What Are Scleral Contact Lenses?

In the beginning…of contact lenses…there were scleral lenses…only.

In the year 1887 a great gift was given to the world of sufferers of distorted vision resulting from corneal tissue that was irregular in shape from disease or trauma.

The contact lens was invented nearly simultaneously by physicians working separately in Germany and in France. Working from drawings of Leonardo da Vinci (1508) and ideas of the British astronomer Sir John Herschel (1828), August Müller and separately Adolph Fick and Eugene Kalt blew glass shells to fit the outer eye and to some extent remedy their visual difficulties. These lenses rested on the conjunctiva of the eye above the sclera or white of the eye and were thus the first scleral contact lenses — the first contact lenses of any sort.

What are Scleral Contact Lenses?

The design and manufacture of scleral lenses has been a story of technological development significant for improvement in comfort, material, and affinity for the ocular surface.

For many years the lenses were partially molded and partially ground from the material of which hard contact lenses are made: PMMA (poly-methyl methacrylate) known as Plexiglas or Perspex. To form these lenses, like tooth implants, a plaster cast is made from a negative mold prepared from dental impression putty. The plastic would be heated and given the shape of the fitting surface of the lens from the plaster cast and then the power and edge curves would be ground onto the outside surface of the lens. Later came preformed trial sets not unfamiliar to those which we use today.

The current generation of scleral lens fitting began sometime in the last fifteen years with the mating of advanced corneal topography measurements, computer driven lathes and the observations of some very clever contact lens scientists. Proprietary designs of scleral lenses offering a variety of diameters, fitting philosophies, and multiple parameters are filling the gaps contact lens specialists have been wrestling with using smaller corneal contact lens designs for decades with less than optimal results. Most recently a firm has begun manufacturing lenses with a 3-D printer from an image generated from the eye. One eye…one lens, the lens is meant to fit like a fingerprint.

When discussing contact lens treatment, experts are experts because they agree that, any sort, size, or design of lens will have both positive and negative effects on the eyes and the tissues surrounding them. While it is true that many of the fitting and comfort issues confronted with corneal lenses of any size and design can be managed well with scleral designs, the scleral lens can also be difficult for some patients; for some eyes; for some conditions.

From the outset the larger size of the today’s scleral lens provides comfort on par with soft contact lenses for exactly the same reason: their size. Also, like soft contact lenses the scleral will not move around on the surface of the eye allowing the wearer a much more relaxed contact lens experience — there is no necessity to balance small corneal lenses between tense eyelids – vision can be enjoyed in any direction of gaze. The lenses will not fall off the eye and the increased size is a clear plus in finding a dropped contact lens.

On the other hand the quality of vision gained with scleral lenses specifically in cases of distorted corneae is far more comparable to that achievable with corneal GP lenses than with soft contact lenses in most cases.

Over the years my keratoconus patients have benefited from a series of contact lens breakthroughs that have variously improved the quality of their vision, their comfort with contact lenses, or in some other way the health of their eyes. Some years ago I “re-invented” the piggy-back system of contact lens wear which I summarized in 2008 in an article published in the Contact Lens Spectrum. Piggy-backers would place their vision restoring firm contact lens on top of a disposable daily wear lens of minimal focusing power. The soft lens would reduce the sensation of the firm lens while in many cases preventing the contact lens from abrading the cornea. More recently I have been successfully moving patients to scleral lenses because there is certainly less bother (only one lens per eye) and far less worry over corneal abrasions as the lens rests on the conjunctiva over the sclera and maintains a fluid cushion over the cornea itself.

Scleral lenses are finding their place in the world of contact lens fitting primarily to remedy vision problems from very irregular or otherwise damaged corneae both those caused by developing disease and trauma through injury or surgery. More and more, these lenses are requested by patients with normal eyes who want to enjoy the benefits provided by these lenses while participating in sports or other activities.

Scleral lenses are renowned for their greater comfort. In many cases a correctly fitted lens can be worn for many waking hours. Many patients have found that they benefit from exchanging the fluid from the reservoir from time to time throughout the day. The fluid that fills the lens-cornea space is sterile, non-preserved normal saline or in some cases saline with a non-preserved tear substitute added when needed for improved comfort.

A proper care regimen for scleral lenses is not different from that for any other contact lens manufactured from a firm oxygen permeable material. The lenses require cleaning upon removal, soaking in a recommended solution appropriate to the material of the lens and a periodic treatment to remove protein deposits. Of course, the exact care specifications will vary from patient to patient according to the evaluation of their contact lens specialist.

Just like any lens modality, the fitting requires expertise. Many who fit and dispense contact lenses rely on boxed soft lenses for their patients. When corneae become distorted those lenses will hardly fill the need. Greater expertise is required to fit rigid corneal lenses needed for these more problematic surfaces. The decision of the corneal lens expert to move on to the world of larger lenses is not of the same magnitude as that from boxes to corneal GP lenses. The investment is more a matter of time spent in discussion with the manufacturer’s fitting consultants, some reading, a webinar or two and keeping up to date with the lens designs that are available.

I was not among the first to use the current generation of scleral lenses, but when the opportunity knocked some years ago, I realized the importance of this form of contact lens and I believe I have positively influenced the quality of life of many of my patients.

5/28/15

Bezalel Schendowich, OD
Medical Advisory Board of the National Keratoconus Foundation
Fellow of the International Association of Contact Lens Educators
Clinical Supervisor & Specialty Contact Lens Fitter, Sha’are Zedek Medical Center, Jerusalem, Israel

Selecting Your Best Vision Correction Options

Today technology has evolved to a point where patients either with normal refractive errors such as nearsightedness, farsightedness, astigmatism and presbyopia or those with ocular diseases that require specialized vision correction options such as those with keratoconus all have spectacular alternatives to maximize their visual performance. With the multitude of choices available, how does an individual make the decision which to take advantage of? Well let’s begin by saying that the input from your eye care professional is critically important. You need to be properly educated not only about the various options that are applicable to your individual situation but about the advantages and disadvantages of these options.

Normal Refractive Error Options

Let’s begin by discussing vision correction options available to those with normal refractive errors. Basically stated, these individuals have the ability to utilize spectacles, contact lenses or if they are appropriate candidates, consider the refractive surgical alternatives.

Glasses
Today spectacle lens technology has evolved to the point where exceptional vision quality can be achieved with lens designs that allow for the selection of almost any frame size or shape. Thin lens technologies have enabled those with high prescription powers to not only see amazingly well, but to wear glasses that remain quite thin and attractive even with some of the most extreme prescription powers. Your eye care professional can discuss the various lens material options that best work for your situation. New high index materials are not only thin but are very light weight. A concern for some however can be the significantly higher costs associated with these lens materials. For those who need multifocals, new digital and free form progressive addition lenses (PALs) have dramatically increased the success rates associated with adaptation to PALs.

Contact Lenses
Contact lens alternatives for those with normal refractive errors have also dramatically developed technologically over the past years. Today virtually every patient with normal refractive error is a candidate to wear contact lenses. Developments such as astigmatic contacts, multifocal contacts, and hybrid (rigid center / soft periphery) contact lens designs along with the introduction and the tremendous growth in the use of single use daily disposable contacts has made one form or another of contact lenses something to consider for almost everyone. Today’s CLs are healthier, more comfortable and provide better vision than ever before. CLs have the advantage of superior peripheral vision, more natural vision “sensation” and obvious advantages for demanding physical activities. With contemporary contact lens materials and designs we have successfully addressed issues that limited many people in the past such as concerns of poor comfort due to dryness, contact lens vision instability and contact lens induced complications associated with over-wear and over-use of lenses. Your eye doctor should always present contact lens options to you regardless if you ask or not. So often patients think that they can’t wear contacts, so it does become the responsibility of your doctor to inform and educate you about CL alternatives.

Combination of Glasses and Contact Lenses
So how do you decide if you should be a contact lens wearer or a glasses wearer? Who said you have to? The two vision correction options are not mutually exclusive; in fact they are quite synergistic. All contact lens wearers should have an excellent pair of glasses to use. Contacts may be more cosmetically acceptable to many, they may be much better for various physical activities such as sports, however there are many times when glasses may be preferred such as at the end of a long day of contact lens wear, first thing in the morning before inserting your CLs, or on those days you just don’t want to bother with your CLs or simply prefer the look of your glasses for some situations. Today even the person who predominantly wears glasses can consider part time contact lens wear. Single use daily disposable (DD) CLs are the perfect option for such an individual. DD CLs are now even available in astigmatism and multifocal designs!

Refractive Surgery
Refractive surgery is also developing and is more effective and safer today than ever before. An experienced and skilled eye doctor is in the best position to consult with you in order to determine if you are an excellent candidate for the various refractive surgical options available. Again, having refractive surgery does not always eliminate your need for glasses or contact lenses. Although that would be the optimal outcome, many patients still use glasses and contact lenses after having refractive surgery. Typically the glasses and contact lenses are far less strong and are used significantly less often than prior to surgery. Some patients need them due to complications of surgery while others need them when outcomes did not perfectly correct vision and of course refractive surgery does not stop eyes from changing over the years, so many patients who had successful refractive surgery may experience vision changes years after surgery that require the use of glasses, contacts or both.

Irregular Refractive Error Options

Specialty Contact Lenses
Next let’s talk about choices in vision correction for those with irregular corneas and other conditions that are termed “medically necessary” vision correction cases. Individuals with irregular corneas such as those with keratoconus or post LASIK or other refractive surgery induced ectasias often require contact lenses that in essence “mask” the irregularity of the cornea. In the past this equated with the fitting of rigid corneal contact lenses, however today many other alternatives can be considered such as the fitting of scleral large diameter gas permeable contacts, hybrid CLs designed for irregular corneas and even combination systems of soft lenses with corneal gas permeable lenses (called “tandem” or “piggyback” CL systems). These CL alternatives provide advantages such as improved comfort, improved eye health response by limiting contact lens to cornea bearing, and improved contact lens positioning and stability which positively impacts visual performance.

Combination of Contact Lenses With Glasses
It should be clearly stated that spectacle lens alternatives still can have a significant role in the treatment of individuals with irregular corneas. Often glasses can be prescribed that provide adequate vision if even for part time and limited applications. While less severe cases may perform quite well with glasses as their primary modality of vision correction. Your doctor may need to modify the power of your glasses prescription in order for you to adapt to wearing glasses, however even a modified prescription power can frequently allow for some degree of visual function and allow for the ability to reduce the number of contact lens wearing hours during the day.

Surgical Procedures
Application of certain surgical and medical procedures such as intra-corneal ring segments (Intacs TM) or corneal collagen cross linking (CXL) for corneal irregularity can often help these patients in various ways and may allow for perhaps a less complex contact lens application or easier adaptation and improved function with glasses. Management of these diseases and conditions is quite complex and requires the expertise of doctors with extensive experience. Your doctor, if appropriately skilled and experienced can provide you with all of the required information and education so that you both can jointly decide on the best vision correction options for you.

In conclusion, patients today have numerous options for their vision correction. These options each have advantages and disadvantages but in most cases can be utilized synergistically. The role that your eye care professional plays in consultation and education of the vision correction alternatives applicable to you cannot be over stated. Vision is a precious gift and you should experience the highest quality of visual performance possible.

2/26/15

S. Barry Eiden, OD, FAAO
Medical Director, North Suburban Vision Consultants, Ltd.
NSCV Blog: www.nsvc.com/blog
President and Founder, International Keratoconus Academy of Eye Care Professionals

Cataract Surgery and Keratoconus

1/8/15

The eye works like a camera, specifically a digital camera. There is the front lens of the camera (cornea), the aperture (iris), the film (retina), and a cable to take the image to the brain (optic nerve). This “camera” also has an additional lens – the natural crystalline lens, which lies behind iris. This natural lens is flexible when we are young, allowing us to focus at distance then instantaneously up close. Around age 40-45, this natural lens starts to stiffen, necessitating the need for reading glasses for most people. This stiffening is the beginning of the aging process that eventually leads to formation of a cataract. We refer to the lens as a cataract when it becomes sufficiently cloudy to affect ones quality of vision. In general, cataract surgery is one of the safest and most successful of all surgeries performed. The basics of cataract surgery in eyes with keratoconus is very similar to non-keratoconic eyes.

Keratoconus (KC) affects this “camera” by causing the front lens (cornea) to bulge. This causes the optics to be distorted. In many cases, this can be corrected for with hard contact lenses (CL) or spectacles; in other cases a corneal transplant may be necessary. When it comes time for cataract surgery in the setting of KC, there are several factors that need to be considered.

Corneal Stability
The first thing to be considered is the stability of your cornea. In general, KC progresses more in your late teens to early twenties, and then stabilizes with age. A very exciting treatment for KC is collagen crosslinking. This treatment is meant to stiffen the cornea to prevent instability that is inherent to KC. This treatment promises to stop the progression of KC at a young age. Fortunately, with age, the cornea naturally crosslinks and stiffens, therefore when it comes time for cataract surgery, there is little chance of the progression of KC. Your doctor needs to choose the appropriate intraocular lens (IOL) to refocus your eye after surgery. Two of the most important factors in IOL selection are the length of your eye and the shape of your cornea. Long term CL wear can mold your cornea. It is important to assure that you stay out of your CLs long enough for your cornea to reach its natural shape. Depending on how long you have worn your CLs, it may take several months for the cornea to stabilize. This time can be challenging as your vision will be suboptimal (because you can’t wear CLs), and will be changing (as your cornea reaches its natural shape). When your cornea does stabilize, it is important to determine whether the topography (shape) is regular or irregular. This “regularity” is also known as astigmatism. If the astigmatism is regular, light is focused as a line – generally, this distortion can be fixed with glasses. However, if the astigmatism is irregular, light cannot be focused with glasses, and hard CLs are needed to provide optimal focusing. If you have had a corneal transplant, I generally recommend all your sutures to be removed to allow your new cornea to reach its natural shape.

IOL Selection
The second thing to be considered is the type of IOL. IOLs allow your doctor to refocus the optics of your eye after surgery. In many cases, the correct choice of IOL may decrease your dependence on glasses or CLs. There are several factors that are important when considering the correct IOL for a keratoconic patient. The amount and regularity of your astigmatism plays a very significant role in IOL selection. In general, there are four types of IOLs available in the US – monofocal, toric, pseudo-accomodating, and multifocal. In general I do not recommend multifocal IOLs in patients with KC. These IOLs allow for spectacle independence by spitting the light energy for distance and near, however, with an aberrated cornea (which is what happens in KC), these IOLs do not fare well. If there is a low amount of regular astigmatism or irregular astigmatism, your best bet is a monofocal IOL. This is the “standard” IOL that is covered by your health insurance. If you have higher amounts of astigmatism that your doctor determines is mostly regular, you may benefit from a toric (astigmatism-correcting) IOL. These IOLs can significant improve your uncorrected vision and really decrease your dependence on glasses. It is important to realize that monofocal and toric IOLs only correct vision at one distance. With a monofocal IOL you still can wear a CL to fine-tune your vision, however, with a toric IOL, in general you will need glasses for any residual error. There is a pseudo-accomodating toric IOL available, and this may be a good option if you are trying to decrease your dependence on glasses and correct some of your astigmatism. These IOLs are relatively new to the US market.

If You Had A Corneal Transplant
In the setting of a corneal transplant many of the same factors need to be considered – stability of the graft, choice of IOL, etc. In addition, the health of the graft has to be judged. Prior to cataract surgery in my patients with corneal transplants, I make sure to remove all of their sutures and give the cornea time to stabilize (just as if they were a CTL wearer). If you are a CL wearer, the same rule of being out of the TL until the topography is stable applies. The health of a transplant needs to be established prior to undergoing cataract surgery. The cornea has five main layers to it – the back layer (inside) is called the endothelium. This layer is responsible for “pumping” fluid out of the cornea, allowing it to stay clear. In all eyes there is a loss of endothelium cells with cataract surgery. I generally perform a “specular microscopy,” which allows me to visualize and quantify the corneal endothelium prior to surgery. This allows me to risk stratify you before your surgery. It is important to realize that corneal transplants have a lifespan and may have to be repeated in the future.

Keep in mind, there is some uncertainty in biometry (the process of selecting an IOL) in all eyes – this error can be higher in keratoconic eyes. This highlights why assuring stability is important. Equally important is picking the correct IOL for your situation. Also, keep in mind that I have discussed generalities in this article. Your individual case could be different. This is a conversation best left between you and your surgeon. In general, cataract surgery and keratoconus or a corneal transplant can be a very safe and effective way in restoring vision.

Sumit (Sam) Garg, MD
Interim Chair of Clinical Ophthalmology and Medical Director
Gavin Herbert Eye Institute at the University of California, Irvine

Adjustments Can Help With Depression

11/25/14

Eye disease can lead to isolation and depression. But making some adjustments can help with the depression. Robin Heinz Bratslavsky (pictured below with her oldest son) was diagnosed with keratoconus (KC) 20 years ago at age 25. Now a mother of two who works from home as a freelance editor. She participates in NKCF’s KC-Link.

When I was diagnosed with KC, I was an editor at a major women’s magazine. The diagnosis didn’t mean much to me at the time. Things changed when I was fitted with RGPs. I had limited wear time and pain, and I started to feel anxious about my career. There were times I had to leave work early and drive to my eye specialist — several times a week. As a young editor in a highly competitive field, I was concerned these absences would interfere with my ability to move up at the magazine.

When I had my first child, my husband and I decided I would stay home with him and work on a freelance basis. I’ve been doing this for 14 years now. Through a series of corneal abrasions, infections and lens-tolerance issues, I have had to rely heavily on my husband and family and friends to drive me and my children when my eyes would not cooperate. I have had moments of extreme despair, because I am not used to being so dependent. My husband works incredibly long hours, and he used to travel a lot. I was always worried I would not be able to drive my children in an emergency.

As my KC has progressed, I have moments in which my normally well-controlled clinical depression manifests, and I feel helpless because of my vision limitations. My sons are both avid soccer players, and I miss a lot of their on-field accomplishments, because I simply cannot see well enough.

At this point, I wear Kerasoft lenses, and I have had Intacs placed in my right eye. My vision, corrected, is about 20/30, but that can vary from day to day. After 20 years, it appears my KC is stabilizing, so I have a pair of emergency glasses; they get me to approximately 20/60, so I can’t drive, but I can function somewhat around my house to give my eyes a break. I’ve been living with KC for a long time; it’s a manageable disease — as long as you are willing to make some adjustments.

Robin Heinz Bratslavsky
Keratoconus Advocate

Lens Care If You Wear Contact Lenses and Use Cosmetics

9/23/14

In a continuation from his article on Proper Contact Lens Care, Mr. Ward, Director of the Emory Contact Lens Service, also offers tips if you wear contact lenses and use cosmetics. Several of these pointers apply even if you don’t wear contact lenses, but want to protect your eyes.

The Bullet List of Contact Lens Care For Users Of Eye Area Cosmetics

If possible look for eye makeup specifically labeled for use by contact lens wearers; use premium products.

Apply eye area cosmetics after inserting contact lenses (this will help prevent cosmetic contamination of lens surfaces from handling of cosmetics).

Remove lenses before removing makeup.

Remove makeup daily with mild soap and water; do not use oil or petroleum based make up removers; specifically, avoid moisturizing bar soap and an eye makeup remover that contains mineral oil and cocoa butter.

Choose water based makeup; avoid any oil based, or ‘waterproof’ eye area products (oils will travel across the skin and contaminate the tear film).

Avoid ‘lash-extending’ mascaras with artificial fibers, and apply mascara only to the end of lashes; do not apply mascara to the base of the eyelash or on the eyelid margin.

Do not apply oil-based moisturizers on the eyelids (oils can spread on the skin).

Do not apply any makeup to the eyelid margin (shelf), between the eyelashes and the eyeball.

Apply face powders sparingly; use pressed powder instead of loose powder; try to stay away from the eye area as much as possible; avoid frosted.

Choose liquid or gel eye shadows rather than powders.

Use caution with hair styling sprays. If possible, spray aerosols with eyes closed and step back out of the mist before opening the eyes. These gel/wax/lacquer type sprays can significantly coat your contact lenses.

Replace eye makeup at least every three months; do not share cosmetics.

And, please note that an automobile’s rear view mirror is not intended for makeup application while driving.

Michael A. Ward, MMSc, FAAO
Director, Emory Contact Lens Service
Emory University School of Medicine

Proper Contact Lens Care Provides Best Vision, Comfort and Ocular Health

9/18/14

Proper contact lens care is essential for the best contact lens wearing experience. Mr. Ward, Director of the Emory Contact Lens Service has shared some valuable information about taking care of your contact lens in the article below. On Tuesday join us for additional tips for people who wear contact lenses and wear cosmetics.

Contact lenses provide alternatives to spectacles, and contact lens wearers report better peripheral vision, depth perception and overall vision quality. Contact lenses can correct near-sightedness, far-sightedness, astigmatism and even correct the need for reading glasses. They are also used to manage some ocular surface diseases.

Contact lenses fall into two basic material types: soft contact lenses (SCL) and rigid gas-permeable (GP) lenses. Soft lenses account for the great majority of the contact lens market. GP lenses require more precise fitting and are often used as specialty devices to correct high prescriptions and/or to manage various ocular disorders and may require longer lens-adaptation time. Regardless of lens type, careful attention to lens care instructions can provide good vision and life-long lens wearing comfort.
Proper lens care depends on the lens type, wearing schedule and other factors. Single-use or daily-disposable soft lenses are prescribed to be worn once and discarded. This is theoretically the safest lens wearing modality in that no lens cleaning, lens care or storage case is required for this modality. Other daily wear soft lenses may be replaced every 2 weeks, monthly or by other schedule. Any and all lenses that are removed each day must be cleaned and disinfected prior to their reuse. Your eye care practitioner should provide specific instructions relative to your lens wear and care needs. General lens care instructions and Dos and Don’ts are bullet-listed below.

A word of caution –
Contact lens wear is quite safe as long as proper lens and storage case care are followed. However, improper lens wear and care can put the lens wearer at risk for serious consequences. Sight-threatening microbial keratitis (corneal ulcer) is the most significant adverse event associated with contact lens wear and is largely preventable. The contact lens storage case is the most likely potential reservoir for contact lens related ocular infections. Therefore, lens storage case care should be high on the list of important lens wearing instructions. Contact lens cases are not meant to be family heirlooms; cases should be replaced regularly, at least every 1-3 months.

The Bullet List of Contact Lens Care Recommendations

Hand washing: Always wash your hands before handling contact lenses. Use mild, basic soap and avoid antibacterial, deodorant, fragranced or moisturizing liquid soaps (many liquid soaps have moisturizers that can contaminate your contacts from handling).
Cleaning, rinsing, and disinfecting: Digital cleaning (rubbing the lens with your finger in your palm) removes dirt and debris and prepares the lens surfaces for disinfection. Rub & rinse thoroughly, even if the product is labeled “No Rub”. Lens storage solutions contain chemicals that inhibit or kill potentially dangerous microorganisms while the lenses are soaked overnight.
- Contact lenses should be cleaned when removed from the eye.
- Do not re-use old solution or “top-off” the liquid in the lens storage case. Empty the storage case daily and always use fresh solution.
- Do not use lens care products beyond their expiration dates. Discard opened bottles after 28 days.
- Do not allow the tip of the solution bottle to come in contact with any surface, and keep the bottle tightly closed when not in use.
- Do not transfer contact lens solution into smaller travel-size containers.
Keep your contact lens storage case clean (inside and out).
- All lens storage cases should be emptied, rinsed, wiped, and air-dried between uses.
- Keep the contact lens case clean and replace it regularly, every one to three months.
- Do not use cracked or damaged lens storage cases.
- Take care to remove residual solution from surfaces of lens case and solution bottles.

Other Dos and Don’ts

Do not wear your lenses during water activities (swimming, hot tubs, showering, etc).
Soft contact lenses should not be rinsed with or stored in water. Soft lenses will change size and shape if exposed to water.
Do not put your lenses in your mouth.
Do not use saline solution or re-wetting drops in an attempt to disinfect lenses. Neither is capable of disinfecting contact lenses.
Wear and replace contact lenses according to the prescribed schedule.
Follow the specific contact lens cleaning and storage guidelines from your eye care professional.
Do not change lens care products without first checking with your eye care practitioner.
Spare rigid (GP) lenses should be stored dry for long term storage { clean, rinse, dry}. New or dry-stored GP lenses should be re-cleaned and disinfected prior to lens wear.
Do not store soft lenses in the storage case for an extended period of time. “Spare” soft contact lenses should be new and stored in their original and unopened packaging.
Do not sleep in your contact lenses unless specifically approved to do so by your eye care practitioner.

For information from the Centers for Disease Control and Prevention, see:
www.cdc.gov/contactlenses/
www.cdc.gov/contactlenses/cdc-at-work.html

Michael A. Ward, MMSc, FAAO
Director, Emory Contact Lens Service
Emory University School of Medicine

Common Pediatric Eye Diseases

8/21/14

In the third of this series, Buddy Russell, from the Emory University Eye Center, provides a great overview of common pediatric eye diseases.

Some Conditions Frequently Seen in Pediatrics

A basic understanding of some of the conditions that may be present in pediatric patients is important to not only know what they are but also understand well enough to explain to the parent or caregiver. The following is intended to be an overview of some of those conditions and not a complete explanation.

Nystagmus – Nystagmus is a vision condition in which the eyes make repetitive, uncontrolled movements, often resulting in reduced vision. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern. As a result, both eyes are unable to hold steady on objects being viewed. Unusual head positions and head nodding in an attempt to compensate for the condition may accompany nystagmus. Most individuals with nystagmus can reduce the severity of their uncontrolled eye movements and improve vision by positioning their eyes to look to one side. This is called the “null point” where the least amount of nystagmus is evident. To accomplish this they may need to adopt a specific head posture to make the best use of their vision. The direction of nystagmus is defined by the direction of its quick phase (e.g. a right-beating nystagmus is characterized by a rightward-moving quick phase, and a left-beating nystagmus by a leftward-moving quick phase). The oscillations may occur in the vertical, horizontal or torsional planes, or in any combination. The resulting nystagmus is often named as a gross description of the movement, e.g. downbeat nystagmus, upbeat nystagmus, seesaw nystagmus, periodic alternating nystagmus. Having nystagmus affects both vision and self-concept. Most people with nystagmus have some sort of vision limitations because the eyes continually sweep over what they are viewing, making it impossible to obtain a clear image. If a refractive error is found, contact lenses may be the most effective way of obtaining best-corrected vision.
Strabismus – Strabismus is any misalignment of the eyes. It is estimated that 4% of the U.S. population has strabismus. Strabismus is most commonly described by the direction of the eye misalignment. Common types of strabismus are esotropia (turn in), exotropia (turn out), hypotropia (turn down), and hypertropia (turn up). Eye misalignment can cause amblyopia in children. When the eyes are oriented in different directions, the brain receives two different visual images. The brain will ignore the image from the misaligned eye to avoid double vision, resulting in poor vision development of that eye. Also, an eye that sees poorly tends to be misaligned. The goal of strabismus treatment is to improve eye alignment, which allows for better work together (binocular vision). Treatment may involve eyeglasses, contact lenses, eye exercises, prism, and / or eye muscle surgery.
Amblyopia – Amblyopia, sometimes called a “lazy eye,” occurs when one or both eyes do not develop normal vision during early childhood. Babies are not born with 20/20 vision in each eye but must develop it between birth and 6-9 years of age by using each eye regularly with an identical focused image falling on the retina of each eye. If this does not occur in one or both eyes, vision will not develop properly. Instead, vision will be reduced and the affected eye(s) are said to be amblyopic. This common condition, affecting up to 4% of all children, should be diagnosed and treated during infancy or early childhood to obtain optimum three-dimensional vision and to prevent permanent vision loss. What causes amblyopia?
Congenital Cataract – A congenital cataract, or clouding of the crystalline lens is present in 2-3 per 10,000 live births of children. The presence of a visually significant cataract in a child is considered an urgent disorder. The resultant form deprivation of vision requires immediate surgery to remove the obstruction, prompt optical correction and amblyopia therapy in unilateral cases. Until the 1970s, it was generally believed that there was no means of restoring the vision in an eye with a unilateral congenital cataract. However, subsequent studies demonstrated that excellent visual results could be obtained with early surgical treatment coupled with optical correction with a contact lens and patching therapy of the fellow eye. However, treatment results continue to be poor in some infants with unilateral congenital cataracts due to a delay in treatment or poor compliance with contact lens wear or patching therapy of the fellow eye. The Infant Aphakia Treatment Study (IATS) was designed to compare the visual outcomes in children 1 to 6 months of age with a unilateral congenital cataract randomized to optical aphakic correction with contact lenses or an intraocular lens (IOL). Children randomized to IOL treatment had their residual refractive error corrected with spectacles. Children randomized to no IOL had their aphakia treated with a contact lens. In previous publications we have shown that the visual results are comparable for these two treatments at 1 year of age, but significantly more of the infants randomized to IOL implantation required additional intraocular surgeries.
Accommodative Esotropia – Accommodative esotropia refers to a crossing of the eyes caused by farsightedness. Accommodative esotropia is a type of strabismus. Children who are farsighted easily and automatically focus on objects at distance and near through accommodation. As a result, a child who is farsighted usually does not have blurred vision. However, in some children who are farsighted, this accommodative effort is associated with a reflex crossing of the eyes. Accommodative esotropia can begin anywhere from 4 months to 6 years of age. The usual age of onset is between 2 and 3 years of age.Full-time use of the appropriate hyperopic glasses prescription or contact lenses will often control the esotropia. When wearing the correction, the child will not need to accommodate and hence the associated eye-crossing reflex will disappear. However, after removing the prescribed correction, the crossing will reappear, perhaps even more than before the child began wearing the correction. Sometimes the correction will only cause the crossing to disappear when the child views a distant object. However, when gazing at near objects, crossing may persist despite the use of the correction. In these circumstances, a bifocal lens is often prescribed to permit the child to have straight eyes at all viewing distances. One potential advantage of contact lenses compared to spectacles when correcting hyperopic powers is the decrease in accommodative demand. The increased effort to converge the eyes with spectacles requires one to over come the resultant base out prism when viewing a near object.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Treatment Options For Children

8/19/14

Here is part two in Buddy Russell’s series; this one focusing on contact lenses as a treatment option for children.

We Are Not Born With Good Vision

The human visual system at birth is poorly developed, but rapidly becomes the remarkable combination of nerve tissue, muscles and optics that provide us with the sense of vision. Those babies born with “perfect” eyes have only the opportunity to develop normal vision. The information processed by the eyes is sent directly to the brain and is interpreted as vision. During the first few weeks, the child sees shapes, lines and space between objects. The child’s visible world is most usable within 8-14 inches of his/her eyes. During this time, the eyes may appear to wander. After about a month or so, the normal child’s eyes will appear more coordinated and they start to show more interest in looking at objects. It is usually in the third month that a child who has normal eyes can fix and follow on a near object. The growth of the eye is a dynamic process, influenced by genetics and the environment.
Early detection of any eye problem is key to treating the disorder. The prevalence of vision problems in children is higher than you might think. For example:

1 in 10 children are at risk from undiagnosed vision problems
1 in 25 will develop strabismus
1 in 30 will be affected by amblyopia
1 in 33 will show significant refractive error
1 in 100 will exhibit evidence of eye disease
1 in 20,000 children have retinoblastoma

As a result of his granddaughter and her eye problem, former President Jimmy Carter initiated a program in 2002 called InfantSEE. This program allows children to have an eye exam at a very young age at no charge to the family. Participating eye doctors provide a more thorough exam than the busy pediatrician. As a result, there is a greater opportunity to detect and treat eye disorders that may otherwise go undetected.

“Have to” Contact Lenses

Fitting pediatric patients is not usually about routine visits and patients who want to wear contact lenses. It is about critical and often urgent situations and patients who have to wear contact lenses. The more common medical indications for contact lenses can be categorized into three groups; anisometropia, irregular corneal astigmatism and “large” refractive errors.

Anisometropia

One of the more common conditions potentially leading to a permanent loss of vision in a young patient is anisometropia. This difference in the refractive errors of the two eyes can lead to suppression of the less clear image. As a result of the non-focused eye, the brain of a young patient simply turns off the blurred eye. Early detection is key to successful treatment. Following the diagnosis of this problem being present, simply correcting the refractive error may be enough. However, it has been reported that as little as one diopter difference between the two eyes corrected with spectacles and the resultant anisokonia, can lead to foveal suppression impacting stereopsis and depth perception. The use of a contact lens or contact lenses alters the effective image size due to the vertex distance being zero compared to either the magnification or minification of the image size due to the vertex distance with spectacles. One of the most severe examples of this condition would be a child with a unilateral congenital cataract and managed with spectacles postoperatively.

Irregular Corneal Astigmatism

Whether acquired or congenital, the presence of irregular corneal astigmatism of the anterior curve of the cornea is best managed with a contact lens. This condition is to be considered urgent if the patient is of a young age. The eye may forever loose the opportunity to be corrected as the resultant amblyopia develops over a short period of time. By neutralizing the corneal irregularities with a contact lens, the eye of a young child will hopefully gain enough vision improvement to avoid the potential permanent loss.
Obviously, patching the better eye may also be necessary if the treated eye’s vision is not as correctable as the unaffected eye. The length of time the child is to be patched is to be determined by the pediatric ophthalmologist or optometrist, as this area of treatment is sometimes controversial. The factors that are considered include the level of vision obtained, age of the child and the condition of the other eye.

Large Refractive Errors

The optics of spectacle correction in high powers have inherent properties that include distortion, prismatic effect and minification / magnification. For instance, the decrease in image size when one views an object through high minus spectacles may result in less vision. This decrease in image size may impact the opportunity to fully develop normal vision in a young child. The smaller image size that is due to the vertex distance of spectacles may be better managed with a contact lens that has a vertex distance of zero thus providing a larger image. This larger image size often increases best-corrected vision.

“Fitting” the Caregiver

Arguably, the most important factor with young children having a good outcome is the parents / caregivers. The technical challenges that exist in these cases are secondary to the ability the fitter must possess to effectively explain and train the person or persons that will take care of the child outside of the office. They must be your partner in the child’s treatment. They must understand the urgency of the situation, they must understand the seriousness of the problem, they must be trained to properly apply, remove and care for the lens / lenses, they must also follow any and all instructions concerning the child. Many of these parents struggle with feelings of nervousness, guilt and sadness. My strategy is to be sensitive to their feelings but not let them feel sorry for themselves too long as the clock is ticking. I provide verbal instructions, written instructions, videos, my email address and a 24-hour phone number. I welcome the caregiver to ask any question at any time. I do my best to let them know that I do care and that I want them and their child to be successful. I am tough on them. There is no good excuse not to do as I have instructed them to do.

When the child and the parent / caregiver are convinced that I am confident in my ability and they know that I do care, the partnership develops as we walk the path together. I want the child to know that they are coming to see me. I want them to know I will reward their cooperation with all phases of the visit. This positive reinforcement may be in the form of a piece of candy, a small toy or just a sticker when the child allows me to see their eye, measure their cornea or intraocular pressure or they just tell me what they can see. Kids love to please us just like they love to please their parents. Reward them for it. Whether you consider this approach bribery or positive reinforcement, it works.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Pediatric Contact Lenses

8/14/14

Because August is Children’s Eye Health Month we are pleased to present a four-part series on pediatric vision issues and contact lenses by Buddy Russell, FCLSA, COMT. With over thirty years experience fitting contact lenses, Buddy is currently an associate of the specialty contact lens service at Emory University Eye Center in Atlanta, Georgia. Buddy is a clinical instructor in Emory’s Ophthalmic Technology Program and teaches students and ophthalmology resident’s contact lens technology.

$Child refractive exam - pediatric contact lenses$ He is a licensed dispensing optician, a Fellow member of CLSA and has been certified by JCAHPO as a Certified Ophthalmic Medical Technologist. He lectures at national and international meetings on contact lens related topics. Buddy has written articles for a number of publications, two chapters for CLSA’s advanced training manual and is a peer reviewer for the Cornea publication. He is also a contributing editor for CLSA’s Eyewitness journal. His current areas of research include pediatric aphakia and keratoconus. He joined the faculty at TVCI in 2006.

The first article will examine that pediatric contact lenses for children go beyond vision correction, the second will explore lenses as a treatment option, the third will look at a variety pediatric eye conditions and the final post will discuss the contact lens fitting challenges you face when you work with children.

Introduction

Working with the pediatric patient and their caregivers / family can be challenging, rewarding, fun, and yet sometimes frustrating. Many of these cases often include factors that are unique to the young patient. In addition to the technical challenges of obtaining the objective data, the fear of uncertainty is often present. The uncertainty of the unknown can either paralyze you or motivate you to step up and simply do what must be done.

The Definition May Vary

The definition of pediatric contact lens fitting can be different to different people. The fitter who works with the occasional twelve-year-old neophyte wearer will define pediatric fitting different from the person that works with babies on a routine basis. Pediatrics is generally defined as a branch of medical care that deals with infants, children and adolescents. The word pediatrics is derived from two Greek words (pais = child and iatros = healer), which means healer of children. Are you a “healer of children” or do you tend to feel better about someone else assuming the challenge and responsibility? This article will discuss some of the conditions, contact lens indications, fitting techniques and challenges that are present with the young patient.

Refractive Indications

What age is “appropriate “ to fit a contact lens on a child? In the absence of a medical indication, Jeff Walline, OD and his colleagues have addressed the answer to this question in the published literature. In addition, the American Academy of Optometry published a position paper in 2004 that stated that by the age of eight, a child was able to handle contact lenses and assume some degree of responsibility. We are all aware that not all eight year olds are capable of dealing with contact lenses. For that matter, not all eighteen year olds are mature enough to assume responsibility for anything. Some of the concerns that a contact lens practitioner may have in fitting these young children include the risk of safety to the child’s health, too much chair time, physical limitations, lack of hygiene, and lack of maturity. These are all legitimate concerns when you consider the child can see well with spectacles.

What does the literature reveal concerning these questions and concerns? Are the answers there?

CLIP Study

The Contact Lens In Pediatrics study compared 169 neophyte wearers in two age groups (children age 8-12 and teens age 13-17) over a period of three months. The summary of the clinical findings in the publication is that adverse events was low and the younger children took a little longer to train application and removal of the contact lenses. The more impressive outcomes from this study was determined by a tool used more frequently in child psychology referred to as the Pediatric Refractive Error Profile (PREP) survey. The PREP survey is a clinically validated quality of life instrument to assess how a child “sees” him or herself. This 26-question survey revealed that contact lenses improved the child’s self image in regards to their appearance, increased confidence in themselves while participating in activities and overall satisfaction of their form of vision correction. These findings were consistent in both age groups. More than 80% of both age groups found contact lenses easy to clean and take care of as all participants were fitted with 2-week disposable soft lenses and used a multipurpose disinfection care system.

The ACHIEVE Study

The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) were published in 2009. Jeff Walline, OD and his colleagues designed this study to find out the effects that glasses and contacts had on the self-perception of the child. This study examined 484 myopic children 8-11 years. The participants were randomized to spectacles (n=237) or contact lenses (n=247) and followed for three years. The children were evaluated at baseline, 1 month and every 6 months for three years by a validated psychology tool for self-perception referred to as the Self-Perception Profile for Children (SPPC). The SPPC instrument allows a 4 point self-assessment in 6 categories; scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct and global self-worth. The participants revealed the most dramatic areas of improvement with contact lenses compared to spectacles in the areas of physical appearance, athletic competence, scholastic competence and social acceptance. Similar to the low occurrence of adverse events with contact lens wear found in the CLIP study, over the three year period there were only 13 adverse events among 9 subjects. In addition, the ACHIEVE study found very similar rates of myopic progression in both groups of patients over the three year period (1.08D spectacle group and 1.27D contact lens group).
What can we conclude from these two studies?

One is that we are in a position to not only help a young person see but we are also in a position to do it safely and assist the child by instilling more confidence in themselves at a young age that may impact them as they mature into an adult who feels good about themselves. Young children are accustomed to following rules. When properly trained, these same young patients may grow into some of the most compliant patients that we have in our practice. There are some practical considerations for prescribing contact lenses to the younger patient. Mary Lou French, O.D. has stated the three M’s are important for success; Maturity (good hygiene, good communication skills, signs of responsibility), Motivation (why do they want contacts? Does the child want them or just the mom or dad? Are they active in activities where freedom from spectacles is important?), Mom (is the mom / dad / older sibling willing to help?). Don’t let age be the deciding factor. Consider your position as one that may positively impact the young patient in how they “see” and feel about themselves.

Buddy Russell, FCLSA, COMT
Associate, Specialty Contact Lens Service
Emory University Eye Center

Children Can Wear Contact Lenses Too

7/24/14

Several studies have shown that children as young as eight years are able to wear gas permeable,^[1-3] corneal reshaping,^[4-8] and soft contact lenses.^[9-12] Gas permeable (hard) contact lenses were originally thought to slow the progression of nearsightedness, but two randomized clinical trials have shown that they do not slow the growth of the eye,^{[1, 3]} so they are primarily fit on children who have difficulty handling soft contact lenses or who have highly irregular corneas (the clear window on the front of the eye) possibly from trauma or eye problems such as keratoconus. Corneal reshaping contact lenses are worn during sleep only. They temporarily flatten the cornea so that a nearsighted child can see clearly throughout the day with glasses or contact lenses. These contact lenses have been shown to slow eye growth in children.^[4-7] Typical soft contact lenses have no effect on the progression of nearsightedness,^[13] but soft bifocal contact lenses (typically worn by adults over the age of 40 who otherwise have difficulty seeing clearly at near) have been shown to slow the growth of the eye.^[14-17]

Children also benefit from contact lens wear other than slowing the progression of nearsightedness. Children feel better about their athletic abilities, their appearance, and their peer interactions when they wear contact lenses than when they wear spectacles.^[11] They even feel smarter if they wear contact lenses than if they wear spectacles, but only if they originally didn’t like to wear spectacles. Children also report that they prefer to participate in activities while wearing contact lenses more than while wearing spectacles, and the most-preferred vision correction is contact lens wear.

It has even been shown that most children (8-12 years of age) require only about five extra minutes to learn how to insert, remove, and care for their contact lenses when compared to teenagers (13-17 years of age). They also show similar benefits as the older group. In fact, children between the ages of 8 and 18 years of age are less likely to require discontinuation of contact lens wear due to problems encountered and also less likely due to experience irritation of the eye due to contact lens wear than college students between the ages of 19 and 25 years.^{[18, 19]} After wearing soft contact lenses for 10 years, those fit as children (7 to 12 years of age) reported similar rates of painful red eyes that required visits to the eye doctor than those fit as teenagers (13 to 17 years of age), and those fit as children as exhibited similar eye health as those fit as teenagers.^[20]

Personal experience, backed up by scientific evidence, shows that children as young as eight years can routinely wear contact lenses. When considering contact lens wear for your child, determine the primary reason you would like your child to wear contact lenses. If it is to slow the progression of nearsightedness, then corneal reshaping and soft bifocal contact lenses are the most effective methods. Unfortunately, neither of these contact lenses comes in a daily disposable modality. If your child doesn’t like to wear glasses or finds it difficult to participate in recreational activities with glasses, then daily disposable contact lenses may be best for your child. Contact lenses that are thrown away daily eliminate the need to clean and care for the lenses, reducing care of the lenses to insertion in the morning and removal at bedtime.

Some doctors believe that children should not be fit with contact lenses until they are teenagers. However, there is considerable evidence that indicates children are very capable of contact lens wear, and they experience significant benefits, visually and socially. Talk to your eye doctor about contact lens wear for your child, and if your doctor says that children should not be fit with contact lenses, consider a second opinion.

References
^[1] Katz J, Schein OD, Levy B, et al. A randomized trial of rigid gas permeable contact lenses to reduce progression of children’s myopia. Am J Ophthalmol 2003;136:82-90. (Go Back)
^[2] Khoo CY, Chong J, Rajan U. A 3-year study on the effect of RGP contact lenses on myopic children. Singapore Med J 1999;40:230-7. (Go Back)
^[3] Walline JJ, Jones LA, Mutti DO, et al. A randomized trial of the effects of rigid contact lenses on myopia progression. Arch Ophthalmol 2004;122:1760-6. (Go Back)
^[4] Cho P, Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Invest Ophthalmol Vis Sci 2012;53:7077-85. (Go Back)
^[5] Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res 2005;30:71-80. (Go Back)
^[6] Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al. Myopia Control with Orthokeratology Contact Lenses in Spain (MCOS): Refractive and Biometric Changes. Invest Ophthalmol Vis Sci 2012. (Go Back)
^[7] Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol 2009;93:1181-5. (Go Back)
^[8] Walline JJ, Rah MJ, Jones LA. The Children’s Overnight Orthokeratology Investigation (COOKI) pilot study. Optom Vis Sci 2004;81:407-13. (Go Back)
^[9] Rah MJ, Walline JJ, Jones-Jordan LA, et al. Vision specific quality of life of pediatric contact lens wearers. Optom Vis Sci 2010;87:560-6. (Go Back)
^[10] Walline JJ, Gaume A, Jones LA, et al. Benefits of Contact Lens Wear for Children and Teens. Eye Contact Lens 2007;33:317-21. (Go Back)
^[11] Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci 2009;86:222-32. (Go Back)
^[12] Walline JJ, Long S, Zadnik K. Daily disposable contact lens wear in myopic children. Optom Vis Sci 2004;81:255-9. (Go Back)
^[13] Walline JJ, Jones LA, Sinnott L, et al. A randomized trial of the effect of soft contact lenses on myopia progression in children. Invest Ophthalmol Vis Sci 2008;49:4702-6. (Go Back)
^[14] Anstice NS, Phillips JR. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology 2011;118:1152-61. (Go Back)
^[15] Lam CS, Tang WC, Tse DY, et al. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol 2014;98:40-5. (Go Back)
^[16] Sankaridurg P, Holden B, Smith E, 3rd, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci 2011;52:9362-7. (Go Back)
^[17] Walline JJ, Greiner KL, McVey ME, et al. Multifocal contact lens myopia control. Optom Vis Sci 2013;90:1207-14. (Go Back)
^[18] Wagner H, Chalmers RL, Mitchell GL, et al. Risk Factors for Interruption to Soft Contact Lens Wear in Children and Young Adults. Optom Vis Sci 2011;88:973-80. (Go Back)
^[19] Wagner H, Richdale K, Mitchell GL, et al. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optom Vis Sci 2014;91:252-61. (Go Back)
^[20] Walline JJ, Lorenz KO, Nichols JJ. Long-term contact lens wear of children and teens. Eye Contact Lens 2013;39:283-9. (Go Back)

Jeffrey J. Walline, OD, PhD
Associate Professor
Chair, Research and Graduate Studies
The Ohio State University College of Optometry

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