Contact lenses are increasingly used for the management of ocular surface disease. During this live webinar, we will discuss lens options, risks and benefits, and clinical pearls to optimize patient outcomes.

Lecturer: Angel Scanzera, OD, FAAO, FSLS, University of Illinois Eye & Ear Infirmary, Chicago, USA

Transcript

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DR SCANZERA: All right. Good morning. My name is Angel Scanzera, and today we’re going to be talking about therapeutic contact lenses in the management of ocular surface disease. I’d like to start with a question. I’ll give you some time to answer that. Okay. So most of you have had some experience with soft lenses. We’ll go over everything today. There are various types of contact lenses, soft being the most common lens. These are mostly used for refractive purposes, but they can also be used for cosmesis, if we need a tinted lens for a patient with significant light sensitivity, and there are therapeutic reasons as well. A rigid gas permeable lens sits entirely on the cornea, but because there is tear film between the contact lens and the cornea, there is improved vision and optics. And these are usually used for patients for refractive correction, but they also help with corneal irregularity, and really the most beneficial patients are ones with corneal irregularity from keratoconus, postgrafts. Hybrid lens is similar to the RGP. It has the RGP center, but it has a soft skirt. So it has the comfort of the soft skirt as well. And the last one is the scleral lens. And this one has really gained more popularity in the last 20 years, even though it’s been around for a long time. It is becoming more common to use it for normal corneas, but it’s most beneficial for patients with corneal irregularity, to help with the optics as well, and therapeutically, to help with ocular surface disease. So the focus is going to be on soft and scleral lenses. I understand everyone’s experience with therapeutic contact lenses is different, and it really depends on what options are available to you. Today we’re going to go over some indications for contact lenses, soft lens parameters and fit assessment, scleral lens overview and fit assessment, and a case review. And the goal is to have knowledge of when to consider a soft or scleral lens for the management of ocular surface disease. I will not be focusing on how to fit a lens. There will be a lecture on this in a couple of weeks, so I recommend that you attend her lecture as well. So what are the therapeutic uses? The main one is mechanical protection. Protection from lid scarring, lagophthalmos, it helps with environmental factors such as dust and wind that can be irritating to a patient with ocular surface disease. It can help with corneal epithelial hydration, wound healing, and pain relief. I keep the drug delivery in parentheses. There are studies on that, but we won’t be focusing on that today. So when should we consider therapeutic lenses? Ocular surface disease is caused by conditions which affect eyelid function, tear production, or integrity of the corneal epithelium. Most commonly for acute problems such as abrasions and erosions, and more chronically for keratitis and severe dry eye. But there are a variety of ocular surface disease, including persistent epithelial defects, neurotrophic keratitis, trauma, pain patients, chronic management of chemical burns. We’ll talk slightly about K-Pros at the end of the lecture. Mainly the idea is that when other treatments aren’t sufficient, a soft and scleral lens should be considered. Most of these patients have tried artificial tears and topical drops. Some have had amniotic membranes trialed, or tarsorrhaphies, and this might be the last option. In our practice we start with a soft contact lens. If the soft contact lens isn’t sufficient, we might then consider the scleral lens. So when it comes to the contact lens parameters, the first thing I want to talk about is the polymer of the lens. Hydrogel lenses are an older material. These lenses tended to cause hypoxia, corneal neovascularization, and edema. And the more popular polymer today is the silicone hydrogel lens. In the US, about 76% of soft contact lens wearers are in a SiHy lens. Internationally, it’s at 65%, with the highest in Switzerland at 91%. The oxygen permeability is the reason that the silicone hydrogel is much better than the hydrogel option. There’s much higher oxygen permeability, which is the ability of the lens to allow oxygen through to the cornea. And the oxygen transmissibility is the oxygen permeability based on the thickness of each lens. So it will be different based on the thickness of each lens. There was criteria published in 1984 to determine that oxygen transmissibility of 37 was the critical number in preventing hypoxia in overnight wear. What I would like to say is for our patients, I don’t put any normal patients or non-ocular surface disease patients in overnight wear. I might fit them with a lens that is approved for that, but I recommend it to lower the risk of infection in those patients. Base curve is the measure of the curvature of the lens. As the number increases, the lens is flatter. The diameter of the lens, and daily versus extended wear. Daily means they’re disinfecting overnight, versus extended wear is wearing it full-time. These are the materials used in the US. As you can tell, at the bottom end is the soft lens. The others are hydrogel. So very low oxygen permeability. More recently, in the last ten years, there have been daily disposable hydrogel lenses, which have been a game changer for our dry eye patients. In the US, almost 25% of patients are in SiHy daily disposables, compared to 37% internationally. If you look up to the Air Optix Night and Day, you can see oxygen permeability is continuing to increase. The FDA does approve these lenses for a specific replacement period, and extended wear, you’ll notice with the Biofinity, they recommend six nights and seven days on, with the lens being good for a week, rather than a month. So the Food and Drug Administration has to approve a lens to be used as a therapeutic. We can use these lenses in a normal patient, but the definition for FDA approval was use as a bandage to protect the cornea, and to relieve corneal pain in the treatment of acute or chronic ocular pathologies, such as bullous keratopathy, corneal erosions, entropion, corneal edema, and corneal dystrophies as well as postsurgical conditions. So if you look at the oxygen permeability, it’s really high. These lenses are all available in two different base curves. We usually will start with one. If the fit isn’t good, we might change the base curve to improve it. These lenses are also approved for specific wear schedules. So the Acuvue Oasys is approved for a two days, but if it’s extended, you can wear it for seven. And in this case the patient should always be on a topical antibiotic. So we’re assessing centration of the lens, we want to make sure there’s full limbal coverage and no exposure. We do want movement of the lens, but we want to make sure that when there is movement, when the patient blinks, there is no limbal exposure during that time as well. I think one of the most important factors is patient comfort. I will ask the patient if they notice dryness, and if they do, how long after they put in the lenses do they notice it. Does it get better when they remove the lenses? That information gives us an idea of if we should just change the base curve or if we should change the material altogether. Deposit formation. There are some lenses that may cause deposits for patients. Sometimes we’ll switch straight to another brand. In other cases, I may just shorten that extended wear period as well. And then for every patient I do evert the upper lids and monitor for papillae. So soft contact lenses have many advantages. They’re fairly easy to fit, they’re readily available. I would recommend having these in-office at all times, in case you do have a patient that needs a therapeutic lens. They provide great initial comfort, and they can help with improving pain in patients with foreign body sensation. They provide full corneal coverage, and they’re available for part-time or short term full-time wear. And they’re fairly inexpensive. Disadvantages: There’s always risk of infection with contact lens wearers, and so the need for prophylactic antibiotic is really important in these patients. There can be severe lens loss in severe dry eye patients. And it may not be the perfect fit for patients who have corneal changes due to injury or chemical burn. So which of the below is not a contraindication for contact lens use? Okay, that was pretty good. So with neurotrophic keratitis, these patients do need to be followed very closely. Because they don’t have sensitivity, they won’t be able to come tell you when they’re in severe pain. Some of them might have blurred vision from epithelial defects and other findings. So our most noted sign is redness. And those patients should be followed very closely and monitored for that. Active infection — we never want to put a contact lens on a patient with active infection. Poor medication compliance and hygiene are also things to consider. For some reason, my slide isn’t changing. There we go. Okay. So for active infection, like we already talked about, we don’t want to put a contact lens on any patients with active infection. Poor compliance, poor access to follow-up care would be a contraindication. Patients with corneal abrasions are really great for using contact lenses, except for those who are already contact lens wearers. We do not want to use that in patients with corneal abrasions who have had contact lens wear. Active cicatricial and Stevens-Johnson syndrome — the question mark is really there. It’s all dependent on the severity of the surface of the eye. They might have an irregular ocular surface, and so you might experience more lens loss, and that’s really a questionable one. Other considerations include how long the attempt to treat is. If there are any other options. And can they wear the lens during the day and use the other options overnight. So in our case, with patients who have ocular surface disease, we tend to put them in a daily disposable lens during the day, and they’ll remove the lens at night, and we’ll use other options such as ointments, lid taping, or moisture chamber goggles. Okay. So now let’s switch over to scleral lenses. A little bit of history. The scleral lenses conceptualized by Leonardo da Vinci in the 16th century. These lenses were manufactured in Europe by Frederick and Albert Muller, and the first lens was a blown glass scleral shell, to treat keratitis in a patient with lid damage. In 1901, Zeiss created the first diagnostic fitting set. So these were first used for ocular surface disease and later for refractive reasons. Fast-forward to 2017, the SCOPE study found that scleral lenses were most often prescribed for corneal irregularity, followed by ocular surface disease and uncomplicated refractive error. We did a retrospective review in our practice, and I’ll say that in our practice, about 75% of patients are prescribed scleral lenses for ocular surface disease. And we do see a lot of surface disease, but we also believe that if we can get a great fit with rigid lenses in corneal irregularity, we’ll do that, and use the scleral lens more as a last resort. So the lens type and fit is really based on the size of the lens. Again, if I have to put a patient with corneal irregularity into a scleral lens, I might start with a smaller scleral lens, unless I can’t vault entirely over the cornea. With a patient who has ocular surface disease, I try to go with a larger contact lens. The reason for that is that we can protect the cornea and the conjunctiva. Some of the limitations are small eyelid apertures. There are some symblepharon formations that might not let us go as big as we want to. There are gas permeable lenses or hybrid cases, so we want a minimum of 100, but if we can get over 140, that’s even better. And some things affect the transmissibility of oxygen to the lens. Tear films — you’ll see on the image on the right, there’s the liquid reservoir. That’s filled with preservative-free saline solution. And it’s vaulting entirely over the cornea. There’s no touch. The smaller that area, the more oxygen is able to get to the cornea. And we also have the posterior haptics that are fitting onto the sclera. Those are supposed to be aligned, but in order to have some tear exchange, we might want one area to be a little bit flatter to allow for that. So what’s the goal of the scleral lens? Protection from mechanical forces, such as the eyelid on blink or eye movements. Maintaining a stable tear film on the ocular surface, which increases oxygen supply to the cornea. Decreasing light scatter in irregular corneas to help with improving vision and to eliminate pain. So the first FDA-approved scleral device was the prosthetic replacement of the ocular surface ecosystem, or PROSE lens. This was based out of the Boston Foundation for Sight, and was indicated for dry eye, limbal stem cell deficiency, disorders of the skin, neurotrophic keratitis, and corneal exposure. And this is a really great lens, because it is highly customizable. You can make changes in 8 quadrants. However, it’s not available everywhere. It’s only available at top institutions within the US, and I believe a few places within India and Japan. The Foundation for Sight made a new lens last year, called the Boston Sight Scleral Lens. It’s available between 18 and 19.5 millimeters, and it’s highly customizable. The lens side is based on scleral anatomy, so there’s a separate fit for the right and left eye. And more recently, late last year, the Boston XO Material was approved for use in therapeutic scleral lenses. That really has changed the name of the game for ocular surface disease patients. Availability of these lenses. So some advantages are these lenses are very customizable. We can really make as many changes as we need to with these lenses. They provide mechanical protection and full corneal coverage, and there’s constant lubrication on the cornea, which helps with our severe dry eye patients and in healing. The disadvantage is the cost is high. Much higher than soft lenses. The length of fitting is a bit lengthy. In order to make it a good fit. However, once these lenses are fit, it usually is good for about a year. And the lenses do cause some midday fogging. You’ll see on the right there’s some fogging, there’s some debris in the tear film. Previously patients had to remove the lens, and I still do have a lot of patients who have to remove the lens in the middle of the day and clean the lens before reinserting it. More recently, there are some different coatings, such as the tangible Hydra-PEG, that do help with that midday fogging. So I’m not gonna go over how to fit a lens. I think the doctor is going to do a good job of that in a few weeks. But I think it’s important to know whether or not you are the person fitting the lens what a good or bad fit is. So if you look at the right picture, we’re looking for central corneal clearing. That first area between the two green lines is the thickness of the scleral lens. Followed by that green section, which is the corneal vaults. And it’s about 300 microns of clearance there. We also want to make sure that the clearance continues into the limbal areas, so that there isn’t any touch. We want scleral alignment. One of the big things to avoid, especially in our persistent epithelial defect patients and neurotrophic patients, is bubbles. So you might have to work with their friends and family to help with that as well. This is a really good resource from Ferris State University that provides pictures to be able to compare what you’re seeing in these images. In the top it discusses central vaulting, in the middle there’s some limbal vaulting, and on the bottom, you can see the edge relationships. So in that bottom left picture, there’s severe edge lift. Patients will complain about this. They’ll say they feel the lens, and they can usually pinpoint exactly where that discomfort is coming from. As you go further and further to the right, there’s more and more impingement on the edge. You’ll see that whitening, the blanching of the blood vessels. With my patients, we try to have them back during the fitting period after one hour, three hours, and six hours of wear. And during that time, the lens continues to settle, so it gives us more and more information. Before I remove the lens, I’ll put in a drop of fluorescein and watch to see if there’s fluorescein exchange under the lens, and when I remove the lens, I’ll immediately check to see if there’s any impression ring under the conjunctiva as well as fluorescein staining. And like I said before, the patient information is really useful. You can ask the patient if they notice discomfort, when is it, is it difficult to remove, is there pain upon removal of the lens. There are a lot of different factors we can gain just from speaking to the patient about it. This is an example of a poorly fit lens. It’s a little bit tight. So we want to align that edge a little bit better. Now we’re gonna switch over to some cases. Some of them are graphic, so I do apologize for that. But let’s get started with a question. Okay, so we might have to go over this one a little bit more. So we’ll start from the top. Every patient who comes in with a corneal abrasion should be put on a prophylactic topical antibiotic to prevent any secondary infection. With patients who have abrasions from fungal or vegetative matter, we do not want to use a bandage contact lens. The other contraindication is patients who are already contact lens wearers. So that would be the answer for this one. Topical NSAIDs — I tend not to use these, but with non-steroidals, if a patient is in severe pain, I might consider it, just to help with improving the pain sensation. And cycloplegic agents — when we think about a patient being hit in the eye — can also cause an anterior chamber reaction. So if they’re complaining of severe light sensitivity, I might consider it, but again, it’s not always used, and really used on a case by case scenario. So going on to our first case, this is a 50-year-old white male that presents with a sudden onset of pain and light sensitivity. He has a history of being hit in the eye with a book two hours prior, and is unable to open the right eye. After we opened it, we instilled proparacaine, and he had a pretty large epithelial defect. I did dilate to make sure the retina was intact. But at the same time, I did instil one drop of cyclopentolate. And then I put on a Night and Day lens for the patient, which is a 30-day extended wear therapeutic lens. And we sent the patient home with the lens and with a topical antibiotic. In this case, we used ofloxacin, four times a day. The patient returned the next day, and the epithelial defect was almost resolved, and there was still some corneal haze. So the patient was instructed to continue with the contact lens, and continue with the topical antibiotics, until follow-up. So I’ll be seeing him tomorrow to remove that bandage contact lens. This is a 67-year-old African-American male. He has a history of thyroid eye disease. He had orbital decompression done twice, in both eyes, most recently about a year prior to seeing me. And his main complaint is foreign body sensation and eye pain in the left eye. So just a brief history. This patient actually presented with a persistent epithelial defect in the left eye, from trichiasis, most likely. The patient was treated with antibiotic and a soft contact lens, and the epithelial defect was almost entirely healed, but the corneal specialist thought at this point that as a long-term treatment a scleral lens might be a good option for the patient. I fit the patient into a 17 millimeter commercially available lens. He was instructed on application and removal and went home with the lens a week later. However, a few days later, the patient returned saying he was a little too nervous using the scleral lens at home. So we did return to the bandage soft contact lens. Currently he is in a Night and Day lens as well. And it is replaced every three to four weeks in the office. We have tried instructing the patient on application and removal, and he just hasn’t been able to do it. So other options are maybe getting a family member involved in the future. So like I said before, I don’t like keeping these patients in soft lenses overnight for so long, because they continue to have to be on prophylactic antibiotic as well. So in the long term, I would like to switch him to a daily disposable silicone hydrogel lens during the day and maybe moisture chamber goggles at night. But at this time we’re replacing the lens in-office every three to four weeks and depilating his eyelashes. This is another patient. 53-year-old female with new complaint of painless left upper lid growth over three months. The patient was diagnosed with adenoid cystic carcinoma. The patient underwent lacrimal gland resection and came to us complaining of severe dryness and pain. So this patient was switched to a scleral contact lens, she underwent biweekly radiation therapy for eight weeks, and was treated with a scleral lens during the daytime and ointment and moisture chamber goggles at night. The symptoms removed. The corneal staining result — I’ll just compare those pictures again, with the scleral contact lens. Question four. What lens option should be considered for this patient? Okay, so this is another one that we can review. In the long run, with this area of inflammation, it might be really tough to fit the Lens. However, there are some options that can be used. The EyePrint can use the molding of the eye to fit the lens. In this patient, this was a fireworks injury three days prior to being seen in our office. So we recommended the patient continue to be seen by his cornea specialist. He underwent amniotic membrane transplant, and was on antiinflammatories for a long period of time. In the long run, this patient might be a really good candidate for scleral lenses. However, soft lenses in this patient would likely cause frequent lens loss, and with that edge of the scleral lens on his conjunctiva, it would be really tough to fit this patient. On the contrary, these are patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. SJS and TEN are inflammatory reactions secondary to drug reactions and infections. They affect the skin and mucous membranes, and can cause blisters, erosions, and unfortunately mortality. There’s a high mortality rate in these patients. So a study by Yip found that 50% of patients with TEN developed late ocular complications. These include severe dry eyes, trichiasis, symblepharon formation, distichiasis, and visual loss. If you look at the patient on the right, you might think this is a poorly fit lens, but this is just a very angry eye. This patient presented about three weeks postpresentation of SJS. In these patients, we actually do want to fit them a little bit earlier in the process, to help with preventing conjunctival keratinization, as well as symblepharon formation. So this is a 41-year-old white male with a history of chemical burn in the right eye. This is him on presentation. He had a history of hydrofluoric acid injury in the right eye in 2005, and within two days had a large partial thickness skin graft from his thigh, which healed very well. So in 2015 he came to see us, presenting with complaint of constant dryness and epiphora. There was also 20/40 vision, 60% corneal thinning, and Dellen formation. The patient was on artificial tears four times a day, UV blocking sunglasses, erythromycin ointment at night, and a moisture chamber at night as well. So we fit this patient in a 15 millimeter commercially available scleral lens. This was a patient who had immediate symptom relief and wanted to go home with the trial lens the same day. He ultimately was fit with this lens, and used the lens during the daytime, with the moisture chamber goggles at night. The epiphora improved immediately, and the corneal punctate epithelial erosions and dellen resolved as well. The patient vision improved to 20/20. I want to point out: This patient thankfully had a really good bell’s reflex, and that did help with some of the dryness prior to presentation with us. I know that K-Pro was spoken about last week. I’m gonna talk about contact lenses with them. Indications for K-Pro include graft failure, aniridia, chemical burn, ocular trauma, herpetic keratitis, and mild forms of autoimmune disease. Complications can include compromised ocular surface due to limbal stem cell deficiency, keratitis sicca, neurotrophic keratitis, and exposure keratopathy. So these patients tend to need a contact lens to help with dryness and surface inflammation. So immediately after surgery, the patient is put into a standard lens, where the oxygen permeability is 18.8. These lenses are selected based on thickness and durability, as well as the availability of the parameters. They’re usually started with 9.8 base curve, plano power, in a 16 millimeter diameter lens. The diameters are available in 12 to 24 millimeters. So it is a really good lens to use with a lot of different options for us. Considerations for the contact lens fit include centration, full coverage, and at UAC, about 30% of patients continue with the fit in the first contact lens that they’re given after surgery. A lot of them are sent for refractive concerns, but also poor lens fit, frequent lens loss or deposits, glare and photophobia are common as well. One consideration is to make sure to have full coverage of the tube shunt and not to have any rubbing along that area. A long-term bandage contact lens is the standard of care for these patients. The Kontur lens is replaced every 6 months. Once they’re seen by the contact lens service, it’s usually due to history of some complications, so these lenses might be replaced more frequently, depending on the patient. The goal of the contact lens is to maintain hydration and protect the corneal tissues surrounding the anterior plate. There’s risk of lens loss and lens deposits. With lens deposits, we may change the patient to a hybrid lens, because that rigid area will not cause deposit. As long as we can center the lens well, the patients can have good optics, and the deposits will only occur on the peripheral part of the lens. This is a patient seen in our clinic. It was a 61-year-old White female with K-Pro. She had a history of presumed keratoconus and multiple failed grafts in both eyes, and she was status post-K-Pro in the right eye. She was followed for a long time in our clinic and at some point ended up having a tube erosion and required a tube revision and scleral patch graft. One thing I didn’t mention earlier is: With the hydrogel lenses, they do stain with fluorescein, so I would remove the hydrogel lens and stain the surface with fluorescein, to check for any epithelial defects, and look especially at the tube in these patients. When it comes to the contact lens, we either want a lens that is large enough to fit entirely over the tube, so that there’s no rubbing of the edge of the lens on the tube, or one small enough that we can center it, that misses the entire tube. And other things that we would consider are if there’s lens fluting, that means that the lens might be too flat. If the lens isn’t moving or they notice impression or blanching on the conjunctiva, we might have to flatten it. Ocular graft versus host disease is typically caused in patients who have had a history of leukemia or lymphoma and underwent allogeneic stem cell transplants. These patients are treated with artificial tears and autologous serum drops. They have a pretty high regimen, and unfortunately, if you speak to these patients, they’ll be using preservative-free artificial tears sometimes every ten minutes. So the goal is to help with decreasing that, to improve their quality of life. And contact lenses are one of those options. So the first case series is of 7 ocular graft versus host disease patients with moderate to severe dry eye, fit with the Night and Day lens. They wore the lens nightly on a continuous basis for 7 nights, and noted improved subjective symptoms and vision. There was no change in fluorescein staining or tear breakup time. In the second case series was a phase II clinical trial examining the efficacy and safety of soft contact lenses for ocular graft versus host disease. These included 19 symptomatic patients, who used a PureVision lens and prophylactic topical antibiotic. They were replaced every two to four weeks. They noticed improved OSDI within two weeks and remained stable at 3 months, but some adverse events included foreign body sensation, swollen eyelids, and excessive tearing. These studies are a little bit older, but there are a lot of daily disposable silicone hydrogel lenses available. So in our clinic, we usually start with a daily disposable silicone hydrogel lens and will consider a scleral lens if there’s no improvement in symptoms or signs. Here’s an example of a patient with ocular graft versus host disease in filamentary keratitis. 55-year-old male with history of multiple myeloma. Poststem cell transplant, five years prior. He complained of dryness, foreign body sensation greater in the left eye than the right eye, intermittent pain and light sensitivity, and had a baseline OSDI of 25. Slit lamp findings showed lid telangiectasia, PEE with filaments, and superior conjunctival staining. You can see a significant amount of filaments in each eye. The patient was already using preservative-free artificial tears, erythromycin ointment, and warm compresses twice daily, and was already fit with a bandage contact lens. He was switched over to a daily disposable SiHy lens, and his OSDI improved to 9, and slit lamp findings — as you can see, the filaments resolved and the punctate epithelial erosions resolved as well. This is a 46-year-old white male, history of severe ocular graft versus host disease, who presented with a non-healing epithelial defect. What treatments might you consider? All right. Good. So really, these patients might be on several different treatments that work together to help with the surface of the eye. A bandage soft lens might be trialed first, and if that doesn’t work, we switch to a scleral lens. In these patients, they have a compromised cornea. We’ll put a preservative-free antibiotic drop into the tear reservoir of the lens prior to insertion, and fill the rest of the lens with a preservative-free saline solution before insertion. And these patients do need to be followed very closely. So this might be one of the cases where I would potentially have a patient wear the lens overnight. But in the long run, if a patient needs to be in a scleral lens overnight there is an option of having them wear one during the day and then change to the scleral lens while the second lens is being disinfected. And it’s important to note especially in ocular graft versus host disease patients that these patients are immune compromised. So it’s really important to monitor them closely. This is our last patient. This is a patient with neurotrophic keratitis. An 18-year-old white male with a history of familial dysautonomia. It’s a genetic disorder that affects the autonomic and sensory nervous system. So these patients end up with decreased corneal sensitivity, so this patient came in complaining of frequent corneal abrasions and blurring of vision in both eyes. Best corrected visual acuity was 20/400 in one eye and counting fingers in the other. Initial ocular findings found erosions in both eyes and central epithelial defect in both eyes as well. Primary treatment includes punctal occlusion, lubrication, ointments, protective goggles, and soft contact lenses. If those options don’t work, we might switch to some of the secondary treatments, including scleral lenses, but also tarsorrhaphy, autologous serum tears, and amniotic membrane transplants. So this patient was fit with a 16.5 millimeter scleral lens in both eyes. We helped the family member train in application and removal of the lenses. With familial dysautonomia, these patients have varying levels of severity. Some might be able to do it on their own, but some might need help from caretakers or family members. Vision improved from 20/400 to 20/50, and from counting fingers to 20/200, and the corneal staining resolved as well. I just want to go over a few resources that are available to you. GPLI has some really great information. Every third Tuesday of the month, they have live webinars, and they can lecture on almost anything, when it comes to custom contact lenses. They’ll discuss scleral and soft lens updates, they’ll also discuss postsurgical care, and it is free to join, so I would highly recommend getting involved and listening to some of those webinars. There are some really great lectures. The scleral lens education society also has great resources, and they work closely with GPLI. You have to sign up for their site, but they have some resources there that are beneficial for you. And if you’re interested in fitting scleral lenses with normal corneas or ocular surface disease, I would highly recommend the new book that came out last year. Contemporary Scleral Lenses. Johns and Barnett did a good job, along with other authors, discussing case scenarios and how to fit the lens, along with a lot of other great information. I would like to thank my colleagues Ellen Shorter, Charlotte Joslin, and Timothy McMahon, for providing some of the cases I used today, and I would like to thank Cybersight for their help in planning these lectures. I think I’ll take questions now.

>> Thank you, Dr. Scanzera. If I could ask you to stop sharing your screen, and if you open up the Q and A box at the bottom of your screen, I see five questions in the queue right now.

DR SCANZERA: Just a second. So the first question: Which kind of contact lens is the best choice for a patient? I think that’s really difficult to say. It’s really dependent on what option is available to you, but like I said, I mentioned some of these therapeutic contact lenses. Things you want to look for are a high oxygen permeability. That’s really one of the most important factors for these patients in helping them prevent corneal edema. Can you use a soft contact lens for bullous keratopathy? Yes, you can. I would still use some ointments at night as well. Can the scleral lens be used for drug delivery? So we didn’t talk about drug delivery today, but with acanthamoeba, with any infection, I would likely recommend against any type of contact lens wear, especially since the highest risk factors for these cases like acanthamoeba are contact lens wear. So what is better for corneal abrasion, observation and antibiotic ointment, or a bandage contact lens? I think this is really dependent on how severe the abrasion is. I don’t use a contact lens every time. I would say most frequently I send the patient home on artificial tears and prophylactic antibiotic. Some ointments at night. Depending on the severity of the patient’s symptoms and how large the abrasion is. I’ll consider a bandage contact lens if the patient is complaining of severe, 9/10 or 10/10 pain, or if they have more light sensitivity. Anything along those lines I might consider, and if it’s a large defect, I might do that as well. What is… Oops, I just lost it. I think I just saw one. What is better for lagophthalmos, surgical treatment or contact lens? In our practice, I think our physicians are very conservative. If we can help it with a contact lens, we’ll always trial that. It’s also patient-dependent. I think it’s a balance of both. And that really… I would say the most important thing is having good co-management with your oculoplastic surgeon. Do I know of any randomized blind study of soft lens material safety and tolerability? I’m not sure if there was a randomized study comparing all of them. There are several studies comparing the benefit of high Dk in tolerability. Sorry I can’t say more. Hi, Dr. Lyons. When it comes to the Prokera lens, I don’t use it here. Usually the cornea specialist will use it. By the time they come to see us, they likely already tried it or decided that the scleral lens is a better option. Age limit for scleral contact lenses? I tend to see more adults here, but you can definitely use them in patients that are children. The main thing with that is really making the patient comfortable and gaining that comfort with the patient really early on in the process, with them and their parent. And so you might have to have the parent involved in insertion and removal of the lens, but like I said again, you have a large contact lens coming to the eye. You want to make sure not to intimidate the patient. That said, they still are a really good treatment option for some people. So patient with a recurrent corneal erosion, which one do you advise? Bandage contact lens or sclerals as a mode of treatment? Again, I always start with the soft contact lens. With corneal erosions, the soft contact lens does need to be used for a longer period of time, so the patient will be on a prophylactic antibiotic and followed for three to four weeks. Sometimes we’ll replace the lens and keep it going for two to three months, if needed, in order for that recurrent corneal erosion to heal. What is your experience in using scleral lenses in CVS. I’m sorry, I’m not sure what that means. Can we use ordinary scleral lenses for drug delivery, compared to the PROSE lens? Like I mentioned, the Boston XO material, as well as the Boston Site scleral licenses are FDA approved for scleral use. When it comes to drug delivery, I don’t have much experience with the research on that. But I think, you know, the PROSE lens is a really good option as a last resort for patients who can’t be fit in anything else. So severe conjunctival inflammation — if we can’t get that with a scleral lens, we might consider some other options. What is your choice of lubricant with a bandage contact lens? The main thing I would say is preservative-free artificial tears are really important. So the preservative is not bothering the eye for such a long period of time. Especially with bandage lenses that aren’t removed on a daily basis. Do you always have to prescribe a bandage lens after removal of a corneal foreign body? I think that’s really dependent on the size of the corneal foreign body and the discomfort of the patient in the healing process. Patient with SJS and corneal ulcer? Would you advise on a bandage contact lens? If it’s a patient with a sterile ulcer, I might consider a scleral lens. If not, then I would likely try to have the corneal specialist treat the ulcer first before inserting the lens, and I want to make sure there is no active infection for those patients. Okay. Any other questions? Thank you for attending the lecture this morning, and thanks to Cybersight for hosting.

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July 30, 2018

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