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

2. 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

3. 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 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

4. 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)

5. Objective Refraction (at lens removal):
BCVA (contact 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 x /30
OS x / /25-2OU
Add M
Binocular vision: well compensated eso (distance) and exo (at near)
Objective

6. 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

7. 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

8. 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 D and D (similar to RGP powers)
VA distance and 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

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

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

11. 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 : x spherical on top of it 20/25-
OS : x spherical on top of if 20/25
Management

12. Follow-ups Patient was seen every month x 6 months
Then, cornea was considered stabilized
2 similar topo 3 weeks interval
Final Rx: OD x / OS x /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

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

14. Enhancement At delivery Patient is able to see well at distance
Lenses well positioned and centred
Central 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

15. 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: 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 Power D 20/20+
OS : BC Diam Power D 20/20+
Enhancements

16. 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