Clinical Dry Eye Management: Diagnosacs, and Treatment

9/22/14 Clinical Dry Eye Management: Diagnos9cs, and Treatment Methodologies Sco? G. Hauswirth, O.D., F.A.A.O. Minnesota Eye Consultants, P.A. Minneapolis, MN Overview •  Nomenclature used in the past: – 
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Dry Eye Syndrome Tear Dysfunc9on Syndrome Ocular Surface Disease Aqueous Deﬁciency Keratoconjunc9vi9s Sicca Etc. etc. etc. Disclosures •  Paid Consultant, Speaker, or Advisor to: –  Alcon Pharmaceu9cals Inc. –  Allergan Inc. –  Bausch+Lomb, Inc. –  BioTissue, Inc. –  NicOx Inc. –  TearScience, Inc. •  Some of the informa9on in this lecture may represent oﬀ-‐label uses of approved drugs or devices. Overview •  Healthy tear layer/ocular surface are important for several reasons: –  Quality of vision –  Quality of life •  Comfort •  Ability to func9on •  Very common; wide variety of presenta9ons •  BEGINS as Tear Dysfunc9on –  Imbalance in some aspect of tear chemistry/physiology –  Increased Osmolarity? Decreased Lipid Layer? •  PROGRESSES to Ocular Surface Disease –  Aﬀects underlying structure and ability for compensatory mechanisms to restore homeosta9c balance –  Pre-‐symptoma9c vs. “Signiﬁcant” Ocular Surface Disease •  Majority of physicians treat based on symptoms –  Important part of the clinical picture –  Variable; may contradict clinical signs Symptoms: What are they? DIAGNOSIS •  Def: “a physical or mental feature that is regarded as indica9ng a disease; par$cularly such a feature that is apparent to the pa$ent” (Oxford dic9onary) •  Downstream eﬀect of a pathology or disrup9on to normal physiologic processes •  Result from breakdown in innate coping mechanisms •  Ques9ons: –  Do we wait for symptoms? –  What symptoms present at the earliest levels? –  Are there other methods? 1 9/22/14 Early Symptoms Changes to The Dry Eye Workup •  Less than 60% of pa9ents with observable dry eye are symptoma9c1 •  For earlier diagnosis, blur or ﬂuctua9ng vision may be one of the best indicators •  PROOF study (Progression of Ocular Findings)2 •  Newer technologies entering the clinical sehng –  Tear osmolarity, interferometry, cytokine assays, protein assays –  A?empt to measure core mechanisms of dry eye –  58.5% of ITF Stage II dry eye presented with moderate or greater complaint of blurred vision vs. 13.7% of controls –  Both groups had baseline of 20/20 vision Diagnos9c Tes9ng: Dry Eye workup • 
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Interferometry (LipiView) Osmolarity (TearLab) MMP-‐9 (InﬂammaDry) Ocular Surface Assessment Tear chemistry –  Diagnos9c Gland Expression –  Each is based on detec9ng a contribu9ng factor of the core mechanisms for dry eye progression –  Each gives valuable insight to understand a diﬀerent aspect of the tear ﬁlm –  Perimetry, OCT, examples of parallel technologies for glaucoma –  Schirmers/ZoneQuick •  Meibography •  Biomarker tes9ng (Sjö) •  Are they valid measures? •  Are they essen9al for every dry eye pa9ent? –  External lids, lid margin, conjunc9va/cornea •  TBUT •  Volumetric Assessment* •  Meibum Assessment** Tear Quality Tests Meibomian gland assessment Understanding Osmolarity •  Deﬁni9on: number of moles of solute in 1L of solu9on –  Ionic/electrolyte content of tear ﬁlm •  Dynamic measurement: in normals, ﬂuctuates small amount throughout day (evapora9on/compensatory mechanisms/
temperature) •  Restoring physiological normality is achieved most rapidly by increasing both tear ﬁlm stability and quie9ng inﬂamma9on Osmolarity as result of stressors •  Increased osmolarity is a result of diﬀerent stressors in Aqueous deﬁcient vs. Evapora9ve dry eye4 •  End result = decreased sensa9on, decreased TF integrity, lacrimal ﬂow –  Garcia: 270 +/-‐4.4mOsml3 •  “Normal”: <308mOsml/eye, <5mOsml diﬀerence between OD/OS and CONSISTENT over 9me –  Increased variability means higher severity of tear dysfunc9on –  Mul9ple measurements needed to assess trends •  Higher number = greater degree of tear ﬁlm disrup9on = higher poten9al for inﬂamma9on and 9ssue degrada9on 2 9/22/14 Inﬂamma9on as a role in Dry Eye Understanding MMP-‐9 •  Inﬂamma9on primarily mediated through T-‐ and NK-‐cells5 •  Triggered by APC – ac9vated likely via dessica9ng stress •  Proteoly9c enzyme useful in degrading extracellular matrix •  Upregula9on of several cytokines (IL-‐17, TNF-‐a, IL-‐1B, et c.) present in pa9ents with dry eye7 •  Amount in tear ﬁlm may be driven up via increased osmolarity11 •  RPS InﬂammaDry: –  Dendri9c cells with MHC II found in conjunc9val epithelium and in lympha9cs6 –  No speciﬁc cytokines or groups correlate with presence or severity of disease8,9 –  Has posi9ve eﬀects in small amounts (<41ng/ml) –  Higher amounts result in dissolu9on of gela9nous basement membrane and intracellular junc9ons –  Increase in staining, changes in surface morphology –  Sensi9vity & speciﬁcity: 85% and 94%, respec9vely –  Predic9ve values: (+) 73%; (-‐)97%12 •  Elevated levels of MMP-‐9 associated with: –  Increasing symptom scores –  Decreased low-‐contrast visual acuity –  Inversely correlated with TBUT •  Likely is associated with 9ssue remodeling10 Meibomian Gland Assessment •  Following expression, may evert lids for more detailed examina9on of condi9on of glands •  Visualize by transilluminator, or via other device (infrared via Keratograph-‐5, confocal miroscopy) •  Grade: –  Length/presence of trunca9on (shortening) –  Absence of glands where there should be some (dropout) Grade Secre5on characteris5cs 0 Clear liquid secre9on 1 Cloudy liquid secre9on 2 Inspissated solid secre9on (toothpaste consistency) 3 No secre9on Lid Func9on Tests •  Close a?en9on to blink func9on reveals that the outer por9on of the lid margin do not close completely14 •  Needs to be enough closure to grab the lower tear meniscus and drag it up over the cornea and conjunc9val surface •  Blinking is dynamic – not 100% every 9me •  Calculate percentage over 20-‐30 seconds •  Liv lids – check for increased laxity (Floppy Lid Syndrome) •  TBUT, Meibomian Gland Func9on done prior to Lid Func9on tests to minimize expression of glands Biomarker Assays •  Systemic disease may leads to increased severity of dry eye •  Several autoimmune condi9ons contribute •  Immune panels may help bridge professions and lead to improvements in pa9ent care •  Sjö test (NicOx; Immco): –  ANA, rheumatoid factor, ESR, SSA (Rho), SSB (La) –  Immunoglobulin levels of: SP-‐1, PSP, CA-‐6 •  In Sjogren’s pa9ents, may have dry eye for 10 years prior to emergence of other complica9ons15 TREATMENTS 3 9/22/14 Treatment Goals •  “Successful” treatment = allevia9on of symptoms? –  Pa9ent-‐dependent vs. objec9ve •  Successful treatment now includes: –  1) Restora9on of normal anatomy & physiology (as much as possible) –  2) Hal9ng/elimina9ng inﬂammatory processes which lead to further disrup9on of 9ssues –  3) Reduc9on of symptoms •  Without #1 and #2, #3 is more diﬃcult to achieve Therapies •  An9-‐inﬂammatories: –  Essen9al for hal9ng progression of immune-‐mediated disrup9on –  Steroid therapy – short v. long term –  Cyclosporine, Tacrolimus •  Increased dosing may result in improved results16 –  NSAIDs –  Doxycycline/Minocycline/Azithromycin •  Secretogogues –  Pilocarpine PO 5mg •  Other: –  Autologous serum (1:5 serum with BSS) q2h x 2 weeks then QID x 3 months Therapies •  Basics: –  Increase hydra9on –  Nutri9onal recommenda9ons •  Tear supplementa9on: – 
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Drive down osmolarity Non-‐preserved v. preserved tears Oil based v. aqueous supplements Gels/ointments Lacrisert (hydroxypropyl cellulose) •  Warm compresses: –  10-‐15 min once to twice per day –  Good apposi9on to lid surface –  Constant temperature (near 120°F – not to induce pain) In-‐oﬃce treatments •  Suppor9ve: –  Bandage CL –  Scleral contact lenses •  Creates reservoir of ﬂuid to protect corneal surface –  Amnio9c membrane •  Allows for a “boost” to allow healing of epithelial defects •  Therapeu9c: –  Punctal occlusion –  Manual gland expression •  Mastroda paddle, Hardten compression forceps –  Maskin probing –  Thermal Pulsa9on (LipiFlow) –  Intense Pulsed Light Thermal Pulsa9on (LipiFlow) •  More eﬀec9ve than at-‐home warm compresses •  Provides heat and pressure to therapeu9cally express the meibomian glands of both upper and lower lids •  Improvement in LLT, TBUT, and pa9ent symptoms las9ng up to 12 months from single treatment17 –  2.75 years from personal experience SUMMARY 4 9/22/14 Wrapping it up References •  Ocular Surface Disease is s9ll very dynamic and undergoing change in a rapid pace • 
•  Eﬀorts towards preven9on, early diagnosis, and normaliza9on of 9ssues • 
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–  Con9nued evolu9on of diagnos9c and therapeu9c technology • 
–  Restoring homeostasis vs. chasing symptoms • 
•  U9lize all tools available •  Pa9ent educa9on and sehng proper expecta9ons is key: • 
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–  It pays to take 9me to closely examine the ocular surface in it’s en9rety • 
•  This area oﬀers an opportunity for subspecialty like no other in eyecare • 
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–  No shortage of pa9ents References • 
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11. Huet E, et al. EMMPRIN modulates epithelial barrier func9on through a MMP-‐mediated occludin cleavage: Implica9ons in dry eye disease. Am J Pathol. 2011 Sep;179(3):1278-‐1286. 12. Sambursky R, et al. Sensi9vity and speciﬁcity of a point-‐of-‐care matrix metalloproteinase 9 immunoassay for diagnosing inﬂamma9on related to dry eye. JAMA Ophthamol. 2013;131(1):
24-‐8. Kaufman HE, et al. The prac9cal detec9on of MMP-‐9 diagnoses ocular surface disease and may help prevent its complica9ons. Cornea. 2013;32(2):211-‐6. 13. Lemp MA, et al. Distribu9on of aqueous-‐deﬁcient and evapora9ve dry eye in a clinic-‐based pa9ent cohort: a retrospec9ve study. Cornea. 2012 May;31(5):472-‐8. 14. Korb DR et al. Evidence sugges9ng that the kera9nized por9ons of the upper and lower lid margins do not make complete contact during deliberate blinking. Cornea. 2013 Apr; 32(4): 491-‐5. 15. Akpek EK, et al. Ocular and systemic morbidity in a longitudinal cohort of Sjogren’s syndrome. Ophthalmology. 2014 Aug 29 [Epub ahead of print]. 16. Dastjerdi MH, et al. High-‐frequency topical cyclosporin 0.05% in the treatment of severe dry eye refractory to twice-‐daily regimen. Cornea. 2009;28(10):1091-‐6. 17. Greiner JV. Long-‐term (12-‐month) improvement in meibomian gland func9on and reduced dry eye symptoms with a single thermal pulsa9on treatment. Clin Experiment Ophthalmol. 2013 Aug;
41(6):524-‐30. 18. Gupta PK, et al. Outcomes of intense pulsed light therapy for treatment of evapora9ve dry eye. ASCRS 2014. Boston, MA. 19. Guo P, et al. PTX3 controls ac9va9on of matrix metalloproteinase 1 and apoptosis in conjunc9vochalasis ﬁbroblasts. IOVS. 2012 Jun; 53(7):3414-‐3423. 1. Bron AJ, et al. Rethinking dry eye disease: a perspec9ve on clinical implica9ons. Ocul Surf. 2014 Apr;12(2 Suppl):S1-‐31. 2. McDonnell P, et al. Progression of Ocular Findings (PROOF) Study of the Natural History of Dry Eye: Study Design and Baseline Pa9ent Characteris9cs. ARVO mee9ng Abstracts June 16, 2013 54:4338. 3. Garcia N, et al. Basal values, intra-‐day and inter-‐day varia9ons in ear ﬁlm osmolarity and tear ﬂuorescein clearance. Curr Eye Res. 2014 Jul;39(7):673-‐9. 4. Bron AJ, et al. Predicted phenotypes of dry eye: Proposed consequences of it’s natural history. Ocul Surf. 2009.7(2):78-‐92. 5. Stern ME, et al. Conjunc9val T-‐cell popula9ons in sjogren’s and non-‐sjogren’s pa9ents with dry eye. IOVS. 2002;43(8):2609-‐14. 6. Schaumburg CS, et al. Ocular surface APCs are necessary for autoreac9ve T cell-‐mediated experimental autoimmune keratoconjunc9vi9s. J Immunol. 2011;187(7): 3653-‐62. 7. Cho9kavanich S, et al. Produc9on and ac9vity of matrix metalloproteinase-‐9 on the ocular surface in dysfunc9onal tear syndrome. IOVS. 2009;50(7):3202-‐9. 8. Enriquez-‐de-‐Salamanca A, et al. Tear cytokine and chemokine analysis and clinical correla9ons in evapora9ve-‐type dry eye disease. Mol Vis. 2010;16:862-‐73. 9. Na KS, et al. Correla9ons between tear cytokines, chemokines, and soluble receptors and clinical severity of dry eye disease. IOVS. 2012;53(9):5443-‐50. 10. Pal-‐Ghosh S, et al. Removal of the basement membrane enhances corneal wound healing. Exp Eye Res. 2011;93(6):927-‐36. References • 
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20. Acera A, et al. Tear MMP-‐9 levels as a marker of ocular surface inﬂamma9on in conjunc9vochalasis. IOVS. 2013 Dec 23;54(13):8285-‐91. 21. Fodor E, et al. Increased tear osmolarity in pa9ents with severe cases of conjunc9vochalasis. Curr Eye Res. 2012 Jan;37(1):80-‐4. 22 Fodor E, et al. Quan9ta9ve evalua9on of ocular surface inﬂamma9on in pa9ents with diﬀerent grade of conjunc9vochalasis. Curr Eye Res. 2010 Aug;35(8):665-‐9. 23. Gumus K, Pﬂugfelder SC. Increasing prevalence and severity of conjunc9vochalsis with aging detected by anterior segment op9cal coherence tomography. AJO. 2013 Feb;155(2):238-‐242. 24. Mimura T, et al. Conjunc9vochalasis and contact lenses. AJO. 2009 Jul;148(1):20-‐5. 25. Pult H, et al. The rela9onship between clinical signs and dry eye symptoms. Eye (Lond). 2011 Apr;25(4):502-‐10. 26. Zhang XR, et al. The eﬀect of age and conjunc9vochalasis on conjunc9val thickness. Curr Eye Res. 2013 Mar;38(3):331-‐4. 27. Hara S, et al. Evalua9on of tear stability aver surgery for conjunctovochalasis. Optom Vis Sci. 2011 Sep;88(9):1112-‐8. 28. Liang L, et al. Ocular surface morbidity in eyes with senile sunken eyelids. Ophthalmology. 2011 Dec;118(12):2487-‐92. 29. Nakakura S, et al. Latanoprost therapy aver sunken eyes caused by travoprost or brimatoprost. Optom Vis Sci. 2011 Sep;88(9):1140-‐4. The Impact of Dry Eye on Contact Lens Wear Dry Eye and the Contact Lens Wearer 5 9/22/14 The Impact of Dry Eye on Contact Lens Wear London Business School Study •  CL pa9ents are 60% more proﬁtable than spectacle only wearers •  Spectacle wearers = Higher ini9al proﬁt •  CL pa9ents = ↑Frequency of eye exams •  Many contact lens pa9ents also buy spectacles •  “We realized that much of the op9cal industry is ironically very myopic.” •  Lost CL Pa9ent = Lost Revenue What is the impact of contact lenses on the tear layer? What is the impact of contact lenses on the tear layer? TFOS: Contact Lens Discomfort: Deﬁni9on Impact of Contact Lenses on Tear Osmolarity •  A condi9on characterized by episodic or persistent adverse ocular sensa9ons related to lens wear, either with or without visual disturbance, resul9ng from reduced compa9bility between the contact lens and the ocular environment, which can lead to decreased wearing 9me and discon9nua9on of contact lens wear 6 9/22/14 Categorizing Contact Lens Discomfort How do we get out CL wearers more comfortable? Eliminate SICS and CIE’s Elimina9ng Corneal Staining •  Diﬀeren9ate between Dry Eye Induced Staining and solu9on or lens induced hyperﬂuorescence PATH The Staining Grid Eyes evaluated 2 hours aver lens applica9on 7 9/22/14 PHMB release over 9me Proac9vely Look for Hyperﬂuorescence •  If it is solu9on induced – change solu9ons or go to DD –  Peroxide if possible •  If it is lens induced, consider if you can improve the ﬁt of the lens on eye •  If it is staining due to dry eye, treat dry eye aggressively •  If you don’t check for and a?ack staining proac9vely, you will have CL dropouts Carnt NA et al. Contact Lens-‐Related Adverse Events and the Silicone Hydrogel Lenses and Daily Wear Care System Used. Arch Ophthalmol. 2009; 127 (12): 1616-‐16231 Corneal Inﬁltra9ve Events (CIE) •  Higher rate in silicone hydrogels due to lipid build-‐up rather than protein build-‐up •  Higher rate with some care systems than others Galyﬁlcon A = Advance; Senoﬁlcon A = Oasys; Balaﬁlcon A = Purevision; Lotraﬁlcon B = O2Op5x; Lotraﬁlcon A = Focus Night N Day OPTI-‐FREE® RepleniSH® MPDS users had on average a 6% incidence per pa9ent-‐month of CIEs. A hydrogen-‐
peroxide-‐based solu9on, CLEAR CARE® Contact Lens Cleaning and Disinfec9ng Solu9on, had the lowest incidence of CIEs. 2012.02.01-‐CN4615 Tilia, Willcox, et al. Incidence of corneal inﬁltra9ve events with a new contact lens disinfec9ng solu9on. Choose the Solu9on •  MPS for new ﬁts •  MPS for those that may be non-‐compliant or not get 6 hours of sleep ® ® ® MPDS MPDS ® MPS •  Peroxide in any instance where there are symptoms ® ® System ® MPDS •  Add lubricant to the lens if needed with Peroxide Presented at AAO, Oct 2011, Boston MA. 2012.02.01-‐CN4615 47 8 9/22/14 How much do lubricant drops help? How much do lubricant drops help? How much do lubricant drops help? Punctal Occlusion and Contact Lenses Restasis and Contact Lenses Contact Lenses and Meibomian Glands 9 9/22/14 Contact Lenses and the Lid Wiper Lid Wiper Lid Wiper Epitheliopathy and Contact Lenses Trea9ng LWE •  Same as trea9ng dry eye disease –  Lubricants –  An9-‐inﬂammatory meds –  Treat MGD –  Restasis –  Ointments or Gels qHS Contact Lens Materials and Dry Eye •  What considera9ons are there for comfort? –  % of water – demand on tear volume •  Higher % = more evapora9on, more interac9ve with tear layer •  Lower % = less evapora9on, less interac9ve with tear layer –  Coeﬃcient of Fric9on – lid wiper epitheliopathy •  Lower = less fric9on •  Higher = more fric9on 10 9/22/14 Coeﬃcient of Fric9on Lens Material Proper9es Dry Eye and Contact Lenses Treat Dry Eye! Stain to try to catch early signs and treat early Evert lids – look for LWE Use plugs / restasis / meds just like in any Dry Eye Pa9ent •  Use Diagnos9c Tools to educate and monitor treatment eﬃcacy •  Choose the best solu9on and lens combina9on •  Daily Disposables can help many pa9ents • 
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OPENING THOUGHTS ON SCLERAL CONTACT LENSES… Scleral Contact Lenses For our Dry Eye Pa5ents Indica9ons of scleral contact lenses WHO: PATIENTS with painful and damaged eyes.!
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 Lid coloboma  
  Improve Vision   Relieve p
ain and suﬀering  Lagophthaloms  Exophthalmos  Corneal Degenera9ons  Trichiasis  Atopic Keratoconjunc9vi9s  Ectropion / Entropion 11 9/22/14 Who are these pa9ents, exactly?   Ocular manifesta9ons of systemic disease  Steven Johnson’s Syndrome, Sjogren’s Syndrome, Ocular Cicatricial Pemphigoid, GVHD, Neurotrophic Kera99s   Dry eye and Ocular surface disease  ABMD, Terrien’s Marginal Degenera9on, LSCD, Corneal scars  Also successful in pediatric popula9ons HOW CAN WE HELP THESE PATIENTS? • 
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PRODUCTIVITY LOSS TIMELY OFFICE VISITS SICK TIME POOR FUNCTION DUE TO DISCOMFORT AND PAIN Scleral Lenses for Ocular Surface Disease How do scleral lenses work? Ocular surface disease remains a primary indica5on for scleral lenses In a study of 517 pa9ents, 69% of scleral lens wearers reported previous failures with other contact lens modali9es. 12 9/22/14 Key Components of Scleral CLs Fibng Pearls for Scleral Lenses to Achieve Maximum Pa5ent Success •  Liquid Reservoir –  No disrup9on of surface epithelium! –  Shield to environment and lid fric9on •  High Oxygen Transmission –  High dK materials •  97-‐160 •  Non-‐preserved environment –  Sodium Chloride Inhala9on Solu9on 0.9% • 
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Amount of corneal vault Limbus concerns Landing Curves Lens diameter Solu9ons and Saline Ar9ﬁcial tears and Scleral contact Lenses •  Must protect the limbus Pa9ent Educa9on •  Scleral Lenses are part of therapy, not a cure •  Vision ﬂuctua9ons: “You s9ll have a dry eye” •  Average / Expected wearing 9me •  Rinsing mid-‐day is normal and some9mes necessary Ouch! •  VA 20/100 •  Slit Lamp: –  Anterior stromal corneal haze –  Small epithelial defect •  Current therapy includes topical an9bio9c and ar9ﬁcial tears, prescribed by other eye care provider KF (Aug 1 2012) •  59 Year old Caucasian Male •  Referred to OMD •  Visits our oﬃce aver one month of consistent blurry vision, burning sensa9on and photophobia OD –  Hx of Herpes Zoster “Shingles” 4 months ago –  On renal dialysis Course of Treatment •  We added Pred Forte QID •  Maintain: Topical lubricants, topical an9bio9cs •  Diagnosed with Zoster Kera99s •  VA improved to 20/50 at Aug 7th visit •  Corneal surface is improved but s9ll irregular •  Maintain course of treatment (Oﬂox, Pred, AT’s) •  Pa9ent returns Aug 21st, 2012 •  Vision is not gehng be?er, eye is sore •  VA 20/60 and SLE reveals new epithelial defects 13 9/22/14 Course of Treatment Course of Treatment Sept 12th: Defect be?er, VA 20/60 •  Sept 5th 2012: Pa9ent returns, eye is hur9ng –  Vision down to 20/200 –  Defect enlarged to 3mm x 4mm •  Added Polytrim and Erythomycin Ung to Ocuﬂox and Pred Forte WHAT IS GOING ON?!
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•  Sept 18th: Defect worse, VA 20/60-‐, Added BCL •  Sept 25th: Defect be?er, VA 20/80 – kept BCL •  Oct 2nd: BCL falls out, defect is very large –  Added autologous serum, ordered custom sov large diameter BCL to hopefully keep in eye • 
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Oct 9th: VA 20/125 BCL maintained, healing Oct 16th: BCL falls out, defect enlarges Oct 17th: BCL falls out Oct 19th: Lost BCL, defect enlarged again, VA 20/300 Oct 23rd: Replaced BCL, defect 2mmx3mm
(13 visits) Neurotrophic Keratopathy •  Impaired innerva9on to the cornea contributes to a degenera9ve corneal epithelium •  Can produce epithelial keratopathy, ulcera9on and eventual perfora9on Treatment Op9ons •  Goal is to maintain corneal lubrica9on to promote corneal healing •  Bandage CLs were used for several weeks to protect the corneal surface, with no improvement •  VA was down to 20/300, pa9ent was MISERABLE Scleral Lenses for Neurotrophic Kera99s Azpiroz L, Dodd A, PCON July 2012 Ophthalmology Management, Sept 2012 •  Most common cause is a herpe9c lesion of the ophthalmic branch of the trigeminal nerve (V1) –  Hardly spoke at visits, refused to read VA charts •  A tarsorraphy was recommended. •  But the sharp and knowledgeable ODs said: “WAIT! There’s a be?er answer!” 14 9/22/14 Scleral Lens Fihng Scleral Contact Lenses as EW? •  Lens was applied on Visit 14, Oct 23rd 2012 –  Jupiter 18.2 / 46.00 BC –  Careful watch, RTC 48 hours –  Use medica9on drops over scleral lens –  EW x 2 days •  Visit 15: “Eye feels calm” –  Defect is smaller, VA 20/200 –  RTC 4 Days, con9nuous wear of scleral lens •  Visit 16, Nov 6th: NO EPITHELIAL DEFECT! –  Epithelium s9ll irregular, but intact. VA 20/50 A light at the end of the tunnel Cornea, March 2013 •  Aver 1 week of extended wear, vision improved to 20/50 •  Pa9ent was followed weekly for nearly 6 weeks, neovasculariza9on began to develop inferiorly. •  At visit 19, Dec 12, pa9ent was instructed to begin wearing the lens only during the day, which he does most of the 9me. He occasionally wears the lens a few nights per week if eye feels sore. •  Visit 21, Jun 11 2013: Pa9ent regained 20/20 vision through a scleral contact lens. Discon9nued Pred Forte drops. •  Last seen 10/29/13: Doing well, minimal haze, epith smooth Thank you! 15

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