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LATITUDE SCLERAL

Can Scleral Lenses Help Patients with RK Scarring?

One of most successful scleral lens patients arrived to the office for her annual contact lens evaluation.

She is an 80 year old female who had radial keratotomy (RK) surgery years ago. She did quite well for many years, but then her vision started to decline. She ended up having some corneal epithelial splitting issues due to the RK incisions, and Dr. Wellish had to fix those areas and then stitch them (you can see the stitches in the photos).

She also has 3+ nuclear sclerotic cataracts. When I saw her a year ago, I thought the vision potential was meek, due to her scar tissue from the RK surgery, the irregular corneal shape, the stitches on the cornea and the dense cataracts.

cataract OD cataract OS

If you asked me to guess what the patient’s best corrected vision would be, I would have said, maybe 20/50-20/80 if I had to bet money on it.

For cases like this, I always put a diagnostic scleral lens on and perform a simple over-refraction to see what the vision potential is. To our surprise, she was able to achieve 20/30 in office with a diagnostic scleral lens. She had a very large amount of against the rule astigmatism, which is to be expected in a patient who has dense cataracts.

We decided to proceed with a custom scleral lens called the Latitude. To design this lens, we needed to take 3D images of her eyes using the sMap 3D instrument. Then, the lab uses special software to design custom scleral lenses for each eye.

When we dispensed the Latitude scleral lenses, she was seeing 20/25 and 20/20 in each eye! This was shocking to everyone, and we were so happy for her. The lenses fit her eyes perfectly and she’s done well for the past year.

She arrived today for an annual evaluation of the contact lenses with no complaints. Her vision was 20/25 on the right eye and 20/20 on the left eye. The lens fit remained excellent for each eye, and the surface of the contact lenses were unremarkable. She will follow up with Dr. Wellish as directed, and we are so happy her vision and lens fit have remained stable!

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OCT – OD

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OCT – OS

oct os central

Corneal Transplant Patient Looking To Improve Vision

Thank you for the kind referral from Dr. Tami Le!

49 year old African American male came to us looking for a way to improve his vision. The patient has had corneal transplants in both eyes due to severe keratoconus diagnosed in 2013. His entering visual acuity was 20/200 right eye, and 20/200-1 left eye.

OD corneal transplant OS corneal transplant

After 3D sMap images were taken, it was discovered that the patient had almost 507 microns of scleral toricity in the right eye! The sMap is a special instrument in our office that takes a 3D scan of the patient's eye to determine the shape of the eye. For comparison, a normal scleral toricity is about 125 microns and he has over 500 microns! When someone has a very unique shape, such as this patient, we usually recommend a custom scleral lens right off the bat to minimize the amount of remakes and improve overall success of lens fitting.

OD topo axial

OS topo axial

The patient was fit into Custom Latitude Scleral Lenses in both eyes.

OCT Od Latitude central clearance 353um

OCT OS Latitude central clearance 300um

The lab designed the lenses and shipped them to our office.

The patient came in for his dispense and with the lenses on and an adjusted over refraction, the patient was able to obtain 20/20-2 right eye and 20/25+1 left eye! What a huge improvement in his vision in both eyes! This patient will not only achieve better vision but now he is legal to drive! The functionality of his vision is going to be spectacular!

OD scleral elevation

OS scleral elevation

When we inserted his scleral lenses, he was so excited to be able to see clearly for the first time in years! This is always such a joy to experience in the office.

We are so excited that his vision improved so much and we cannot wait to report his findings from his follow up visits! Keratoconus patients are so rewarding, and it is such a pleasure to help them see better!

Patient Referred To Us For Corneal Inflammatory Condition

Thank you Dr. Stafeeva for your kind referral to our office!

A 59 year old patient was kindly referred to us from her corneal specialist, Dr. Stafeeva.

This patient had a corneal inflammatory condition of unknown etiology and has been managed with many eye drops including antibiotics, steroids, and other eye drops.

Although the inflammation has resolved, she is left with a very large corneal scar with pannus and neovascularization.

You can see from the topography images, the K max is over 60 diopters in a small central island. The scleral topography images show some large amount of scleral toricity and irregularity.

Her habitual glasses are about a +4.50 in each eye and she can see 20/20 in the right eye and 20/200 in the left eye. When we don't know the vision potential of a patient, we always trial a diagnostic lens. With a diagnostic scleral lens and a +1.75 over-refraction, she was able to achieve 20/20 vision in the left eye! She was thrilled with the improvement in her vision.

Due to the large amount of irregularity, we highly recommended a custom scleral lens such as the Latitude scleral lens or the EyePrint lens. She is going to discuss with her husband and let us know which lens she wants to proceed with.

Also, we may need to fit her into a soft contact lens for the OD to account for the anisometropia, but we will determine that at the dispense.

She will continue her primary eye care with Dr. Ochiltree and any cornea care with Dr. Stafeeva.

OS cornea

OS pachy over scar

OS scar (3)

OS topo

sMap scleral elevation OS (1)

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.

topo+od

Corneal topography showing a keratoconus patient

nasal+conj+od

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

RLL+(2)

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.

sMap+OD

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

scleral+elevation+right+eye

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!

eyeprint

The end result is a beautiful scleral lens fit

OCT OD central 287

The scleral lens fit is perfect.

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Keratoconus Patient fit into custom scleral lens

Thank you Dr. Dadej for your kind referral of your keratoconus patient to our office!

This young man was diagnosed with keratoconus about 5 years ago and was fit into hybrid lenses. The hybrid lenses were not comfortable, so he was switched into scleral lenses a few years ago. Hybrid contact lenses are a lens type that combines a gas permeable contact lens with a soft contact lens. The middle of a hybrid lens is made with a gas permeable lens which is then surrounded by a soft contact lens skirt. Hybrid lenses are used for a lot of different patients. The Ultrahealth hybrid lens is intended for Keratoconus patients. Many patients do well with hybrid lenses.

This patient wore scleral lenses successfully for years.

Dr. Dadej did a great job fitting him into new scleral lenses this year, but because of the severity of his keratoconus, the lenses were still not fitting just right. He developed a corneal scar on the right eye and the left eye, and Dr. Dadej referred him to me right away to help prevent a central cornea scar. Central corneal scars can cause significant vision impairment, and may require a corneal transplant if severe enough.

After discussing the different contact lens options, we decided on the Latitude custom scleral lens. We took 3 D images of both eyes and sent the images to Visionary Optics to help design and fabricate Latitude custom scleral lenses for him. With a diagnostic Europa lens and over-refraction, he achieved 20/20 vision in each eye and he was very happy. I am excited for his dispense!

Thank you again Dr. Dadej for thinking of us to help this special patient!

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Sjogren’s patient fit into scleral lenses

A 47 year old female was referred for contact lens evaluation. She was diagnosed with ocular cicatricial pemphigoid and Sjogren’s. These two conditions cause the eyes to be incredible red, irritated and dry. She suffers frm extreme dry eye.Her habitual scleral lenses are several years old and feel that they are getting dirty and fogging. She reports poor night vision with glare and halos. She reports only using preservative free sodium chloride solution to rewet her eyes throughout the day. Her lenses are about 2 years old, per patient.

She was 20/40 right eye and left eye with her current lenses. The front surface of the lenses had poor non-wetting surface and protein deposits. You can see in some of the images how deposited the surface of her lenses were. Both eyes exhibited poor tear film stability, inflamed bulbar conjunctiva, and formation of symblepharon. Symblepharon is a condition in which the under part of the eyelid starts to fuse with the white part of the eye. This can happen with patients that suffer from extreme dry eye. Due to her signs and symptoms, we felt that a custom Latitude lens would provide her the best comfort and vision.

The Latitude is a custom scleral lens that uses 3D imaging technology. The patient looks straight ahead, then up, then down, and the machine captures 3 D images in each gaze. Then, the software stitches the images together. This give the laboratory an incredible amount of information, so that a custom scleral lens can be designed and fabricated.

We worked with the lab to help design her new scleral lenses.

We dispensed her new lenses and she reported noticing immediate improvement in comfort and vision. You can see how well the new lenses fit her eye in the images below. Due to the instability of her tear film, we started her on Cequa as well as recommending preservative free artificial tears to replace the sodium chloride solution for the additional lubricating agents. Cequa is an eye drop intended to help with dry eye syndrome. We are very happy with how the new scleral lenses look and feel on this patient’s eyes!

Financial disclosures: I have no financial interest in any of the companies or products mentioned in this case report.

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.

Corneal Transplant Patient Fit With Custom Scleral Lens

We had the pleasure of seeing one of our keratoconus patients today for a specialty contact lens fitting for his right eye.

This patient has advanced keratoconus in both eyes. Last year, Dr. Stafeeva performed a corneal transplant on the right eye due to the advanced keratoconus disease. Many patients who have scarring on the front of their eye from keratoconus require a corneal transplant. She was waiting for the transplant to heal up on the right eye so she could perform cataract surgery (he had a visually significant cataract on the right eye as well).

In the meantime, we were focusing our efforts on his left eye to help improve the vision and the fit of the scleral lens. He has advanced keratoconus in the left eye with central scarring. He was fit with a scleral lens from another clinic, but when he saw us, the cornea had changed shape, and he advanced to the point where the cornea was touching the inside of the scleral lens. It is not safe for the scleral lens to touch the cornea, so it was important that we re fit him into a safer scleral lens design. He had a standard intraocular lens from cataract surgery in the left eye, as well as a scleral buckle from a prior retinal surgery. Since his eye was a very complicated case, we recommended a more custom scleral lens. A more custom fit scleral lens helps with lens comfort and can decrease redness.

We saw him in the summer of 2020 and ended up fitting his left eye into an EyePrint Prosthetic. With that lens, he was able to achieve 20/60 vision.

Today, we decided to fit his right eye into the Latitude scleral lens. We felt that because of his corneal transplant, along with the toric IOL in the right eye, a custom scleral lens would be the best option for him. With an over refraction of +2.00-3.50×116, he ended up achieving 20/15 vision! The Latitude scleral lens is a great choice for him because the custom fit of the lens will help to center and stabilize the optics of the scleral lens. This will allow for the best possible vision.

We are very excited for his Latitude scleral lens to arrive! With the amount of astigmatism, we did educate him that it could take 1 or 2 additional lenses to center the optics, but we do feel very good about the fact that he will be able to achieve such great vision.

Thanks for Dr. Stafeeva for thinking of us for this fun case!

Comfortable Keratoconus Contacts

We had a nice consultation for a patient who has keratoconus in each eye today!

This keratoconus patient noticed that his vision has declined over the past few months and is in search of a contact lens option to help him see better. He does have a history of hybrid contact lenses, but he had an experience where he could not remove the lens and had to go to the emergency room to get it removed. For that reason, he is seeking other options. Hybrid contact lenses have a corneal gas permeable lens in the center, and then they have a soft contact lens skirt. In theory, you get the vision of a hard contact lens, with the comfort of a soft contact lens.

After reviewing his images from today, we noticed that his retinal health was unremarkable, and his corneas were relatively clear in each eye. For these reasons, we felt a specialty contact lens would be a very good option for him to improve his vision.

Due to his concern for comfort, we decided to fit him into the Latitude scleral lens. The Latitude scleral lens is a very custom lens, made specific to each patient’s eye. First, we use an instrument called the sMap 3D. This device captures the curvature of the entire eye by using a special dye, called sodium fluorescein. The device requires the patient to look up, look down, and look straight ahead. The device captures images in all of the 3 different gazes and stitches the images together to create a 3D image of the surface of the entire eye. The laboratory then uses this information to design an incredibly custom scleral lens.

With a diagnostic scleral lens, he was able to achieve 20/25 in the right eye and 20/20 in the left eye! He also mentioned the comfort was already better than some of the lenses he has tried in the past.

We are looking forward to receiving his lenses and seeing how they fit.

Grateful to be able to help keratoconus patients see better!

Patient With Radial Keratotomy Finds Improvement In Vision With Scleral Lenses

A very nice 79 year old male presented to our office last week from a referral from his ophthalmologist. He has a history of glaucoma, radial keratotomy (RK) surgery, and cataract surgery. He also has a trabeculectomy on the left eye (a surgery performed on patients with severe glaucoma).

His left eye is blind from glaucoma, so he only uses his right eye to see.

With his glasses, he is able to achieve 20/70 vision, but complains that he sees double and he sees shadows. We decided to use the sMap 3 D scleral profilimeter to fit him into a custom scleral lens called the Latitude scleral lens.

We tried a diagnostic scleral lens on to see if an improvement in his vision was possible. With the lens, he could achieve 20/30 vision and stated that the ghosting and double vision is gone!

We ordered the Latitude scleral lens and once it arrives, we will schedule him in office for a contact lens dispense. We are very excited to see if this specialty contact lens will improve his vision and help him see better!

Since he only has one eye, it will be very important for him to properly clean and disinfect the contact lens every day. Since he only has one eye left for vision, we must ensure proper wearing time and lens care to minimize the risk of eye infections due to contact lenses.