Special Applications of Contact Lenses

E5

SAMPLE
The International Association of Contact Lens Educators
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Special Applications of Contact Lenses

Lecture contributors* Robert Terry, Lewis Williams,

Others***
Lecture editor** Bezalel Schendowich
IACLE executive editor** Lewis Williams
IACLE reviewers** Nilesh Thite, Lewis Williams
Lecture updated 2015-Apr-14
Lecture content rechecked 2015-Apr-28

****Original author(s) of lecture(s) **2014/2015 Editors and

Ma Meredith REYES, Christopher SNYDER, David PYE, Prashant GARG, Les DONOVAN, Des
FONN (Editor-in-Chief) reviewers
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 IACLE SPONSORS

Development and delivery of contact lens education by

IACLE is
supported through educational grants and in-kind
contributionsPlatinum Sponsor Silver Sponsors

Industry
Supporters

Donor Sponsor

CIBA Vision Wesley Jessen

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 SAMPLE ONLY

The following slides are an excerpt

from the revised
IACLE Contact Lens Course lecture

Special Applications of Contact Lenses

E5

The International Association of Contact Lens Educators

www.iacle.org
Post-Corneal Surgery CL Fitting

The International Association of Contact Lens Educators

www.iacle.org
Post-Corneal Surgery CL Fitting

RK CL Selection

GP CLs are the modality of choice for post-RK fitting

usually corneal shape is irregular
Trial fitting essential
fluorescein pattern assessment
Try simple CL designs first:
spherical
aspherical
Consider toric if necessary
Orthokeratology designs (reverse geometry) may prove useful
Specialized designs for RK

The International Association of Contact Lens Educators

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Post-Corneal Surgery CL Fitting

CL Fitting
Based on an analysis of corneal topography:
pre-surgical keratometry
corneal topography
Based on the amount of myopia
Large CL Total Diameter (TD)

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Post-Corneal Surgery CL Fitting

CL Fitting: Desirable Features

Adequate peripheral clearance

No bubbles inferiorly
Good tear exchange
Large optical zone extending to the corneal periphery
Larger than normal axial edge clearance

The International Association of Contact Lens Educators

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Post-Corneal Surgery CL Fitting

CL Fitting Assessment

Expect to see:
Central fluorescein pooling
Lens decentration
Bubbles beneath CL

The International Association of Contact Lens Educators

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Post-Corneal Surgery CL Fitting

Solving CL Fitting Problems

Fluctuating Vision

Diurnal variation

Trial a flatter fitting

CL centre thickness
Flare & Glare

BOZD

lens total diameter (TD)

Trial an aspheric design

The International Association of Contact Lens Educators

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Post-Corneal Surgery CL Fitting

Post RK Fitting: CL is decentered: superiorly & nasally

The International Association of Contact Lens Educators

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 Post-Corneal Surgery CL Fitting

Solving Decentration Problems - Superior

BOZD
Modify peripheral curves
Trial an aspheric design
Add prism ballast for high-riding CLs
Consider a reverse geometry design

The International Association of Contact Lens Educators

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 Post-Corneal Surgery CL Fitting

Solving Decentration Problems - Inferior

CL mass
lenticulation
CL total diameter (TD)
Use lower specific gravity (SG) material
Incorporate a minus lenticular design
Large BOZD with flat peripheral curves
Consider a reverse geometry design

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Post-Corneal Surgery CL Fitting

Peripheral Clearance

Excessive
change to an aspheric design
Inadequate
flatten/widen peripheral curves

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Post-Corneal Surgery CL Fitting

Post-Fitting Complications

Significant corneal staining

Recurrent corneal erosions (RCE)

Infection

Vascularization

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Post-Corneal Surgery CL Fitting

Transverse incisions used in an attempt to correct induced astigmatism

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Post-Corneal Surgery CL Fitting

RK Post-Operative Complications
Infection
Epithelial in-growth
Recurrent corneal erosions (RCEs)
Corneal oedema
Globe rupture
Stellate iron lines (epithelial Fe deposits)

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Post-Corneal Surgery CL Fitting

RK-Induced Optical Problems

Over-correction
Under-correction
astigmatism
best-corrected VA
Diurnal in vision
Myopic or hyperopic shift
contrast sensitivity
tolerance of glare

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Post-Corneal Surgery CL Fitting

Photo-Refractive Keratectomy (PRK)

Argon-fluorine excimer LASER (Ar-F)
Emission wavelength of 193 nm
High photon energy breaks molecular bonds
precise tissue removal
Minimal thermal damage to adjacent tissue

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Post-Corneal Surgery CL Fitting

PRK Complications
Persistent stromal scarring
early or late onset
Optical degradation:
loss of BCVA
halos, contrast sensitivity
Decreased corneal sensitivity
Risk of infection
Steroid complications

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Post-Corneal Surgery CL Fitting

LASER-Assisted in situ Keratomileusis (LASIK)

Laser ASsisted In situ Keratomileusis
Palikaris, 1990
For high myopia
Corneal flap cut with microkeratome
LASER reshaping of the exposed stroma to effect desired change
Flap is replaced
Usually, suturing not required
Bowmans Layer preserved

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Post-Corneal Surgery CL Fitting

LASIK Complications 1
Poor microkeratome cut
surgeons (in)experience
loss of suction
too deep corneal perforation
Flap complication
no hinge formed (detached flap)
too thin
too thick
wrinkling
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Post-Corneal Surgery CL Fitting

LASIK Complications 2
Epithelial in-growth
Deposits in the flap
Decentered ablation monocular diplopia
Photophobia
Glare, halos
Dry eye
Subconjunctival haemorrhages
Ptosis
Equipment problems during surgery
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Post-Corneal Surgery CL Fitting

LASIK Complications 3

Refractive problems
over or under correction
induced irregular astigmatism
decentered ablation
regression
GP corneal CLs on LASIK patien
Corneal ectasia
insufficient stromal bed thickness
Corneal inflammation/infection
Flap striae
Diffuse lamellar keratitis

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 Post-Corneal Surgery CL Fitting

Failed LASIK: Post-Surgical Corneal Topography

(Secondary Ectasia)

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 Post-Corneal Surgery CL Fitting

Failed LASIK: Post-Surgical Corneal Topography

(Secondary Ectasia)

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Post-Corneal Surgery CL Fitting

Intra-Stromal Corneal Ring Implants

Barraquer (1949) was first to discuss
intacs developed during 1990s
intacs approved by FDA 2004
Other intra-stromal products introduced subsequently
intacs SK
Ferrara Ring
Keraring
Cornealring

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Post-Corneal Surgery CL Fitting

Intra-Stromal Corneal Ring Implants

A mechanical correction device made from PMMA

4 D myopia limit before spherical aberration becomes a problem

9 - 10 mm diameter
Range of thickness
0.2 - 0.45 mm
thickness dictates refractive effect
Inserted in peripheral stroma
two thirds corneal depth
insertion is not a simple procedure
Full circle, split-ring shape (one piece) or two ( segments

The International Association of Contact Lens Educators

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Post-Corneal Surgery CL Fitting

Intra-Stromal Corneal Ring Implants

Insertion channel @ 68% of
corneal thickness

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 Post-Corneal Surgery CL Fitting

ntra-Stromal Corneal Ring Implants: Contra-Indicatio

Patients with collagen, vascular, autoimmune, or immunodeficiency disease
Pregnancy or breastfeeding
Keratoconus
Recurrent corneal erosions (RCEs)
Corneal dystrophy
Users of:
isotretinoin (Accutane)
amiodarone (Cordarone)
sumatriptan (Imitrex)

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