Eyeworld

C ORNEA 46 | EYEWORLD | JULY 2019 has not responded to medical management including OTC and prescription topical agents, treatment of meibomian gland issues, and punctal occlusion, or if there are lid issues that are not easily or completely addressed with surgery. "Patients with dry eye discomfort but excellent vision in glasses or contacts may not be happy with the logistical demands of scleral lens wear and may have issues with the quality of vision related to surface wetting issues that can arise," Dr. Jacobs said. "Patients with neu- ropathic eye pain respond variably, with better results in patients in whom signaling is periph- eral and not longstanding." Scleral lens complications The leading complication for these devices occurs in corneal transplant patients, said Elise Kramer, OD. "If patients have a low endothelial cell den- sity or they don't have healthy endothelial cells, they will develop corneal edema," Dr. Kramer said. Another complication stems from uncer- tainty around the effects of ocular pressure, which has led clinicians to avoid giving the lenses to patients with ocular hypertension. When there are complications, the alter- natives to scleral lenses are determined by the condition. In the case of ocular surface disease, no other type of lens can replace what the scler- al lens has to offer the surface of the eye, Dr. Kramer said. But in the case of keratoconus or an irreg- ular cornea, other options include hybrid lenses, small rigid lenses, and soft lenses. Cases of lens fogging can be easily trouble- shot by improving the lens fitting, Dr. Kramer said. "If they are developing irritation or fogging with the lens it's probably because the lens is not fitting properly," Dr. Kramer. "Where the lens is landing it can cause fogging because it's putting pressure on the tissue, and it can also cause irritation for the same reason." Other trial runs Dr. Thakrar trials scleral lenses for keratoconus and ectasia patients prior to corneal transplanta- tion in order to measure potential vision. "If the vision can be corrected to 20/50 or better, we often will proceed with the lens rather than pursue surgery. However, this criterion will vary from case to case depending on the VA of the other eye and the patient's visual needs," Dr. Thakrar said. "Nevertheless, a contact lens refraction is necessary for many of these patients in order for the patient and sur- geon to make an educated decision on whether to pursue cornea transplantation." Unusual indications for scleral lenses include ocular chronic graft-versus-host disease and Stevens-Johnson syndrome, Dr. Jacobs said. Other good candidates for the lenses are patients with cranial nerve VII dysfunction that is congenital, from tumor, from surgery, or post-viral. "Often eye doctors focus on 'fixing the lids,' but that may be insufficient for mainte- nance of corneal integrity and comfort," Dr. Jacobs said. "Patients with 'blepharoplasty gone bad' can be excellent candidates." Finally, scleral lenses can be a good solu- tion for patients with complications after laser refractive surgery as well as those with declining and fluctuating vision after RK. "Surgeons are often reluctant to offer this option; after all, the patients chose surgery to avoid contact lenses," Dr. Jacobs said. "But scleral lenses correct vision wonderfully in these patient and are well-tolerated even if conven- tional contact lenses were not." Dry eye referral A patient with dry eyes can still wear soft lenses, but when dry eye worsens, patients can become intolerant to soft lenses. "That's where the scleral lens can fit in nice- ly because the scleral lens holds a reservoir of fluid that bathes the corneal tissue, potentially treating dry eye while they are wearing the lens," said William Trattler, MD. Dr. Jacobs refers dry eye patients for scleral lenses when there is a surface breakdown that continued from page 44 Financial interests Kramer: BostonSight Scleral, Euclid Systems Corporation Jacobs: None Thakrar: Bausch + Lomb, Precision Technology Trattler: None

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