A UNIQUE PIGGY BACK SYSTEM TO RESTORE CORNEAL REGULARITY Dr Langis Michaud O.D. M.Sc. FAAO (Dipl) FSLS FBCLA Professor École d’optométrie

Disclosure Honorarium and speaker fees, travel or research grants ALCON ALLERGAN BAUSCH & LOMB BLANCHARD LABS COOPER VISION GENZYME CANADA JOHSON & JOHNSON VISION CARE SCLERAL LENS EDUCATION SOCIETY Disclosure

Subjective Patient demographics : CG, 54 YO, Caucasian Female Chief complaint: Contact lens intolerance + eye redness Last exam: 3 years Ocular, medical history: Fitted in RGP lenses > 30 years ago. Always been comfortable with no issue about lenses or ocular health Her last pair of contact lenses was purchased 4 years ago Boston Envision OD (dominant) -13,00 BC 7,85 Diam 9.5 – lenticular OS -10.00 BC 7.90 Diam 9.5 –lenticular; fitted in monovision Cleaning: Boston simplus – no rub. Tap water to rinse. Hx of laser photocoagulation for retinal braks (5 years ago) No contributive medical background. Subjective

Subjective (2) Medications: None Other salient information CG works as a white collar for a governmental agency. She is doing computer work 8h00/day in the same dry environment for the last 15 years. Subjective (2)

Objective Refraction (at lens removal): BCVA (contact lenses) @ distance OD 20/25 OS 20/50 OU 20/25 BCVA at near (monovision) 1.8M OD 0.5 M OS O.5 M OU Refraction (at lens removal): OD -16.00 -0.75 x 30 20/30 OS -15.50 -0.75 x 110 20/30 +1 20/25-2OU Add +2.75 0.50M Binocular vision: well compensated eso (distance) and exo (at near) Objective

OBJECTIVE Posterior Blepharitis OU (grade 1- easy expression of slightly turbid meibum). Conunctival hyperemia (Nasal/Temporal) grade 2-. Papillae (upper conjunctiva) grade 1+ OD, grade 1 OS. VLK Temporal and nasal OD>OS Cornea guttata grade 1 OU. Topographie: warpage OU- pseudokeratoconus

ASSESSMENT Primary/leading Plan Corneal warpage 2nd to lens warpage and bad fit Corneal vascularized limbal keratitis OU (VLK) Lens spoilage Plan Treat VLK Do not wear actual lenses Restore corneal shape Improve lens fit and comfort ASSESSMENT

Treatment Lenses management Medication: Steroids QID x 2-4 weeks Fluorometholone XX% Moxifloxacine BID as a prophylaxis x 1 week Lubrication : Non preserved artificial tears q2h00 to q4h00 Discard actual RGPs Wait for corneal restoration and Rx stabilization to refit lenses No glasses available Options Scleral lenses High DK soft lenses Comfilcon A lenses -13.00D and -10.00 D (similar to RGP powers) VA 20/30 @ distance and 0.8M @ near Trained to handle lenses and to use soft lens care regimen (hydrogene peroxide) Instructed toremove lenses to instill steroids F/U X 1 month

Follow-up @ 1 month Refraction: Topo maps OD -17.50 -1.50 x 20 20/25- OS -16.75 -1.75 x 140 20/25 Topo maps Warpage reduced but still there

Topo Maps initial vs 5 years (2011 vs 2016) OD OS Topo Maps initial vs 5 years (2011 vs 2016)

Management Condition improved but not stabilized Medication Steroids reduced to TID x 1 wk then BID x 1 week Lubrication QID Contact lenses High DK toric lenses not available at this time Masking astigmatism: not an option Solution: Piggy back of a spherical + a toric siHy lens Monovision: OD : -4.50 -1.25 x 20 + -10.00 spherical on top of it 20/25- OS : -4.50 -1.25 x 140 + -9.00 spherical on top of if 20/25 Management

Follow-ups Patient was seen every month x 6 months Then, cornea was considered stabilized 2 similar topo maps @ 3 weeks interval Final Rx: OD-16.50 -2.75 x 15 20/25+1 OS-15.50 -2.50 x 135 20/25 Add +2.50 Options to refit Remain in a piggy-back system 2 soft High DK lenses High DK DD lens + RGP Scleral RGPs Monovision vs MF Long HX of succesful monovision However binocular vision should be maintained. Follow-ups

Trials in sclerals Best fit achieved with a mini-scleral Parameters High DK material (150) Parameters OD: BC Diam 14.9 Power -14 D 20/20 OS : BC Diam 14.9 Power -13.50 D 20/20 OD = dominant, ordered accordingly Trials in sclerals

Enhancement At delivery Patient is able to see well at distance Lenses well positioned and centred Central clearance @ 30 min: 215 um /195 um Limbal clearance oK No issues with conjunctival landing Insertion : not an issue Patient is able to see well at distance Near vision needed adaptation (0.8 + difficult) Better with a +0,50 D OS Wait 2 weeks to see to evaluate outcome

Enhancements @ 2 weeks : same findigns, near vision still difficult Lenses are worn 13h00 / day, comfort is good Options Increase CX OS: modified monovision Use of oblate design to lower minus power Oblate design 3 options: 70-110-150 um = 2,4, 6D of difference To do it: Overvault x 150 um Then oblate 150 to keep sag the same, even lower Bonus: increased limbal clearance In this case OD: BC Diam 14.9 Power -9.50 D 20/20+ OS : BC Diam 14.9 Power -9.00 D 20/20+ Enhancements

Discussion Conclusion Oblate design compensates for corneal Q value Reduces spherical aberration Gain: 10% magnification Make a difference for high myopes and presbyopes Help to keep MF and binocular vision Creative Optometry Soft lens piggyback to compensate for high refractive errors With astigmatism With presbyopia Scleral lenses can be fitted on normal corneas Oblate designs can be used to optimize optical outcome on a prolate cornea Discussion Conclusion