Contact lenses - College of Optometry

09/04/2014
CONTACT LENSES:
MY MOST INTERESTING CASES
Andrea M. Janoff, OD, FAAO
Assistant Professor of Optometry
Chief of Service, Cornea & Contact Lens
Nova Southeastern University College of Optometry
HYBRID OPTIONS
FOR ECTASIA & IRREGULAR ASTIGMATISM
 Softperm®
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-1985, Wesley Jessen – not avail
Low Dk-Styrene GP/Hema Skirt
3 Steep BCs for Keratoconus
 SynergEyes
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Designs for KCN
Synergeyes KC ® , 2005 & ClearKone ®, 2009
Both Paragon HDS 100 GP
Both Low Dk Poly-Hema Skirt
UltraHealth™, 2013
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130 Dk GP / 84 Dk Silicone Hydrogel Skirt
CASE 1 – KERATOCONIC PATIENT
25yo female w/ Keratoconus: +CL Awareness, OD
+Vogt’s striae, +Apical Scarring, +Munson’s Sign OU
+ Steep Sim-K OU = Advanced KCN
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09/04/2014
CASE 1 – KERATOCONIC PATIENT – TOPO OU
CASE 1 – KERATOCONIC PATIENT IN
SOFTPERM® WITH FLAT SC OD /FLAT BC OS
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Habitual CL: Softperm® Hybrid (Wesley Jessen)
OD 6.9BC / -3.75DS /14.3 OAD
DVA 20/60
 Fit Assess:
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Adequate GP Fit
Flat Skirt Fit - Edge Fluting
OS 6.5BC / -3.00DS / 14.3 OAD
DVA 20/50
 Fit Assess:
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Flat GP Fit w/ Steepest BC
+Punctate Epithelial Erosions over apex, from flat fit
CASE 1 – KERATOCONIC PATIENT IN
SOFTPERM® - NEEDS MODIFIED FIT
 Steep
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 Rx
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Availability:
-3.00DS to -16.00DS, in 0.50D steps > -8.00DS
 Fixed
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BC w/ SC, 6D Flatter than BC
BC 6.9mm (49.00D) w/ SC 7.85mm (43.00D)
BC 6.7mm (50.37D) w/ SC 7.60mm (44.37D)
BC 6.5mm (51.87D) w/ SC 7.35mm (45.87D)
Parameters:
GP Diam 8.0mm / OZD 7.0mm
OAD 14.3mm
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09/04/2014
CASE 1 – KCN PATIENT NEEDS INDEPENDENT
PARAMETER MODIFICATION: PIGGY-BACK
 Flexlens
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Piggy-Back SCL
Formerly Paragon Vision Sciences, Now XCEL
BC Range: 6.08-10.80mm, in 0.3mm steps
Diameter Range: 12.5-16.0mm, in 0.5mm steps
Material: Was only available in Hydrogel, now
available in Sihy (Definitive Material)
Power plano, but available in higher Rx
Anterior Cut-out:
 6.5-12.5mm, in 0.1mm steps
 Manufacturer: 1.0mm Larger than GP OAD
I use 8.6-8.8 larger to reduce GP dislocation
CASE 1 – KCN PATIENT EMPIRICAL REFIT TO
TRICURVE GP OVER FLEXLENS PB, OD
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GP Portion : Tricurve GP mimicks Hybrid GP*
Boston ES Material with Custom Thin Design
BC 6.85 mm / Rx -4.00 DS / CT 0.08 mm
 OAD* 8.0 mm / OZD* 7.0 mm
 SC
7.65mm Radius / 0.3 mm Width
 PC
8.65mm Radius / 0.2 mm Width
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Hydrogel Portion : Flexlens Piggyback
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BC
7.20mm / Rx plano / Hydrogel
OAD 14.5mm / Cut-Out Diam 8.6mm (GP Diam+.6)
CASE 1 – CUSTOMIZED PIGGYBACK DESIGN
IN KERATOCONUS: MIMICKING A HYBRID LENS
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SYNEREGEYES KC ® (2005)
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Aspheric BC
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Expected Fit: LFT
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Fixed Parameters:
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GP Diam 8.4mm
GP OZD 7.8mm
OAD 14.5mm
Adjustable Parameters:
BC 5.7mm to 7.10mmm, in .2mm steps
SC 0.7mm Flatter than BC = Steep SC
SC 1.0mm Flatter than BC = Medium SC
 SC 1.3mm Flatter than BC = Flat SC
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CASE 2 – 5YO MALE W/ BLEPHAROPHIMOSIS
REFERRED FOR HYBRID: SCARRING VS ECTASIA
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Blepharophimosis:
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Congenital - narrowed horizontal palpebral fissure
Occurs alone or in Syndrome: BPES
Autosomal dominant inherited mutation in FOXL2 gene
Blepharophimosis-Ptosis-Epicanthus Inversus Synd.
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Blepharophimosis: Narrow Horizontal PFD of 20-22mm (nml is 25-30mm)
Ptosis: Severe, Bilateral and Symmetric - 2° to Dysplasia of Levator
Epicanthus Inversus: Fold arises from lower lid, obscures Medial Canthus
Telecanthus: NML Interpupillary + wide Intercanthus distances
“E” Diagnosed at six months of age:
+Blepharophimosis; +Ptosis w/ vertical
head tilt (back), chin up, and over-action
of frontalis muscle.
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: SCARRING VS ECTASIA
Pre-surgical:
+Telecanthus
+Epicanthus Inversus
Other facial features in BPES: short philtrum, broad nasal bridge and
low set ears. Strabismus Amblopia - Esotropia most common deviation.
Pre-surgical:
Normal Hirshberg Reflex No Vert/Horiz Deviation, OS
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09/04/2014
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: SCARRING VS ECTASIA
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Ptosis Surgery OU at 2yo to widen vertical IPA
S/P Levator muscle resection to correct Ptosis, OU
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Post Surgical Developments, OS:
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Recalcitrant corneal abrasion
Central corneal ulcer – MK - from improper Tx of abrasion
Stromal scarring w/ irregular astigmatism
30^ Constant Left Esotropia – CLET
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: SCARRING VS ECTASIA
OD: Hyperopia + Regular Astigmatism
OS: Hyperopia + Irregular Astigmatism
+2.50-4.25x165 DVA 20/200
Was referrred for Hybrid OS,
Patch Tx w/ eventual Strab Sx
5yo: 30^ CLET, 40 L-Hypotropia, +global fusion
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: FIT W / CUSTOM PIGGYBACK
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HVID 7mm OS – unable to insert Hybrid due to
14.5 OAD and patient’s postsurgical tight lids small HVID
Fit Aspheric GP for 2º Irregular Astigmatism:
Custom Visions Ultrathin® 8.3mm OAD
 Determined OAD/BC after trial with 8.5mm
Spherical GP; anticipated better Nafl pattern w/
Aspheric back surface for corneal irregularity
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09/04/2014
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: FIT W / CUSTOM PIGGYBACK
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Fit with Flexlens Piggyback® 13.0mm OAD
based on pt’s HVID; Estimated BC and Ordered
Cut-out Diameter .7mm> than GP Diameter:
13.0 OAD / Plano / 8.2BC / 9.0mm cut-out
Flexlens Piggyback®:
well centered 13mm OAD
SCL with 9.0mm cut-out diam
appearing as a white ring on
photograph, taken w/o GP.
Hioxifilcon B, 49% water, clear
material was used as no Sihy
available at this time.
CASE 2 – 5YO MALE W / BPES, REFERRED
FOR HYBRID: FIT W / CUSTOM PIGGYBACK
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Ordered GP to trial w/ Fluresoft over ordered
Flexlens – GP BC /Power were modified for best fit
and vision - Orx determined once Over Ret done.
DVAOS improved to 20/70
Patch therapy performed, occluding OD x 2 hrs/day
 DVA OS further improved to 20/30 OS
 With concentration “E” was able to reduce the angle
of deviation on command, indicating he was ready
for a more extensive VT
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CLEARKONE ® (2009)
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Spherical Base Curve
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Expected Fit:
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Fixed Parameters:
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~100μ Clearance
GP Diam 8.4mm
GP OZD 7.8mm
OAD 14.5mm
Decentered ectasia & Keratoconus
Adjustable Parameters:
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12 Vaults in 50 micron steps (50μ – 600μ)
4 Skirts (Steep, Steep2, Medium, Flat)
Powers: +10.00 to -20.00
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09/04/2014
CASE 3 - POST LASIK ECTASIA / POST PK REFERRED FOR HYBRID VS SCLERAL GP
41 yo female – hx of Lasik OU with eventual PK OS
Wears Biofinity MF OD and Alden Toric, during day
 Unable to see at night – home bound after sundown
 Has trialed all lens modalities from Synergeyes KC
to Semi Slceral GP, all with out success
*Pt has 7.5mm Pupil in Dim lighting*
 With Hybrid-ClearKone® + Scleral GP, discomfort
 Good DVA/Some Discomfort w/ Flexlens ® SCL
carrier for Lens Mode small diameter GP
 DVA best OS w/ Donut Prosthetic carrier:
Alden 8mm black with 3.5mm Clear Zone
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CASE 3 - W ITH DONUT PROSTHETIC PBS –
1ST X NIGHT DRIVING AFTER 7 YRS
Large Pupils 2 to Systemic Meds
IOP’s too low for GLC gtts
 Pt likes her eye color –
does not want STD Prosthetic
 OS DVA 20/20- /1st x night driving
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ULTRAHEALTH™ (2013)
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RG Aspheric BC
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Expected Fit:
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Fixed Parameters:
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~100μ Clearance
GP Diam 8.4mm
GP OZD 6.0-6.5mm
OAD 14.5mm
Adjustable Parameters:
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11 Vaults in 50 micron steps (50μ – 550μ)
4 Skirts in mm (Flat 2=8.7, Flat=8.4, Medium=8.1, Steep=7.9)
Powers: +25.00 to -25.00
Laser Marking: H for UH, Vault, and SC
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09/04/2014
ULTRAHEALTH™ (2013)
AS OCT: ~100µ APICAL CLEARANCE
GP Thickness
Central Clearance: ~50µ loss w/ wear
Cornea
ULTRAHEALTH™ (2013)
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New Material
Super Hi Dk GP portion: 130 Dk – petrafocon A
Silicone Hydrogel Skirt: 84 Dk / hem-larafilcon A
 Sihy does not absorb Sodium Fluorescein - use std Nafl
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New Fitting Protocol-view lens after 3-4mins on eye
Start with Flat Skirt 8.4mmSC / 250µ BC diagnostic lens
If Apical Clearance, Vault in 100µ steps til 1st touch
 When 1st Touch is light, will order 100µ higher Vault
 When 1st Touch is heavy, will order 150µ higher Vault
 SC w/ assessed with last Dxtic trial lens:
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If NO lens mov’t or NO visible ILZ, trial same Vlt, Flatter SC
If XS mov’t or XS bearing at ILZ, trial same Vlt, steeper SC
ULTRAHEALTH™ (2013)
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New Fitting Protocol-view lens after 3-4mins on eye
Start with Flat Skirt 8.4mmSC / 250µ BC diagnostic lens
If Apical Touch, Vault in 100µ steps til 1st Clearance
 If lens prior to 1st Clear was Light Touch, will order 50µ
higher Vault
 If lens prior to 1st Clearance was Moderate to Heavy
Bearing, will order 100µ higher Vault
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SC w/ assessed with last Dxtic trial lens:
If NO lens mov’t or NO visible ILZ, trial same Vlt, Flatter SC
If XS mov’t or XS bearing at ILZ, trial same Vlt, steeper SC
 If NO lens mov’t or NO visible ILZ, trial same Vlt, Flatter SC
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