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LONG-TERM EFFECTS OF SCLERAL LENS WEAR: THE GOOD AND THE BAD

Karen G. Carrasquillo, OD, PhD, FAAO, FSLS, FBCLA

Salaried employees of BostonSight®

No proprietary interest in BostonSight® PROSE treatment

Indications – Ocular Surface Disease

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DRY EYE SYNDROME• Ocular chronic GVHD• Sjögren’s syndrome• History of refractive surgery (LASIK, PKP)• Rheumatoid arthritis• After radiation

LIMBAL STEM CELL DEFICIENCY• Stevens-Johnson syndrome (SJS)• Aniridia• Cicatricial conjunctivitis/ocular cicatricialpemphigoid• Chemical/thermal injury

EPIDERMAL OCULAR DISORDERS• Goldenhar syndrome• Ectodermal dysplasia• Atopy• Epidermolysis bullosa

NEUROTROPHIC KERATITIS• Herpes zoster (shingles)• Herpes simplex (ocular herpes)• Familial dysautonomia• Trigeminal nerve dysfunction• Moebius syndrome• After surgery

CORNEAL EXPOSURE / LAGOPHTHALMOS• Anatomic• Paralytic- Acoustic neuroma

Indications – Irregular Cornea

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DEGENERATIONS• Keratoconus• Keratoglobus• Pellucid marginal degeneration• Terrien’s marginal degeneration• Salzmann’s nodular degeneration• Ehlers-Danlos syndrome

DYSTROPHIES• Cogan’s dystrophy• Bowman’s dystrophy• Granular corneal dystrophy• Lattice corneal dystrophy• Meesmann’s corneal dystrophy

AFTER SURGERY• Cornea transplant (PK, PKP)• Radial keratotomy (RK)• Photorefractive keratectomy (PRK)• Phototherapeutic keratectomy (PTK)• Epikeratophakia• LASIK• Open globe injury

CORNEAL SCARRING• After infection• After trauma

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Limbal Compression

• Neovascularization• Microcystic corneal

edema• Suction

Haptic Impingement

• Conjunctivaqlstaining – ridge (chronic)

• Hypertrophic nodule (acute)

Fitting over tubes

• Prevention of Tube erosion in glaucoma

THE BAD

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Resolution of VLK

• Chronic corneal GP wear

Support of Ocular Surface

• Healing PED• PED

prevention• K-PRO

dessication• s/p Corneal

melts

Corneal remodeling

• When is a scar a scar?

THE GOOD Considerations when fitting scleral lenses

• Limbus

- Palisades of Vogt

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• Complications

- persistent epithelial defects

- Corneal conjunctivalization

- Chronic inflammation

- Corneal neovascularization

Chan, C. and Holland, E. (2013) Severe Limbal Stem Cell Deficiency From Contact Lens Wear: Patient Clinical Features. Am. J. Ophthalmol., 155(3), 544-549.

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THE BAD• BCVA decreased from • b/w 20/30-20/40 to 20/50- Noticeable to pt- Reports hazy/blurry vision

• 57 yo caucasian female• H/O KCN/DES/Cogan’s• SCL OD 20/20-2• PROSE device OS Only• BCVA OS fluctuates b/w

20/30-20/40

Case #1

Cornea s/p 4 hrs lens removal and no lens wear

Pre Post

Diam 18mmBC change:7.90 to 8.50mm

Modification of limbal zone After increasing limbal clearanance

BCVA improves back to 20/30 range

No MCE after 8 hr challenge

LESSON: NEED TO PAY ATTENTION TO LIMBAL CLEARANCE

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Limbal Compression

• M.S. 62 y.o. female with Stevens-Johnson Syndrome

• PROSE treatment 2005

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Limbal Compression

• M.S. 62 y.o. female with Stevens-Johnson Syndrome

• PROSE treatment 2005

• Examination in 2009 showed central neo

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Limbal Compression

• M.S. 62 y.o. female with Stevens-Johnson Syndrome

• PROSE treatment 2005

• Examination in 2009 showed central neo

• Refit 2010 with higher limbal vault

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Limbal Compression

• M.S. 62 y.o. female with Stevens-Johnson Syndrome

• PROSE treatment 2005

• Examination in 2009 showed central neo

• Refit 2010 with higher limbal vault

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Examination in 2015 shows inactive vessels

Limbal Compression

• MB 54 y.o. male with Stevens-Johnson Syndrome

• PROSE Treatment 2008

• Limbal compression – active centrally progressing neo 2012

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Limbal Compression

• MB 54 y.o. male with Stevens-Johnson Syndrome

• PROSE Treatment 2008

• Limbal compression –active centrally progressing neo 8/2012

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Retreatment from16.5 mm diameter to 20.0 mm diameter

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Limbal Compression – results after refitting

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Refit from16.5 mm diameter to 20.0 mm diameter Increase limbal clearance

BEFORE

Inactive vessels (2/2014)

AFTER

Haptic Compression

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Haptic Alignment

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Edge impingement and staining

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Edge impingement and staining

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Case #1 – Hypertrophic Nodule

• 67 y.o. female – s/p PKP with h/o keratoconus OU

• Longstanding PROSE®

lenses OU

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• Developed symptomatic hypertrophic nodule infero-nasally OD

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Scalloped edge to avoid nodule

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Interim lens with channel

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Interim lens with channel

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Resolving with channel

Final lens

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Case #2 - Hypertrophic Nodule• 27 year old fit with commercial scleral lens that were fit 1

year prior to initial

• presented complaints of tenderness OD with lens wear

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• Examination revealed inferior impingement with adjacent raised hypertrophic nodule

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Final fit

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Case Study #3

• 67 year old female with limbal stem cell deficiency

• PROSE device wearer since 2012

• Developed IN HT Nodule OS

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Case #3 - Hypertrophic Nodule

• Unable to refit into larger diameter

• Discontinue PROSE device wear, soft contact lens

• Resolution after 3 weeks

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Fitting over tube

• 34 year old Caucasian male with h/o neurotrophic keratopathy from DM and neovascularglaucoma

• Supero-temporal shunts OU

• History of corneal ulceration

• Failed EW CL

• Goals of PROSE treatment:

• Support ocular surface

• In the process, do not compromise IOP

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Fitting over tube

• Conjunctival staining pattern after 3 hours of PROSE device(no channel) wear –staining over shunt area

• Custom-designed milled channel over 10:30 o’ clock position in PROSE device

• Conjunctival staining pattern after 3 hours of PROSE device wear (milled channel) – no staining over shunt area.

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THE GOOD

Relief of severe dry eye symptoms

Improved lens tolerance

Great optics

Protection from the lids and environment

Ability to vault cornea and reduce for scarring

Avoid fitting irregular corneal surfaces

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RESOLUTION OF VLKFROM CHRONIC RGP

WEAR

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Baseline

Cressey, A., Jacobs, D.S., and Carrasquillo, K.G. (2012) Management of vascularized limbal keratitis (VLK) with prosthetic replacement of the ocular surface system. Eye and Contact Lens 38(2):137-40

6 mos s/p PROSE 6 mos s/p PROSE 2 yrs s/p PROSE 4 yrs s/p PROSE 2 yrs s/p PROSE

SUPPORT OF THE OCULAR SURFACE

Recalcitrant Persistent Epithelial Defects(PEDs)

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NK

FD

Diabetes

CNV Palsy

Acoustic Neuroma

HSV

HZO

OthersOthers

LSC

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SJS

Chemical Injury

Trauma

Others

OTHERS

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NK -Diabetes LSCD

PEDs

GVHD/s/p PKP

Complications s/p K-PRO

• 83 year old female

• H/O Fuchs, s/p failed PK x3 OD

• s/p K-PRO OD

• Intolerance to SCL 2’ dryness

• Chronic exposure/?corneal thinning/PED

• UCVA CF @ 2’

• Fitted 2010

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24hrs EW 48hrs EW

• BCVA 20/70

• No further epithelial breakdown in 5 years

• Healthy corneal tissue

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Support of ocular surface s/p Rheumatoid Melt

UCVA 20/200

Fitted 201145 46

BCVA 20/30+25 yrs stable ocular surface

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CORNEAL REMODELING

Neurotrophic Keratopathy

• Presenting age: 3 year old Female

• History: Arnold Chiari malformation, hydrocephalus, seizures, myelodysplasia, partial agenesis of the corpus callosum, CN5 palsy, exposure, strabismus surgery, persistent epithelial defect

• Parents apply and remove

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Neurotrophic Keratopathy

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• Presenting vision preferential looking DVA 20/89 OD and 20/130 OS

• After 9 months Snellen Chart DVA 20/40+1 OD and 20/70+1 OS

• Noticeable improvement in opacity and remodeling after 9 months

Neurotrophic Keratopathy

Presenting age: 8 year old Male

History: presumed herpes simplex virus

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• Reduction in opacity and neovascularization after 2 years of treatment

• Entering DVA was 20/40 remains 20/20 after 2 years

Familial Dysautonomia – April 2015

• 34 yo Female

• DVAsc : OD CF 6” PH NI, OS CF 12” PH 20/400

6 MONTHS AFTER TREATMENTOD CF 6” PH NI CF @36”/OS CF 12” PH 20/400 20/500

Limbal Stem Cell Deficiency

• 58 year old Female

• H/O SCL over-wear

• H/O multiple ulcers

• DVA OS 20/400 PH 20/100

• Neovascularization and opacity encroaching visual axis

November 2013 May 2014Improved to 20/30-2 PH NI

Chronic Exposure, right side paralysis from trauma.

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2011BCVA 20/50

2015BCVA 20/20

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Conclusions

Special consideration should be given to limbal area when fitting scleral lenses

Adequate haptic alignment is needed to avoid potential acute or chronic hypertrophic ridges

Scleral lenses have prosthetic device function

They serve a great role supporting ocular surface even in recalcitrant cases to conventional therapy

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