3/24/2018

History: Mixing the Molding

Compound

Scleral and mini-scleral lenses

March 2018

History: Inserting the Molding

History
• Joseph Dallos MD Compound
‒ Hungarian ophthalmologist
‒ eye molding
‒ 1st to take impressions of living eyes using Negocoll (a dental
molding compound)

History: Removing the Molding

History: Molding Kit
Compound

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History: Mixing the Castone History: CL Modification

History: Making the (+ve) Mold History: Corneal CLs

• Kevin Tuohy – 1948 (Beverley Hills, CA, USA)
‒ patented the first plastic corneal CL
‒ TD: 11.0 mm, tC: 0.4 mm
‒ monocurve design with a base curve & a rounded edge
‒ required to be fitted 1.50 D flatter than the flattest ‘K’

Rebirth of the Scleral CL

History: Molding the Scleral CL
• Newer CL materials:
‒ higher O2 permeability (Dk)
‒ do not rely on tear exchange beneath the CL
‒  ↑ corneal physiology
• Manufacturing:
‒ advancement in, & automation of, lathing
• ↑ understanding ocular shape:
‒ topography
‒ anterior segment imaging (OCT)

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Modern Day Scleral CLs Classification of Scleral CLs

Scleral Lens Education Society

Mini-Scleral: TD = HVID + (<6 mm)

Large Scleral: TD = HVID + (>6 mm)

Materials: GP Anatomy of a Scleral CL

• High Dk materials
‒ Menicon Z Dk = 163
‒ Bausch + Lomb, Boston XO Dk = 100
‒ Bausch + Lomb, Boston XO2 Dk = 141
‒ Contamac, Optimum Extra Dk = 100
‒ Contamac, Optimum Extreme Dk = 125
‒ Lagado, Tyro 97 Dk = 97
‒ Paragon, HDS 100 Dk = 100

Classification of CLs by TD Fitting Goals

• Clears (vaults) the central cornea
• ↑ limbal clearance
‒ bright ring of fluorescein above the limbus
• Scleral alignment
‒ all pressure, weight, & bearing of the CL should be on
the sclera

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Apical Clearance ∆s Viewed with Slit-

lamp & OCT

At baseline After 8 hours

Apical Clearance Change over 8 hours

Limbal Clearance
of Wear

Scleral CL edge
PLTF
Cornea Bulbar conjunctiva
Sclera

Apical Clearance Viewed with Slit-lamp

Limbal Clearance Zone
& OCT

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Inadequate Limbal Clearance
Appropriate Scleral Landing Zone
Note: No vessel stricture, blanching,
or ‘disappearance’ @ CL edge
Scleral CL Indications
GP CL fitting anomalies/difficulties
• Irregular astigmatism
‒ post-traumatic
‒ Penetrating Keratoplasty
‒ keratoconus
‒ Pellucid Marginal Degeneration
‒ post-refractive surgery
• Post herpetic infection
• Athletes
• Poor CL centration
• Poor CL stability
• Corneal GP CL intolerance
3/24/2018
Scleral CL Indications continued…
Therapeutic indications:
• Chemical burns
• Ocular pemphigoid
• Stevens Johnson syndrome
• Symblepharon management
• Graft vs host disease
• Exposure keratitis
• Neurotrophic keratopathy
• Persistent epithelial defect(s)
• Severe dry eye
‒ Sjogren’s syndrome
‒ filamentary keratitis
‒ limbal stem cell deficiency
Ocular Surface Disease
Pre-Scleral CL After 2 months of
scleral CL wear
When to Consider a Scleral CL
• Topography…
– Axial vs Elevation maps
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CL Options: The Return of Scleral CLs Axial Display (Power) Map

Large TD Corneal CL Designs &

Elevation Maps (in PMD)
Irregular Corneas

Assessing Corneal Shape: Differences Corneal CL on a PMD Cornea

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Use of Elevation Maps: CL Type Selection Corneal CL Fitted on Patient VY (Post-Hydrops)

When the difference in corneal
height (along any given meridian)
is > 400 µm, consider a scleral CL
design
Note: Frothing & bubbles in PLTF
due to excessive CL clearance

Scleral CL Fitted on Patient VY (Post-

Post-Hydrops Patient VY (Axial Map)
Hydrops)

Patient VY (Post-Hydrops):
Elevation Height Difference Large Diameter Corneal CLs

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Scleral CL Comfort: A Comparison of 2

Step 1: CL TD
Designs • Objective
‒ complete corneal vaulting
‒ limbal clearance

Fitting Scleral CLs Step 2: Initial BOZR Selection

BOZR: Mean K + 1.00 D
Example: K’s: 43.00 D @ 180 / 46.00 D @ 090
Initial Diagnostic Lens: 45.50 D

Step 2: Initial BOZR Selection

Scleral CL Prescribing
• Select Total Diameter (TD)
‒ palpebral fissure size / globe size / corneal clearance
• Select initial BOZR
‒ mean K + 1.00 D
‒ example: 44.00 D @ 180 / 46.50 D @ 090 → 45.25 +1.00 D = 46.25 D
• Scleral Radius Interpretation (7.30 mm)
‒ CL edge should rest above the conjunctiva
Too Steep Optimum Fit Too Flat

Threshold for bubbles forming in the PLTF is between 80 & 100 µm

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Step 3: Scleral Radius Interpretation

Step 2: Initial BOZR Selection
Edge Lift
Optimum Fit • Assess edge’s impingement on conjunctival vessels
‒ view at high magnification
‒ if edge buried: ↑ edge lift by 50 µm
‒ if clearance excessive: ↓ edge lift by 50 µm

Step 2: Initial BOZR Selection Step 3: Scleral Radius Interpretation

Corneal Vaulting

Step 3: Scleral Radius Interpretation Excessive Scleral Clearance

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Scleral CLs Scleral CLs: Application Bubble

• CL movement
‒ minimal to none
• CL BVP
‒ over-refraction over the best fitting diagnostic CL

Scleral CLs: Lens Application Scleral CLs: Lens Re-Application

• Sterile

• Preservative-free

• pH balanced

In-Office Scleral CL Application Fitting Scleral CLs

Filling

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Fitting Scleral CLs: Goals Anterior Segment OCT

• Clears (vaults) the central cornea
• ↑ limbal clearance  bright ring of fluorescein above the
limbus
• Scleral alignment
‒ all pressure, weight, & bearing of the CL should be on the
sclera

Comparison of Corneal & Scleral Anterior Segment Anatomy: Limbal

Sags Profile

Traditional (but erroneous)

concept of the corneal-
scleral junction

The reality

Landing Point of a 16.5 TD Scleral

Anterior Segment OCT
CL

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Scleral CLs: Lens Edge

Fitting by Sagittal Height
Impingement • Determine the anterior eye’s sagittal height for:
‒ chord length at 15.0 mm (for a 16.5 mm TD scleral CL)
‒ then add 0.30 mm (300 µm) to that sagittal height

Bulbar conjunctival ‘compression

ring’ following scleral CL removal

Tangent Angles & the Scleral Curve Apical Clearance = 300 µm

Cornea

Limbus

Sclera

Calculating Scleral CL Sagittal

Tangential Angles
• Height
Scleral CL sagittal height:
‒ Eye’s Total Sagittal Height = 2100 + 1900 = 4000 µm
(= sag @ 10 mm + sag @ 15 mm)
‒ Initial diagnostic CL = 4,300 µm. i.e.
‒ 4,000 µm sagittal height + 300 µm apical clearance

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Scleral CLs: Corneal Clearance Scleral CLs: Change in Edge Lift

CL, PLTF, & Cornea in Transverse Section

Cornea

Diagnostic Scleral CL: CL Settling Scleral CLs: Fitting by Sagittal

Over 4 Hours • Topography Height
‒ capable of  sag heights within chord lengths of 10.0
mm
‒ is there a typical sagittal height beyond 10.0 mm (i.e.
between 10 mm & 15 mm)?

Scleral CLs: Sagittal Height (Sag

Scleral CLs: Edge Lift Elevation
Height)
• Average sag height between a 10.00 & 15.0 mm chord
‒ approximately 2,000 µm
‒ found to be the same in ‘normal’ & keratoconic eyes

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Normal & Keratoconus Sags

Calculation of Scleral CL Sag
Compared

Cornea/Sclera Sag = 2,000 microns

Corneal Sag = 1,727 microns
Corneal Clearance = 300 microns
Total Sag = 4,027 microns

Sag from 10 to 15 mm Chords

Scleral CLs: Fitting by Diagnosis
Unaffected by rassessed
55 keratoconics Corneal Apex
Flattest apical radius
52.00 D (6.50 mm)
Average apical radius
63.00 D (5.35 mm)

Comparison of Sags from 10 to 15

Scleral CLs: Fitting by Diagnosis
mm: Normal vs KC

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Anterior Segment Shape Tangent Angle Scleral CL Design

• When fitting a scleral CL, an understanding of the basic ocular
shape is important because there are potential CL
interactions with areas other than the cornea, e.g. the limbus
& sclera
‒ the anterior eye is not a symmetrical solid
‒ the edge of SCLs & scleral CLs meet the NASAL paralimbal
zone before the temporal equivalent
‒ that leads to routine TEMPORAL decentration

Traditional Cornea / Sclera Shapes Zone 1: Central Zone

A New Understanding of Scleral

Final Apical Clearance
Shape

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Change in Apical Clearance Over

Central Zone (Zone 1)
Time
300 to 400 µm of apical clearance upon CL insertion

Change in Apical Clearance Over 8

Scleral CL Settling
Hours

Excessive Apical Clearance Upon

Scleral CL Settling: OCT Imaging
Insertion

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Tangent Angle Scleral CL Design:

Scleral CL Settling: OCT Imaging
Zone 2 - Limbal

Tangent Angle Scleral CL Design:

Scleral CL Settling: OCT Imaging
Zone 2

Scleral CLs: Excessive Apical Tangent Angle Scleral CL Design:

Clearance Zone 2

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Scleral CLs: Reconfiguring the

Scleral CLs: Limbal Clearance
Limbal Zone

Scleral CLs: Inadequate Limbal

Clearance Tangent Angle Scleral CL Design:
Zone 3 - Scleral

Remember that the

limbus hosts stem cells

Scleral CLs: Reconfiguring the Tangent Angle Scleral CL Design:

Limbal
A ∆ in the scleral clearance from theZone
standard to +5 ° not only helps Zone 3 - Scleral
clear the limbus but it also ↑ the sag height of the CL by 125 µm

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Zone 3 (Scleral): Scleral Radius Zone 3 (Scleral): Conjunctival

Interpretation Vessel Blanching

Zone 3 (Scleral): Scleral Radius

Anatomy of the Anterior Segment
Interpretation

NASAL

Zone 3 (Scleral): Conjunctival

Compression/Indentation Anterior Segment: Horizontal &
Vertical Asymmetries
N sag > T & I sag > S
but… I > N >T >S

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O2: The ‘Pacific U’ Scleral CL

Scleral CLs
Corneal Swelling Study

Dk

O2: The ‘Pacific U’ Scleral CL

Scleral CLs: The O2 Issue
Corneal Swelling Study
Dk
Dk
Dk

O2: The ‘Pacific U’ Scleral CL

O2: The No CL Wear Situation
Corneal Swelling Study

Dk

Dk

Dk

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O2: The ‘Pacific U’ Scleral CL O2 Considerations: Scleral CL

Corneal
Dk Swelling Study Fenestration

Scleral CLs: Tear Exchange Under

O2 Considerations
the CL

O2 Considerations: Scleral CL Scleral CLs: Tear Exchange Under

Fenestration the CL

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Scleral CLs: Tear Exchange Under

Scleral CLs: Insertion
the CL

Scleral CLs: Tear Exchange Under a Scleral CLs: Insertion – 2 or 3-

Settling CL Finger Technique

Scleral CLs: Insertion – Other

Scleral CLs: Insertion & Removal
Techniques
more control
Air ‘bell’ in handle

less control
No air ‘bell’ in handle

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Scleral CLs: Removal Scleral CLs: Complications

Scleral CLs: Lens Care Scleral CLs: CL Deposits

Scleral CLs: Lens Care Scleral CLs: Poor Wetting

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Scleral CLs: CL Cleaning In Situ Scleral CLs: Conjunctival Prolapse

Scleral CLs: CL Cleaning Scleral CLs: Conjunctival Prolapse

Scleral CLs: Lid Responses to CL

Scleral CLs: Conjunctival Prolapse
Wear

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Scleral CLs: Post-CL Clouding -

Scleral CLs: Conjunctival Prolapse
Minimal

Scleral CLs: Transient Conjunctival Scleral CLs: Post-CL Clouding -

Prolapse Significant

Scleral CLs: Particulates in the Post-

Scleral CLs: Post-CL Clouding
CL Saline

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Scleral CLs: Proteins in the Tear

Scleral CLs: Is Saline Appropriate?
Reservoir

Scleral CLs: Proteins in the Tear

Scleral CLs: Solution Reaction
Reservoir - Minimal

Scleral CLs: Proteins in the Tear Scleral CLs: Solution Reaction –

Reservoir -Significant White Light

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Scleral CLs: Solution Reaction – Scleral CLs: Fitting Considerations -

Fluorescein Staining Pinguecula

Scleral CLs: Fitting Considerations - Scleral CLs: Fitting – Pinguecula

Pinguecula (Blanched)

Scleral CLs: Fitting Considerations - Scleral CLs: Fitting – Pinguecula

Pinguecula (Large TD CL)

T N

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Scleral CLs: Fitting Considerations -

Symblepharon

Scleral CLs: Fitting Considerations -

Symblepharon

Scleral CLs: Future Considerations

Dk

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