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Patient comfort and visual outcomes of mini-scleral contact lenses
Abstract
Objective:
To evaluate short-term visual outcome, patient acceptance, and tolerance of mini-scleral contact lenses (SCLs) in the management of various corneal pathologies.
Design:
Retrospective case series.
Participants:
Thirty-two patients (40 eyes) who received mini-SCLs.
Methods:
Single-centre retrospective case series, between February 2010 and January 2013, of 32 patients (40 eyes) with various corneal pathologies who were offered either Maxim 5R, Maxim 7, or Maxim 7 × 11 mini-SCLs for nonsurgical optimization of visual correction. Patients were followed up at 1 and 3 months for assessment of best-corrected visual acuity, comfort, length of daily wear, and complications.
Results:
Thirty-two patients (40 eyes), with a mean age of 41 ± 16 years, opted to receive mini-SCLs. Eighteen patients had previously undergone surgery such as penetrating keratoplasty, deep anterior lamellar keratoplasty, and intraocular lens implantation. The median best-corrected visual acuity improved from 0.3 logMAR (range 0-1.3) before mini-SCLs, to 0.05 logMAR (range 0-1) with mini-SCLs (p < 0.0001). At 1-month follow-up, the median length of wear was 10 hours/day (range 1.5-15). At 3-month follow-up, the median length of wear was 12 hours/day (range 2-15). All eyes were comfortable at initial use of mini-SCLs and 91% were comfortable at 3-month follow-up.
Conclusion:
Mini-SCLs may be a comfortable management option for patients with keratoconus and other corneal pathologies who are unable to achieve adequate visual outcome with traditional spectacles or rigid gas-permeable contact lenses.
... C-ScCLs and ScCLs are not usually the first choice to fit but are commonly prescribed when other CLs (SCLs, RGPCLs, PBCLs [94], and HCLs [106,107,112,113]) show tolerance problems [117,118] or do not provide acceptable VA. [48][49][50][118][119][120][121]. ...
... In the same way, Rathi et al. [125] observed that 75% of patients improved more than 2 lines of visual acuity. Recently, Yan et al. [117] reported an improvement from 0.88 logMAR to 0.10 logMAR in KC patients using mini SsCLs. ...
... For this reason, the absence of this movement and considerable central and peripheral clearance, mainly in mini and large SsCLs, provides a good comfort and tolerance to these lenses. One clear example of this was the Yan et al. [117] study where all eyes included were reported as comfortable at initial use of mini SsCLs, and 91% were comfortable after a 3-month follow-up. Similar values were described previously by Pecego et al. [121] for a 3-month follow-up, reporting good tolerance in 77% of eyes fitted with Jupiter scleral lenses. ...
Objectives
To describe the past 20 years' correction modalities for keratoconus and their visual outcomes and possible complications.
Methods
A review of the published literature related to the visual outcomes and possible complications in the context of keratoconus management using nonsurgical procedures for the last 20 years (glasses and contact lenses) was performed. Original articles that reported the outcome of any correction modalities of keratoconus management were reviewed.
Results
The most nonsurgical procedure used on keratoconus management is the contact lens fitting. Soft contact lenses and soft toric contact lenses, rigid gas-permeable contact lenses, piggyback contact lens system, hybrid contact lenses, and scleral and corneoscleral contact lenses form the contemporary range of available lens types for keratoconus management with contact lenses. All of them try to restore the vision, improve the quality of life, and delay surgical procedures in patients with this disease. Complications are derived from the intolerance of using contact lens, and the use of each depends on keratoconus severity.
Conclusions
In the context of nonsurgical procedures, the use of contact lenses for the management of keratoconic patients represents a good alternative to restore vision and improve the quality of live in this population.
... The authors found that all patients in their study could be fitted with the hybrid contact lens, with the lens providing good ocular comfort and BCVA of 0.05 logMAR or better in 80 % of the subjects. Lastly, scleral lens use as an option for visual rehabilitation after PK has dominated the literature in the past 2 decades [481][482][483][484][485][486][487][488], with these studies documenting good success after between 3 months and 9 years after fitting. Three of 31 patients (~10 %) fitted with scleral lenses post-PK discontinued due to discomfort over a period of 3 years or more [486]. ...
... Scleral lens fitting is a popular modern form of visual correction after PK, although scleral lenses have also been used to treat grafts with ocular surface disease such as filamentary keratitis [322]. Just as with corneal lens designs, low level evidence in the form of case series document successful lens fitting with mini-scleral designs [481][482][483][484][485], sclerals [75,484,486,487,503], and custom designs with asymmetric peripheries such as the PROSE lens [439]. ...
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.
... Similar to our results, this number is between 2 and 3.2 in the literature. 1,17,18 OCT imaging has improved modern scleral lens fitting by providing accurate measurements for trial lens selection and contact lens fit assessment and preventing ocular complications associated with lens application. High-resolution imaging of the anterior segment has also provided more information on corneal and scleral morphology and physiology. ...
... Scleral lenses are expected to be more comfortable than gaspermeable rigid contact lenses because they rest on the sclera and do not touch the cornea. In a study by Yan et al. 18 , 91% of patients reported comfortable 10-hour daytime lens wear. In another study evaluating patient satisfaction, 78.9% comfort, 78.2% visual quality, and 87.7% overall satisfaction were reported. ...
Objectives:
To assess the visual performance of a mini-scleral lens in patients with keratoconus and to evaluate its fit by optical coherence tomography (OCT).
Materials and methods:
Twenty-nine eyes of 24 patients with keratoconus were fitted with a mini-scleral lens (Esclera; Mediphacos Inc., Belo Horizonte, Brazil). Diagnostic lenses were used in the initial fitting process. The lens fit was evaluated by the fluorescein pattern and also by anterior segment OCT (RTVue, Optovue Inc., Fremont, CA). Within 30-45 minutes after insertion, the lens fit parameters including central corneal and limbal clearance, and peripheral landing zone alignment were evaluated by OCT. High- and low-contrast visual acuity (VA), subjective performance for comfort and vision (5-point Likert scale), and overall satisfaction with the lens (100 mm visual analog scale [VAS]) were measured before and after lens wear.
Results:
The mean decimal high-contrast VA (best spectacle-corrected VA: 0.40±0.14 vs VA with the scleral lens: 0.93±0.12, p<0.0001) and low-contrast VA (best spectacle-corrected VA: 0.60±0.24 vs VA with the scleral lens: 1.15±0.18, p<0.0001) significantly improved with lens wear. The mean central corneal clearance was 120.7±24.5 μm. There were no correlations between the keratometric values and the sagittal depth of the scleral lens. The mean number of trial lenses required for ideal fit was 2.2 lenses (range: 1-8). Patients reported high scores for comfort (mean score: 4.69; range: 4-5), vision (mean score: 4.62; range: 3-5) and overall satisfaction with the lens (mean VAS score: 88.1; range: 70-100).
Conclusion:
The mini-scleral lens provided good high- and low-contrast visual acuity and high patient satisfaction in patients with keratoconus. Anterior segment OCT imaging facilitated the evaluation of the fit.
... [21] Yan P et al. also assessed the improvement in the VA from 0.3 logMAR before scleral lenses to 0.05 logMAR with scleral lenses. [24] Similar to these results, in the present study, best spectacle-corrected high-contract VA improved from 0.47 ± 0.25 logMAR to 0.03 ± 0.07 logMAR with scleral lenses, representing a clinically and statistically significant improvement. ...
PURPOSE
The purpose of the study is to evaluate the visual outcomes and improvement in quality of life (QOL) of patients with keratoconus with scleral lenses.
METHODS
In this prospective study, 14 patients (28 eyes) with bilateral keratoconus were fitted with scleral lenses (McAsfeer 16.00 mm) in Pune city, Maharashtra, India. Uncorrected visual acuity (VA), best spectacle-corrected VA, and VA with scleral lenses were evaluated. The patients were given the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) for judging the QOL, before and after using scleral lenses for 3 months.
RESULTS
The mean uncorrected VA of the 14 patients with a mean age of 28.64 ± 6.57 years was 1.18 ± 0.19 logMAR. Best spectacle-corrected high-contrast VA improved from 0.47 ± 0.25 logMAR to 0.03 ± 0.07 logMAR with scleral lenses ( P < 0.001). Best spectacle-corrected low-contrast VA improved from 0.68 ± 0.22 logMAR to 00.47 ± 0.10 logMAR with scleral lenses ( P < 0.001). Along with the increase in overall median scores on the NEI VFQ-25 from 1735 to 2930 points ( P < 0.001), the distance and near activities ( P < 0.001), vision-specific mental health ( P < 0.002), social functioning ( P < 0.004), and driving ( P < 0.005) improved after using scleral lenses for 3 months.
CONCLUSION
Scleral lenses can be an effective and safe management option for patients with keratoconus leading to an improved vision and QOL.
... Dear Editor, Visual acuity mostly depends on the smooth surface of the cornea, and pathologies such as irregular astigmatism, increased higher-order aberration, and corneal scars are known to decrease visual acuity. Scleral contact lenses (SCLs) can correct such abnormalities and therefore be used as a treatment option by not only optimizing optical correction in ectatic corneal disorders, but also hydrating cornea and neutralizing ocular surface in ocular surface diseases (OSDs) [1][2][3]. ...
... 1 The post-lens fluid reservoir created by a SL -along with rigid gas permeable material -provides a smoother anterior ocular surface and neutralizes corneal irregularities while simultaneously keeping the anterior ocular surface moistened. This lack of contact between the SL and the densely innervated corneal surface promotes better comfort [2][3][4][5][6][7] and enhanced optical quality 8,9 compared to other contact lens modalities. Thus, SLs have a wide range of indications, from optical correction of irregular corneas and ocular surface protection to refractive error correction. ...
Scleral lenses (SLs) present several unique advantageous characteristics for patients. As these lenses are mainly fitted in severely diseased eyes, a thorough evaluation of the ocular surface before and after SL fitting and the on-eye SL fitting evaluation are essential and help minimize potential physiological complications. This review will explore the current and emerging techniques and instrumentation to best measure SL performance ensuring optimal lens fitting, visual quality, comfort and physiological responses, highlighting some potential complications and follow-up recommendations. A single physician could perform the great majority of evaluations. Still, the authors consider that the assessment of SL fitting should be a collaborative and multidisciplinary job, involving contact lens practitioners, ophthalmologists and the industry. This publication has reviewed the most up-to-date work and listed the most used techniques; however, the authors encourage the development of more evidence-based recommendations for SL clinical practice.
... [15][16][17][18] Mini SLs or largeSLs have also been successful in managing higher-order aberrations and optical correction of refractive errors in patients who have developed ectasia and scar following lamellar or PK, laser in situ keratomileusis, and corneal ring segment implantation. [19][20][21] In a general sense, SLs can treat a broad spectrum of refractive errors and OSDs, especially for those in whom conventional methods of therapy have failed. ...
Objective:
To report indications, fitting feasibility, and safety of miniscleral design (MSD) lenses in children.
Methods:
Medical records of patients aged <18 years at the time of referral to Contact Lens Clinic of Farabi Eye Hospital, because of inadequate spectacle-corrected visual acuity, rigid gas-permeable or soft contact lens intolerance, and ocular surface disease were reviewed. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), best-corrected vision with the lens (CCVA), lens parameters, and comfortable daily wearing time (CDWT) were documented.
Results:
Seventy-two eyes of 52 pediatric patients were fitted with MSD lens over a 9-year period. The indications for MSD lens fitting were keratoconus (29 eyes), corneal scarring from ocular trauma (16 eyes), ocular surface diseases (25 eyes), and postkeratitis corneal scar (2 eyes). The average UCVA and the mean difference between CCVA and BSCVA were 1.20 and 0.55 logarithm of the minimal angle of resolution, respectively, which shows statistically significant improvement. This significant increase in vision was even seen in those who were referred for the management of ocular surface diseases. The mean CDWT for most patients was 10 hr/day.
Conclusion:
Miniscleral design lens can be used as a safe and helpful modality to provide good vision and comfort in children experiencing ectatic disorders, traumatic corneal scars, and ocular surface diseases.
... Non-infectious infiltrative keratitis is an uncommon complication of scleral lenses wear with only two cases reported [486,487]. ...
Contact lens-related complications are common, affecting around one third of wearers, although most are mild and easily managed. Contact lenses have well-defined anatomical and physiological effects on the ocular surface and can result in other consequences due to the presence of a biologically active material. A contact lens interacts with the tear film, ocular surface, skin, endogenous and environmental microorganisms, components of care solutions and other antigens which may result in disease specific to contact lens wear, such as metabolic or hypersensitivity disorders. Contact lens wear may also modify the epidemiology or pathophysiology of recognised conditions, such as papillary conjunctivitis or microbial keratitis. Wearers may also present with intercurrent disease, meaning concomitant or pre-existing conditions unrelated to contact lens wear, such as allergic eye disease or blepharitis, which may complicate the diagnosis and management of contact lens-related disease.
Complications can be grouped into corneal infection (microbial keratitis), corneal inflammation (sterile keratitis), metabolic conditions (epithelial: microcysts, vacuoles, bullae, tight lens syndrome, epithelial oedema; stromal: superficial and deep neovascularisation, stromal oedema [striae/folds], endothelial: blebs, polymegethism/ pleomorphism), mechanical (corneal abrasion, corneal erosion, lens binding, warpage/refractive error changes; superior epithelial arcuate lesion, mucin balls, conjunctival epithelial flaps, ptosis, discomfort), toxic and allergic disorders (papillary conjunctivitis, solution-induced corneal staining, incomplete neutralisation of peroxide, Limbal Stem Cell Deficiency), tear resurfacing disorders/dry eye (contact lens-induced dry eye, Meibomian gland dysfunction, lid wiper epitheliopathy, lid parallel conjunctival folds, inferior closure stain, 3 and 9 o'clock stain, dellen, dimple veil) or contact lens discomfort. This report summarises the best available evidence for the classification, epidemiology, pathophysiology, management and prevention of contact lens-related complications in addition to presenting strategies for optimising contact lens wear.
... Physiological adverse events surveyed included corneal hydrops, pingueculitis, corneal inflammatory events (symptomatic and asymptomatic), [38][39][40][41][42] contact lens-associated red eye, corneal abrasion, phlyctenulosis, and microbial keratitis. Lens-related adverse events included the presence of lens deposits, 26 lens intolerance, 43,44 tear reservoir clouding, 11,45-47 difficulty handling the lenses, 45,48 and poor lens wettability. 26 Specific details of the complications and their management strategies were documented. ...
Significance:
This study affirms the long-term safety and efficacy of scleral contact lens use in patients with keratoconus.
Purpose:
This study aimed to evaluate the safety and efficacy of contemporary scleral contact lenses in the visual rehabilitation of the keratoconic population.
Methods:
A retrospective study of keratoconic subjects examined between 2013 and 2018 was conducted. Subjects were included regardless of age, sex, pre-existing morbidity, or scleral lens design. Only eyes fit successfully with scleral contact lenses for ≥1 year were included. Exclusion criteria were prior corneal surgery, dystrophy, degeneration, and trauma.
Results:
A total of 157 eyes of 86 subjects met the study criteria. The mean Keratoconus Severity Score at initial fitting was 3.6 ± 1.0. Lenses were gas-permeable and nonfenestrated, with a mean overall diameter of 15.8 ± 0.6 mm and 70.1% toric scleral periphery. Physiological adverse events occurred in 9.6% of eyes, including microbial keratitis (0.6%), phlyctenulosis (0.6%), corneal abrasion (1.3%), contact lens-induced acute red eye (1.3%), corneal infiltrative events (1.3%), pingueculitis (1.3%), and hydrops (3.2%). Lens-related adverse events were documented in 55.4% of eyes. Adverse events related to surface issues included poor wetting in 1.9%, handling in 3.8%, reservoir fogging in 7.0%, lens intolerance in 7.6%, deposit in 8.9%, and broken lenses in 26.1% of eyes. The most common management strategies involved refits (54.0% of interventions), patient reeducation (29.5%), medical treatment (5.5%), surgical referral (6.8%), adjustment to wear time (2.5%), surface treatment (1.2%), and lens replacement (0.6%). Best-corrected distance logMAR visual acuity improved significantly from a mean of 0.50 in spectacles to a mean of 0.08 in scleral lenses (P < .0001). During the study period, 14.6% of eyes lost best-corrected scleral lens visual acuity, all from keratoconus progression.
Conclusions:
Consistent with other groups, our study demonstrates excellent safety and efficacy of scleral contact lenses in subjects with keratoconus.
... These patients will also have the additional benefit of better comfort than that provided with corneal lenses. 46 The increasing incidence of keratoconus and associated management costs can cause a socio-economic burden to patients, practitioners and governments 47 in low-income contexts. Despite the limited resources, the results of this study demonstrate that with a basic keratometer, slit lamp, complimentary small measuring devices and limited trial contact lens sets, the majority of KC patients were able to achieve normal visual acuity and emmetropia with their corneal RGP contact lenses. ...
Introduction
Visual acuity (VA) and refractive error (RE) remain important parameters in the management of keratoconic (KC) patients. Despite rapid amelioration in capacity of diagnostic equipment, these remain inaccessible to the majority of practitioners in low-income countries. Notwithstanding limitations, practitioners are expected to utilize existing resources to satisfactorily manage their increasing numbers of keratoconic patients.
Purpose
To determine the changes in visual acuity and refractive errors with diagnostic and management options available in low-income contexts.
Methods
A descriptive, retrospective chart analysis of medical records dating back 5 years was employed in this study. Records of patients prescribed with corneal rigid gas permeable (RGP) and scleral lenses were analyzed. Data on age, gender, stage of keratoconus, pre-, and post-visual acuities and refractive errors, mode of correction and lens parameters were evaluated.
Results
A total of 124 medical records were analyzed. Males comprised 58.9% and females 41.1% of the total sample, with a mean age 20.86 ± 9.50 years. The mean unaided VA in logMAR notation was 1.0±0.19, while corrected VA was 0.18±0.17. There was a significant improvement (p=0.001) in VA with corneal RGP contact lenses (mean 0.19±0.17) as compared to unaided VA (mean 1.29±0.20). Scleral lens VA also improved from a median of 1.06 to −0.01 logMAR; p=0.001. The mean RE before RGP contact lens fitting was −9.43±2.37 diopters (D) which improved to −0.41±0.78D. RE reduced significantly (p=0.001) after fitting with both corneal RGP lenses (from a mean of −9.80±4.46D to −0.45±0.80D) and scleral lenses (from a median of −8.00D to −0.02D).
Conclusion
Significantly improved visual acuity and refractive error status were achieved with all KC patients. Despite the diagnostic equipment and contact lenses design limitations, practitioners in low-income contexts can fit the relatively more affordable corneal RGP lenses to positively impact the daily living experiences of their KC patients.
... This finding is of significance because for the first time, well adapted, habitual CoL wearers are shown to exhibit better comfort scores with SL in a RCT. Furthermore, although SL are better tolerated by patients unable to tolerate CoL [5,35,49], the present research indicates that 47 % of successful, habitual CoL wearers, who demonstrate equivalent visual and Qol outcomes in both lens types, preferred SL for their future use. The most likely explanation for this, is that even in individuals who are successful and well adapted CoL wearers, the particular SL fitting features, may contribute to the significantly better comfort and frequent preference of SL. ...
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Purpose. To compare the comfort and visual performance of corneal rigid gas permeable contact lenses (CoL) and scleral rigid gas permeable contact lenses (SL) in participants with corneal ectasia, successfully wearing “habitual” CoL.
Methods. In a randomised controlled trial (RCT) with a 2x2 crossover, 34 participants were recruited and randomised into two groups. Group 1 (sequence AB), were fitted in period 1, with new CoL and after a 4-week washout period, in which habitual CoL were worn, were fitted with and crossed-over to SL, period 2. Group 2 (sequence BA), were first fitted with SL in period 1 and after a washout period of 4 weeks, crossed-over to new CoL, period 2. The medial lengths in weeks of Periods 1 and 2 were: 17.5 (IQR 12.4) and 14.5 (IQR 6.2) respectively. The outcome measures for visual performance were best corrected visual acuity and the contrast sensitivity function. Vision related quality of life (Qol) was assessed using the National Eye Institute Visual Function Questioannaire-25 and reported subjective perception of vision (SPV) and reported subjective perception of comfort (SPC) scores, recorded on a scale from 1–10. The final outcome measure was the selection of the preferred lens type at the completion of the RCT.
Results. Significantly higher SPC scores were found for SL compared to CoL (p=0.002). Significantly higher SPC scores for CoL were found in participants who selected CoL as their preferred lens for future use, compared to those who selected SL (p=0.009). All other outcomes exhibited no significant difference between the experimental lenses. CoL were preferred by 53% (n=16) and SL by 47% (n=14).
Conclusion. Significantly better comfort was reported for SL compared with CoL. Significantly higher comfort in CoL was found in those who preferred CoL, than those who preferred SL. Successful CoL wearers whose SPC in CoL is < 7 are likely to achieve better comfort with SL. On average, successful CoL wearers found SL more comfortable and there are unlikely to be any significant visual or visual Qol advantage or disadvantage in refitting successful keratoconic CoL wearers with corneal ectasia with SL and vice versa.
... 39 However, comfort evaluation is highly subjective and it is worth to have an initial comfort score to compare with. Yan et al. 40 referred that all eyes were comfortable at the beginning of SL wear and that 91% maintained the comfort at the 3-month appointment. Lee et al. 39 administered OSDI questionnaire before scleral lens fitting and after several months of lens wear by telephone and concluded that the average OSDI score decreased significantly (fewer symptoms, from 58.42646.22 to 18.99617.93). ...
Purpose:
To report the fitting aspects, clinical findings, and symptoms over 12 months of scleral lens (SL) wear.
Methods:
Sixty-nine patients with irregular cornea due to ectasia or surgical procedures (IC group) or regular corneas with high ametropia (RC group) completed the 12-month prospective follow-up period. Patients were evaluated at baseline, lens dispensing visit, 1 month, 3 months, 6 months, and 12 months for assessment of comfort, fitting aspects, and slitlamp findings. Comfort was assessed with the Ocular Surface Disease Index (OSDI) questionnaire and Dry Eye Questionnaire. Slitlamp evaluations comprised on-eye lens fitting (lens alignment and tear reservoir thickness) and anterior ocular surface health after removing the lens (edema, hyperemia, staining, and adverse events).
Results:
OSDI Scores were significantly reduced after 1 month of SL wear comparing to baseline (from 47.0±22.7-23.9±14.7 in IC group, P<0.001 and 27.0±16.1-17.0±13.7, P=0.029 in RC group, P<0.05), without statistical significant differences from 1 to 12 months. Tear reservoir thickness showed a significant reduction at V1m (122 μm on IC group and 126 μm in RC group, P<0.05), that continued over time until V12m (195 and 184 μm lower compared with Baseline (P<0.05, Wilcoxon). Hyperemia and staining were significantly higher after SL removal when compared with baseline (P<0.05), and maintained the same behavior over the 12 months. There were no severe adverse events during the entire follow-up period.
Conclusions:
Comfort enhancement promoted by SL remained over the entire follow-up. Despite no severe adverse events recorded over the 12 months of follow-up, higher hyperemia and staining grades were found after SL removal when compared with no-lens condition.
... SLs are a good option to enhance visual quality and comfort [16,30,60,123], and hence quality of life [32,123,125,126]. In a retrospective review, 18.7% of all SL patients who presented between Table 2 Conditions for which SL wear is potentially contraindicated or needs caution. ...
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.
... There has been a dramatic increase in the number of scleral publications from 2012 to 2016 compared to the previous 5-year period based on a recent study on the body of scleral lens-related scientific research [1]. Recent literature includes single-center, retrospective case series which generally describe a single lens design and unified fitting philosophy [2][3][4][5][6][7]. Studies on observed or potential impact of scleral lenses on ocular surface structures have also been published within the past 5 years [8,9], as has research on the structure and contour of conjunctival, episcleral, and scleral tissue [10][11][12][13]. ...
Purpose:
To describe patient-specific outcomes of scleral lens wear utilizing a variety of lens designs across multiple practice settings as reported in an international practitioner survey.
Methods:
An electronic survey was administered to eye care providers who prescribe scleral lenses in which they were asked to describe their most recently examined established scleral lens patient. Data was collected on patient characteristics, lens designs, wearing schedules, care products, and visual and physiological outcomes of lens wear. Descriptive analysis of data was performed.
Results:
A total of 292 responses were received. Participants represented 26 countries. The most commonly reported indication for scleral lens wear was corneal irregularity (87%) followed by ocular surface disease (8%), refractive error (4%) and 1% with multiple indications. Visual acuity improved from 0.4 ± 0.4 (mean ± SD) to 0.1 ± 0.2 in eyes with corneal irregularity (p < 0.001), from 0.3 ± 0.3 to 0.1 ± 0.3 in eyes with ocular surface disease (p < 0.001), and from 0.1 ± 0.1 to 0.0± [0.1] in eye with refractive error (p = 0.01). Prior to scleral lens wear, corneal staining was present in 55% of patients; staining was present in only 35% of patients following scleral lens wear. The number of topical ophthalmic drops needed decreased from 1.7 ± 0.9 to 0.8 ± 0.8 in patients with corneal irregularity (p < 0.001) and from 3.5 ± 1.7 to 1.1 ± 1.0 in patients with ocular surface disease (p < 0.001). The number of drops used by patients with refractive error remained stable, with these patients using an average of 2.0 ± 1.0 drops prior to scleral lens wear and 1.7 ± 1.5 drops following scleral lens wear.
Conclusions:
Patients with corneal irregularity experienced the greatest improvement in visual acuity, but patients with ocular surface disease and refractive error also achieved better visual acuity with scleral lenses. Ocular surface condition improved in patients with both corneal irregularity and ocular surface disease; patients with ocular surface disease experienced the most dramatic improvement. Patients who wore scleral lenses to correct uncomplicated refractive error did not experience an improvement in signs or symptoms of ocular surface disease.
... Most of the previous studies measured the clinical performance of the ScCL in terms of improvement in VA [13,[15][16][17]. To the best of our knowledge, this is the first study reporting the objective and subjective results of a new design of corneoscleral contact lens namely Rose K2 XL in cases of irregular corneas with a recording of its role in correcting of mesopic vision and HOAs. ...
Objectives
To study the fitting and the visual rehabilitation obtained with a corneoscleral contact lens, namely, Rose K2 XL in patients with irregular cornea.
Methods
This prospective study included 36 eyes of 36 patients with irregular cornea fitted with Rose K2 XL. Refractive and visual outcomes and mesopic and aberrometric parameters of fitted eyes were assessed at 2 weeks, 3 months, and 6 months after the initial lens use. Objective and subjective parameters of patient satisfaction and lens comfort were noted. Causes of lens discontinuation and complications were also recorded.
Results
Average logMAR VA improved significantly from 0.95 ± 0.09 without correction to 0.04 ± 0.05 six months after lens wear. Similarly, mesopic and aberrometric measures were significantly improved. Statistical analysis of the subjective patients' responses showed a significant acceptance of the lens by most of them. At the end of follow-up, the mean wearing time was 9.9 ± 2.9 hours per day. The most common cause of wearing discontinuation was persistent discomfort (16.7%) and high lens expenses(16.7%). Self-assessed questionnaire showed statistically significant improvement in nearly all measured subjective parameters.
Conclusion
Rose K2 XL lenses provide patients with irregular cornea with both quantitative and qualitative optimal visual function with high degree of patient comfort and satisfaction.
Objectives:
To evaluate the visual outcome of mini-scleral contact lenses (MSLs) in keratoconus following the resolution of acute hydrops.
Methods:
This was a prospective observational case series of patients of healed hydrops in keratoconus fitted with an MSL (Keracare, Acculens, Lakewood, CO) who were managed for acute hydrops medically or surgically at least 3 months prior. Uncorrected visual acuity, best spectacles-corrected visual acuity, best lens-corrected visual acuity, topographic indices, keratometric indices, contact lens parameters, and ocular aberrometric changes were evaluated. All patients were followed up for at least 3 months.
Results:
Eighteen eyes of 17 patients were included in the analysis. The mean post-hydrops topographic values of the eyes included flat keratometric value (K1) 64.93±10.88 (range 44.30–93.40) diopters (D), steep keratometric value (K2) 70.41±10.92 D (range 45.8–98.6 D), and Kmax of 79.53±17.73 D (range 50–130.2). The final mini-scleral lens's mean dioptric power was −8.56±3.96 D (range −18 to −4). Visual acuity significantly improved from post-hydrops resolution uncorrected visual acuity of 1.5±0.71 logMAR to 0.79±0.18 logMAR best spectacles-corrected visual acuity to 0.27±0.01 logMAR best lens-corrected visual acuity (P-value <0.0001). Similarly, there was considerable improvement in corneal aberrometric values after wearing an MSL. At the 3-month follow-up, 15 patients (16 eyes) were compliant to contact lens use with a minimum of 6 to 8 hr daily while two patients (2 eyes) were poorly compliant.
Conclusions:
A MSL is a valuable option for visual rehabilitation in keratoconus following the resolution of acute hydrops.
Purpose
To measure the corneoscleral limbus and anterior sclera parameters of normal Chinese adults by swept-source optical coherence tomography (OCT).
Materials and Methods
In this cross-sectional study, a total of 56 Chinese subjects with ametropia were evaluated in the Eye Hospital of Wenzhou Medical University from September 2020 to December 2020, including 26 (46.4%) men, with an average age of 24.7±1.8 years old. The OCT SS-1000 (CASIA, Tomey, Tokyo, Japan) was used to measure the sagittal height, corneoscleral junction (CSJ) angle, and scleral angle.
Results
The chord was across the corneal center and the line connecting the center of the cornea and the center of the chord was perpendicular to the chord. The mean sagittal height at chord lengths of 10.0, 12.3, and 15.0 mm were 1,756±72, 2,658±110, and 3,676±155 μm, respectively. The absolute values of the differences between horizontal and vertical meridians at three chord lengths were 54±40, 70±67, and 117±95 μm, respectively. One-way analysis of variance showed that the differences of CSJ angles at 12.3-mm chord and scleral angles at 15.0-mm chord in the four segments were statistically significant ( F values were 32.01 and 13.37, respectively, both P <0.001). The CSJ angles from low to high were 176.53±2.14° (nasal), 178.66±1.84° (inferior), 179.13±1.20° (temporal), and 179.31±1.68° (superior), and 87.5% of the nasal angles were less than 179°. The scleral angles from high to low were 38.35±2.47° (temporal), 38.26±3.37° (superior), 35.37±3.10° (nasal), and 35.30±4.71° (inferior).
Conclusions
The morphology of corneoscleral limbus and anterior sclera is asymmetrical in normal Chinese adults. The nasal side of the corneoscleral limbus has the largest angle, and the superior and temporal sides of the scleral angle are larger.
Background: To measure the corneoscleral limbus and anterior sclera parameters of normal Chinese adults by swept-source optical coherence tomography (OCT).
Methods: In this cross-sectional study, a total of 56 Chinese subjects with ametropia were evaluated in the Eye Hospital of Wenzhou Medical University from September 2020 to December 2020, including 26 (46.4%) men, with an average age of 24.7±1.8 years old, and a spherical equivalent of -2.05±0.46 D. The optical coherence tomograph SS-1000 (CASIA, Tomey, Tokyo, Japan) was used to measure the sagittal height, corneoscleral junction angle (CSJ), corneal angle, and scleral angle. One-way analysis of variance and least significant difference test were used to compare the differences in the four segment parameters.
Results: The mean sagittal heights of the right eyes at chord lengths of 10.0, 12.3, and 15.0 mm were 1756±72, 2658±110, and 3676±155 μm, respectively. The absolute values of the differences between horizontal and vertical meridians at chord lengths of 10.0, 12.3, and 15.0 mm were 54±40, 70±67, and 117±95 μm, respectively. The differences of CSJ and corneal angles at 12.3 mm chord and scleral angle at 15.0 mm chord in the four segments were statistically significant (F values were 32.01, 21.31, and 13.37, respectively, all P values < 0.001). The CSJ angles from low to high were 176.53±2.14° (nasal), 178.66±1.84° (inferior), 179.13±1.20° (temporal), and 179.31±1.68° (superior), and 87.5% of the nasal angles were less than 179°. The corneal angles at 12.3 mm chord from high to low were 40.31±2.80° (nasal), 39.46±2.41° (temporal), 37.20±2.26° (inferior), and 37.50±2.28° (superior). The scleral angles at 15.0 mm chord from high to low were 38.35±2.47° (temporal), 38.26±3.37° (superior), 35.37±3.10° (nasal), and 35.30±4.71° (inferior).
Conclusion: The morphology of corneoscleral limbus and anterior sclera is asymmetrical in normal Chinese adults. The nasal side of the corneoscleral limbus has the largest angle, and the superior and temporal sides of the scleral angle are larger. From the corneoscleral limbus to the anterior sclera, the superior side becomes steep and the other segments become flat.
A scleral contact lens lies on the sclera, not the cornea, which differs from a rigid gas permeable (RGP) contact lens, and has shown successful clinical outcomes in patients unable to tolerate glasses or RGP contact lenses because of a severely deformed cornea. In addition, a scleral lens forms a tear film between the cornea and contact lens that stabilizes the ocular surface and could be a useful therapeutic option. The mini-scleral contact lens is a useful therapeutic option for visual improvement and symptom control in patients with corneal abnormalities such as keratoconus, corneal opacity, ocular surface disease, and irregular corneal astigmatism.
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.
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.
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.
Mini-scleral lenses are an increasingly popular contact lens modality; however, there are relatively few reports regarding the unique aspects of their fitting and potential complications. We report a complication of mini-scleral lens wear in a 44-year-old female patient using the lenses for keratoconus. Her mini-scleral contact lenses were non-fenestrated and fitted to vault over the cornea and seal at the periphery. The patient presented with an acute red eye (non-ulcerative keratitis), characterised by unilateral severe conjunctival and limbal hyperaemia, corneal infiltration and pain. Refitting the lens to increase the corneal vault clearance did not prevent recurrence of the keratitis, some five months later. Successful prevention of further episodes of the acute red eye was achieved through improved patient compliance with lens cleaning, disinfection and lens case procedures. Lens hygiene may be particularly important for mini-scleral lenses with a sealed fitting.
To describe the use of Jupiter scleral lenses (Medlens Innovations, Front Royal, VA; and Essilor Contact Lenses, Inc., Dallas, TX) in the management of keratoconus.
We performed a single-center retrospective chart review of our initial 32 patients with keratoconus evaluated for scleral lens wear. All patients were referred for scleral lens evaluation after exhausting other nonsurgical options for visual correction. Diagnostic lenses were used in the initial fitting process. If adequate fit could not be achieved with standard lenses, custom lenses were designed in consultation with the manufacturers' specialists. The following measures were evaluated for each patient: ability to tolerate and handle lenses, visual acuity with scleral lenses, number of lenses, and visits needed to complete the fitting process.
Fifty-two eyes of 32 patients were evaluated for scleral lens wear. Of these, 12 patients (20 eyes) decided not to pursue scleral lens wear after initial evaluation. One patient (2 eyes) abandoned the fitting process after cataract surgery. The remaining 19 patients (30 eyes) were fit successfully. The average number of lenses ordered per eye was 1.5. The fitting process required an average of 2.8 visits. Standard lenses were prescribed for 23 eyes, and custom designs were needed for 7 eyes. Median best-corrected visual acuity improved from 20/40 (mean, 20/76) before scleral lens fitting to 20/20 (mean, 20/30) after fitting. Follow-up ranged from 3 to 32 months.
Jupiter scleral lenses provide acceptable visual acuity and comfort in patients with keratoconus. The availability of diagnostic lenses facilitates the fitting process.
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.
We evaluated the use of a highly gas-permeable, fluid-filled scleral lens for patients with diseased corneas for whom conventional contact lens strategies failed. Fifteen patients were successfully fit with individually fabricated scleral lenses. Significant corneal hypoxia, which limited the use of previous polymethylmethacrylate scleral lenses, was not encountered. Preliminary results suggest that a gas-permeable scleral lens may offer therapeutic as well as visual benefit to some patients with severe corneal disease.
Keratoconus and other noninflammatory corneal thinning disorders (keratoglobus, pellucid marginal degeneration and posterior keratoconus) are characterized by progressive corneal thinning, protrusion and scarring; the result is distorted and decreased vision. The etiology and pathogenesis of these disorders are unknown but may be associated with a variety of factors, including contact lens wear, eye rubbing, Down's syndrome, atopic disease, connective tissue disease, tapetoretinal degeneration and inheritance. Recent advances in techniques for biochemical and pathological investigation are now allowing further exploration in these areas. Early diagnosis is aided by the finding of irregular corneal astigmatism with inferior corneal steepening. Treatment ranges from simple spectacle correction to keratoplasty. In this review, the past and present literature on corneal thinning disorders is reviewed and practical approaches to diagnosis and management are outlined.
Keratoconus is a bilateral noninflammatory corneal ectasia with an incidence of approximately 1 per 2,000 in the general population. It has well-described clinical signs, but early forms of the disease may go undetected unless the anterior corneal topography is studied. Early disease is now best detected with videokeratography. Classic histopathologic features include stromal thinning, iron deposition in the epithelial basement membrane, and breaks in Bowman's layer. Keratoconus is most commonly an isolated disorder, although several reports describe an association with Down syndrome, Leber's congenital amaurosis, and mitral valve prolapse. The differential diagnosis of keratoconus includes keratoglobus, pellucid marginal degeneration and Terrien's marginal degeneration. Contact lenses are the most common treatment modality. When contact lenses fail, corneal transplant is the best and most successful surgical option. Despite intensive clinical and laboratory investigation, the etiology of keratoconus remains unclear. Clinical studies provide strong indications of a major role for genes in its etiology. Videokeratography is playing an increasing role in defining the genetics of keratoconus, since early forms of the disease can be more accurately detected and potentially quantified in a reproducible manner. Laboratory studies suggest a role for degradative enzymes and proteinase inhibitors and a possible role for the interleukin-1 system in its pathogenesis, but these roles need to be more clearly defined. Genes suggested by these studies, as well as collagen genes and their regulatory products, could potentially be used as candidate genes to study patients with familial keratoconus. Such studies may provide the clues needed to enable us to better understand the underlying mechanisms that cause the corneal thinning in this disorder.
The multicenter Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study is a prospective, observational study of 1,209 keratoconus patients. We report on the prevalence of corneal scarring in these patients. We also report on the test-retest repeatability of corneal scar documentation at the slit-lamp biomicroscope by trained clinicians and by masked photograph readers and on the scarring-status agreement at baseline between clinicians and photograph readers.
Clinicians and masked photograph readers graded each cornea as to scarring status. Patients were examined by clinicians, and their corneas were photographed at baseline (2,297 nongrafted eyes of 1,209 patients) and at a repeated visit (258 nongrafted eyes of 138 patients). These photographs were evaluated by the masked readers at the CLEK Photography Reading Center (CPRC). Clinicians reported corneal scars in right eyes at baseline as "definitely not present" in 53.9%, "probably not present" in 8.4%, "probably present" in 8.2%, and "definitely present" in 29.4% of patients. A weighted kappa statistic of 0.83 (95% confidence interval from 0.78 to 0.88) indicates that agreement is excellent between baseline and repeated assessments for the presence of a corneal scar by clinicians.
Agreement is very good between baseline and repeated photograph-reader assessments for the presence of a scar, with a weighted kappa of 0.77 (95% confidence interval, 0.72-0.82). The kappa statistic comparing photograph-reader scarring assessments with clinician results was 0.69 (95% confidence interval, 0.66-0.71).
The data also suggest better agreement between clinicians and readers when Vogt's striae and corneal nerves were observed. The data also suggest better agreement when corneal staining was not observed by the photograph readers. The CLEK Study protocol for determining the presence of scars is highly repeatable.
The multicenter Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study is a prospective, observational study of 1,209 keratoconus patients. We report on the factors associated with corneal scarring at baseline.
We defined corneal scarring as scars that had been detected both by the clinician examining the patient with the slit-lamp biomicroscope and by masked readers of corneal photographs at the CLEK Photography Reading Center. We investigated associations between corneal scarring and patient variables including gender, ethnicity, a family history of keratoconus, a history of ocular trauma, eye rubbing, contact lens wear, rigid contact lens fitting relationships, and corneal findings (such as curvature, Vogt's striae, Fleischer's ring, and central/apical staining). Multiple logistic regression analysis using generalized estimating equations to adjust for the correlation between eyes was used for analysis.
The following factors were found to increase the odds of corneal scarring at baseline in the CLEK Study: corneal staining (odds ratios (OR) = 3.40, 95% confidence interval 2.53-4.59), contact lens wear (OR = 3.51, 95% confidence interval 2.27-5.45), Fleischer's ring (OR = 1.63, 95% confidence interval 1.11-2.40), steeper first definite apical clearance lens base curve radius (per diopter, OR = 1.29, 95% confidence interval 1.25-1.33), and age (per decade, OR = 1.54, 95% confidence interval 1.35-1.75).
These baseline data suggest that corneal scarring in keratoconus is associated with corneal staining, contact lens wear, Fleischer's ring, a steeper cornea, and increasing age. The factors that imply added risk for corneal scarring that may be affected by practitioner intervention are staining of the cornea, contact lens wear, and the contact lens fitting relationship.
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.
Fluid-ventilated, gas-permeable scleral lenses are a valuable front-line tool in the management of severe ocular surface disease. In addition to enhancing vision, they have the potential to reduce greatly the disabling ocular pain and photophobia associated with SJS, TEN, and ocular cicatricial pemphigoid. They are also useful in healing some PEDs that are refractory to all other treatment strategies and in reducing PED recurrence in stem cell-deficient and neurotrophic corneas. The therapeutic benefits of these lenses are provided by the oxygenated aqueous environment they create over the corneal epithelium. The oxygenated precorneal fluid compartment that is maintained at neutral pressure protects the epithelial surface from the desiccating effects of exposure to air and the friction generated by blinking and avoids the shearing forces generated during the blink-induced movement of soft lenses.
The purpose of this study was to describe the current indications for scleral contact lens (ScCL) management at Moorfields Eye Hospital, London.
A database of 1003 patients (1560 eyes) seen between September 1999 and May 2003, either assessed for an ScCL trial or to follow up previously issued lenses, was analyzed.
The major contact lens indication groups were keratoconus or other primary corneal ectasia (PCE), corneal transplant, and ocular surface disease (OSD). The 3 main small groups were aphakia, myopia, and ptosis. A total of 538 patients continued lens wear in 1 or both eyes, for a total of 808 eyes. The total numbers of eyes for each contact lens indication were PCE, 496 (61.4%); corneal transplant, 150 (18.6%); OSD, 91 (11.4%); aphakia, 17 (2.1%); myopia 21 (2.6%); ptosis 14 (1.7%); and a miscellaneous indication, 19 (2.2%). The percentages were similar to those of the total group of 1560 eyes. Seven hundred twenty lenses (89.1%) were rigid gas permeable (RGP), 708 were nonventilated, and 12 were fenestrated; 88 (10.9%) were ventilated polymethylmethacrylate or ptosis props.
ScCLs continue to play a significant role in the management of corneal abnormalities, especially PCE, corneal transplant, and OSD. The great majority of lenses in use were nonventilated RGP designs.
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.
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.
Scleral rigid gas-permeable lenses play an important and underappreciated role in the treatment of corneal disease. This review provides an update on scleral rigid gas-permeable lenses for the visual rehabilitation of ectasia and irregular astigmatism, and an update on scleral rigid gas-permeable lenses in the therapy of ocular surface disease.
Several series and one case report present advances in the treatment of ocular surface disease with scleral rigid gas-permeable lenses. In addition, there are two reports describing one center's consecutive case experience using modern scleral lens design, predominantly in patients with ectasia and postkeratoplasty astigmatism. Finally, a comprehensive article reviewing the history and principles behind current scleral rigid gas-permeable lenses, with particular attention to the use of scleral rigid gas-permeable lenses in the management of ocular surface disorders was published.
Clinicians who treat patients with ocular surface disease should be aware of scleral rigid gas-permeable lenses as a therapeutic option for their patients. Advances in lens design make scleral rigid gas-permeable lenses a practical option for an increasing number and variety of patients with corneal disease.