CORNEA EWAP SEPTEMBER 2022 45 sized lenses allow physicians to manage other corneal conditions—like keratoconus, corneal irregularities, LSCD—in addition to dry eye disease. How they work Scleral lenses work because they vault over the cornea and you can fill them with yuid, Dr. Mian said. “When it’s sitting on the surface of the eye, it’s bathing the corneal surface with yuid, so it’s helping manage the dryness by always keeping a ¼tear film’ over the surface of the eye. Also, it’s mechanically protecting the surface of the eye as a lot of issues that occur in severe dry eye patients are because of the lids constantly rubbing against the surface that’s dry and causing pain and discomfort,” Dr. Mian said. Dr. Jacobs also stressed how these lenses create an improved environment for the ocular surface, bathing the corneal epithelium in artificial tears that are used to fill the reservoir and shielding the ocular surface from evaporation and mechanical disturbance from the lids. They are typically a later treatment, in keeping with the DEWS II report, she said. “Typically, these are only considered after failure or insufficient response from the use of lubricant drops, gels, ointments, punctal occlusion, and treatment of the lids.” Dr. Mian also discussed how these lenses are usually an option reserved for patients with more severe dry eye disease. They are not for those with mild to moderate disease because it is a burden in the sense that patients must invest time and money into fitting, daily insertion and removal, and disinfecting and filling solutions. “It’s not for any dry eye patient; it’s for those who have more severe disease, or they have other ocular conditions and dry eye.” For mild dry eye disease, Dr. Mian suggested using treatments like artificial tears, punctal plugs, and prescription medications. According to Dr. Jacobs, there is good data that scleral lenses improve the ocular surface and quality of life in patients with ocular surface disease in the setting of chronic graft-versus-host disease and chronic Stevens-Johnson syndrome. Patients with exposure keratitis, be it anatomic or paralytic, also do well with scleral lenses since their lids can’t protect the ocular surface adequately, she said. She added that scleral lenses can be useful in neuropathic pain because they can reduce nociceptive signaling related to evaporation from the ocular surface. Many neuropathic pain patients also require concurrent systemic treatment to reduce hypersensitivity to the presence of the lenses and to reduce central sensitization. “Scleral lenses are game changers for corneal ectasia,” Dr. Jacobs said. “It is clear from reports from around the world that they reduce the need for penetrating keratoplasty substantially. With modern large diameter designs and capacity to modify sagittal height independent of base curve, there is no cone too steep to be fit.” In terms of cases to avoid, Dr. acobs said there are no specific contraindications. “Patients with neurotrophic keratitis are at risk of complications with any contact lens, but scleral lenses can promote healing and clearing of the cornea in children with familial dysautonomia and patients with neurotrophic keratitis from tumor, surgery, herpes simplex, or herpes zoster,” she said. “Interestingly, patients with non-specific dry eye, dry eye after LASIK, or Sjogren’s syndrome tend to fail with scleral lenses. They can be hypersensitive to the presence of the lens on the eye, and if they have excellent vision at the 20/20 or 20/25 level, they may find that the lenses, which add optical interfaces, degrade the vision to an intolerable level.” Dr. Mian added that scleral lenses may be particularly helpful for those dry eye patients who are seeking to wear contact lenses. A lot of patients with dry eye disease have a hard time tolerating ordinary soft contact lenses but still would like to wear them so they don’t need glasses to see. Scleral lenses are an alternative that helps both their vision and dry eye disease. He also discussed how scleral lenses may be beneficial for patients with other conditions. For example, they could be helpful in patients who have neurotrophic corneal disease. They have decreased sensation, so the surface breaks down more easily, Dr. Mian said, and these patients can benefit from scleral lenses because they add to the tear film and add a layer of protection. Similarly, he said that patients who have exposure keratopathy, where the eyes don’t close well, tend to have problems with surface and dry eye disease abrasions, so these lenses could be helpful. Managing patients In terms of comanaging patients with an optometrist, Dr. Jacobs said that some optometrists may think that once the patient is fit and trained in insertion and removal, they don’t need to be seen for a whole year, such as would be the case for an ordinary soft contact
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