Melissa Barnett

Contact lenses in the management of keratoconus.

The range of contact lens modalities currently available for the successful optical correction of keratoconus is greatly expanded. We review lens types currently available for the nonsurgical management of keratoconus, including rigid gas-permeable (GP) lenses, intralimbal lenses, corneoscleral lenses, scleral lenses, hybrid lenses, and piggyback lenses. In this review, we discuss the contemporary range of available lens types and the circumstances in which they are best used.

Jupiter Scleral Lenses: the UC Davis Eye Center experience.

Purpose: 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. Method: 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. Results: 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. Conclusions: 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.

Use of Scleral Lenses and Miniscleral Lenses After Penetrating Keratoplasty.

Purpose: To examine the clinical outcomes of scleral lenses for visual rehabilitation after penetrating keratoplasty (PK). Methods: A retrospective review was conducted for 34 patients (48 eyes) who had a history of prior PK and were fit with scleral lenses between October 2009 and December 2013 at the UC Davis Eye Center. Results: The most common initial indication for PK was keratoconus in 27 eyes (56%). Thirty-three eyes (69%) had previously been fit with other types of contact lenses, with small-diameter rigid gas-permeable lenses being the most common. The improvement in best-corrected visual acuity with a scleral lens compared with prior spectacle refraction or other contact lens was a mean of two best-corrected visual acuity lines. Forty-four eyes (91.7%) achieved functional vision with best scleral lens-corrected visual acuities of 20/40 or better. Patients who continued wearing scleral lenses were significantly more likely to report “good” subjective vision compared with patients who abandoned scleral lens wear (P=0.009), although change in objective best-corrected visual acuity did not differ significantly. There were no cases of infectious keratitis. Six eyes (12.5%) developed graft rejection; 3 were able to resume scleral lens wear. Nineteen eyes (39.5%) discontinued scleral lens wear for various reasons, the most common reason for discontinuation of lens wear was difficulty with scleral lens insertion or removal (8 eyes, 42.1%). Conclusion: Scleral lenses are effective and safe in patients who have had PK. There was a mean gain in visual acuity, with the majority of patients achieving 20/40 vision or better. The patients subjective perception of vision was a significant factor in determining whether scleral lens wear was continued or abandoned.

Scleral gas permeable lenses have come of age

The very first scleral contact lenses applied to the human eye in the late 1880’s by the visionary practitioners Friedrich and Albert Müller, Adolf Eugen Fick, Carl Zeiss, Eugène Kalt and August Müller (no relation to the Müller brothers) were ahead of their time but did not work very well [1–3]. The concept was brilliant but the technology simply was not available to provide the materials necessary to ensure clinical success and nor the equipment to machine the complex curvatures that shapes todays scleral lenses. A century later, materials, originally gas impermeable, had improved to the point where it appeared that the wear of scleral gas permeable (SGP) lenses became a viable proposition [4]. Pioneers in the now reborn scleral lens field, Donald Ezekiel, Ken Pullum and Perry Rosenthal reported promising results [5–8]. Add a few years and the development of the current computer driven lathes, now able to cut a combination of complex surfaces and we have truly arrived at a device that could be the first choice for irregular corneal surfaces, severe dry eye disease and a multitude of ocular pathologies including keratoconus and post-surgical ectasias. Today we even, on occasion, dispense SGPs to normal and healthy eyes! The SGP is now readily available to practitioners, who developed an interest in this field but it is no longer a device limited to those practitioners with their own laboratory to manufacture these lenses. Albeit a small market, the SGP is nonetheless the fastest growing one in the contact lens field [9].

Customary practices in the monitoring of dry eye disease in Sjogren's syndrome

Purpose Diagnostic testing for dry eye disease (DED) in Sjogrens syndrome (SS) is well described. Little is published about monitoring this systemic autoimmune DED. We analyzed the SS related DED tests used in North American optometric practices and compared academic settings to private practice settings. Methods A retrospective chart review of 123 SS charts from 6 optometric practices in North America was conducted. Testing done during the first examination following a SS diagnosis was recorded on Research Electronic Data Capture (REDCap) database. The complete data file was reviewed and testing type and methodology were compared. Results Symptoms of DED (98.4% of charts),meibomian gland dysfunction (76.4% of charts), corneal staining with fluorescein (75.6% of charts) and anterior blepharitis (73.2% of charts) were the most frequently recorded variables. Clinicians used different methodologies to measure and grade these variables. Private practitioners were more likely to use symptom questionnaires and grading scales and to describe anterior blepharitis. Academic settings were more likely to record TBUT and tear meniscus height. Conclusions The monitoring of DED in SS is not uniform in optometric offices across North America. Creating accepted standards of testing will improve the ability of clinicians and researchers to communicate and understand the course of DED in SS.

Sjogren’s syndrome in optometric practices in North America

PURPOSE To describe the presentation of dry eye in Sjogrens syndrome (SS) in optometric practices, to report on the methodology used in dry eye monitoring and to explore the level of corneal staining versus age and time of disease. METHODS Records of SS patients were reviewed in 6 optometric sites. A standardized abstraction tool was developed to collect data from the records including: health history, medications and symptoms and signs of dry eye. The methods of testing symptoms and signs of dry eye were recorded. Variables were recorded at each site and collated at the University of Waterloo. The first visit after January 1, 2000 was selected for description in this paper. RESULTS 123 charts were included. The average time since diagnosis was 7.2 years ±5.1 years. Symptoms of dryness were present in 110/123 = 89.4% of charts. Corneal fluorescein staining was present in 96/123 = 78% of charts. MGD was present in 52% of charts. There were significant differences in the protocols and grading systems used in these 6 sites. Corneal staining levels did not change with greater age or length of disease. CONCLUSION These 123 SS patients presented with a large variation in their symptoms and signs. Symptoms of dryness and corneal fluorescein staining were the most commonly recorded presentations. There was a great deal of inconsistency in dry eye protocols among offices. Future prospective research with standardized testing will contribute to our understanding of the best dry eye protocols for SS patients.

Keratoconus and Personality-A Review

Purpose: To assess the existing literature on the subject of keratoconus and personality and to propose a theory that might account for the perceived personality changes associated with this condition. Methods: A literature search was conducted in the PubMed database using the term “keratoconus” in combination with keywords such as personality, psychiatry, psychology, anxiety, depression, or psychosis. A total of 15 articles pertaining to personality and psychiatric disorders in keratoconus were retained and reviewed. Results: Although patients with keratoconus tend to score differently on personality scales compared with normal controls, the literature fails to substantiate the existence of a unique “keratoconic personality.” Instead, patients with keratoconus prove to have more dysfunctional coping mechanisms that specifically alter their interaction with health care providers and may account for the persistent clinical impression of less respectful, conforming, and cooperative patients. Conclusions: We hypothesize that the stage of life at which keratoconus commonly presents plays a crucial role in personality and coping mechanism development that significantly affects behavioral patterns and the relationship with caregivers.