SCLERAL CONTACT LENSES

Keratoconus Patient Referred To Us For Contact Lens Consultation

Thank you Dr. Wellish for your kind referral of your patient to our clinic!

We had a very nice 48 year old patient referred to us for a contact lens consultation.

He was diagnosed with keratoconus in his 20’s, but his corneas remained stable throughout the years, and he was able to get by with spectacles.

Over the last 2 years, he noticed a huge decrease in the vision in both eyes. He was seen by Dr. Abrams, who inserted Intacs in the right eye, and then later Dr. Wellish performed corneal crosslinking on the left eye to stabilize the vision.

Intacs OD OS cornea

NaFL 1 od Nafl os 2 (2)

He complains that his vision is very poor and distorted and also his left eye suffers from extreme dry eye. He uses Oasis tears in both eyes, along with autologous serum in the left eye. He also uses Restasis in the right eye twice per day to help with dry eye syndrome.

With glasses, he can see 20/60 “double” in the right eye and 20/150 “distorted” in the left eye.

Due to his highly irregular corneal issues, we decided to proceed with the EyePrint Prosthetic with each eye.

pachy od intacs

topo od

topo os

We took an impression of the ocular surface in each eye and then fit him with a diagnostic scleral lens to check his vision potential. With an over-refraction, he could see 20/40 in the right eye and 20/30-2 in the left eye. He also noticed his left eye felt much less dry with the scleral lens on!

We send the impressions to the lab and we will see him in 1 week for his dispense and training. He will continue to use his Restasis drops as recommended, and he will fill the bowl of the scleral lens with autologous serum and Nutrifill. He will also use Tangible Clean MPS.

We are looking forward to helping him see better!

Scleral Lens Assessment Video by Dr. Stephanie Woo

How do I evaluate a scleral lens?

Often times I am asked to discuss scleral lens assessment. What do you look for? What equipment is needed? Any other advice?

Here is a short video of me assessing a scleral lens on a patient's eye.

First, I get an overall view of the lens to make sure there are no bubbles. I also evaluate the font surface for wettability issues or scratches or deposits.

Next, I have the patient look up, down, to the left, and to the right. This helps me evaluate the edges of the lens to see how the lens is interacting with the conjunctiva. After I take a look at the lens with the slit lamp, I will then check the central clearance and edges with an OCT machine.

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.

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.

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.

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

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.

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.

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).

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.

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:

Leucci, M., & Carter, M. (2018). Clinical signs in keratoconus. Optometry Today (London), 58(11), 86.
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.
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
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
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.
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
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
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
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
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

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)

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.

OD 20210219 113937183.01

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.

Right+eye+new+latitude+lens+inf

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!

Next: What are custom scleral lenses?

Can I Use Eye Drops With Scleral Lenses?

Is it safe to use eye drops while wearing hard lenses or scleral lenses?

This is a question we get almost every single day.

In general, it is ok to use preservative free artificial tears while you are wearing contact lenses. In some cases, you can use eye drops that say “for contacts” on the label. The reason you can’t use regular eye drops is because most eye drops contact preservatives. This is normally not that much of an issue for the surface of the eye, because blinking and tearing will flush the preservatives off of your eye surface fairly quickly. However, when you wear contact lenses, the preservatives stick to the contact lens material and then that gets held onto the surface of your eye for many hours.

Your eye doctor will be able to recommend a safe eye drop specific to your unique eye and the type of contact lenses you wear. If you have a compromised ocular surface, it is very important to use preservative free products to limit the amount of BAK or other preservatives that make contact with your eye.

Keep in mind that 90% of eye drops that you see on the shelf of your locals stores are made to be used WITHOUT contacts.

If you have questions, talk to your eye doctor. Your eye doctor knows your eye the best and they are experts in eye drops!

Find out what eye drops Dr. Woo recommends here.

Can Corneal Transplant Patients Wear Scleral Lenses?

Can corneal transplant patients wear scleral lenses?

We had the pleasure of seeing a kindly referred patient for a specialty contact lens consultation yesterday.

This 78 year old white female has a positive ocular history of radial keratotomy (RK) surgery in both eyes in 1990, followed by a corneal transplant in the right eye in 1995, and then had LASIK on top of the right transplant in 1998. Radial keratotomy was a surgery performed in the late 1980’s and early 1990’s to help correct patient’s vision. It has now been replaced with safer options such as LASIK and permanent contact lenses.

Both eyes underwent cataract surgery in 2014.

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Right eye corneal transplant

She complains that her vision is blurry, distorted and double. This is very common for patients who’ve undergone RK surgery. Because of the scalpel cuts into the cornea, this creates an irregular shape, which distorts the image coming into your eye. This results in fuzzy, wavy, fluctuating, blurry vision. She was kindly referred by her corneal specialist, Dr. Casey at Nvision, to our clinic for an evaluation.

With glasses, she can see 20/200 “double” in the right eye and 20/50 “double” in the left eye. The corneal transplant looked clear centrally with minimal neovascularization inferiorly. RK scars were present on both eyes. When I assess a corneal transplant, I make sure that the center of the transplant is clear. If there is major scar tissue or haze within the transplant, there may not be an opportunity for vision improvement. Luckily, for this patient, her corneal transplant is very clear.

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Left eye showing radial keratotomy (RK) scarring

When I am not sure if a patient will see better with a specialty lens, I always place a diagnostic lens on the eye. This will help us determine whether or not a specialty contact lens will improve your vision. If we put a diagnostic lens on and perform a few short tests, it will determine the best potential for vision improvement. For instance, let’s say you can only see the 20/400 line at the eye doctor (the big “E”). If we are not sure whether or not your vision will be helped with a contact lens, we will place a diagnostic lens on your eye and re-assess the vision. If your vision improves, it is certainly worth it to move forward with the fitting process.

Before that, we took sMap 3D images of each eye to map the shape of her sclera, the white part of the eye. Then, we placed diagnostic Europa scleral lenses onto the eyes to see what her best vision would be. There was superior touch with the diagnostic lenses on the right eye (see the OCT image), so we knew a traditional scleral lens may not be the best option for her. A more custom lens would be better suited for her unique eye shape.

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OCT imaging showing superior touch

With scleral lenses, she could achieve 20/50 in the right eye and 20/40 in the left eye. When a patient doesn’t see better on the visual acuity chart, I always ask them to rate the “quality” of their vision. She stated the letters were much sharper and less distorted. Since the vision improved the overall quality and clarity of her vision, we decided to order the Latitude custom scleral lenses.

We are really hoping to improve her vision with these special lenses!

Thank you Dr. Casey for your kind referral of your patient to our clinic!

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Can you use scleral lenses for sports vision?

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Topography of keratoconus patient’s right eye

Thank you Dr. Jen Burke for your kind referral!

Dr. Burke sent a 17 year old patient to use for a corneal consultation. Even though the patient can see 20/20 with glasses, he reports seeing “lines” in his vision when he looks at a light source, especially at night.

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Topography of keratoconus patient’s left eye

A topography was taken of each eye, and you can see that both eyes exhibit irregular astigmatism. The left eye has more irregularity than the right eye. The steeper area on the left eye is also displaced nasally, so as the pupil gets bigger at night, it gets into the steeper shape, which can cause even more distortion.

As a hobby, he races formula drift, so his visual quality is very important.

With glasses, he can achieve 20/20 in the right eye and 20/30+2 in the left eye. He reports that the letters on the left eye appear more blurry and distorted.

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Photo of patient’s right eye

His pachymetry readings do not show a super thin cornea, which is great news.

We trialed the Europa scleral lens today, to see if it improved his visual quality. With an over-refraction, he could see 20/15 in the right eye and 20/15 in the left eye. He noticed the distortion was gone in the left eye, too.

We decided that the Latitude custom scleral lens would offer him the best vision and comfort, so we took 3D images of both eyes today. That information was sent to the lab and will be used to design custom fit lenses for each eye.

We are hoping that scleral lenses will help him see better and help with some of the visual disturbances. Looking forward to seeing him at his dispense appointment next week!

Thanks again Dr. Burke for thinking of us!

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Contact Lens Options for Corneal Transplant Patients

A very interesting corneal transplant patient arrived today for a consultation.

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You can see the double running suture for this corneal transplant patient

He had a herpes scar years ago, which led him to a corneal transplant in the left eye in 2018. After the transplant healed, he was fit into spectacles to improve his vision. He has always suffered with poor vision after the transplant, but claimed he didn’t know there were any other options.

I am always surprised when patients tell me that they’ve undergone a corneal transplant, but have not tried any contact lens options to correct their vision. When you get a corneal transplant, it creates a very irregular surface. This irregular surface usually requires a specialty contact lens such as a corneal gas permeable lens or a scleral lens to help smooth out the optical surface. By using a special type of contact lens to re-direct the light entering your eye, the result can be a remarkable improvement in vision.

He sought out another opinion from Dr. Wellish, and Dr. Wellish recommended a scleral lens to improve his vision.

He can see 20/200 “double” with best corrected glasses in his left eye. If you’ve been to the eye doctor, you know that the big “E” is the largest letter on the vision chart. The big “E” represents 20/400 vision, which is very poor vision. As the numbers on the vision chart get smaller, the better your vision is. Hence the term “20/20.” Someone with 20/20 vision has perfect vision. In this patient’s case, 20/200 is also very poor vision.

The transplant has a double running suture, which is what you see in the photo. This technique provides the benefits of a single continuous running suture with the added safety and security of a second continuous running suture. Corneal transplant patients run the risk of hypoxia, and not getting enough oxygen to their transplant. If this happens, patients will need to limit their wearing time with the scleral lens, or change to a different lens modality, such as a corneal gas permeable lens.

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The corneal topography for his left eye shows a high amount of irregularity

We placed a diagnostic Ampleye scleral lens: 4400 sag/ 8.04 BC/ -4.00 on his left eye to see what his vision potential could be, and he was able to achieve 20/20 vision with a +4.50 over-refraction! He was thrilled with the vision and comfort of the lens. When patients have an irregular corneal shape, I always place a diagnostic lens on top of their eye to see what their potential vision is. There have been times where the lens does not improve the vision, but it is better to find out now, instead of going through the whole fitting process.

Imagine barely seeing the big E on the vision chart and then improving the vision so that you can see the smallest line of letters! This is such a huge improvement in vision, and it will be life changing for this patient. It’s cases like these that put a huge smile on my face and warms my heart. I love helping patients see better!

We are excited to see him for his dispense in about 1 week.

Thank you Dr. Wellish for trusting us with this special patient!

Monovision scleral lenses

monovision scleral lenses

We saw a 66 year old male with a history of monovision LASIK OU 20 years ago. In the last few years, he began showing signs of ectasia OU and found about 9D of astigmatism. This is a very high amount of astigmatism! For reference, most soft contact lenses can only go up to -2.75D. His right eye (distance) was 20/30 far and left eye (near) was OS 20/ 20 at near but describes ghosting and shadowing. Both eyes, he was seeing 20/25 distance. He felt modest about his vision and was functioning well in his daily activities but wanted to see if he could see better.

With a diagnostic lens, he noticed a significant improvement in his vision and was eager to proceed. He was fit with the Latitude scleral lenses and kept in monovision. This goes to show that the number on the chart (ie 20/20) may not always correlate to the quality of vision. Even if a patient can see the letters on the chart, the letters may still have ghosting or appear doubled. This can be very debilitating for patients.

We saw him a week after his dispensing his new lenses and was thrilled to see how well he was doing with the new lenses! His vision was OD 20/ 20 far, OS 20/ 25+ near and OU 20/ 20 distance. Although he felt that his vision before the lenses were decent, he was most surprised at how much more he was able to see in his daily life. He described noticing the new details of the distant mountains during his daily drives to work.

Thank you Dr. Jenny Wong for your excellent care for this patient and for this update!

We love helping patients like these achieve vision that they haven’t seen in years!

Thank you Dr. Paul Casey for this fun case!

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