ArticleLiterature Review

Scleral lens use in dry eye syndrome

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Abstract

Dry eye syndrome can be difficult to manage in severe or refractory cases. In patients in whom traditional treatments have limited efficacy, alternative treatments may be considered for dry eye syndrome, including scleral lenses. The present review summarizes the evidence regarding scleral lens use in dry eye syndrome. Scleral lenses have become a viable option for severe dry eye syndrome, and have been shown to be efficacious and well tolerated, with most reports citing improved visual acuity and relief of symptoms. Currently, there are 18 manufacturers of scleral lenses, although published reports on scleral lenses primarily focus on the BostonSight PROSE and the Jupiter Lens. Scleral lenses are efficacious and well tolerated for use in severe dry eye syndrome. Further research is needed to compare different sizes and types of lenses, and to standardize outcome measures.

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... Their major advantage lies in the vaulting of the cornea (and the subsequent apical clearance) that avoids direct mechanical stress to this ocular tissue. The development of new lens materials, computer-generated lens geometries as well as new insights into the anterior scleral shape and corneo-scleral junction have contributed to improve designs and oxygen transmissibility allowing better ocular health, longer wearing time and ease of lens fit [2][3][4][5]. ScLs are typically prescribed for corneal ectasia (primary corneal ectasia like keratoconus) [6] and ocular surface diseases, when a patient's cornea shows intolerance to other forms of vision correction (corneal rigid gas permeable and soft lenses materials) and they do not provide adequate visual acuity to the patient [1]. ScLs have shown good results in patients with graft versus host disease, dry eye disease (DED) and exposure keratopathy among other conditions [1], but also for high ametropias [7] and for cosmetic purposes such as in atrophia bulbi [5,8]. ...
... ScLs allow for a better centration of the lens and an easier adaptation to simultaneous vision due to the stability of the image provided by the scleral design. Furthermore, ScLs have demonstrated the ability to maintain tear film homeostasis beneath the lens [4][5][6]. ...
Article
Purpose: To assess and compare the effect of the corneo-scleral lenses (C-ScL) and scleral lenses (ScL) on tear film parameters and central corneal thickness (CCT) in healthy presbyopic subjects. Methods: Thirty subjects wore two contact lenses (CLs), randomly assigned, of neutral power, but of different diameters, 12.7mm (C-ScL) and 18mm (ScL) and being equal in the others parameters: material (HS100) and centre thickness (0.29mm). At baseline, 20min after insertion and at 8h, the tear meniscus area (TMA) and CCT was measured (with optical coherence tomography) as well as tear osmolarity. Results: TMA revealed statistical differences for both lenses at 20min (p<0.001), and also at 8h (p=0.003), being greater for the C-ScL. CCT showed statistical differences for both lenses at 20min (p=0.002), and also at 8h (p=0.001), being lower for the C-ScL. Osmolarity did not reveal statistical differences at 20min (p=0.29), while it was statistically different at 8h (p=0.03), being lower for the C-ScL. Conclusions: C-ScL lead to a lesser reduction in the TMA and a lower induced hypoxic stress than the ScL. Osmolarity levels remained within normal values across the day with no clinical difference between lenses. Both designs can represent a good optical platform for correcting presbyopia as well as protecting the ocular surface by vaulting the cornea.
... Scleral lenses are widely used for the treatment of ocular surface disease. They may be of benefit in patients with dry eye syndrome [83] whom have had limited relief with traditional treatments. These lenses are filled with sterile saline and placed over the cornea, creating a liquid bandage and minimizing symptoms of dry eye. ...
... Although there is a risk of complications that can occur with the use of scleral lenses for example, neovascularization, corneal oedema or keratitis [83], these contact lenses may be the only option available to some patients with compromised ocular surface. ...
Article
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Natural products have been in use long before the introduction of modern drug therapies and are still used in various communities worldwide for the treatment of anterior eye disease. The aim of this review is to look at the current non-pharmaceutical modalities that have been tried and assess the body of existing evidence behind them. This includes alternative medicine, existing non-pharmaceutical therapy and more recent low and high tech solutions. A detailed search of all available databases including MEDLINE, Pubmed and Google was made to look for English-language studies for complementary and alternative treatment modalities (CAM), natural therapies and new modalities for anterior eye disease such as blepharitis, dry eye and microbial keratitis. We have included a broad discussion ranging from traditional treatments like honey and aloe vera which have been used for centuries, to the more recent technological advances like Intense Pulsed Light (IPL), LipiFlow and photoactivated chromophore for corneal cross linking in infectious keratitis (PACK-CXL). Alternative management strategies may have a role in anterior eye diseases and have a potential in changing the way we currently approach them. Some of the available CAM could play a role if incorporated in to current management practices of not only chronic diseases like blepharitis and dry eye, but also acute conditions with significant morbidity like microbial keratitis. Further large-scale randomized control trials stratified by disease severity are required to improve our understanding and to evaluate the use of non-pharmaceutical therapy against current practice.
... Por ejemplo, en pacientes con ojo seco acuo-deficiente o evaporativo, incluidos el síndrome de Sjögren, la enfermedad injerto-contra-huésped, la rosácea y la DGM grave, deben utilizarse gafas protectoras, sustitución protésica del ecosistema de la superficie ocular (PROSE) o lentes de contacto de bajo contenido en agua para limitar la exposición a las condiciones ambientales adversas. [100][101][102][103][104] Dispositivos Electrónicos Para pacientes con uso excesivo de dispositivos electrónicos con pantallas digitales, como computadoras, tabletas y teléfonos inteligentes, recomendamos aumentar la administración de lubricantes tópicos y aplicar la regla 20/20/20 (cada 20 minutos, apartar la vista de la pantalla y centrarla en algo situado a 20 pies de distancia durante 20 segundos) para relajar el reflejo de acomodación y reducir la fatiga visual. 105,106 Manejo de la Inflamación Palpebral El Panel Mexicano y otros han sugerido que la blefaritis anteriormente descrita y la DGM pueden tener lugar en cada fase de gravedad en pacientes con EOS. ...
Article
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La enfermedad del ojo seco (EOS) tiene una prevalencia mayor que muchas otras enfermedades sistémicas importantes, como las enfermedades cardiovasculares y la diabetes mellitus, y supone un importante menoscabo en la calidad de vida de los pacientes afectados. Es un motivo de consulta habitual en clínicas oftalmológicas en todo el mundo. Hoy en día, el diagnóstico y el enfoque terapéutico de los especialistas en córnea y superficie ocular deben reservarse para casos de ojo seco graves y crónicos asociados con enfermedades sistémicas autoinmunes o con patologías complicadas de la córnea y la superficie ocular. En dichos casos, el diagnóstico y el enfoque terapéutico suelen ser complejos, elaborados, prolongados y costosos, dado el uso de cuestionarios extensos sobre ojo seco, equipos de diagnóstico electrónico no invasivos y pruebas clínicas de laboratorio y auxiliares de diagnóstico. Más aún, otros especialistas en el cuidado ocular atienden un considerable número de casos de EOS, por lo que su diagnóstico, clasificación y manejo deberían ser algo sencillo, práctico, asequible y efectivo. Considerando que muchos pacientes que van a clínicas no especializadas para el tratamiento del ojo seco se beneficiarían de una mejor atención oftalmológica, hemos decidido elaborar un sistema práctico de clasificación de la EOS en base a su gravedad, para ayudar a los profesionales de la salud visual a discriminar los casos que precisen derivación de los pacientes a clínicas de alta especialidad. Además, proponemos un enfoque sistemático y consideraciones generales de manejo para mejorar los resultados terapéuticos de los pacientes en base a la gravedad de la enfermedad.
... They began regaining popularity as new technology and lens materials increased their gas-permeability and a variety of ocular surface diseases that could not be treated by soft contact lenses showed benefit from SCLs. 2 SCLs allow for the maintenance of a fluid reservoir between their posterior surface and the anterior surface of the cornea, providing both improved lubrication and refraction. 3 In addition to correcting corneal astigmatism, SCLs have successfully treated a variety of diseases of the ocular surface including keratoconus and ectatic disorders, severe astigmatism, Stevens-Johnson syndrome, microphthalmia, and severe dry, especially after soft lenses and punctal occlusion have failed. ...
Article
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Purpose: Scleral contact lenses (SCLs) are devices that allow a fluid reservoir between the contact lens and the cornea, providing both improved lubrication and refraction. Consequently, SCLs have been used for significant refractive error in addition to a wide range of ocular surface diseases. We present the first case of a woman who complained of severe dryness and pain following resection of an adenoid cystic carcinoma of her lacrimal gland with complete resolution of her symptoms with a SCL. Observations: A woman who complained of severe dryness and pain following resection of an adenoid cystic carcinoma of her lacrimal gland presented to the ophthalmology clinic. She had no subsequent lacrimal function without relief from conventional dry eye treatments. However, early treatment with a SCL successfully preserved her ocular surface, improved her corneal staining pattern, and improved her vision. Conclusions and importance: While other options exist, including permanent tarsorrhaphy, lid taping, or moisture goggles, the SCL allowed the combination of cosmesis, visual function, and ocular surface rehabilitation.
... Secretagogues may be used subsequently, if topic therapies have not reached the target, and further immunosuppressants and biologic agent may be useful [57]. Most recently, new treatment are under investigation, including eye platelet-rich plasma [61] and scleral lens [62]. ...
Article
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Eye involvement represents a common finding in patients with systemic autoimmune diseases, particularly rheumatoid arthritis, Sjogren syndrome, seronegative spondyloarthropathy, and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The eye is a privileged immune site but commensal bacteria are found on the ocular surface. The eye injury may be inflammatory, vascular or infectious, as well as iatrogenic, as in the case of hydroxychloroquine, chloroquine, corticosteroids, and bisphosphonates. Manifestations may affect different components of the eye, with episcleritis involving the episclera, a thin layer of tissue covering the sclera; scleritis being an inflammation of the sclera potentially leading to blindness; keratitis, referring to corneal inflammation frequently associated with scleritis; and uveitis as the inflammation of the uvea, including the iris, ciliary body, and choroid, subdivided into anterior, posterior, or panuveitis. As blindness may result from the eye involvement, clinicians should be aware of the possible manifestations and their management also independent of the ophthalmologist opinion as the therapeutic approach generally points to the underlying diseases. In some cases, the eye involvement may have a diagnostic implication, as for episcleritis in rheumatoid arthritis, or acute anterior uveitis in seronegative spondyloarthritis. Nonetheless, some conditions lack specificity, as in the case of dry eye which affects nearly 30 % of the general population. The aim of this review is to elucidate to non-ophthalmologists the major ocular complications of rheumatic diseases and their specific management and treatment options.
... Optimal fitting strategies are needed to improve patients compliance. [264] ...
Article
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Background: Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface that results in symptoms such as discomfort, visual disturbance, and tear film instability, with potential damage to the ocular surface. The principal pathological mechanisms of DED are hyperosmolarity and inflammation. These mechanisms are deeply interrelated and lead to a self-perpetuating "vicious circle". Methods: The objective of this review is to describe novel pharmacological and non-pharmacological treatments for DED. Results: Based on the better understanding of the physiopathology of the disease, new treatment strategies have been developed. Conclusion: The focus of the management of DED has been taken away from just reducing symptoms and redirected towards specific targets of its physiopathology, being inflammation the most addressed topic.
... 7,8 Unfortunately, most treatments have modest effects on KCS symptoms and they do not improve quality of life. Although scleral lenses are a valid treatment option to treat dry eye syndrome after failure of other topical therapies, [9][10][11][12] there are limited data regarding their use for severe cGvHD-related KCS. [13][14][15][16][17] Of note, none of those studies specifically assessed both corneal damage and dry eye-related impairment of quality of life. ...
Article
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Chronic GvHD-related keratoconjunctivitis sicca (cGvHD-related KCS) can significantly alter the quality of life of patients after allogeneic hematopoietic stem cell transplantation. The aim of this work was to assess the efficacy and tolerability of scleral lenses to treat severe cGvHD-related KCS. In this retrospective, multicenter study, we included 60 consecutive patients diagnosed with cGvHD-related KCS and fitted with scleral lenses. Patients were evaluated at baseline and at 2 months with the following tests: the Ocular Surface Disease Index (OSDI) to assess quality of life, the Oxford score to grade corneal damage and the logarithm of minimal angle of resolution (Log MAR) scale to determine visual acuity. We observed improvement in quality of life in 58 patients (97%). All parameters improved at 2 months. We observed significant differences at 2 months compared with baseline for the mean OSDI (86 versus 30, respectively, P<0.001), the mean Oxford score (3.2 versus 1.3, respectively, P<0.001) as well as visual acuity (Log MAR of 0.33 versus 0.10, respectively, P<0.001). Treatment with scleral lenses was discontinued in only 5 patients (8%) with a median follow-up of 20.5 months (range: 2–125 months). Scleral lenses were very efficient and well tolerated in patients with severe cGvHD-related KCS.
... A wide range of options including dietary supplementation, tear retention via mechanical procedures such as punctal occlusion, and use of mechanical barriers such as scleral lenses, antibiotics, secretagogues, and even amnion membranes have been suggested as therapies, all primarily guided to managing the progression of tissue degeneration and improvement of symptoms. 5,[7][8][9][10][11] Other common treatment options aimed at promoting improvement of symptoms include tear supplementation using palliative therapies such as lubricant eye drops and medication classes such as nonsteroidal agents, steroids, and immunosuppressants often used concomitantly. [12][13][14] Symptoms of dryness are assessed in clinical settings via the use of validated questionnaires that help in quantifying subjective complaints. ...
Article
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Purpose The aim of this study was to evaluate the effectiveness of lifitegrast 5% ophthalmic solution in reducing the symptoms of eye dryness using Ocular Surface Disease Index (OSDI) questionnaire. Methods A single-center study was undertaken to evaluate the clinical outcomes. Fourteen subjects (12 female and 2 male) with symptoms of dry eye and a positive history of recent use of artificial tears were included in the study. OSDI questionnaire scores on the severity of symptoms, visual functionality, and quality of life related to the condition were recorded pre- and post-therapy. Subsequently, score data were analyzed for statistical significance. Results The mean age of the 14 subjects was 44.86 (standard deviation [SD] ±3.08) years, with a range of 23–62 years. Mean duration of the evaluation was 28.79 days with a range of 25–34 days. Baseline OSDI mean score was 49.40 (SD ±1.28), and post-therapy mean score was 42.26 (SD ±0.99). Data analysis revealed that the scores were statistically significantly improved post-lifitegrast therapy in comparison to baseline (p=0.00041). Conclusion Lifitegrast 5% ophthalmic solution may be a beneficial therapeutic option in the management of symptoms associated with dry eye disease.
... Locally applied omega-3 essential fatty acids have anti-inflammatory properties and thus improve the quality and quantity of the ocular film [100]. Most recently, new treatments are under investigation: eye platelet-rich plasma has been proven effective and safe to treat ocular surface disorders [101], and scleral lens may also be effective [102]. Specific contact lenses, i.e., large-diameter gas-permeable scleral contact lenses, may be used in selected patients with severe dry eye, as they protect the ocular surface and provide continuous hydration of the ocular surface. ...
Article
Full-text available
Sjögren’s syndrome is currently considered an “autoimmune epithelitis,” as exocrine glands, especially salivary and lacrimal, are progressively destructed by an immune-mediated process associated with specific serum autoantibodies and local lymphocyte infiltrate. Xerostomia remains a key complain in patients with Sjögren’s syndrome but should be evaluated also for other causes such as xerogenic medications, followed by radiation and chemotherapy for head and neck cancers, hormone disorders, infections, or other connective tissue diseases. Further, xerophtalmia (also known as dry eye) frequently associated with keratoconjunctivitis sicca cumulatively affects approximately 10–30% of the general population with increasing incidence with age and is more frequently secondary to non-autoimmune diseases. On the other hand, numerous patients with Sjögren’s syndrome manifest signs of systemic dryness involving the nose, the trachea, the vagina, and the skin, suggesting that other glands are also affected beyond the exocrine epithelia. Skin involvement in Sjögren’s syndrome is relatively common, and various manifestations may be present, in particular xeroderma, eyelid dermatitis, annular erythema, and cutaneous vasculitis. Additional skin non-vasculitic manifestations include livedo reticularis which may occur in the absence of vasculitis, and localized nodular cutaneous amyloidosis possibly representing lymphoproliferative diseases related to Sjögren’s syndrome. The treatment of skin and mucosal manifestations in Sjögren’s syndrome is similar regardless of the cause, starting from patient education to avoid alcohol and tobacco smoking and to pursue dental hygiene. In conclusion, a strict collaboration between the dermatologist and the rheumatologist is essential in the adequate management of Sjögren’s syndrome skin and mucosal manifestations.
... It is crucial that patients understand the application and removal process and are trained in handling ScCL as patients may have initial difficulty with this process. 13 Hygiene and compliance are also fundamental in preventing the development of infections. 14 This paper will discuss ScCL problems related to handling, care, and compliance. ...
Article
Full-text available
Scleral contact lens (ScCL) handling may be challenging and is the principle reason for ScCL drop out. ScCL care systems are more intricate than other lens modalities and include solutions for cleaning, disinfection, storing, rinsing and filling the lens; respecting the use of each solution recommended is fundamental. Replacement of the lenses, solutions, case and plungers are important in order to decrease the risk of adverse events associated with ScCL wear. Compliance is crucial regarding hygiene, solution use, case and plunger care, wear time, follow-up schedule, and handling techniques. Non-compliance may lead to discontinuation of ScCL due to difficulties associated with this unique lens design. This paper presents complications secondary to handling, care and compliance that clinicians and patients may encounter while wearing ScCL. Instructions are provided to enhance the understanding on management surrounding these issues. This manuscript includes three tables to summarize types of complications, their symptoms, clinical signs, etiology, and management for a quick find index for easy consultation during daily clinical practice.
... Estos componentes favorecen la reparación epitelial y el mantenimiento de la homeostasis de la superficie ocular. Otra estrategia posible en casos de ojo seco grave es el uso de lentes de contacto escleral PRO-SE (Prosthetic Replacement of the Ocular Surface Ecosystem) 61 . El uso de tapones de puncta lagrimales es controversial, y generalmente no se recomienda en el SS debido a que la acumulación de citocinas y metaloproteasas en la lágrima induce mayor inflamación de la superficie ocular 56 . ...
Chapter
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El síndrome de ojo seco es un trastorno multifactorial que suele ir acompañado de diversas enfermedades sistémicas. Entre otros trastornos congénitos, destacan la alácrima, la displasia ectodérmica anhidrótica, el síndrome de displasia ectodérmica, ectrodactilia y paladar hendido y el síndrome de Riley-Day, entre otras. Enfermedades dermatooculares como la rosácea, el penfigoide de membranas mucosas, la epidermólisis bullosa, el eritema multiforme mayor, la necrólisis epidérmica tóxica y la enfermedad injerto-contra-huésped. Además de enfermedades más frecuentes de origen autoinmune como los trastornos endocrinos: diabetes mellitus y disfunción tiroidea (hipotiroidismo, enfermedad de Graves y tiroiditis de Hashimoto), así como enfermedades vasculares del colágeno como el SS1, la artritis reuma-toide (AR), el lupus eritematoso sistémico (LES) y la esclerosis sistémica progresiva (ESP), entre otras. Estas últimas enfermedades serán las que discutiremos en este capítulo.
... It has been reported that PROSE (prosthetic replacement of the ocular surface ecosystem) has been used for treating severe DED by maintaining a stable tear film, protecting from exposure, and preventing friction-induced microtrauma. 45 There has not been any report describing the combined use of PROSE and topical steroids. Setting Figure 4. Relationship between PKS placement duration and the therapeutic lasting effect. ...
Article
Purpose: To evaluate the clinical efficacy of self-retained cryopreserved amniotic membrane in treating dry eye disease. Methods: Retrospective review of 10 patients treated with self-retained cryopreserved amniotic membrane (PROKERA® Slim [PKS], Bio-Tissue, Miami, FL) for moderate-to-severe dry eye refractory to conventional maximal medical treatments. Patients' symptoms, use of medications, conjunctival inflammation, corneal staining, and visual acuity were compared before and after treatment. Results: PKS was placed in 15 eyes of the 10 patients for 4.9 ± 1.5 days. All patients experienced symptomatic relief for a period of 4.2 ± 4.7 months (p<.001). Such improvement was accompanied by reduction of OSDI scores (p<.001), use of topical medications (p<.001), conjunctival hyperemia (p<.001), corneal staining (p<.001), and improvement of the visual acuity (p=.06). Linear regression analysis estimated that the optimal duration of PKS placement was 5 days to achieve an average symptom-free duration of 4 months in patients with dry eye. Surprisingly, PKS placement also generated improvement in the contralateral eyes. Conclusion: This pilot study suggests that self-retained cryopreserved amniotic membrane via PKS can be used to treat moderate dry eye diseases and warrants further prospective controlled studies.
... By neutralizing optical aberrations, scleral lens can provide significant improvement in visual acuity for various irregular corneal conditions, such as severe keratoconus and postpenetrating keratoplasty [1][2][3][4] . Scleral lens can adequately retain tear reservoir between the posterior surface of the scleral lens and the cornea to efficaciously manage severe dry eye in a variety of chronic ocular surface diseases 1,[5][6][7][8][9] . Intractable ocular surface diseases are a collection of conditions with sustained ocular pain, permanent visual decrement due to persistent ocular inflammation, keratinization or conjunctivalization of the cornea and limbal stem cell deficiencies. ...
Article
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To report the efficacy and safety of large diameter scleral lenses and determine their suitability in Asian subjects with intractable ocular surface diseases. This prospective study enrolled intractable ocular surface diseases subjects with uncorrected visual acuity > counting finger but ≥ 0.3 logMAR and best-corrected visual acuity (BCVA) ≥ 0.3 logMAR, to fit large diameter scleral lenses for 12 weeks. 21 eyes (13 subjects) consisting ten eyes (47.6%) with persistent epithelial defects, 6 (28.6%) with graft-versus-host disease, 4 (19.0%) with Stevens–Johnson syndrome and one (4.8%) with severe dry eye were ultimately enrolled. Primary outcome measures were the visual acuity, corneal and conjunctival fluorescein staining, Ocular Surface Disease Index (OSDI), and National Eye Institute 25-Item Visual Function Questionnaire (NEI-VFQ-25). At week 12 with large diameter scleral lenses, BCVA improved from 0.77 logMAR to 0.27 logMAR ( P < 0.001). High-grade corneal and conjunctival fluorescein staining proportion decreased from 61.90 to 14.29% and 52.38 to 9.52%, respectively ( P = 0.0036 and 0.0063, respectively). OSDI and NEI-VFQ-25 improved from 67.89 to 34.69 and 51.40 to 64.48, respectively ( P < 0.001). No adverse effects were observed. In Asians with intractable ocular surface diseases, large diameter scleral lens improves visual acuity and alleviates signs and symptoms of ocular surface diseases without any significant complications. Trial registration Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (Project No. HI12C0015 (A120018)). Clinical Trials.gov, NCT04535388. Registered 18 August 2020—Retrospectively registered, http://clinicaltrials.gov/ct2/show/NCT04535388 .
... There are numerous case series that describe the successful management of dry eye patients, including those with Sjøgren syndrome, with fluid-ventilated scleral lenses [14,74,147,[262][263][264]. There is a single case report of polymicrobial and microbial keratitis in a Sjøgren patient in association with scleral lens use [265]. ...
Article
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The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.
... There are numerous studies and clinical examples suggesting the safety and efficacy of scleral lenses in the treatment of diseases such as dry eye syndrome (DES) of various severity [6][7][8], Stevens-Johnson syndrome [9], Sjogren's disease [10], and neurotrophic keratopathy [11]. Scleral lenses are also successfully used to treat persistent corneal epithelial defects [12]. ...
Article
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Background. Scleral lenses, due to their benefits, hold a specific position among all types of contact lenses. Some years ago, they began to be used successfully not only for the correction of complex types of refractive errors, when other types of correction failed to achieve satisfactory visual function and visual rehabilitation of patients, but also as a therapeutic system in the management of ocular surface disease. Purpose. To evaluate the efficacy of rigid gas permeable miniscleral contact lenses as a therapeutic system in the management of patients with dry eye syndrome by filling the space under the lens with a non-preserved sodium hyaluronate solution. Materials and methods. In the study, 7 patients (11 eyes) with keratectasias after corneal surgery and concomitant dry eye syndrome were included. In the treatment and rehabilitation of these patients, miniscleral contact lenses were used during daytime with additional filling of the space under the lens with a non-preserved sodium hyaluronate solution. Results. As a criterion of the effectiveness of miniscleral contact lens use for therapeutic purposes, along with a significant increase in visual function in patients with complex corneal pathology, the elimination of discomfort due to restoration of the corneal epithelium integrity and improvement of their quality of life is considered.
... However, the limitation is its availability, expense and need of training for its application and removal. [108][109][110] ...
Article
Background: Aqueous deficiency dry eye disease is a chronic and potentially sight-threatening condition, that occurs due to the dysfunction of the lacrimal glands. The aim of this review was to describe the various recent developments in the understanding, diagnosis and treatment of lacrimal gland insufficiency in aqueous deficiency dry eye disease. Methods: A MEDLINE database search using PubMed was performed using the keywords: "dry eye disease/syndrome", "aqueous deficient/deficiency dry eye disease", "lacrimal gland" and "Sjogren's syndrome". After scanning through 750 relevant abstracts, 73 eligible articles published in the English language from 2016 to 2021 were included in the review. Results: Histopathological and ultrastructural studies have revealed new insights into the pathogenesis of cicatrising conjunctivitis-induced aqueous deficiency, where the lacrimal gland acini remain uninvolved and retain their secretory property, while significant ultrastructural changes in the gland have been observed. Recent advances in diagnosis include the techniques of direct clinical assessment of the lacrimal gland morphology and secretion, tear film osmolarity, tear film lysozyme and lactoferrin levels, tear film interferometry and lacrimal gland confocal microscopy. Developments in the treatment of aqueous deficiency dry eye disease, apart from the nanoparticle-based tear substitutes, include secretagogues like diquafosol tetrasodium and rebamipide, anti-inflammatory topical agents like nanomicellar form of cyclosporine and lifitegrast, scleral contact lenses, neurostimulation, and acupuncture for increasing the amount of tear production, minor salivary gland transplantation, faecal microbial transplantation, lacrimal gland regeneration and mesenchymal stem cell therapy. Conclusions: Significant advances in the understanding, diagnosis and management of lacrimal gland insufficiency and its role in aqueous deficiency dry eye disease have taken place within the second half of the last decade. Of which, translational breakthroughs in terms of newer drug formulations and regenerative medicine are most promising.
... For example, in patients with ADDE or EDE, including Sjögren syndrome, GvHD, rosacea or severe MGD, protective eyeglasses, prosthetic replacement of the ocular surface ecosystem (PROSE), or low-water content contact lenses should be used to limit exposure to adverse environmental conditions. [100][101][102][103][104] Electronic Devices For patients with excessive use of electronic devices with digital screens such as computers, tablets, and smartphones, we recommend increasing the administration of topical lubricants and applying the 20/20/20 rule (every 20 minutes, look away from the screen and focus the gaze on something at 20 feet for 20 seconds) to relax the accommodation reflex and reduce eye strain. 105,106 Management of Lid Inflammation The Mexican Panel and others suggested that anterior blepharitis and MGD may occur at every severity stage in DED patients. ...
Article
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Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.
... In progressive causes of DED generally seen with autoimmune pathologies, aggressive intensive IMT in acute phases followed by long term maintenance therapy can help limit disease progression. In addition to medical therapy, the use of scleral lenses such as prosthetic replacement of ocular surface ecosystem (PROSE) lenses helps relieve the symptoms, stabilizing the surface and visual rehabilitation of these patients [66]. ...
Article
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Dry eye disease (DED) is an emerging health concern causing significant visual, psychological, social, and economic impact globally. In contrast to visual rehabilitation undertaken at late stages of DED, measures instituted to prevent its onset, establishment, or progression can alter its natural course and effectively bring down the associated morbidity. This review attempts to present the available literature on preventive strategies of DED at one place, including strategies for risk assessment and mitigation, targeting a wide range of population. A literature search was conducted using PubMed and an extensive literature review on preventive strategies for DED was compiled to put forth a holistic and strategic approach for preventing DED. This can be undertaken at various stages or severity of DED directed at different tiers of the health care system. Conclusion: This review intends to put emphasis on preventive strategies being adopted as an integral part of routine clinical practice by general ophthalmologists and specialists to tackle the burden of DED and improve the quality of the lives of the patients suffering from it.
Article
Objectives: To examine the relationship between central lens thickness and central corneal edema during short-term closed eye scleral lens wear. Methods: Nine participants (mean age 30 years) with normal corneas wore scleral lenses (Dk 141) under closed eye conditions on separate days with nominal center thicknesses of 150, 300, 600, and 1,200 μm. Epithelial, stromal, and total corneal edema were measured using high-resolution optical coherence tomography immediately after lens application and after 90 min of wear, before lens removal. Data were corrected for variations in initial fluid reservoir thickness and compared with predictions from theoretical modeling of overnight scleral lens wear. Results: Scleral lens-induced central corneal edema was primarily stromal in nature. The mean±standard error of corrected total corneal edema was 4.31%±0.32%, 4.55%±0.42%, 4.92%±0.50%, and 4.83%±0.22% for the 150-, 300-, 600-, and 1,200-μm lenses, respectively. No significant differences in the corrected total corneal edema were observed across all thickness groups (P=0.20). Theoretical modeling of overnight scleral lens wear seemed to overestimate the relative increase in central corneal edema as a function of decreasing lens Dk/t for values lower than 25. Conclusion: The magnitude of scleral lens-induced central corneal edema during short-term closed eye lens wear did not vary significantly with increasing central lens thickness. Theoretical modeling of overnight closed eye scleral lens wear seems to overestimate the effect of increasing lens thickness.
Article
Objectives Dry eye disease (DED) is arguably the most frequent ocular disease encountered in ophthalmic clinical practice. DED is frequently an underestimated condition causing a significant impact on visual function and quality of life. Many systemic autoimmune diseases (SAIDs) are related to moderate to severe DED. The main objective of this review is to enhance the awareness among ophthalmologists of the potential association of an underlying SAID in a high-risk patient with DED. Methods An exhaustive literature search was performed in the National Library of Medicine's Pubmed, Scopus, Web of Science, and Google Scholar databases for all English language articles published until November 2021. The main keywords included “dry eye disease” associated with autoimmune, connective tissue, endocrine, gastrointestinal, hematopoietic, vascular, and pulmonary diseases. Case reports, series, letters to the editor, reviews, and original articles were included. Results Although DED is frequently associated with SAIDs, its diagnosis is commonly delayed or missed, producing significant complications, including corneal ulceration, melting, scleritis, uveitis, and optic neuritis resulting in severe complications detrimental to visual function and quality of life. SAID should be suspected in a woman, 30 to 60 years old with a family history of autoimmunity, presenting with DED symptoms and extraocular manifestations including arthralgias, dry mouth, unexplained weight and hair loss, chronic fatigue, heat or cold intolerance, insomnia, and mood disorders. Conclusions Establishing the correct diagnosis and treatment of DED associated with SAIDs is crucial to avoid its significant burden and severe ocular complications.
Article
Introduction: Dry eye disease (DED) is a multifactorial condition of the tears and ocular surface. New insight on the pathogenesis of dry eye has resulted in development of novel treatments. Current management paradigms vary from self-administered (e.g., artificial tears) to practitioner-administered (e.g., punctal occlusion) modalities. Areas Covered: In part A of this series, the spectrum of pharmacological agents for treatment of DED was reviewed. Part B discusses the current and emerging non-pharmacological therapeutic modalities, which include punctal occlusion, contact lenses, inserts, eyelid warming devices, thermal pulsation system, intense pulsed light, acupuncture, meibomian gland probing, moisture chamber spectacles, tarsorrhaphy, meibomian gland expression, autologous submandibular gland transplantation, and amniotic membrane placement. In preparing this review, a Medline, PubMed and Cochrane Database search of the medical literature for the period between January 1978 and July 2016 using a wide range of keywords was conducted. Only treatment modalities that had their efficacy and safety investigated in clinical studies are included. Expert Commentary: Many patients have multiple mechanisms contributing to DED and appropriateness of each available treatment should be considered on a case-by-case bases. There are multiple devices under investigation in the pre-clinical stage, which have promising data in treating DED.
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BSR and BHPR Guideline for the Management of Adults with Primary Sjögren’s Syndrome Elizabeth Price1, Saaeha Rauz2, Anwar Tappuni3, Nurhan Sutcliffe4, Katie L. Hackett 5, Francesca Barone6, Guido Granata6, Wan-Fai Ng5, Benjamin A. Fisher6, Michele Bombardieri7, Elisa Astorri7, Ben Empson8, Genevieve Larkin9, Bridget Crampton10 and Simon Bowman11 on behalf of the BSR and BHPR Standards, Guideline and Audit Working Group 1Department of Rheumatology, Great Western Hospital NHS Foundation Trust; 2Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, and Birmingham and Midland Eye Centre, UK; 3Queen Mary, University of London; 4Department of Rheumatology, Barts Health NHS Trust; 5Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, UK and Newcastle upon Tyne Hospitals NHS Foundation Trust, UK; 6Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK and Department of Rheumatology, Queen Elizabeth Hospital, Birmingham, UK; 7Centre for Experimental Medicine and Rheumatology, Queen Mary, University of London; 8Modality partnership, The Laurie Pike Health Centre, Birmingham; 9Kings College Hospital, London; 10British Sjögren’s Syndrome Association, Birmingham, UK; 11Queen Elizabeth Hospital, Birmingham, UK Correspondence to: Elizabeth Price, Great Western Hospital NHS Foundation Trust, Swindon, SN3 6BB, UK. E-mail: Elizabeth.price@gwh.nhs.uk Key words: Sjögren’s, guideline, management, sicca Executive Summary Scope and Purpose Background Primary Sjögren’s syndrome (pSS) is a chronic, immune-mediated, condition (1) typically presenting in women in their 5th or 6th decade, although up to 10% of cases occur in men. The prevalence in women in the UK is 0.1-0.4% (2). Patients characteristically present with dryness of the eyes and mouth but systemic features are common and B-cell lymphoma affects 5-10% (3, 4). Objective of Guideline This document aims to provide a pragmatic, practical guideline for the management of adults with pSS. Target audience The target audience includes rheumatologists, general physicians, general practitioners, specialist nurses and other specialists (e.g. ophthalmologists, dental practitioners and Ear, Nose and Throat Specialists). Areas NOT covered This guideline does not cover the detailed management of patients with secondary Sjögren’s or patients with Lymphoma who should be managed in conjunction with oncologists and haematologists. The management of children is not specifically covered although is similar to that for adults with special emphasis on good dental care and hygiene. Rigor of Development & limitations A search was undertaken for all relevant evidence from 1990 to January 2016. The level of evidence was graded from Ia through to IV and A through to D. See appendix 1 for full details of search criteria and Level of Evidence (LOE) definitions. A Strength of Agreement (SOA) was calculated for each recommendation and the results expressed as an SOA score (0-10) with percentage of respondents scoring the recommendation ≥7 in brackets. Recommendations were only included where the mean SOA was ≥7 and >75% respondents scored ≥7. The Guideline Eyes I. Conservation of tears by humidification and avoidance of systemic medication that exacerbates dryness LOE Ib/A; SOA 8.9 (97%) II. Stimulate meibomian gland secretion daily using warm compresses, commercially available eye bags or other devices and perform lid hygiene if required. LOE III/C; SOA 8.9 (93.3%) III. If persistent meibomian gland inflammation and blepharitis treatment with doxycycline 50mg od for a minimum of 3 months may be effective. LOE IV/D; SOA8.83 (92.9%) IV. Early referral to an ophthalmologist for review and consideration of insertion of punctual plugs or cauterisation. LOE II/B; SOA 9.27 (100%) V. Recommend liposomal sprays to reduce evaporative tear loss and replace the meibomian gland layer LOE III/C; SOA 8.29 (92.8%) VI. Start with simple lubricating drops using the most cost-effective options (see Table 1 for preparations) LOE IV/D; SOA 9.3 (93.3%) VII. Avoid preservative containing preparations LOE I/A; SOA 9.21 (92.9%) VIII. Refer patients with severe dry eye, not responding to conventional treatment, to specialist commissioned centres for consideration of serum eye drops. LOE IIb/B; SOA 9.5 (100%) IX. Low dose steroid containing eye drops for short term use under ophthalmic supervision only LOE Ib/A; SOA 9.64 (100%) X. Avoid long term use of topical steroids LOE Ib/A; SOA 9.64 (100%) XI. Ciclosporin eye drops or ointments under ophthalmic supervision for chronic inflammation LOE Ib/A; SOA 9.38 (100%) XII. Use topical NSAIDs with caution under ophthalmic supervision only LOE IIb/B; SOA 9.86 (100%) XIII. A trial of Pilocarpine 5mg once daily increasing stepwise to 5mg qds is recommended for patients with significant sicca symptoms. LOE IIb/B; SOA 9.08 (92.3%) XIV. Prescribe mucolytic eye drops to patients with mucous threads or ocular surface filaments LOE III/C; SOA 9.38 (100%) XV. Refer patients with severe dry eye and associated blepharospasm to a specialist centre for consideration of Botulinum toxin treatment LOE III/C; SOA 9.17 (100%) XVI. Refer patients with severe dry eye and corneal ulceration, not responding to conventional treatment, to specialist centre for consideration of ‘bandage’ contact lenses or corneal grafting. LOE III/C; SOA 9.15 (92.9%) Mouth I. Advise excellent oral hygiene, limit sugar intake and avoid food and drinks other than plain water between meals and from 1 hour before bedtime and through the night LOE IV/D; SOA 9.8 (100%) II. Assessment by an Oral Medicine specialist and/or regular visits to a general dental practitioner LOE IV/D; SOA 9.8 (100%) III. Avoid acidic and sugar containing products in dentate patients. LOE IV/D SOA 9.87 (100%) IV. Humidify the environment LOE III/C; SOA 9.13 (100%) V. Brush teeth at least twice daily (but not immediately after eating) including before bed using a pea sized amount of high fluoride toothpaste and use fluoride containing oral gel on teeth twice daily LOE I/A; SOA 9.8 (100%) VI. Alcohol free chlorhexidene mouth wash twice daily for maximum of 2 weeks every 3 months can help prevent gum disease LOE IV/D; SOA 9.0 (100%) VII. Use fluoride containing mouth wash, gel or spray as required for symptomatic relief. LOE III/C; SOA 9.43 (92.8%) VIII. Chew xylitol containing sugar free gum. LOE IIb/B; SOA 9.67 (100%) IX. A trial of Pilocarpine 5mg once daily increasing stepwise to 5mg qds if significant sicca symptoms. LOE IIb/B; SOA 9.77 (100%) Treatment of oral Candida I. Ssimple candida infection (visible white plaques) - oral nystatin liquid 1ml five times daily for 7 days. Repeat for 1 week in 8 if frequent recurrence. LOE IV/D; SOA 9.86 (100%) II. Erythematous infection (red, raw tongue or oral cavity) - fluconazole 50mg od for 10 days. LOE IV/D; SOA 9.86 (100%) III. Treat angular cheilitis with miconazole topically for 2 weeks. LOE IV/D; SOA 9.86 (100%) Management of Salivary Gland enlargement I. Consider baseline ultrasound to assess for active inflammation, infection and stones. LOE IV/D; SOA 9.7 (100%) II. If acute inflammation, in the absence of infection and stones, consider short course of oral prednisolone or intra-muscular Depomedrone. LOE IV/D; SOA 9.01 (100%) III. Massaging the glands reduces inflammation in chronically inflamed glands LOE IV/D; SOA 9.31 (92.8%) Systemic dryness I. A trial of Pilocarpine 5mg once daily increasing stepwise to 5mg qds if systemic dryness. LOE IV/D; SOA 9.08 (92.3%) II. Anon-hormonal vaginal moisturiser +/-topical oestrogen if vaginal dryness. LOE I/A; SOA 9.8 (100%) Treatment of Systemic Disease Non-pharmacological interventions for systemic disease I. Advise a graded exercise programme for fatigue. LOE IIb/B; SOA 9.33 (93.3%) II. Provide written information and details of appropriate support groups and on-line resources LOE IV/D; SOA 9.8 (100%) Pharmacological treatment for systemic disease I. Hydroxychloroquine (6mg/kg) for those with skin, joint disease or fatigue LOE IIa/B; SOA 9.64 (100%) II. Ciclosporin A may be helpful in patients with significant joint involvement LOE III/C; SOA 8.58 (85.7%) III. Azathioprine may be considered in patients with systemic complications. LOE III/C; SOA 9.09 (100%) IV. Methotrexate is useful for patients with an associated inflammatory arthritis. LOE IV/D SOA 9.54 (100%) V. Mycophenolate may be considered in patients with systemic complications. LOE III/C; SOA 9.1 (100%) Corticosteroids I. Intermittent short courses of oral or intramuscular steroid for systemic flares and significant organ manifestations with or without additional immunosuppressive treatment. LOE III/C; SOA 9.2 (100%) II. Low dose oral prednisolone for persistent constitutional symptoms in patients with inadequate response to other immunosuppresants. LOE IIb/B; SOA 8.92 (100%) Cyclophosphamide I. Cyclophosphamide (usually in combination with steroids) for patients with organ threatening systemic complications. LOE III/C; SOA 9.09 (100%) Rituximab I. Rituximab for specialist use in patients with significant systemic manifestations refractory to other immunosuppresives and those with lymphoma, Immune thrombocytopaenia, vasculitic neuropathy or cryoglobulinaemia. LOE IIb/B; SOA 9.43 (100%) Intravenous Immunoglobulins I. Immunoglobulin treatment for Sjögren’s associated myositis and neuropathies if the patient has failed to respond to treatment with conventional immunosuppression. LOE III/C; SOA 9.43 (100%) Colchicine I. Colchicine as adjunctive treatment if cutaneous manifestations or pericarditis not responding to other treatments. LOE III/C; SOA 8.45 (85.7%) Dapsone I. Dapsone as adjunctive treatment if cutaneous manifestations not responding to hydroxychloroquine. LOE III/C; SOA 8.8 (100%) Topical Tacrolimus I. Topical Tacrolimus as adjunctive treatment if cutaneous manifestations not responding to hydroxychloroquine. LOE III/C; SOA 8.75 (100%) Treatments NOT recommended I. Leflunomide and Penicillamine are not routinely recommended for Primary Sjögren’s Syndrome. Level of evidence III/C; SOA 9.8 (100%) II. Belimumab and Abatacept are not currently recommended although they merit further study. Level of evidence IIb/B & III/C; SOA 9.46 (92.8%) III. Anti-TNF, IFN alpha and Anakinra therapies are not recommended for treatment of Primary Sjögren’s Syndrome Level of evidence Ib/A; SOA 9.38 (85.7%) IV. Tociluzimab and Efalizuab are not recommended for the treatment of Primary Sjögren’s Syndrome. Level of evidence III/C; SOA 9.82 (100%) V. Dehydroepiandrosterone (DHEA) substitution treatment is not recommended in Primary Sjögren’s Syndrome. Level of evidence Ib/A; SOA 9.45 (100%) Management of Pregnancy I. Consider low dose aspirin to improve placental implantation LOE IIb/B; SOA 8.27 (92.8%) II. Monitor with serial US if anti Ro and/or La positive and consider referral to specialist centre LOE IIb/B; SOA 9.71 (100%) III. Review all medication in pregnancy. Hydroxychloroquine may be continued throughout pregnancy and breastfeeding LOE I/A; SOA 7.91 (85.7%) Assessment & Management of Lymphoma I. Review high risk patients regularly and warn patients to report firm, painless glandular swelling that doesn’t settle LOA IV/D; SOA 9.86 (100%) II. Investigate suspicious lesions with local US, biopsy and CT chest, abdomen and pelvis for staging LOA III/C; SOA9.77 (100%) Conclusion pSS is a chronic, debilitating condition that warrants effective management. All patients should be counselled and offered topical management for sicca symptoms. Systemic treatment should be considered early in those with constitutional symptoms. Reference 1. Fisher BA, Brown RM, Bowman SJ, Barone F. A review of salivary gland histopathology in primary Sjögren's syndrome with a focus on its potential as a clinical trials biomarker. Ann Rheum Dis. 2015;74(9):1645-50. 2. Bowman SJ, Ibrahim GH, Holmes G, Hamburger J, Ainsworth JR. Estimating the prevalence among Caucasian women of primary Sjogren's syndrome in two general practices in Birmingham, UK. Scandinavian journal of rheumatology. 2004;33(1):39-43. 3. Ramos-Casals M, Solans R, Rosas J, Camps MT, Gil A, Del Pino-Montes J, et al. Primary Sjogren syndrome in Spain: clinical and immunologic expression in 1010 patients. Medicine. 2008;87(4):210-9. 4. Ramos-Casals M, Brito-Zeron P, Solans R, Camps MT, Casanovas A, Sopena B, et al. Systemic involvement in primary Sjogren's syndrome evaluated by the EULAR-SS disease activity index: analysis of 921 Spanish patients (GEAS-SS Registry). Rheumatology (Oxford, England). 2014;53(2):321-31.
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The members of the Management and Therapy Subcommittee undertook an evidence-based review of current dry eye therapies and management options. Management options reviewed in detail included treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, surgical approaches, dietary modifications, environmental considerations and complementary therapies. Following this extensive review it became clear that many of the treatments available for the management of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due to a lack of appropriate masking, randomization or controls and in some cases due to issues with selection bias or inadequate sample size.
Article
Purpose The current paradigm for therapy of recalcitrant ocular surface diseases (OSD) consists of a sequential, step-up treatment approach. A combinatorial topical therapy (anti-inflammatory/immunosuppressive [steroid] with immunomodulatory [pooled human immune globulin] and tear substitute [serum]) that simultaneously targets several immunological pathways may be more efficacious. This report evaluates if the combinatorial therapy resulted in clinical benefit in patients with recalcitrant OSD. Methods We performed a retrospective case study of patients receiving topical, preservative-free, compounded formulations of steroids, pooled human immune globulin, and serum tears. Outcome measures included visual acuity, ocular surface disease index (OSDI), ocular discomfort score, subjective global assessment (SGA), corneal staining, conjunctival redness, and slit lamp photographs. Results Patients consisted of one male and 11 females ranging in age from 27 to 87 years old. Pathologies included ocular graft-versus-host disease (n = 4), Sjögren's syndrome (n = 3), ocular cicatricial pemphigoid (n = 1), pemphigus vulgaris (n = 1), peripheral ulcerative keratitis (n = 1), Stevens-Johnson syndrome (n = 1), and giant papillary conjunctivitis (n = 1). All patients were “improved” or “much improved” on SGA after combinatorial therapy. There was a clinically meaningful reduction in OSDI, ocular discomfort, corneal staining, and conjunctival injection. Additionally, three patients had improvement in their visual acuity (one from 20/400 to 20/20). Adverse effects included increased intraocular pressure in two patients, presumably due to topical steroid use. Conclusions Combinatorial therapy provides clinical benefit by reducing the symptoms and signs in recalcitrant OSD. Our study provides the rationale for performing prospective clinical trials to evaluate the efficacy of combinatorial therapy for treating recalcitrant OSD.
Article
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Article
Purpose To examine the relationship between central post-lens fluid reservoir thickness and central corneal oedema during short-term closed eye scleral lens wear, and to compare these empirical oedema measurements with open eye lens wear data and current theoretical modelling for overnight scleral lens wear. Methods Ten participants (mean ± standard error 30 ± 1 years) with normal corneas wore scleral lenses (Dk 141 × 10⁻¹¹ cm³ O2(cm)/[(sec.)(cm²)(mmHg)) under closed eye conditions on separate days with an initial central post-lens fluid reservoir thickness considered to be low (160 ± 7 μm), medium (494 ± 17 μm), or high (716 ± 16 μm). Epithelial, stromal, and total corneal oedema were measured using high-resolution optical coherence tomography immediately after lens application and following 90 min of wear, prior to lens removal. Data were compared to open eye scleral lens induced corneal oedema and a theoretical model of overnight closed eye scleral lens wear (Kim et al., 2018). Results Central corneal oedema was primarily stromal in nature and increased with increasing fluid reservoir thickness; the mean total corneal oedema was 3.86 ± 0.50%, 4.71 ± 0.28% and 5.04 ± 0.42% for the low, medium, and high thickness conditions, respectively. A significant difference in stromal and total corneal oedema was observed between the low and high fluid reservoir thickness conditions only (both p ≤ 0.01). Theoretical modelling overestimated the magnitude of central corneal oedema and the influence of fluid reservoir thickness upon corneal oedema during closed eye conditions. Conclusion Scleral lens induced central corneal oedema during closed eye lens wear increases with increasing fluid reservoir thickness, but at a decreased rate compared to theoretical modelling.
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This opening chapter describes the evaluation and management of three patients with increasing severity of aqueous-deficient dry eye disease (AD-DED) (the management of meibomian gland disease, which frequently coexists with aqueous deficiency, is discussed in Chap. 2). The diagnosis and management of these three cases follows the Dry Eye Workshop (DEWS) recommendation which is based on the severity levels (Table 1.1). In Case 1, with mild dry eye disease (severity level 1), the emphasis is on proper history and counseling with lifestyle modifications. Case 2, with more moderate disease (severity level 2), highlights the use of anti-inflammatory therapy and the option of punctal plugs. Case 3, with more severe disease (severity level 3), discusses the advanced treatment options including total punctal occlusion, serum tears, and scleral lenses.
Article
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Purpose: The aim of this study was to evaluate the anterior surface of scleral contact lens and ocular surface wettability before and after one-month of scleral lens wear in patients with keratoconus. Methods: Forty-nine patients with keratoconus (36.26 ± 9.03 years) were recruited. The sample was divided into two groups: patients with intrastromal corneal ring (KCICRS group) and patients without ICRS (KC group). TFSQ, Schirmer I test, Ocular Surface Disease Index (OSDI questionnaire), tear break-up time (TBUT) and corneal staining were evaluated in two different visits: Baseline (before lens wear) and one-month visit (10 min after lens removal). Visual Analog Scale (VAS questionnaire) was filled in just after inserting the lenses and just before removing them. TFSQ mean and inferior were evaluated over the contact lens surface at the moment of inserting the lens (baseline visit) and after 8 h of lens wear (one-month visit). Results: Anterior corneal surface TFSQ values increased in all groups after scleral lens wear (p < 0.05). However, there were no statistical differences found at the moment of inserting or after 8 h of lens wear on previous contact lens surface TFSQ (p > 0.05). No changes were found in tear volume for total and in KC and KCICRS groups (p > 0.05). For all groups, there was a statistical decrease of TBUT (p < 0.05). In addition, OSDI score, corneal staining and VAS score improved after scleral lens wear from baseline in total and in both KC and KCICRS groups (p < 0.05). Conclusion: The scleral contact lens surface keeps its wettability after one-month of wear. However, the wettability of the ocular surface is worse after contact lens wearing.
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SS is a chronic, autoimmune disease of unknown aetiology for which there is no known curative treatment. Although dryness of the eyes and mouth are the classically described features, patients often experience drying of other mucosal surfaces and systemic manifestations, including fatigue and arthralgia. There is an association with other autoimmune diseases, especially thyroid disease, coeliac disease and primary biliary cholangitis. Systemic features may affect up to 70% and include inflammatory arthritis, skin involvement, haematological abnormalities, neuropathies, interstitial lung disease and a 5–10% lifetime risk of B cell lymphoma. Treatment should aim to empower patients to manage their condition; conserve, replace and stimulate secretions; prevent damage; and suppress underlying systemic disease activity.
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Research and reviews have resulted in clear indications for scleral lens (SL) wear. Those indications include visual rehabilitation; therapeutic use in managing ocular surface diseases, lid and orbit disorders; and refractive correction to enhance visual quality, comfort and quality of life. In some cases, the use of SLs may be contraindicated: the presence of low endothelial cell density; Fuchs’ endothelial corneal dystrophy; glaucoma (because of the risk of an increase in intraocular pressure and the existence and location of draining devices and blebs); or overnight wear. While the literature provides an extensive description of the indications for scleral lens wear, the authors recognize that there is no paper reporting the contraindications to their use. The aim of this review is to illustrate the conditions for which SL wear is potentially contraindicated or requires caution. Improved knowledge of SL limits should reduce the risk of adverse events and increase the likelihood of fitting success.
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Patients with Graves’ ophthalmopathy can be very challenging to manage secondary to the complex nature of their disease presentation. Patients may present with a variety of ocular findings including: lid retraction, periorbital and lid swelling, chemosis, conjunctival hyperemia, proptosis, optic neuropathy, restrictive myopathy, exposure keratopathy and/or keratoconjunctivitis sicca. Mini-scleral and scleral lens designs have been important in the management of irregular and regular corneas, and in the therapy of ocular surface diseases. We present here the case of a 48-year-old Caucasian male who had been diagnosed with Graves’ ophthalmopathy 13 years earlier. With significant ocular surface staining and over ten diopters of astigmatism, the patient had never been able to wear contact lenses comfortably. After being fit with the Mini-Scleral Design™ lenses, his vision improved to 20/25 OU, his ocular surface improved, and overall quality of vision increased.
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Scleral contact lenses (ScCL) have gained renewed interest during the last decade. Originally, they were primarily used for severely compromised eyes. Corneal ectasia and exposure conditions were the primary indications. However, the indication range of ScCL in contact lens practices seems to be expanding, and it now increasingly includes less severe and even non-compromised eyes, too. All lenses that partly or entirely rest on the sclera are included under the name ScCL in this paper; although the Scleral Lens Education Society recommends further classification. When a lens partly rests on the cornea (centrally or peripherally) and partly on the sclera, it is called a corneo-scleral lens. A lens that rests entirely on the sclera is classified as a scleral lens (up to 25 mm in diameter maximum). When there is full bearing on the sclera, further distinctions of the scleral lens group include mini-scleral and large-scleral lenses. This manuscript presents a review of the current applications of different ScCL (all types), their fitting methods, and their clinical outcomes including potential adverse events. Adverse events with these lenses are rare, but the clinician needs to be aware of them to avoid further damage in eyes that often are already compromised. The use of scleral lenses for non-pathological eyes is discussed in this paper.
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Boston ocular surface prosthesis (BOSP) is a scleral contact lens used in the management of patients who are rigid gas permeable (RGP) failures as with corneal ectasias such as keratoconus and in those patients who have ocular surface disease such as Stevens-Johnson syndrome (SJS). To report utilization of BOSP in a tertiary eye care center in India. We retrospectively reviewed charts of 32 patients who received BOSP from July 2008 to May 2009. Indications for fitting these lenses, improvement in visual acuity (VA) before and after lens fitting and relief of symptoms of pain and photophobia were noted. Paired t-test was used for statistical analysis using SPSS version 16.0 for Windows. Thirty-two patients (43 eyes) received these lenses. These consisted of 23 eyes of 17 patients who failed RGP trials for irregular astigmatism and corneal ectasia such as keratoconus and post radial keratotomy and scar and 20 eyes of 15 patients with SJS. Mean age of RGP failures was 27.94 years. Pre- and post-BOSP wear mean LogMAR VA was 1.13 and 0.29, respectively, in RGP failures. The P value was statistically significant (P < 0.001). In patients with SJS, LogMAR VA was 0.84 ± 0.92 before and 0.56 ± 0.89 after lens wear. The P value was statistically significant (P < 0.001). VA improved by >2 lines in 7/20 eyes (35%) with SJS, with improvement in symptoms. BOSP improves VA in patients who have irregular astigmatism as in ectasias and RGP failures and improves vision and symptoms in patients with SJS.
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Purpose: To evaluate the effect of the Boston Ocular Surface Prosthesis (Boston Foundation for Sight) on higher-order wavefront aberrations in eyes with keratoconus, eyes that have undergone penetrating keratoplasty, eyes that have undergone refractive surgery, and eyes with ocular surface diseases. Design: Prospective, clinical study. Methods: The study evaluated 56 eyes of 39 patients with irregular astigmatism who were treated with the Boston Ocular Surface Prosthesis when conventional treatments failed. Patients were sorted into 4 clinical groups based on the underlying cause of irregular astigmatism, including keratoconus (group 1), post-penetrating keratoplasty (group 2), post-refractive surgery (group 3), and ocular surface diseases (group 4). Another 6 eyes of 5 patients who were treated with rigid gas permeable lenses also were evaluated. Best-corrected visual acuity; topographic refractive indices, including spherical, cylindrical, spherical equivalent values; and higher-order and total wavefront aberration errors were noted at baseline and after fitting the lens. Results: In all groups, higher-order wavefront aberration error was noted to decrease significantly in eyes wearing the Boston Ocular Surface Prosthesis (P<.001, P=.001, P=.002, and P=.001, respectively). By post hoc analysis, significant differences in the level of higher-order aberrations were observed only between groups 1 and 4 (P=.012) and groups 1 and 2 (P=.033). In the overall group, mean correction rate of higher-order aberration error with the Boston Ocular Surface Prosthesis was 72.3%. However, in eyes with rigid gas permeable lenses, 2 eyes demonstrated increased higher-order aberration error, whereas the mean correction rate in other 4 eyes was only 42.5%. Conclusions: With its unique structure, the Boston Ocular Surface Prosthesis was found to be very effective in reducing higher-order wavefront aberrations in patients with irregular astigmatism resulting from a number of corneal and ocular surface conditions who had not responded satisfactorily to conventional methods of optical correction.
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To determine whether parameters of anterior corneal contour as identified by topographic analysis (steep and flat simulated keratometry, reference sphere) predict the base curve of Jupiter scleral lenses in patients with dry eye syndrome and keratoconus. We identified 33 eyes with dry eye syndrome and 21 eyes with keratoconus that were fit with Jupiter scleral lenses of standard design between June 2006 and July 2009. Steep and flat simulated keratometry powers and shape factor from axial topographic maps, reference sphere from elevation maps, and base curve of the scleral lens prescribed for each eye were recorded. Correlations between topographic indices and base curve were evaluated by using the Pearson correlation coefficient, and significances were completed by using generalized estimating equation models. In dry eye syndrome, the base curve of the final scleral lens prescribed correlated with the steep keratometric power (r = 0.70, P = 0.05, n = 33), the flat keratometric power (r = 0.71, P<0.001, n = 33), and the reference sphere (r = 0.73, P = 0.002, n = 33). In eyes with keratoconus, base curve also correlated with the steep keratometric power (r = 0.72, P<0.001, n = 19), the flat keratometric power (r = 0.70, P<0.001, n = 19), and the reference sphere (r = 0.68, P<0.001, n = 21). There were no correlations between base curve and shape factor. In eyes with normal and abnormal ocular contour, base curve of scleral lenses correlates with reference sphere and steep and flat keratometric powers, but the predictive relationship is weak (r ∼0.50). Diagnostic fitting may be the most efficient method of fitting scleral lenses at present.
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To describe the use of the Jupiter scleral contact lens (Medlens Innovations, Front Royal, VA or Essilor Contact Lens, Inc., Dallas, TX) in the management of ocular manifestations of chronic graft versus host disease (cGVHD). This study is a retrospective case series. Five consecutive patients with severe keratoconjunctivitis sicca (KCS) associated with cGVHD that could not be adequately managed with conventional therapy were evaluated for scleral contact lens wear between January and December 2007. All patients were evaluated with lenses from the standard 18.2 mm Jupiter B diagnostic fitting set. If lenses of standard design failed to provide adequate fit, custom lenses were designed. Three outcome measures were evaluated: the patient's ability to tolerate and successfully handle the lenses, improvement in symptoms of KCS, and improvement in visual acuity. All 5 patients (10 eyes) were successfully fit with Jupiter scleral lenses. Six eyes of 3 patients were successfully fit with lenses of standard design. Standard parameters were altered to achieve adequate fit in 4 eyes of 2 patients. All patients reported subjective improvements in comfort with Jupiter scleral lenses, and best-corrected vision improved in 7 of the 10 eyes fit within the first several months of contact lens wear. The remaining 3 eyes maintained the visual acuity measured before scleral lens wear (20/20 in 2 eyes, 20/40 in 1 eye). Duration of follow-up ranged from 4 to 14 months. Jupiter scleral lenses can relieve symptoms of KCS and may improve vision in patients with cGVHD.
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To describe the use of overnight wear scleral contact lenses (Scl CLs). The authors describe 7 patients using this modality of contact lens wear. Most of the lenses were made from highly gas-permeable materials, but a long-standing case is also reported when the lenses were made from PMMA, which is impermeable to gases. There is a range of therapeutic indications for the use of Scl CLs. The development of rigid gas-permeable (RGP) materials has widened this range. Seven case reports are presented which describe patients in whom severe ocular surface disease has been managed with overnight-wear Scl CLs. The indications were: corneal exposure, post-radiotherapy complications, Stevens Johnson disease, recurrent erosion and congenital or post-surgical lid defects. Scl CLs provide a therapeutic option for a range of complicated corneal and ocular surface conditions for which the treatment by other methods is either unsuitable or less effective. They have several advantages over silicone rubber and hydrogel lenses. The relative ease of handling for some patients allows removal for cleaning, their rigidity gives stability and a high degree of protection to the ocular surface, and the presence of a pre-corneal fluid reservoir optically neutralises an irregular corneal surface. Highly oxygen-permeable materials enable consideration of overnight wear in appropriate circumstances.
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Dry eye syndrome (DES) is believed to be one of the most common ocular problems in the United States (US), particularly among older women. However, there are few studies describing the magnitude of the problem in women and how this may vary with demographic characteristics. Cross-sectional prevalence survey. Study population: we surveyed 39,876 US women participating in the Women's Health Study about a history of diagnosed DES and dry eye symptoms. Main outcome measure: we defined DES as the presence of clinically diagnosed DES or severe symptoms (both dryness and irritation constantly or often). We calculated the age-specific prevalence of DES and adjusted the overall prevalence to the age distribution of women in the US population. We used logistic regression to examine associations between DES and other demographic factors. The prevalence of DES increased with age, from 5.7% among women < 50 years old to 9.8% among women aged > or = 75 years old. The age-adjusted prevalence of DES was 7.8%, or 3.23 million women aged > or = 50 in the US. Compared with Whites, Hispanic (odds ratio [OR] = 1.81, confidence interval [CI] = 1.18-2.80) and Asian (OR = 1.77, CI = 1.17-2.69) women were more likely to report severe symptoms, but not clinically diagnosed DES. There were no significant differences by income (P([trend]) =.78), but more educated women were less likely to have DES (P([trend]) =.03). Women from the South had the highest prevalence of DES, though the magnitude of geographic differences was modest. Dry eye syndrome leading to a clinical diagnosis or severe symptoms is prevalent, affecting over 3.2 million American women middle-aged and older. Although the condition is more prevalent among older women, it also affects many women in their 40s and 50s. Further research is needed to better understand DES and its impact on public health and quality of life.
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Keratoconjunctivitis sicca (KCS) occurs in 40%-60% of patients with chronic graft-versus-host-disease (cGVHD) after allogeneic hematopoietic cell transplantation. Although immunosuppressive therapy is the primary treatment of chronic GVHD, ocular symptoms require measures to improve ocular lubrication, decrease inflammation, and maintain mucosal integrity. The liquid corneal bandage provided by a fluid-ventilated, gas-permeable scleral lens (SL) has been effective in mitigating symptoms and resurfacing corneal erosions in patients with KCS related to causes other than cGVHD. We report outcomes in 9 consecutive patients referred for SL fitting for cGVHD-related severe KCS that was refractory to standard treatments. All patients reported improvement of ocular symptoms and reduced the use of topical lubricants after SL fitting resulting from decreased evaporation. No serious adverse events or infections attributable to the SL occurred. The median Ocular Surface Disease Index improved from 81 (75-100) to 21 (6-52) within 2 weeks after SL fitting, and was 12 (2-53) at the time of last contact, 1-23 months (median, 8.0) after SL fitting. Disability related to KCS resolved in 7 patients after SL fitting. The use of SL appears to be safe and effective in patients with severe cGVHD-related KCS refractory to conventional therapies.
Article
Aim: To determine the prevalence and identify associated risk factors for dry eye syndrome in a population in Sumatra, Indonesia. Methods: A one stage cluster sampling procedure was conducted to randomly select 100 households in each of the five rural villages and one provincial town of the Riau province, Indonesia, from April to June 2001. Interviewers collected demographic, lifestyle, and medical data from 1058 participants aged 21 years or over. Symptoms of dry eye were assessed using a six item validated questionnaire. Presence of one or more of the six dry eye symptoms often or all the time was analysed. Presence of pterygium was documented. Results: Prevalence of one or more of the six dry eye symptoms often or all the time adjusted for age was 27.5% (95% confidence interval (CI) 24.8 to 30.2). After adjusting for all significant variables, independent risk factors for dry eye were pterygium (p<0.001, multivariate odds ratio (OR) 1.8; 95% CI 1.4 to 2.5) and a history of current cigarette smoking (p=0.05, multivariate OR 1.5; 95% CI 1.0 to 2.2). Conclusions: This population based study provides prevalence rates of dry eye symptoms in a tropical developing nation. From our findings, pterygium is a possible independent risk factor for dry eye symptoms.
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To present a comprehensive review of current and historical literature on scleral lenses. A comprehensive search of several databases from each database's earliest inception to May 23, 2014 was conducted by an experienced librarian with input from the author to locate articles related to scleral lens design, fabrication, prescription, and management. A total of 899 references were identified, 184 of which were directly related to scleral lenses. References of interest were organized by date, topic, and study design. Most of articles published before 1983 presented lens design and fabrication techniques or indications for scleral lens therapy. Case reviews published after 1983 identified major indications for scleral lenses (corneal ectasia, ocular surface disease, and refractive error) and visual and functional outcomes of scleral lens wear. Statistically significant improvements in visual acuity, vision-related quality of life, and ocular surface integrity were reported. Reviews of ocular and systemic conditions suggested that comprehensive management strategies for these conditions could include scleral lenses. Early work investigating scleral lens fitting characteristics, optical qualities, and potential physiological impact on anterior ocular structures have been published in the past 5 years. Indications for scleral lens wear are well-established. Developing areas of research on the physiologic impact of scleral lens wear on the ocular surface, the use of technology to improve scleral lens vision and fit, and the impact of these devices on the quality of life should further enhance our understanding of scleral lenses in the future.
Article
Purpose: The aim of this study was to describe the outcomes of 50% autologous serum (AS) eye drops after long-term use in a large cohort of patients with dry eyes. Methods: A retrospective cohort study was conducted on all patients treated with 50% AS eye drops at our institution between June 2008 and January 2013. Records were reviewed for clinical history, systemic risk factors, dry eye etiology, patients' symptoms, and adverse events. Ocular surface evaluation included Schirmer testing with topical anesthesia, fluorescein staining, and ocular surface disease index. Data were reviewed at initial visit, 1 month, and every 3 to 6 months during treatment with AS. Paired t tests were performed to compare the progression of signs and symptoms of dry eye disease. Results: A total of 123 eyes of 63 patients were evaluated with a mean follow-up of 12 months (range, 3-48 months). Corneal fluorescein staining (mean baseline, 1.77 ± 1.1) improved at the 3- to <6-month, 6- to <12-month, and final follow-up (mean: 1.2 ± 1.0, 1.3 ± 1.0, and 1.1 ± 1.1; P = 0.003, 0.017, and 0.0003, respectively). Schirmer scores (mean baseline, 6.6 ± 6.5 mm) improved at the 12- to 24-month follow-up (mean = 10.7 ± 11.4, P = 0.03), whereas ocular surface disease index scores (mean baseline, 54.1 ± 22.3) improved at the 3- to <6- and 6- to <12-month follow-up (mean: 49.5 ± 8.2 and 39.3 ± 21.4, P = 0.029 and 0.003, respectively). No complications were noted. Conclusions: Fifty percent AS eye drops seem to be a safe and effective long-term treatment for dry eye disease, especially in patients with severe disease who have exhausted all other conventional forms of treatment.
Article
Purpose: To investigate and validate methods for measuring the radius of anterior scleral curvature using anterior segment optical coherence tomography images. Methods: Twenty-four volunteers were enrolled in this study. Anterior segment optical coherence tomography images, centered on horizontal/vertical limbus, including adjacent anterior sclera, were obtained in addition to conventional images centered on the optical axis. Central horizontal, nasal, and temporal optical coherence tomography images were consolidated to a new image for subsequent analyses. The reference points of limbal surface and three scleral points were marked nasally and temporally. The radius of a best-fit circle to the six scleral points was derived (the BFC [best-fit circle] method) and the radii of two circles, the centers of which are on the optical axis and pass through the points of the scleral surface at 2 mm from the limbus nasally and temporally, were calculated (the axial method). To assess the reliability and accuracy of each method, intraobserver and interobserver agreements were analyzed and the radii of contact lenses with known curvatures were measured. Results: The mean (±SD) radius of a BFC was 13.12 (±0.80) mm. The mean (±SD) radius of nasal anterior scleral curvature (13.33 ± 1.12 mm) was significantly greater than that of temporal anterior scleral curvature (12.32 ± 0.77 mm) (paired samples t test, p < 0.001). The BFC and axial methods showed excellent intraobserver and interobserver agreements for measurements (intraclass correlation coefficient > 0.75, p < 0.001), whereas both methods showed a tendency to slightly underestimate the actual curvature of a rigid contact lens of known dimensions (-0.07 ± 0.13 mm [the BFC method] and -0.19 ± 0.07 mm [the axial method], Wilcoxon signed rank test, p = 0.173 and p = 0.028, respectively). Conclusions: Anterior segment optical coherence tomography is a valuable tool for measuring the radii of anterior scleral curvatures by image processing and mathematical calculation and can provide useful information in specific clinical situations such as designing scleral lenses.
Article
Purpose To describe the management of ocular surface disease with commercially available scleral lenses. Design Retrospective case series at a tertiary referral center. Participants A total of 212 patients (346 eyes) who were evaluated for scleral lens therapy for the management of ocular surface disease between June 1, 2006, and November 30, 2011. Methods Retrospective review of medical records and analysis of a survey mailed to all patients who completed the scleral lens fitting process to evaluate the long-term success of scleral lens therapy in the management of ocular surface disease. Main Outcome Measures Therapeutic outcome of scleral lens therapy, improvement in visual acuity with scleral lenses, indications for scleral lens wear, and efficiency of fitting process. Results Of the 212 subjects, 115 (188 eyes) successfully completed the scleral lens fitting process, and therapeutic goals (improved comfort, ocular surface protection, or resolution of keratopathy) were achieved in all but 2 of these subjects. Visual acuity improved with scleral lens wear, from 0.32±0.37 logarithm of the minimal angle of resolution (logMAR) (mean ± standard deviation; Snellen equivalent, 20/42) with habitual correction to 0.12±0.19 logMAR (Snellen equivalent, 20/26) with scleral lenses (P < 0.001). The most common indications for scleral lens therapy were undifferentiated ocular surface disease, exposure keratopathy, and neurotrophic keratopathy. Subjects had attempted an average of 3.2 (range, 0–8) other forms of intervention before scleral lens wear. Scleral lens fitting was completed in an average of 3 visits (range, 2–6), with an average of 1.4 lenses/eye (range, 1–4). Three patients experienced complications during scleral lens wear that resolved without loss of visual acuity, enabling resumption of scleral lens wear. Conclusions Commercially available scleral lenses can be successfully used in the management of moderate to severe ocular surface disease. The scleral lens fitting process can be completed efficiently for most eyes by using diagnostic trial lenses. In addition to protecting the ocular surface, scleral lenses improve visual acuity in patients whose surface disease has compromised vision.
Article
The aim of this study was to report and discuss the clinical experience with PROSE (Prosthetic Replacement of Ocular Surface Ecosystem) practice at a tertiary eye care hospital. Retrospective data of patients who were prescribed PROSE during April 2011 to March 2012 in a tertiary eye care center in south India were analyzed. Data collected include patient demographics, indications of scleral lens fitting, previous correction modality, PROSE parameters, best-corrected visual acuity (BCVA) with spectacles, and BCVA with PROSE at initial assessment and few hours of wear. The BCVA before (with glasses) and after PROSE fitting was recorded in logMAR units. The age of the patients ranged between 13 and 68 years (male:female 60:25) with a mean age of 32.44±13.45 years. Mean BCVA improved by 0.3 logMAR units (3 lines) after fitting with PROSE. There was a statistically significant difference between pre- and post-PROSE BCVA (P=0.0001). Failure of rigid gas-permeable lens fitting or intolerance was the common indication for PROSE in corneas with irregular astigmatism (refractive conditions). The other reasons for which PROSE was prescribed were pain, photophobia, comfort, ghosting of images, and frequent loss of smaller lenses. Toric scleral haptic was indicated in 62 eyes. The diameter, vault, and haptic measurements of PROSE in ocular surface disorders were much less and flatter than that of refractive conditions. PROSE device is a very useful alternative for irregular corneas to improve visual acuity, to improve comfort, and for symptomatic relief.
Article
To estimate dry eye prevalence in the Beaver Dam Offspring Study (BOSS), including a young adult population, and investigate associated risk factors and impact on health-related quality of life. Cohort study. The BOSS (2005-2008) is a study of aging in the adult offspring of the population-based Epidemiology of Hearing Loss Study cohort. Questionnaire data on health history, medication use, risk factors, and quality of life were available for 3275 participants. Dry eye was determined by self-report of frequency of symptoms and the intensity of those symptoms. Associations between dry eye and risk factors were analyzed using logistic regression. The prevalence of dry eye in the BOSS was 14.5%, 17.9% of women and 10.5% of men. In a multivariate model, statistically significant associations were found with female sex (Odds Ratio (OR), 1.68; 95% Confidence Interval (CI), 1.33-2.11), current contact lens use (OR, 2.01; 95%CI, 1.53-2.64), allergies (OR, 1.59; 95%CI 1.22-2.08), arthritis (OR, 1.44; 95%CI, 1.12-1.85), thyroid disease (OR, 1.43; 95%CI, 1.02-1.99), antihistamine use (OR, 1.54; 95%CI, 1.18-2.02), and steroid use (OR, 1.54; 95%CI, 1.16-2.06). Dry eye was also associated with lower scores on the Medical Outcomes Short Form-36 (β=-3.9, p<0.0001) as well as on the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) (β=-3.4, p<0.0001) when controlling for age, sex, and comorbid conditions. The prevalence of dry eye and its associated risk factors in the BOSS were similar to previous studies. In this study, DES was associated with lower quality of life on a health-related quality of life instrument and the vision-specific NEI-VFQ-25.
Article
Ocular graft-versus-host disease (GVHD) is a common complication that occurs after allogeneic transplantation. It can cause severe dry eyes that are described as having a burning, gritty, and painful sensation. Ocular GVHD can affect quality of life by causing pain and photophobia, limiting activities of daily living (e.g., reading, watching television), compromising safety while driving, and permanently damaging vision. Pre- and post-transplantation evaluations by an ophthalmologist are recommended. Routine assessments using the National Institutes of Health eye score should be administered to patients at each follow-up visit to their transplantation physician. Treatment options include lubricating eye drops, immunomodulator and steroid drops, and punctal occlusion. Relieving symptoms is difficult, and although multiple treatment options exist, many are ineffective. The Boston Foundation for Sight's scleral lens is an available option that promotes corneal healing and symptom relief. The current article discusses treatment options and supportive care measures for patients with ocular GVHD aimed at relieving symptoms and preventing complications.
Article
This is the first reported case of Acanthamoeba keratitis (AK) in a Boston scleral lens user. Consequently, the risk factors and treatment for AK need to be addressed in this unique case. We conducted a retrospective case study of a 45-year-old man using Boston scleral lens diagnosed with AK. Risk factors for infection and management of the condition were assessed. This 45-year old Boston scleral lens user's risk factors for developing AK included dry eye syndrome, autologous serum tear use, potential tap water exposure, and long-term systemic corticosteroid use. His infection was refractory to medical management and required deep anterior lamellar keratoplasty for curative treatment. Ophthalmologists should have a higher level of suspicion for AK in all scleral lens users and consider the use of deep anterior lamellar keratoplasty for refractory cases.
Article
Scleral contact lenses are used to treat symptoms of severe dry eyes. Procedures for fitting scleral lenses have been vague because of lack of standardized guidelines. This retrospective case series sought to establish average vault over central cornea in successful scleral lens wearers with dry eyes. Anterior segment optical coherence tomography was used to measure the distance between the posterior lens surface and cornea in 20 eyes of 12 consecutive patients successfully fit in the Vanderbilt Scleral Lens Clinic. Mean vault was 380 ± 110 μm. There was no correlation between vault and corneal curvature or vault and visual acuity. With a large SD in average vault, precision in central vault does not seem to be important in scleral contact lenses for successful fit for dry eyes.
Article
To describe the epidemiology of dry eye in the adult population of Melbourne, Australia.
Article
Purpose: To determine the type and distribution of ocular conditions cared for in a clinic dedicated to scleral devices and to report the clinical outcomes afforded by this approach. Methods: Fifty-one charts of patients fitted unilaterally or bilaterally with a scleral device (Prosthetic Replacement of the Ocular Surface Ecosystem - PROSE) in a two year period were retrospectively reviewed. Patient demographics, ocular diagnoses, associated systemic conditions, best corrected visual acuity (BCVA) before and after fitting, Visual Function Questionnaire score (VFQ-25), and ocular surface disease index (OSDI) score were collected. Results: All 51 patients were successfully wearing the PROSE device for a period of anywhere from weeks to years. The most common reasons for fitting were to relieve symptoms of moderate to severe dry eye syndrome ("DES", n=25), management of refractive problems ("refractive", n=23) with keratoconus being the most common (n=14), and to manage other anomalies ("other", n=3). Best corrected visual acuity (logMAR) improved with the wearing of the PROSE device for both the DES (17 letters) and the refractive group (10 letters), but not the "other" group. No serious complications were recorded for any of the patients. Conclusions: The PROSE device is a useful option not only for the management of ocular surface disease and optical imperfections, but also for other ophthalmic conditions. Moderate to severe dry eye was the most common anomaly managed, followed by eyes with irregular corneal astigmatism. DES and refractive patients experienced improvement in visual acuity with wearing of the PROSE device.
Article
Purpose: To investigate the feasibility of correcting ocular higher order aberrations (HOAs) in keratoconus (KC) using wavefront-guided optics in a scleral lens prosthetic device (SLPD). Methods: Six advanced KC patients (11 eyes) were fitted with an SLPD with conventional spherical optics. A custom-made Shack-Hartmann wavefront sensor was used to measure aberrations through a dilated pupil wearing the SLPD. The position of SLPD, that is, horizontal and vertical decentration relative to the pupil and rotation were measured and incorporated into the design of the wavefront-guided optics for the customized SLPD. A submicron-precision lathe created the designed irregular profile on the front surface of the device. The residual aberrations of the same eyes wearing the SLPD with wavefront-guided optics were subsequently measured. Visual performance with natural mesopic pupil was compared between SLPDs having conventional spherical and wavefront-guided optics by measuring best-corrected high-contrast visual acuity and contrast sensitivity. Results: Root mean square of HOA in the 11 eyes wearing conventional SLPD with spherical optics was 1.17 ± 0.57 μm for a 6-mm pupil. Higher order aberrations were effectively corrected by the customized SLPD with wavefront-guided optics, and root mean square was reduced 3.1 times on average to 0.37 ± 0.19 μm for the same pupil. This correction resulted in significant improvement of 1.9 lines in mean visual acuity (p < 0.05). Contrast sensitivity was also significantly improved by factors of 2.4, 1.8, and 1.4 on average for 4, 8, and 12 cycles/degree, respectively (p < 0.05 for all frequencies). Although the residual aberration was comparable to that of normal eyes, the average visual acuity in logMAR with the customized SLPD was 0.21, substantially worse than normal acuity. Conclusions: The customized SLPD with wavefront-guided optics corrected the HOA of advanced KC patients to normal levels and improved their vision significantly.
Article
The aim of the DEWs Definition and Classification Subcommittee was to provide a contemporary definition of dry eye disease, supported within a comprehensive classification framework. A new definition of dry eye was developed to reflect current understanding of the disease, and the committee recommended a three-part classification system. The first part is etiopathogenic and illustrates the multiple causes of dry eye. The second is mechanistic and shows how each cause of dry eye may act through a common pathway. It is stressed that any form of dry eye can interact with and exacerbate other forms of dry eye, as part of a vicious circle. Finally, a scheme is presented, based on the severity of the dry eye disease, which is expected to provide a rational basis for therapy. these guidelines are not intended to override the clinical assessment and judgment of an expert clinician in individual cases, but they should prove helpful in the conduct of clinical practice and research.
Article
Aim: To report a rare case of microsporidial and polymicrobial keratitis in a patient with Sjogren's syndrome and ocular cicatricial pemphigoid. Method: This is a descriptive case report. A 66-year-old lady diagnosed with Sjogren's syndrome (SS) and ocular cicatricial pemphigoid (OCP) presented to us with microbial keratitis after using a Boston sclera contact lens for a painful epithelial defect. After 9 days of medical treatment, she underwent therapeutic penetrating keratoplasty. Results: 10% potassium hydroxide and calcofluor white wet mount revealed microsporidial spores. Gram positive cocci and Gram variable bacilli on Gram stain were identified as Staphylococcus epidermidis and Corynebacterium accolens in culture. Histopathological examination of the corneal tissue confirmed the presence of microsporidial spores. Conclusion: Microsporidal keratitis can occur in patients with severe ocular surface disease due to SS and OCP. Predisposing factors include dry eye, local and systemic immunosuppression and Boston scleral contact lens. Early surgical intervention may be needed to eradicate the infection.
Article
Purpose: Most ophthalmologists are unaware of the therapeutic applications of gas-permeable scleral contact lenses for the prevention and treatment of ocular complications in patients with facial nerve palsy and concomitant neuroparalysis. Methods: The case reports refer to 3 patients who developed unilateral lagophthalmos and corneal anesthesia after an acoustic neuroma or intracranial tumor resection. Two patients explicitly requested a tarsorrhaphy to be opened because they were incapacitated by the limited visual acuity and visual field. Tarsorrhaphy was not an acceptable aesthetic solution for the third patient. Fluid-ventilated scleral lenses were fitted because they protect the cornea by creating a precorneal fluid reservoir while optimizing visual acuity. Results: The follow-up periods were 3, 17, and 18 years. Two patients wear the contact lenses full time, but the wearing time is limited to 10 hours per day for the third patient. All patients were instructed not to wear their lenses while sleeping. Two eyes required a corneal transplant, but lens wear could be resumed 4 to 6 weeks after transplantation. The learning curve for the insertion and removal of this large-diameter lens is the main obstacle for a patient, especially when there is loss of corneal sensation. Conclusion: Scleral lens wear is a valid long-term alternative to standard treatment options such as tarsorrhaphy for patients with corneal exposure and corneal anesthesia as a consequence of postsurgery facial nerve paralysis. Scleral contact lenses provide these patients with effective protection of the ocular surface in an aesthetically acceptable way while optimizing visual function.
Article
Prosthetic replacement of the ocular surface ecosystem is a treatment developed by the Boston Foundation for Sight that uses a Food and Drug Administration-approved prosthetic device for the treatment of severe ocular surface disease to improve vision and discomfort in addition to supporting the ocular surface. Facial nerve paralysis has multiple causes including trauma, surgery, tumor, stroke, and congenital lagophthalmos. Subsequent lagophthalmos leading to exposure keratitis has been treated with copious lubrication, tarsorrhapy, eyelid weights, chemodenervation to yield protective ptosis, and palpebral spring insertion. Each of these treatments, however, has limitations and potential complications. The prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and dessication in addition to improving vision. This report describes 4 patients with exposure keratitis who were successfully treated with prosthetic replacement of the ocular surface ecosystem devices at 2 clinical sites.
Article
Objective: To evaluate fitting feasibility and efficacy of mini scleral contact lenses in moderate to severe dry eye patients. Methods: Prospective interventional case series, this study included those patients with grades III and IV dry eye disease, whose symptoms could not be controlled by conventional treatments. Demographic data, UCVA, BSCVA were evaluated before fitting. Mini scleral lens fit was assessed by single experienced practitioner and best corrected vision with mini scleral lens was assessed. After dispensing mini scleral lens, BCVA with mini scleral lens, and possible contact lens related problems were assessed in each visit. Ocular comforts, frequency of artificial tear use, contact lens handling problems were asked in each follow up visit. For those who did not choose to wear lenses, the reason was asked. All data were analyzed using descriptive statistical tests. Results: Twenty eyes of 13 patients were fitted. Mini scleral lens was dispensed for 19 eyes in them assessment of fit was either ideal (n=9) or acceptable (n=10). Seven patients got their lenses; four patients (seven eyes) of them were satisfied with their lenses based on decrease in discomfort and dry eye symptoms, decrease artificial tear need frequency and improvement in visual acuity during mean follow up period of 18.25 months (range: 15-20). None of them was affected with any contact lens related complication. Conclusion: Mini scleral contact lenses can be considered helpful in management of moderate to severe dry eye.
Article
We report an interesting case of therapeutic scleral lens management of bilateral exposure and neurotrophic keratopathy resulting from bilateral cranial nerve (CN) palsies including V, VI and VII, which caused lagophthalmos and anaesthetic corneas. Subsequent development of severe exposure keratitis with vascularisation and keratinisation of the inferior cornea was previously treated with intensive ocular lubrication, botulinum toxin injections to the upper eyelid levator muscle, temporary tarsorrhophies, bilateral amniotic membrane grafts, punctal plugs, lid taping, gold eyelid weights and soft bandage contact lenses. Corneal integrity was re-established but visual acuity remained significantly compromised by corneal vascularisation, scarring and keratin deposits. Visions on presentation to the contact lens department were R 1.90logMAR, L 1.86logMAR. Therapeutic, high Dk, non-fenestrated, saline filled, scleral lenses were fitted. Daily wear of these lenses have protected and hydrated the cornea, enabling corneal surface recovery whilst retaining visual and social function. The visual acuities 6 months post-scleral fitting with lenses in situ are R 0.90logMAR and L logMAR0.70.
Article
The aim of this study was to evaluate both the indications for and results of fitting the Jupiter Scleral Lens in patients with corneal abnormalities. This was a retrospective case review of 63 patients (107 eyes) fitted with scleral lenses between October 2009 and March 2011 at the UC Davis Eye Center. Sixty-three percent of 107 eyes were in patients with keratoconus. Other conditions included high postkeratoplasty astigmatism and corneal scarring. The improvement in best-corrected visual acuity compared with previous contact lens or glasses correction was a mean gain of 3.5 Snellen lines (SD=2.6). Seventy-eight percent of patients found the scleral lenses to be comfortable or comfortable. Twenty-five eyes discontinued the wear after at least 3 months. Jupiter Scleral lenses are a good alternative for patients with corneal abnormalities and for those who failed other types of lens rehabilitation. Seventy-seven percent of eyes fit with Jupiter Scleral Lenses were still wearing after a follow-up of 3 months.
Article
Objective To collect questionnaire data from patients in a large clinical population that would allow for an estimate of the prevalence of self-reported symptoms of dry eyes, Methods, A 13-point questionnaire (The Canada Dry Eye Epidemiology Study, CANDEES) was mailed to all optometric practices in Canada in October 1994, with the request that it be completed by 30 successive nonselected patients, Results, Four hundred fifty sets of questionnaires (total, 13,517) were analyzed (a 15.7% return rate) from patients aged from <10 years to >80 years; 55% were in the 21- to 50-year age group; 60.7% were female; and 24.3% were contact lens wearers, A total of 28.7% reported dry eye symptoms, of whom 24.2% reported concurrent dry mouth, 24.5% had worse symptoms in the morning, 30.3% reported concurrent lid problems, and 35.7% reported a history of allergies, Of the 3716 patients reporting symptoms, 62 (1.6%) were in the ''severe'' category and 290 (7.8%) were in the ''constant but moderate'' category, Contact lens wear, concurrent allergies, dry mouth, lid problems, or use of medications increased the chance of a patient reporting dry eye symptoms, Conclusions, The prevalence of patients reporting any level of symptoms of dry eyes was approximately 1 in 4; severe symptoms were reported by 1 in 225 patients.
Article
To study the indications and the challenges while fitting scleral contact lens (ScCL) filled with fluid prior to lens insertion in pediatric patients. We retrospectively reviewed charts of patients of 16 years or less who received ScCL (PROSE - Prosthetic Replacement of the Ocular Surface Ecosystem, Boston Foundation for Sight, Needham Heights, MA, USA) that were filled with fluid (Normal saline) before lens insertion during July 2006 to April 2010. The main goal of ScCL fitting was to improve vision in patients having keratoconus (KC) and improve the ocular microenvironment in ocular surface disease (OSD). Visual acuity before and after lens wear was noted. Fluid-filled ScCL were dispensed to 15 patients (20 eyes). The indications for ScCL fitting were KC (n = 3 eyes), Stevens Johnson syndrome (SJS, n = 13 eyes), radiation keratopathy (n = 1 eye), combined KC and SJS (n = 1 eye) and KC and vernal keratoconjunctivitis (VKC, n = 2 eyes). Mean age of the patients was 12.85 years. The average daily lens wear was 9 h. The vision improved by 2 lines or more in 85% and dropped by 2 lines or more in 45% eyes after 4 h of lens wear due to tear debris collection. None of the patients had any complications. Patients were self sufficient inserting and removing ScCL. Two patients had broken lenses during the follow-up. ScCL are useful for pediatric patients who have OSD, irregular astigmatism or the two coexisting; KC combined with VKC or SJS, helping to maintain the health of the ocular surface and improves vision in these patients.
Article
To evaluate the influence of peripheral ocular topography, as evaluated by optical coherence tomography (OCT), compared with traditional measures of corneal profile using keratometry and videokeratoscopy, on soft contact lens fit. Ocular surface topography was analyzed in 50 subjects aged 22.8 years (SD ±5.0) using videokeratoscopy (central keratometry, corneal height, and shape factor) and OCT to give both full sagittal cross-sections of the cornea and cross-sections of the corneoscleral junctions. Corneoscleral junction angle, corneal diameter, corneal sagittal height, and scleral radius were analyzed from the images. Horizontal visible iris diameter and vertical palpebral aperture were analyzed from digital slit lamp images. Lens fit was graded after 30 minutes wear of a -2.50 D commercially available standard hydrogel (etafilcon A, modulus 0.30 MPa) and silicone hydrogel (galyfilcon A, 0.43 MPa) design of similar geometries (8.30-mm base curve, 14.0-mm diameter). The mean horizontal corneal diameter was 13.39 mm (SD ±0.44). In many cases, there was a tangential transition at the corneoscleral junction. The corneoscleral shape profile analyzed from cross-sectional OCT images contributed significantly (P < 0.001) to the prediction of soft contact lens fit compared with keratometry and videokeratoscopy, accounting for up to 24% of the variance in lens movement. The fit of the stiffer material silicone hydrogel lens was better able to be predicted and was more varied than the hydrogel contact lens. The extra peripheral corneoscleral data gained from OCT characterization of ocular surface architecture provide valuable insight into soft contact lens fit dynamics.
Article
To describe the therapeutic benefits of scleral lenses in the management of severe ocular surface disease attributable to toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS). Retrospective study. Clinical records of 39 patients (67 eyes) fitted with scleral lenses for refractory ocular surface disease attributable to SJS or TEN were reviewed. To assess vision-specific quality of life, each patient completed the Ocular Surface Disease Index (OSDI) questionnaire and the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Slit-lamp examination was performed at regular intervals to detect side effects. Main outcome measures were best-corrected visual acuity (VA) and OSDI and NEI VFQ-25 composite score before and 6 months after scleral lens fitting. The mean age was 35.8 +/- 13.9 years. Scleral lens fitting failed in 3 patients. The mean follow-up was 33.3 +/- 17.6 months. Among fitted patients, VA in the better eye (36 patients, 36 eyes) progressed from 0.73 to 0.50 logarithm of the minimum angle of resolution (P = .0001) 6 months after scleral lens placement. The mean OSDI improved from 76.9 +/- 22.8 to 37.1 +/- 26.7 (P = .0001). Thirty-two NEI VFQ-25 composite scores were available. The mean NEI VFQ-25 composite score improved from 25.1 +/- 16.8 to 67.4 +/- 22.1 (P = .0001). No serious adverse events attributable to the scleral lenses occurred. Scleral lens use appears to be efficient and safe for visual rehabilitation of refractory ocular surface disease attributable to TEN and SJS.
Article
The indications and outcome of the wear of gas-permeable (GP) scleral contact lenses in 118 eyes of 85 patients attending a Scleral Contact Lens Clinic during a 5-year period from July 1988 to June 1993 were analysed. Ninety-nine eyes (83.9%) were originally fitted with PMMA lenses and were subsequently changed to GP lenses, whereas 19 (16.1%) were fitted with GP lenses from the outset. The mean duration of GP scleral lens wear was 15.3 months, with a range between 3 and 58 months. The indications for refitting the cases previously wearing PMMA scleral lenses with GP material were related to problems of chronic hypoxia. Thirty-three eyes (26.8%) had previous episodes of corneal oedema, and of the 27 that had a minimum of 3 months' follow-up, none experienced further episodes of oedema. Of the 32 eyes (26%) that had developed corneal vascularisation associated with PMMA scleral lens wear, two eyes were noted to have significant vessel regression after a period of GP wear, whereas in the remainder of cases, vessels remained static and nonprogressive. Thirty additional eyes (24.2%) experienced inadequate wear times associated with discomfort, and in these eyes the change to GP scleral lenses produced a statistically significant reduction in the inability to wear lenses beyond 4 h (p < 0.05).
Article
This study was designed to assess public awareness and symptoms of dry eye in Japan by a population-based, self-diagnosis study. Two thousand five hundred participants chosen randomly from the general population were sent a questionnaire consisting of 30 questions pertaining to symptoms and knowledge of dry eye. Awareness of the condition called "dry eye" was very high at 73%. Most of the knowledge of dry eye was obtained through the media (e.g., television, 58.8%; newspapers/magazines, 46.6%), and only a fraction of the knowledge was from physicians (6.8%). As many as 33% of participants responded that they believed they had dry eye according to the self-diagnosis criteria, of which 25% used over-the-counter eyedrops daily. The majority of eyedrop users were dissatisfied with their therapeutic effects, and only 11% sought professional help. Habits in lifestyles that were associated with self-diagnosed dry eye were contact lens use (p < 0.001), a history of allergic conjunctivitis (p = 0.002), and video display terminal tasks (p = 0.058). Although public awareness of dry eye in Japan was high, only a minority of the population seems to consult professionals for diagnosis and symptomatic relief.
Article
To describe the therapeutic benefits of nonfenestrated gas-permeable scleral contact lenses in the management of patients with ocular surface disease. The charts of 49 consecutive patients (76 eyes) with ocular surface disease whose management included the use of gas-permeable scleral contact lenses were reviewed. We also developed a questionnaire to assess the impact of lens wear on subjective aspects of activities of daily living. The mean age of the 49 patients was 44.6 years (range, 3 to 87 years); 31 patients were female and 18 were male. The most common indication for fitting of the lenses was Stevens-Johnson syndrome (54 [71%] of the 76 eyes). Other indications included ocular cicatricial pemphigoid, exposure keratitis, toxic epidermal necrolysis, postherpetic keratitis, congenital deficiency of meibomian glands, superior limbal keratoconjunctivitis, Sjögren syndrome, and inflammatory corneal degeneration. The mean follow-up was 33.6 months (range, 2 to 144 months). Improvement in best-corrected visual acuity (defined as a gain of 2 or more Snellen lines) was observed in 40 (53%) of the eyes. In eight (53%) of the 15 eyes with active corneal epithelial defects at the time of lens fitting, the defects healed, whereas in the remaining seven eyes the corneal epithelial defects remained unchanged. Forty-five (92%) of the 49 patients reported improvement in their quality of life as a result of reduction of photophobia and discomfort. The mean wearing time of the gas-permeable scleral contact lenses was 13.7 hours per day (range, 4 to 18 hours). Many patients had preparatory surgical procedures before lens fitting (for example, punctal occlusion or mucous membrane grafting), and some had visual rehabilitation surgical procedures (for example, keratoplasty and/or cataract surgery) after lens fitting. Gas-permeable scleral contact lens wear provides an additional effective strategy in the surface management and visual rehabilitation of patients with severe ocular surface disease.
Article
To describe the vision-correcting and therapeutic benefits of gas-permeable scleral contact lenses (GP-ScCL) in the management of irregular corneal surface disorders and ocular surface diseases. The charts of 48 consecutive patients (66 eyes) whose management included the use of GP-ScCL were reviewed. The most common indication for fitting the lenses was keratoconus in patients who had to stop wearing other types of corneal lenses (44 eyes, 74.6%). Other indications included extreme corneal irregularity after penetrating keratoplasty, nonhealing corneal ulcer, postoperative dry eye syndrome following laser in situ keratomileusis (LASIK), severe exposure keratitis and acid burn. Mean follow-up was 17 months (range, 2-96). Mean wearing time of the GP-ScCL was 16.2 hours per day (range, 3-18). Visual acuity of 20/40 or better was achieved in 90.9% of keratoconus patients and in 81.8% of postkeratoplasty patients. A gain of two or more Snellen lines was observed in 94.5% of eyes treated for improving vision. Marked subjective improvement in quality of life was reported by 86% of the patients, mainly as a result of improvement in their visual function and reduction in discomfort. Five patients (seven eyes) failed to wear GP-ScCL. GP-ScCL can provide successful and safe visual and therapeutic solutions for ocular conditions when conventional contact lenses and medical treatment have failed and where surgery is undesirable or contraindicated.
Article
To describe the epidemiology of dry eye in an elderly Chinese population in Taipei, Taiwan. A population-based cross-sectional study. The Shihpai Eye Study was a population-based survey of eye diseases in the elderly (> or =65 years) in Shihpai, Taipei, Taiwan. Noninstitutionalized residents, as of July 1999, were identified by using the official household registration database. A total of 2045 subjects were selected, and 1361 (66.6%) people participated in the study. Among them, 822 (60.4%) were men. Trained interviewers administered a standardized questionnaire pertaining to dry-eye symptoms. Objective examinations of dry eye included tear film breakup time, Schirmer test, fluorescein stain of the cornea, and anatomic assessment of the meibomian glands via slit-lamp biomicroscopy. Frequency of dry-eye symptoms and positive dry-eye tests. In this population, 33.7% (459/1361) were symptomatic, defined as reporting 1 or more dry-eye symptoms often or all of the time. Women were more likely to report frequent symptoms of dry eye (odds ratio, 1.49; 95% confidence interval, 1.19-1.87). Among those who were symptomatic, 78.9% (362/459) had a low tear film breakup time (< or =10 seconds), 62.5% (287/459) had a low Schirmer test result (< or =5 mm), and 61.7% (283/459) had abnormal anatomic features of the meibomian glands. Furthermore, 85.4% (392/459) were symptomatic and had either a low Schirmer score or an abnormal meibomian gland assessment. Of those symptomatic, 49.9% (229/459) indicated that they had visited an eye doctor, 5.4% (25/459) responded that they had been diagnosed with dry eye, and 47.5% (218/459) reported current use of eyedrops. This is the first report of population-based data of dry eye that includes symptoms and signs in elderly Asians. The prevalence of dry eye, although varied according to definition, is relatively higher in this study than that reported for whites. Further studies are needed to determine whether this is due to racial or environmental factors.
Article
To examine the diagnostic indications and relative merits of a fluid-ventilated, gas-permeable scleral lens for improving vision impaired by irregular astigmatism and for providing a therapeutic environment for managing severe ocular surface disease. After a review of scleral lens development and a description of current design and manufacturing innovations, indications for fitting the Boston Scleral Lens were evaluated based on a retrospective review of all available records of patients fitted with this device, and outcome experiences were described. A total of 875 eyes of 538 patients were fitted with the fluid-ventilated, gas-permeable scleral lens during the past 18 years. Most patients were fitted in the past 4 years. Indications included managing severe ocular surface disease and rehabilitating vision impaired by irregular astigmatism associated with corneal disorders. Rigid gas-permeable contact lenses either were not tolerated or were contraindicated in all eyes. Outcomes included improved vision and reduced ocular pain and photophobia associated with severe ocular surface disease. Scleral lenses promoted healing of persistent epithelial defect (PED) refractory to other treatments and prevented PED recurrence in stem cell-deficient and neurotrophic corneas. Microbial keratitis occurred in 4 of 22 eyes treated with extended scleral lens wear for PED after penetrating keratoplasty. The fluid-ventilated, gas-permeable scleral lens is an important front-line tool for managing many corneal disorders refractory to other treatment measures or otherwise requiring keratoplasty.
Article
To evaluate the indications for modern scleral lenses and their clinical performance in patients who were fitted with scleral lenses at the authors' practices. In this cross-sectional survey, all the necessary data were obtained at the first follow-up visit during the 5-month study period. There were four types of scleral lenses: spherical, front-surface toric, back-surface toric, and bitoric. The preformed scleral lens fitting technique developed at Visser Contact Lens Practice was used in all patients. The lenses were cut by precise Sub Micron Lathing from a Boston Equalens II blank at Procornea. Visual acuity and slitlamp findings were recorded. A specially designed classification for scleral lens fitting was used to investigate clinical performance. The largest proportion of the 178 patients (284 eyes) were diagnosed with keratoconus (143 [50.4%] eyes) followed by postpenetrating keratoplasty (56 [19.7%] eyes). The remaining diagnoses were irregular astigmatism, keratitis sicca, corneal dystrophy, and multiple diagnoses. The ratio of spherical to back-surface toric designs was 1:1.1. Clinical examination showed sharp increases in visual acuity (median increase, 0.45) and safe physiologic responses of the anterior eye. All the patients could continue to wear scleral lenses, with 79.2% with the same lens parameters. Several types of corneal abnormality were managed successfully with modern scleral lenses. The main indication was optical correction of an irregular corneal surface. Satisfactory clinical performance meant that all the patients could continue to wear their scleral lenses.
Article
To determine if the Boston Scleral Lens Prosthetic Device (BSLPD) reduces symptoms and improves quality of life in patients with severe dry eye from chronic graft-versus-host disease (cGvHD). This is a noncomparative interventional case series reporting 33 consecutive patients with severe dry eye from cGvHD, unresponsive to conventional therapy, who were fitted with the BSLPD. A patient survey was undertaken after lenses were dispensed and worn regarding the effect of scleral lens wear on their symptoms, quality of life, and activities of daily living. The patient population was characterized from a retrospective chart review. Survey data were tabulated. BSLPD wear resulted in improvement in pain, photophobia, and general quality of life in nearly all patients, with more than half reporting the highest improvement level for pain (52%) and photophobia (63%), and more than two thirds (73%) reporting the highest improvement level for quality of life. There was improvement in reading and driving in >90% of those who reported previous compromise, with >60% reporting the highest improvement level for each of these activities. The BSLPD mitigates symptoms and improves quality of life in patients with severe dry eye from cGHvD.
Article
To report the use of a custom-designed, fluid-ventilated, gas-permeable scleral lens in the treatment of patients under 13 years of age. We retrospectively reviewed the medical records of all patients under 13 years of age who were fitted with the Boston Scleral Lens at the Boston Foundation for Sight from January 1996 through June 2006. Age, sex, ophthalmic diagnosis, systemic diagnosis, prior surgical intervention, complications, lens fit and wearing failures, and duration of lens use are reported. Boston Scleral Lenses were fitted in 47 eyes of 31 patients referred after failure of conventional therapy. Patients ranged in age from 7 months to 12.92 years (mean, 7.75 years) at time of fitting. There were 16 girls and 15 boys in this group. The mean duration of documented scleral lens use was 24 months (range, 0-85 months). A broad range of refractive and ocular surface disorders was treated with this modality, with the vast majority of patients having ocular surface disease (27/31, 87%) rather than refractive disorders (4/31, 13%). Congenital corneal anesthesia syndromes and Stevens-Johnson syndrome each accounted for over one-third of the patients. The Boston Scleral Lens is a custom-designed, fluid-ventilated, rigid gas-permeable scleral lens that vaults the cornea retaining a pool of oxygenated artificial tears over the corneal surface. The Boston Scleral Lens is a treatment option, after failure of conventional therapy, for a broad range of ocular surface and refractive disorders in the pediatric age group. Pediatric ophthalmologists should be aware of this treatment modality, particularly in the management of severe ocular surface disease.
Article
Case report study of a novel method of fitting large rigid gas-permeable lenses (cornea-scleral, mini-scleral, scleral). Nine patients with different corneal and refractive conditions were fitted with scleral-type rigid gas-permeable lenses using high resolution ocular coherence tomography. All patients achieved excellent visual acuity and comfort. Lenses were well tolerated without significant complications. Three cases are discussed in detail. Two of the 3 patients had previously undergone fitting with trial lenses so that the different methods could be compared with respect to number of lenses used to achieve a final fit. High resolution biometry proved to be a highly useful fitting tool and seems to offer a more accurate and efficient alternative to fitting scleral-type lenses compared with the trial lens method.