with good edge alignment. There is a very light feather touch on the apex of the cone, which is visible with the wratten filter.


The Rose K 2 lens was very well centered.

Stay tuned for his dispense!

NEXT: WHAT IS KERATOCONUS?

How Do I Get Insurance to Pay for My Scleral Lenses?

How do I get insurance to pay for my scleral lenses?

If you have medical or vision insurance, they may contribute toward the cost of scleral lenses.

Some insurance companies such as VSP or Eyemed will reimburse eye doctors quite well for scleral lenses, and many offices accept this insurance for scleral lenses.

Other insurance plans reimburse eye doctors poorly for scleral lens fittings. Some of them reimburse less than the cost of the lenses! In this case, it is not feasible or realistic to expect your doctor to fit you into scleral lenses.

One way to get your insurance to cover scleral lenses is to have your doctor write you a letter of medical necessity.

This letter should include”

– Patient’s name

– Patient’s date of birth

– Date patient was seen

– Patient diagnosis

– Patient’s vision (uncorrected)

– Patient’s vision (corrected with glasses)

– Patient’s vision (corrected with scleral lenses)

– Abnormal findings

– Recommended treatment and plan

– ICD 10 codes

– CPT codes

– V codes

The letters we write for patients explain to the insurance company why the patient needs scleral lenses. Usually, our patients suffer from a medical eye condition such as keratoconus, corneal scarring, corneal transplants, RK scarring, post LASIK, etc so the reason they need scleral lenses is to improve their vision. Other patients have medical eye conditions such as extreme dry eye, graft-vs-host disease, sjogren’s, stevens-johnson and other disorders related to the ocular surface. Whatever the reason is, we will write a letter explaining to the insurance company the need for scleral lenses.

before+and+after+severe+dry+eye+with+scleral+lenses

Our patient who has extreme dry eye. Notice the major difference in her eyes before and after scleral lenses.

You can also have your doctor give you a list of diagnosis codes, ICD-10 codes, CPT codes, and V codes, along with the pricing for each service. This will allow the insurance company to see what is being requested, and the specific dollar amount needed.

Your insurance company may also request to speak with the doctor. In this case, your doctor will set up a meeting with the insurance company to explain your medical eye condition and explain why scleral lenses are necessary.

With some help from your doctor, you may be able to get a portion or the entire scleral lens fitting covered through your insurances.

Do Scleral Lenses Work for Everyone?

Do scleral lenses work for everyone?

Scleral lenses are becoming a very popular contact lens choice for a variety of patients. Scleral lenses have given us the ability to fit even the most complicated eyes. Scleral lenses are also very comfortable compared to other contact lens modalities. Corneal gas permeable lenses are notorious for their significant discomfort. While the vision is excellent in corneal GP lenses or hard contact lenses, the comfort can sometimes be unbearable, which leads many patients to discontinue wear.

Luckily, scleral contact lenses are much more comfortable, so many doctors select that as a first line approach. In the past, scleral lenses were used as a “last ditch effort.” Doctors would usually fit patients into corneal gas permeable lenses, hybrid lenses, and other lenses before reaching for a scleral lens.

While scleral lenses are a great option for many patients, not all patients can wear scleral lenses. Sometimes patients have a very difficult time inserting a scleral lens. They cannot hold their eyelids open far enough or perhaps their eye is too sensitive and blinks the lens right off of the eye. Also, some patients have eye conditions that will not support a scleral lens.

Corneal transplant patients often fall into this high risk category. Patients who’ve had corneal transplants are at greater risk for corneal edema and graft rejection. For this reason, many patients are unable to wear scleral lenses. Scleral lenses cover the entire cornea, which limits the amount of oxygen that gets to the transplant. The cornea requires oxygen to stay healthy. If the cornea cannot keep up with the oxygen demands, it can start to develop swelling, also known as edema. This swelling causes the transplant to become cloudy and then it causes the vision to become blurry.

Scleral lenses can also cause the corneal transplant to reject, which is very scary. This is why it is so important to follow up with your doctor. They need to assess the health of your eye and the cornea to ensure any contact lens is not causing any damage.

For many transplant patients, a corneal gas permeable lens is the best option. A corneal GP lens does not cover the entire cornea. Every time you blink, the contact lens moves and gets fresh tears underneath the lens to nourish the cornea. Patients who wear corneal GP lenses are at much less risk of corneal edema and transplant rejection compared to patients who wear scleral lenses.

If you have a corneal transplant, be sure to check with your eye doctor to find out what type of specialty contact lens is the best for your eye safety.

corneal+gp+lens+on+patient+with+PKP+and+glaucoma

Corneal transplant patient with glaucoma wearing a corneal gas permeable contact lens

CASE REPORT – CORNEAL TRANSPLANT PATIENT

Keratoconus patient switched from corneal gas permeable lenses to scleral contact lenses

Kind referral of a Keratoconus patient from Dr. Starlin!

▪️Keratoconus patient who has been wearing corneal GP lenses for the past 20+ years.

▪️His vision has been great over the years, as well as comfort, but over the past 3 years he has noticed that the lenses keep dislodging from his eyes and he has to replace them 4 times per year.

▪️After reviewing his case and taking measurements of his eyes, we decided to try scleral lenses in office. Scleral lenses are a great option for patients who have issues with lens dislodgment. Since scleral lenses are tucked under the upper and lower lids, they do not dislodge from the eye like corneal GP lenses do.

▪️With the Ampleye scleral lens, he was able to achieve 20/25 in the right eye and 20/20 in the left eye! The central clearance was excessive, so we altered the sag in each eye by 200 um.

▪️The topography looks a bit strange in the left eye, but that is likely due to his habitual corneal GP altering the true corneal shape.

▪️Looking forward to his dispense next Friday! All of the new Cornea and Contact Lens Residents will be able to witness his dispense live, so it will be very exciting!

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Corneal Transplant Patient Fit With Gas Permeable Contact Lens

Kind referral of a corneal transplant patient from Dr. Shibiyama from UCLA/Jules Stein!

Older gentleman with a history of keratoconus in each eye. He had bilateral transplants back in the 1970’s and 1980’s and they held up for quite some time!

He also has a history of glaucoma with bleb surgery in each eye, and a shunt in the right eye.

The right eye underwent cataract surgery 2 years ago, and also received a new corneal transplant in March, and is ready to be re-fit into a new specialty contact lens.

The left eye transplant looks great, however, due to a large cataract, his vision is limited in that eye. He is wanting to get the right eye fit with a contact lens prior to proceeding with cataract surgery in the left eye.

The left eye has a hugely elevated bleb, so the corneal lens was specifically designed by Dr. Shibiyama to decenter laterally and inferiorly to protect the bleb.

The topography did not look severely irregular in the right eye, so I chose the ACE corneal gas permeable fitting set. The 7.0 base curve actually centered quite well, and I was pleased with the fluorescein pattern. With an over-refraction, he could achieve 20/80 vision. Despite a beautiful transplant and clear IOL, the vision is limited due to his advanced glaucoma.

With the help of Art Optical expert consultants Bethany and Erik, we designed the lens and got it ordered. Will keep you posted on his results!

Keratoconus Patient Fit With Scleral Lens

Thank you Dr. Ortiz for your kind referral of this keratoconus/dry eye patient!

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This patient suffers from a corneal transplant as well as a pterygium

A hispanic male presented to the office for a contact lens consult. He was diagnosed with keratoconus years ago, by another eye doctor. Keratoconus is an eye disease where the cornea, the front part of your eye, changes shape and becomes thinner and steeper over time. The danger of the eye becoming steeper and steeper and thinner and thinner over time means that the vision can become more distorted and blurry. It can also lead to eye issues such as corneal hydrops and possibly issues that would lead to a corneal transplant. Common treatment options include glasses, hard contacts, gas permeable contacts, hybrid contact lenses, and scleral lenses. Corneal crosslinking should also be considered for keratoconus patients.

This patient had corneal crosslinking in the right eye a few months ago and he is scheduled for the left eye in 2 months. Cross linking helps to stabilize the cornea and prevent it from worsening, or help slow it down. Cross linking is highly recommended for many keratoconus patients and should be considered. There are 2 types of cross linking, epi-on and epi-off. This patient has an epi-off crosslinking procedure called Peshcke cross linking.

A corneal transplant is not something that should be considered in the early days of keratoconus. Most of the time, corneal transplants are reserved for patients who have issues that cannot be resolved with traditional treatments such as eye drops, glasses, contacts, soft contacts, hybrid contacts, gas permeable contacts, hard contact lenses, or scleral contact lenses. If patients cannot see clearly with any of the aforementioned items, a corneal transplant may be warranted.

Corneal transplants also come with risk. Many times, the patient will be on medicines and eye drops for a very long period of time, and in some cases for the rest of their life. There is also a risk of a rejection. Also, 30% of corneal transplant patients end up with glaucoma, which is an incurable eye disease. If we can prevent a corneal transplant, we will.

This patient he was fit into corneal gas permeable lenses by another eye doctor many years ago. He claims that his vision is quite good with the lenses, but they are very uncomfortable. Especially in dusty and windy environments.

He does have some central scarring on the right eye and some scarring inferior/temporal on the left eye. The scarring is likely from his corneal gas permeable lens being a bit too flat for his eye and/or the keratoconus worsening.

He also has severe dry eye, which Dr. Ortiz has been managing. He has been using Oasis tears every hour with and without his contacts. He also had punctal plugs inserted by Dr. Ortiz to help with his severe dry eye.

After evaluating the eye, we discussed the different options. I did make a strong recommendation for a scleral lens compared to a corneal gas permeable lens to try and prevent the scar tissue from worsening. The scleral lens will also provide better comfort for him and hopefully help with his dry eye syndrome too. Since scleral lenses are filled with non-preserved liquid, it can act as a barrier to the outside world and lubricate the eye all day. Many patients are actually fit into scleral lenses who have extreme dry eye.

eyeprint 3d scanning

The EyePrint Pro uses a 3 D scanner to create a perfectly fit scleral lens

Eyeprint mold after setting

An impression of your entire eye is taken to design a custom fit lens

Due to the keratoconus, corneal scarring, pterygium and severe dry eye, the patient opted for the EyePrint Prosthetic. The EyePrint Prosthetic is a lens that is custom made specifically for a patient’s eye. An impression is taken of the entire ocular surface, which takes about 3 minutes in office. The impression is then sent to the lab in Colorado, where the impression is scanned with a 3-D scanner. After that, the lens is fabricated and then shipped back to the doctor.

We obtained an impression of the right eye in the office today and then placed a diagnostic lenses on his right eye. We then placed a diagnostic scleral lens onto the eye with 8.04 base curve and -8.00 power. With the traditional scleral lens, there was some compression at 3:00 and 9:00, especially where the pterygium was. This will not be an issue once the Eyeprint PRO is designed. With the diagnostic lens, he was able to achieve 20/30 vision. This is typical for patients who have central corneal scars.

The lens was designed and ordered today and should arrive here soon!

Thanks again Dr. Ortiz for your kind referral! It is always a pleasure managing keratoconus patients together!

High myopia patient fit into scleral contact lens

Thank you Dr. Isozaki for sending us this fun case!

34 year old Asian male was seen at UCLA by my good friend and classmate, Dr. Veronica Isozaki. He has a long history of corneal gas permeable lens wear, since he was about 10 years old.

After a very thorough case history, and after examining his current lenses, he mentioned that his last eye doctor in New York was attempting “orthokeratology daytime lenses.” I didn’t know what he meant until I saw the lens fit on his eye and the topographies.

The lenses both showed central bearing with midperipheral pooling (not a classic orthokeratology pattern, but I can see what he meant by ‘daytime orthokeratology lenses.” The left eye also shifts during blink which causes a chance in his vision.

We reviewed a variety of lens options extensively, and we decided to attempt an oblate scleral lens for now. I could attempt to redesign lenses based on his current topography, but the artificial shape might cause me to chase the lens fit over and over again. I recommended starting fresh with a scleral lens and we can monitor his corneal “unmolding” and if he truly wants to go back to the corneal gas permeable lenses, we will have a much better baseline.

The over-refraction was not attempted due to the autorefract data being -22.25 in the right eye and -22.75 in the left eye.

With an oblate design and also adjusting the base curve, we were able to decrease the power to about -16.00.

The first lens will be sort of a custom diagnostic lens. He knows that the shape of his eye and potentially the power will need to be adjusted as things progress. Will keep you posted on his results!

What to expect during a scleral lens fitting

What to expect during a scleral lens fitting:

Full video on YouTube:

https://youtu.be/C-igXQ_J_KY

▪️Your Doctor will take several images and measurements to determine the best lens for your eye.

▪️Then, a series of scleral lenses may be placed on the eye.

▪️The Doctor will evaluate the fit with the microscope and other imaging to determine if any changes are needed.

▪️They will then check your vision to determine what power to add to the lenses.

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