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Scleral Lens Management and Ocular Surface Disease Jason Jedlicka, OD, FAAO What are the effects of Anterior Segment Disease? Decreased productivity Increased rates of depression What are the causes of Anterior Segment Disease? Stevens Johnson Syndrome Chronic Graft vs. Host Disease (GVHD) Sjogen’s Syndrome Eye surgery, such as LASIK, PRK, RK, corneal transplants, or scleral buckle Herpes Zoster (shingles) Herpes Simplex (ocular herpes) Essential Lacrimal Insufficiency Meibomian Gland Disease / Dysfunction Arthritic Conditions / Systemic Inflammatory Disease Medications Corneal Dystrophies and Degeneration What can we do to treat Anterior Segment Disease? Artificial Tears / Lubricating agents Restasis Steroids Punctal Plugs / Lacrimal Plugs / Occlusion Oral Supplements Oral Medications Tarsorraphy Scleral Lenses Quality of Life with Anterior Segment Disease Traditional treatments have low rates of success Scleral Lens rates of success can be over 70% Not only in managing eye pain / discomfort but also in improvements in mental health What is a scleral lens? Corneal lenses Corneoscleral lenses Scleral lenses What is the history of scleral lenses and how did we get here today? Lens material permeability Lathing technique and software How are scleral lenses different than other therapeutic options? Vs. BSCL Add moisture to the system rather than deprive the system of moisture Vs. Surgery Lower risk and reversible Vs. Medical therapy Less effort and significantly aids vision as well Moisture chamber = continuous protection How are scleral lenses different than other options for vision correction Stable Comfortable Customizable Cases Reports Scleral Lens Terminology Sag / Central Clearance – the total lens depth Limbal Vault / Clearance We should generally strive to not bear on the limbus Limbal stem cells are vital and cannot be compromised Scleral haptic / edge profile Needs to contour the scleral fairly well to provide comfort and proper fit Compression Impingement Local versus generalized So you want to get started… how to do it… Get Fitting Sets Diameter is the driver of how lenses are fit and their function Larger lenses can vault more = larger fluid chamber more expensive may require edge modification (toricity) more than smaller Severe Ocular Surface Disease will oftern require a larger lens At LEAST 16 mm or larger in my opinio Once you have chosen your desired diameter, then you should decide upon an optimal / desired sag Trial lens selection Middle of the set “Eye it up” Fitting guide Inserting the lens Use device or tripod fingers In office: saline and NaFl strip At home / daily = saline vials / non-preserved saline / NPAT How to assess Use cobalt blue filter and a general overview Look for areas of touch or limbal bearing over more than 2-3 clock hours If the lens looks like it touching superiorly, lift the lids and see if better centration causes better clearance If so, not as concerning Use white light and an optic section Scan back and forth Don’t use cobalt filter – it creates a “glow to the fluorescein and makes the vault look greater than it is Also harder to see the scleral lens and cornea to compare thickness to How much vault is enough? 100?? 200?? 400?? No agreement for sure now, in general larger lenses = more vault With OSD need more vault, I would shoot for 250 minimum You will lose vault with settling (about 125 microns) Allow for this if the patient is a new fit or has not worn lenses for a few days or longer Someone that came in wearing sclerals and you are refitting them will not settle as much as their conjunctiva and sclera are already compacted with the prior lens wear More unhealthy epithelium = more vault If you don’t allow for settling, you could get lens / corneal touch and damage a weak epithelium Healthier epithelium = less vault needed Unhealthy endothelium = more oxygen needed = less vault desired??? Choice of limbal clearance Need limbal clearance to avoid damaging the limbal stem cells Too much clearance can cause limbal edema More important in the ocular surface disease patient to make sure the limbus is well cleared Hence the larger diameter lenses How much is right? Typically a shallow clearance but one that is observable with a slit lamp and NaFl that extends just past the limbal area. Haptic / Landing Zone Should be as aligned as possible to the sclera If you observe blanching of conj vessels a the very edge, you need a flatter landing zone If you observe blanching inside the edge, you may need to steepen the landing zone If you observe sectoral blanching or compression, you may either live with it or perhaps go toric or quad specific Uneven bearing can lead to redness and discomfort due to being too tight in an area or bubbles / awareness / debris due to being too loose in an area Material consideration Hyper DK materials should be used, really no strong reason not too HDS 100 Boston XO and XO2 Contamac Extra and Extreme Tyro 97 Managing the Scleral lens wearer Cleaning Peroxide (with or without neutralization disc) GP cleaner with peroxide GP cleaner with GP storage solutions and saline rinse Progent Polishing / Qtip / Buffing Insertion DMV Ring O Ring Devices Removal DMV Manual Filling and insertion Non-preserved / non-buffered vials Non-preserved / buffered saline Non-preserved artificial tears At Follow up History Ask for symptoms Check VA – over refract if VA is reduced Also may need to do topography over to check for flexure Check vault with white light prior to touching lens Check for compression sectorally or over larger areas Check for staining at each follow up Always document staining (preferably with photo) prior to fitting as most will have some staining and we don’t want to confuse old staining with new. If new staining exists, consider cleaning and filling solutions Check for corneal edema, especially in those with poor endothelium