c ontact l ens u pdate a discussion of new (and old) lenses for keratoconus, post surgery, and...

CONTACT LENS UPDATEA discussion of new (and old) lenses for keratoconus, post surgery, and severe dry eye.Cathy Wittman, OD

Texas Tech University

Topography Review

The numbers (indices)SimK: Simulated Keratometry: Instead of

using two data points in each of two orthogonal meridians as in traditional keratometry, the topographer samples multiple points along the steepest and flattest meridians.

Topography Review

CEI: Corneal Eccentricity Index (aka E-VALUE): A measure of corneal eccentricity, a global shape factor.Negative e-value: A negative e-value indicates

a flat central zone with a steep mid-periphery (oblate surface).

Zero e-value: A perfectly spherical cornea.Positive e-value: A cornea that is steep

centrally and flattens peripherally (prolate surface). This is the most common.

The average e-value of the normal cornea is about 0.43.

Greater than 0.7 suspect keratoconus.

Topography Review

SAI: Surface Asymmetry Index (similar to the I-S Value- the Inferior-Superior Value):Measures the difference in corneal powers

at every ring (180 degrees apart) over the entire corneal surface). The I-S Value typically compares five points of the superior half of the cornea with five points of the inferior half.

Corneas with a difference of 1.4-1.9D within one meridian, suspect keratoconus. Over 1.9D highly suspect keratoconus.

Topography Review

Color Scale: Normalized and AbsoluteNormalized: The color scale is normalized

around the median dioptric value for that specific map.

Absolute: The color scale is fixed from map to map, so a certain color represents a certain dioptric value for every patient.

Topography Review

With-the-rule astigmatism

Topography Review

Against-the-rule astigmatism

Topography Review

Normal Cornea

Topography Review

Pellucid Marginal Degeneration

Topography Review

Keratoconus

Topography Tip

If you are having trouble capturing a topo image, use thin disp SCL, NPATs, & have pt blink just before capture.

BEFORE AFTER

Topographers

Confoscan: Corneal Confocal Microscope

Case #1

BVA with specs 20/150

Penetrating injury caused corneal scarring nasally (blue) and distorted the pupil nasally. Because of the position of the “cone” superior temporally, all standard sized RGPs decentered temporally and caused the patient to see through the peripheral curves nasally.

Case #1

Case #1

15.0mm Digiform-N Corneal-Scleral Lens

20/60+

Truform Tru-Scleral and Digiform CScleral

The Tru-Scleral lens by Truform has a diameter range of 16-20mm, with a standard size of 18mm that is vented by radial channels that are cut into the periphery. The Digiform corneal-scleral lens has a diameter range of 13.5 to 16mm. We have two fitting sets of 15.0mm lenses at TTU; the N (normal) and the K (keratoconic).

To avoid bubbles, have patients fill the lens with solution and look down when inserting the lens.

Remove using a DMV positioned close to the bottom edge of the lens or remove without a DMV using one finger at top edge and another finder at lower edge.

Truform Tru-Scleral and Digiform Biggest Caution: Do not fit this lens tightly! Even though the lens is fenestrated, you can

cause harm by fitting too tightly. Let the lens sit in patient’s eye for 15 to 30

minutes and re-assess. You cannot assess fit by looking at movement.

Scleral lenses have minimal if any movement. Observe for blanching vessels, NaFl indentions at

lens edge, and difficulty removing the lens because of lens suction. These things mean the lens is too tight.

You should have tear exchange underneath the lens.

The Digiform also available in a post surgical fitting set.

Tru-Kone and Digiform

Case #2: Stevens Johnson Syndrome

Pt required a PKP OD because of a perforated cornea. Pt also required a partial tarsorrhaphy OD.

First presented to our clinic after being discharged from the burn unit after treatment of Stevens Johnson Syndrome.

Subconj Avastin injection given during follow up care after PKP for neovascularization.

Pt is using Vitamin A ointment in each eye. Fit into Digifrom N1 15.0mm scleral lens by

Truform.

Case #2

Good apical clearance. The goal is no corneal contact to maintain thick tear layer between cornea and lens. (Pt is on Vitamin A ointment which is which is causing disruption of tear film on surface of the lens).

Case #3

PKP patient who discontinued wearing her RGP six months ago due to discomfort and was 20/70 in that eye in her spectacles.

Case #3

Digiform corneal-scleral 15.0, BC 7.4

Actually too flat. Nasal edge lift. Bearing. See next slide.

Case #3

Digiform K1 15.0, BC 7.1

Edge lift eliminated. Nice NaFl pattern. Minimal bearing in flat meridian.

Salzman’s Nodular Degeneration

Digital Camera

TRUFORM TRUKONE

Fitting set recommended. We have a fitting set here at TTU. Works with most mild to moderate

keratocones and some more advanced cones.

If you cannot find a good fit with the Trukone, move on to the Quadrakone.

TRUFORM QUADRAKONE

Peripheral curve system can be altered in different quadrants, in order to provide a customized fit for each patient. They dot the steepest quadrant.

When the keratoconus has progressed to a point where you cannot eliminate the inferior edge lift caused by the cone, you can steepen the base curve in the inferior quadrant to “lip” the lens in and minimize edge lift.

I have found that if you decrease the overall diameter as much as possible without getting the peripheral curves into the pupil, you can minimize edge lift.

REVITALEYES

A soft contact lens developed by Metro Optics that is FDA approved for post laser refractive surgery patients.

Is not recommended for PKP patients. Made of Hioxifilcon B

SYNERGEYES Hybrid Lens with a rigid center and soft skirt. Biggest complaint has been the Dk of the

skirt. Low oxygen permeability has been attributed to neo and corneal edema.

Some practitioners feel the skirt can tighten over time contributing to less oxygen permeability and prefer piggyback (RGP with silicone hydrogel).

SynergEyes A: For patients with astigmatism SynergEyes Mutifocal: For presbyopes SynergEyes KC: For keratocones SynergEyes PS: For post-surgical patients:

PKP, refractive surgery, corneal trauma

Fitting Sets

RevitalEyes and Synergeyes

Wavefront Technology

Myopia, Hyperopia, and Astigmatism are Low Order Aberrations.

Aberrometers measure High Order Aberrations; Coma, Trefoil, Spherical Aberration, and Irregular Astigmatism.

Readings from the aberrometer are then used to design a lens. This is similar to the iZone spectacle lenses that are available.

Most dramatic results with patients who did not have a good outcome with refractive surgery.

Wavefront Analyzer

PEDIATRIC CONTACT LENSES

Silsoft Made of Elastofilcon A Can be worn overnight. Parameters

Kontur Cannot be slept in. Occluder Lenses (can also use Adventures in

Color) Parameters

SpecialEyes Made of Hioxifilcon Any curve, any power, any axis

Mutifocal and Bifocal Contact Lenses

Frequency and Proclear Multifocal contact lenses still working well. Proclear has a toric multifocal that we’ve had some success with.

Bausch and Lomb’s Purevision Multifocal is still working well.

Vistakon is coming out with a new multifocal. Best clarity still with RGPs.

R&D Here at TTU

Dr. Ted Reid is doing research on a selenium coating that would give protection against microbial infection.

Selenium Treated Contact Lenses

Pseudomonas Untreated CL Pseudomonas Treated CL

Selenium Treated Contact Lenses

Staph Aureus Untreated CL Staph Aureus Treated CL

New Treatments for Keratoconus

Collagen Crosslinking and Riboflavin (C3-R)Over the course of a lifetime the cornea

becomes progressively stiffer due to natural cross-linking between the collagen fibres.

Epi is abraded from the cornea and the riboflavin drops are applied. UV light is then focused onto the cornea for 30 minutes then a bandage contact lens is worn for 3-4 days.

This causes the cornea to become more rigid because riboflavin strongly absorbs UV light which increases the cross-linking of the collagen fibers.

New Treatments for Keratoconus

Intacs Corneal Implant Flattens the steep part of the cornea or cone to

reduce vision distortions.

PROSTHETICS

Donnie Franklin, B.C.O., B.A.D.O. (Board Certified Ocularist, Board Approved Diplomate Ocularist) of Fort Worth Eye Prosthetics comes to our department monthly to fit prosthetic eyes. If you have a patient who has a prosthetic eye that needs polishing or replacing, Donny can do that for you. His number is 817-429-8086 or Toll Free at 866-427-8130.

TTU Friendly Staff and Residents

LOW VISION UPDATEA demonstration and discussion of electronic low vision devices.

Cathy Wittman, OD

CCTVS

They have become more compact with flatter screens.

Merlin LCD Monitor sizes; 17”, 19”, and 22” 2.4x to 77x mag

CCTVS

The AcrobatUp to 65x19” monitorCan be used for distance or nearPivoting, sliding arm“Luggable”Good for studentsCan be used for

applying cosmetics.

PORTABLE CCTVS

Amigo3.5x to 14xTilting ScreenFreeze FrameCan connect to TV for

increased mag

PORTABLE CCTVS

Nemo4.5x to 9xFreeze Frame

JORDY

2x to 28x distance viewing 2x to 70x near viewing on 20” monitor (not

included) or can view the material on the virtual reality monitors built into the Jordy.

Optional desktop stand attached to a monitor, it can be used as a desktop video magnifier.

MAX AND MAX PANEL

The Max: 16-28x Connects to any tv

or monitor Cost Effective The Max Panel: It’s

the Max with a slim LCD platform.

Less mag than the Max (10-14x) because of the small LCD.

VIDEOLUPE PLUS

3x stand magnifier when used without a monitor or tv.

Up to 16.5x on a 28” tv.

Made by Eschenbach.

COMPACT +

Thin and light. Provides up to 10x

on a 4.3 inch widescreen.

Collapsible handgrip.

Snapshot button for capturing images

5 viewing modes.

KNFB READER

Recommended Reading Keratoconus: What Do We Know?: Eef van der

Worp, BSc, FAAO, FIACLE http://www.clspectrum.com/article.aspx?article=100943

"Eccentricity" is in Against Thin: DIANNE ANDERSON, O.D., F.A.A.O. AND RANDY KOJIMA, F.O.A.A. http://www.optometric.com/article.aspx?article=102288

Contact Lenses and Wavefront Aberrometry: Kenneth A. Lebow, OD, FAAO http://www.clspectrum.com/article.aspx?article=102254

Post-Penetrating Keratoplasty: Association of Optometric Contact Lens Educators http://www.aocle.org/livlib/post_surgB.htm

Recommended Reading Corneal Topography Tips: Paul M. Karpecki, OD

http://www.optometric.com/article.aspx?article=5077 Validating Corneal Topography Maps: Randy

Kojima, FOAA http://www.clspectrum.com/article.aspx?article=100638

Corneal Topography and Imaging: Michael W Fung, MD http://emedicine.medscape.com/article/1196836-overview

Advanced Keratoconus (hydrops): Bruce W. Anderson, OD http://gpli.info/education/book/case-39.htm

Contact Lens Case Report (VLK): Mark Andre, FAAO, Patrick Caroline, COT, FAAO http://www.clspectrum.com/article.aspx?article=12982

THANK YOU!

Dr. Cathy WittmanAppts: 806-743-2020

Direct Office Line: 806-743-9500 ext 270Cathy.wittman@ttuhsc.edu