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SCLERAL LENSES FOR DRY EYE

Keratoconus Patient Wore Gas Permeable Contacts For Many Years

Thank you Dr. Ochiltree for this kind referral!

73 yo female has worn gas permeable lenses for many years due to keratoconus.

Keratoconus patients are not able to wear traditional contact lenses or glasses due to the irregular shape of their eye. Many times, corneal gas permeable lenses, hybrid lenses, custom soft lenses or scleral lenses are needed to improve their vision.

Over the past 8 years, we have successfully managed her with corneal gas permeable lenses.

In the last few months, she reported that the lenses were starting to slip and move around with increase in discomfort. She reported a long history of dry eyes with excessive mucous strands and her primary care optometrist (Dr. Ochiltree) told her that her gas permeable lenses had protein and deposits building up on the lens surface.

Upon our examination, she had several areas of dellen, SPK with staining, corneal neovascularization and pannus. We also found that her gas permeable lenses had heavy protein and lipid deposits and scratches.

At this point, we reviewed some of the options. The first option is we could keep her into the same corneal gas permeable lens type of lens. We also discussed some of the pros and cons of other lens designs such as hybrid lenses and scleral lenses. After discussing all designs, she chose the custom scleral lens.

Due her dry eye syndrome, corneal neovascularization and high scleral toricity, we felt that she would be most successful in a custom scleral lens.

Patients with dry eye may benefit from scleral lenses. This is due to the fact that there is a layer of liquid that bathes the eye all day. Gas permeable lenses rest directly on the cornea, so they can rub and irritate the eye surface. Scleral lenses do not touch the cornea at all, and rest on the white part of the eye, which has significantly less nerve endings. This results in a very comfortable lens for many dry eye patients.

With the help of Visionary Optics, we were able to design custom scleral lenses using 3D technology.

Switching between GP lens wear and scleral lenses can take some time to get used to. The patient was surprised at the stability of her vision when she looked toward her right and left. She could see 20/20 at distance out of each eye and she was happy with the comfort! Overall, she has been very happy with the change! We are excited to see how she progresses over the next few weeks.

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Latitude® Custom Scleral Lenses

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Dry Eye Patient Fit Into Custom Scleral Lens

Thank you Dr. Wellish for this kind referral.

66 year old Male was referred to us for a scleral lens consultation for dry eyes. This patient had a h/o of PRK (corneal transplants) in both eyes in the 1990’s and had recently undergone cataract surgery in the right eye

He opted for the Multifocal PC IOL for the right eye (so he could see distance and near without glasses) and was interested in doing the same for his left eye. Unfortunately, his signs of dry eyes were too severe to proceed. Dr. Wellish kindly referred him to us to help heal his left eye with a scleral lens. Our goal was to fit him into a scleral lens to help hydrate and protect the cornea, allowing it to heal for possible cataract surgery.

With a diagnostic lens, his vision improved significantly and was suspected that it could be good enough to delay cataract surgery. Due to his high scleral toricity, we recommended a custom scleral lens to maximize the fit and comfort of the lens.

After wearing the Latitude lens for about 3 weeks, he was able to achieve 20/20 in the distance! The Latitude scleral lens is a custom scleral lens that uses 3D imaging to create a custom fit scleral lens. At this point, we incorporated multifocal optics into the left scleral lens to match the multifocal IOL in the right eye. He has been very happy with his vision near and far in both eyes, and sometimes feels that his left eye is more comfortable throughout the day than his right eye! The plan is to continue monitoring his cataract and managing the signs and symptoms of his dry eyes.

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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 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!

Monovision scleral lenses

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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Lupus patient with extreme dry eye

Thank you Dr. Mallinger for this kind referral.

We have 77 yo F with a h/o of lupus erythematosus and severe dry eyes was referred to us for a scleral lens consult. Her current regime for managing her dry eye symptoms included topical steroids, constant instillation of various artificial tears, and taping her eyelids at night when she sleeps. She has tried punctal plugs, ectropion repair, medicated dry eye drops and stem cell procedures with no improvement. She reports spending most of her time sitting in the dark with her eyes closed due to her severe discomfort and light sensitivity.

When we saw her, she was very light sensitive and was wearing sunglasses inside. She had 2+ inflammation and 4+ diffuse SPK OU. She had a lot of difficulty keeping her eyes open due to her discomfort and pain from the dryness. Her VA was 20/60 right eye and 20/200 left eye with no correction.

With all that she had been through, we felt that it was worth trying a scleral lens to protect her corneas from the outside environment and allow them to bask in continuous moisture to allow them to heal. We recommended the EyePrint Prothesthic due to her highly irregular corneal surface.

It was night and day after the first time we inserted her lenses. She was able to hold her eyes open and reported significant comfort compared to her naked eye. Unexpectedly, she was able to achieve 20/25 vision! Due to the severity of her condition when we assessed her, we plan on having her wear the lenses continuously with close monitoring for the next few weeks.

We will keep you posted

Is There Hope For Severe Dry Eye Patients?

Such gratitude helping complex patients!

Our 62 year old female returned to clinic for a second EyePrint Prosthetic dispense. She suffers from severe glaucoma in both eyes, and only has vision out of the right eye. She also suffers from autoimmune issues and recurrent uveitis in both eyes.

Dr. Saboori performed glaucoma surgery on her right eye and saved her vision and she has done well over the past year. She has been able to see about 20/50 out of the right eye. Unfortunately, over the past few months, she has developed severe ocular surface disease, and her eyes are extremely dry. Dr. Lin did an excellent job managing her with all sorts of dry eye treatments such as Restasis, Xiidra, artificial tears, gels, amniotic membranes, and serum tears.

Despite all of these treatments, her eye remains very dry, which is debilitating for her. She complains that her eyes are in constant pain. She also complains her eyes are so dry, she has to constantly use artificial tears to lubricate the surface. She is also very sensitive to light. She walks around indoors and outdoors with dark sunglasses due to her light sensitivity.

She was kindly referred to us for a specialty contact lens evaluation. When we saw her, she had declined and was seeing 20/200. She explained that her eyes were in constant pain and she was miserable all the time.

At this point, we recommended something called the EyePrint Prosthetic. Because she has a very large tube shunt, it is important to fit the lens exactly to the contours of her eye. We performed the eyeprint fitting in office and designed a custom lens based on that impression.

She arrived for the EyePrint dispense when the lens arrived, and with a small prescription added to the lens, she could see about 20/50. She was thrilled that she had functional vision and her eye was no longer in pain. She felt immediate relief with the lens. We checked on the lens about 1 week later to confirm that the lens was resting on the tube shunt properly. After we confirmed the fit to be ideal, we re-ordered the lens with a new prescription.

We saw her for a dispense today with the new Rx and upon insertion, she achieved 20/30 vision! She was so incredibly happy with how well she could see and her eye felt so much better.

The lens was finalized and she will return to Dr. Lin and Dr. Saboori for dry eye management, glaucoma management, and all other eye care needs. It is such an honor to help these types of patients.

Find out what Toni has to say about her experience at our office:

Stevens-johnson treatment options

Steven’s-Johnson is a rare, but very serious disease. Stevens-Johnson Syndrome (also known as SJS) is unpredictable and can happen to anyone. It is caused by a reaction to a medication or infection. It starts off with flu like symptoms, but then spreads throughout the body in the form of a painful rash and blisters. Mucous membranes are affected, which is why eye doctors become involved.

SJS is a serious condition which requires hospitalization. After being released from the hospital, the patient usually works with a team of doctors to manage different parts of their body.

SJS patients usually have extremely dry eyes, inflamed eyes, and severe eye pain. Many patients wear very dark sunglasses indoors and outdooors. Often times, the pain is so bad, they keep their eyes closed the entire day and night. Their quality of life can be very poor.

We are fortunate to work with some of these special patients.

A 79 year old female arrived at the office last week for a consultation. She had SJS 30 years ago, and still suffers from a variety of issues. Regarding her eyes, she stated her eyes were incredibly painful all the time. She has to put preservative free artificial tears in her eyes every few minutes, around the clock! Her eyes are red, swollen, and highly sensitive to light.

You can see in the photo that her eyes are very swollen. She wears dark sunglasses all the time due to her severe light sensitivity. She keeps her eyes closed majority of the day because they hurt when she opens them.

For these types of patients, I highly recommend the EyePrint Prosthetic. This is due to the fact that we only have a very small eyelid fissure to work with. For SJS patients, they can’t keep their eyes open even for a few seconds, so it makes fitting their eyes very difficult.

By taking an impression of the surface of the entire eye, the lab is able to design a specialized custom lens. This is the best option for SJS patients, in our opinion.

We were able to take multiple impressions of each eye and send those to the lab to be fabricated.

She arrived to our office for the dispense and we inserted the lenses for her. She was thrilled with the vision and the comfort of her eyes. She wore them over the weekend and when we saw her for her follow up, she said, “You’ve given me a new lease on life!”

You can see in the photo that her eyes are much less swollen and much less red when she has the lenses in her eye. This is because the scleral lens is filled with a preservative free saline, that bathes her eye all day. This also forms a protective barrier between her delicate eye and the outside environment. Scleral lenses can be life changing for these patients. We are honored to work with these special patients – we love seeing their eyes heal and get another chance on life!

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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.

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

CASE REPORT – CORNEAL TRANSPLANT PATIENT

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.