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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.

OD corneaOS cornea

OD pannus at 800OS cornea and temporal conj irregularity

cornea OD

cornea OS

Latitude® Custom Scleral Lenses

OD OCT central clearance 152

OD OCT nasal edge

OD OCT temp edge

OS OCT central clearance 165

OS OCT nasal edge

OS OCT temp edge

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!

What Are Custom Scleral Lenses?

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

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

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

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Corneal topography showing a keratoconus patient

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

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.

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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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What is scleral topography?

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

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

sMap+OD (1)

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

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

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

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

scleral+elevation+right+eye (1)

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

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

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

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

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

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.

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.

Keratoconus patient with scar tissue achieves 20/40 vision!

We had a very pleasant patient with keratoconus kindly referred to our office for a specialty contact lens consultation.

He’s had keratoconus for years, and over time, he has developed corneal scars in both eyes. The right eye scar is much more dense and central than the left eye. Due to the limited vision potential (20/150) in the right eye, Dr. Debry recommended a corneal transplant for the right eye and a specialty contact lens for the left eye.

The left eye also has some scar tissue centrally, but we decided to try a diagnostic scleral lens in office to see what the potential vision could be. He sees 20/80 with his glasses in the left eye. With a diagnostic Europa lens, he achieved 20/40 vision, even with the corneal scar!

We decided to design a Latitude scleral lens for him, to account for some of the scleral irregularities that you see in the photos.

We will see him next week for his dispense. He is getting his corneal transplant with Dr. Debry early next week and then he will see us later in the week for his scleral lens dispense. Thanks Dr. Debry for trusting us with this patient! We love helping keratoconus patients see better!

Scleral Lenses Help Dry Eye Patient

Thank you Dr. Landin for this kind referral

36 yo HF who has a history of PRK at age 15 and reports that it may have resulted in a scar OS and dry eyes. She prefers soft CL wear over glasses but feels discomfort with the lenses due to her dry eye symptoms. She has tried various artificial tears and lid scrubs with no improvement in comfort.

Her vision in her soft contact lenses were 20/30 OD and 20/80 OS.

She currently wears Biofinity XR toric lenses due to her high prescription.

From her slit lamp evaluation, her corneal scar looked elevated and was surrounded by areas of superficial punctate keratitis. We suspected her dry eye signs to have been exacerbated with the Soft CL mechanically rubbing the elevated area.

From her evaluation, she seemed like a great scleral lens candidate especially with the goal of achieving clearer vision and better comfort with lens wear from her dry eye symptoms.

We dispensed her Europa Scleral lenses and was able to achieve 20/20 vision with both eyes. She reported better comfort in comparison to her habitual lenses. With the scleral lenses vaulting over her cornea, the area of elevation will not be further aggravated and will allow the cornea to heal.