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Recognizing and Handling Unusual Contact Lens Cases Jason Jedlicka, OD, FAAO Presbyopic Problem Children Dealing with the Astigmatic Presbyope Options Single Vision CL’s + readers Monovision Modified monovision Multifocal CL’s Soft Lenses Hybrid GP corneal aspheric concentric translating GP scleral and mini-scleral Presbyopia – addressing the need Millions of presbyopes Contact lens wear declines with age while the need for correction increases New Soft Multifocal Technology Resolving this case – Translating GP fit Scleral Multifocal – Multiple Benefits Dry eyes Corneal Astigmatism Kill 2 birds with one stone – Case Report JJ – 57 yo with dry eyes and myopia astigmatism Fit in Scleral to treat dry eye as well as correct vision Bifocal added for good measure Truform, Acculens, AVT, others? Front versus back MF Optimizing position Sclerals can decenter inferiorly Using a toric scleral zone can aid in centration Also keep diameter on the smaller side Keep vault to the shallower end (150-250?) Keratoconus Conundrums Soft Lenses to the Rescue Mild KC Go to GP right away?? Disposable Torics – can they work? Sclerals Soft lens designs for KC More options and better alternatives Kerasoft, Novakone, Soft K, Yamakone, Flexlens New designs and what they offer When will soft lenses work better? When GPs and sclerals still leave residual loss of BCVA in a milder cone, consider a soft lens fit, can often get equal vision with a lens patients will prefer KC with concomitant ocular disease Don’t miss the rest of the eye! Cases 1 and 2 – Cataracts and KC When to opt for surgery Picking an IOL Torics? Picking a lens power Case 3 - Plaquenil Maculopathy The problem assuming that reduced vision is due to the cornea Case 4 - Glaucoma Don’t neglect full eye care If needed, book your KC patients for a double exam slot so you can do a routine as well as a fit / refit Resolving BCVA with Sclerals Sometimes we get a great fit but VA is still not perfect – why? Posterior Corneal distortion Toricity – Regular and Irregular Some designs work better optically than others Higher order aberrations Spherocylidrical OR Flexure Don’t assume – do an over topo or over K Don’t hold lids apart or have the patient “open wide” – this will affect the lid position and flexure If flexure is occurring, either increase lens thickness (not just CT) or go to a toric design or both Toric Sclerals When astigmatism is NOT from flexure Back toric scleral zone if possible to aid stability Front toric cylinder to correct cylinder HOA correction on sclerals This is in the works and may be available soon The Magical World of Contact Lenses Neurotrophic Keratitis Healing the Eye Case 1, HZO Use of scleral lens as a Bandage / Therapy to correct VA and heal corneal surface Consider sclerals sooner in the treatment process Extended wear can be very acceptable Non-healing Epithelial Defects Post PTK Case 2, post PTK defect Use of a scleral lens as a bandage to help heal the surface Prokera worked only fairly BSCL did not work great Scleral lens gave best healing results Extended Wear – with post DMEK – corneal edema issues? Severe Dry Eye Sclerals can give life back again Case 3, severe dry eye Scleral lens on extended wear basis Patient’s corneal doctors comments Extended wear is worth the risk in some situations Extreme Makeover Ocular Edition Use of prosthetic lenses to restore appearance Hand painted and pre-printed prosthetics can make a difference in lives Use of lenses in monocular patients with high RX Severe RX in one eye only, ok for contact lens? Considerations When is this ok? Stressing compliance and thinking outside the box Piggybacking Problem Eyes Salzman’s Nodular Degeneration Adding a GP to a BSCL restores function 37 yo female with poor vision OU secondary to Salzman’s Post graft in one eye with complications Unable to work or keep a drivers license Using BSCL already Adding a corneal GP changes her life Considerations in this instance Trauamtic and Scarred Conj case Adding a BSCL to a GP to help with ocular surface and lens fit 50 year old male post trauma GP lens provides good vision but ocular surface is rough Irregular sclera precludes scleral lens?? soft BSCL under GP improves ocular surface and helps provide a more stable fit Eyeprint in the future?? Twice as Nice - Using Scleral lenses to treat vision issues in patients undergoing medical therapy 52 year old male Medical History Non-Hodgkin's Lymphoblastic Lymphoma, diagnosed 2007, currently in remission Underwent extensive chemotherapy and radiation Later required T-cell transplant Ocular and Contact Lens History Keratoconus diagnosed many years ago Currently using intralimbal design GP contact lenses “Secondary diagnosis” to his dry eyes in this case Chief Complaint Eyes are extremely dry after chemotherapy treatments Symptoms are constant and affect him everyday Contact lens wear has become intolerable Average wearing time is about 2 hours per day Secondary complaint Lenses feel unstable Using a scleral lens to accomplish everything Correct vision Provide stability Provide comfort from dry eyes Specialty contact lenses can be rewarding and change the lives of our patients!
