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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