Sceral Lens Market Size 2021: Global Industry Forecast to 2026

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Introduction to scleral Contact lenses

• Dr. Desinee Drakulich O.D.

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Disclaimer

• I do not have any affiliations nor am I paid by
  any of the companies that are used in this
  presentation.

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Outline for todays class

• Historical overview of scleral lens
• Detailed review of structure and design
• Detailed process of fitting
• Introduction of sagittal depth
• Peripheral curves
• Edge lift
• Diameter
• Slit Lamp images
• OCT images
• Why and when we use scleral lenses
• Advantages and Disadvantages
• Comparing other RGPs

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First Glass Scleral Contact Lens
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Size Comparision
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Size Comparision
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Brief History of Scleral Lenses

• The scleral contact lens was the first contact
  described in medical literature.
• In 1888, Adolf Fick developed the first blown
  glass scleral contact.
• Also in 1888, Eugene Kalt started using blown
  glass scleral contacts for the treatment of
  keratoconus.
• In 1889, August Mueller made himself a ground
  glass scleral lens for his high myopia and used
  it for his doctorial dissertation.

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Brief History of Scleral Lenses

• Scleral CLs never really progressed much after
  that due to the poor oxygen permeability of
  glass.
• Re-introduced in 1900s with the advent of PPMA
  material. More oxygen permeable than glass but
  still not great. Fenestration was added to try
  to increase oxygen permeability.
• Developers started making lenses small to allow
  the tear to flow under the CL and increase oxygen.

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Brief History of Scleral Lenses

• In 1970, scleral lens were re-introduced again in
  Rigid Gas Permeable materials.
• Lens were difficult to fit and intimidating due
  to there relative size.
• With the recent focus on Dry Eye Disease contact
  lens companies have began promoting scleral
  lenses as a suitable solution for dry eye
  patients who want to remain in contacts.

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Oxygen
PPMA Material
RGP Material
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Oxygen Permeability of Different Materials (Dk/t)

• Glass 0 Dk/t
• PPMA 0 Dk/t
• Boston EO 31-61 Dk/t
• Boston XO 61-100 Dk/t
• Fluoroperm 151 151-200 Dk/t
• Air Optix Night and Day 140 Dk/t
• Scleral Lenses 10 - 36.7 Dk/t in center
• 17.4 62.6 Dk/t in peripheries

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Structure of Scleral Lenses
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Jupiter Scleral Lens

• The Jupiter Scleral Lens has two designs 15 mm
  diameter and the 18 mm diameter.
• Both are true scleral lenses, meaning they bear
  on the sclera and vault the cornea.
• Both have 5 curves organized in 3 zones

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The 3 zones of the Jupiter CL

• The Corneal Zone the central corneal curve and
  the Aspheric peripheral corneal curve.
• The Limbal Zone the Aspheric scleral curve.
• The Scleral Zone the Aspheric scleral curve and
  the Aspheric edge curve.

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Jupiter CL
Central Corneal Curve
Aspheric peripheral curve
Aspheric Scleral Curve
Aspheric Scleral Curve
Aspheric edge curve
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3 Designs

• The Jupiter Standard central and peripheral
  curves in Zone 1 are the SAME.
• The Jupiter Advanced Keratoconic central curve
  STEEPER than peripheral curve.
• The Jupiter Reverse Geometry central curve
  FLATTER than the peripheral curve.
• There is a fourth design Toric Scleral Zone
  front toric with double slab off ballasting.

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Available Parameters

• Base Curve any
• Diameter 13.5 mm to 24.0 mm
• BV power - 50.00 D to -75.00 D in 0.25 steps
• Cylinder power - -0.25 D to 15.00 D in 0.25 steps
• Axis 1 to 180 in 1 steps
• Diagnostic lenses 14 pre-designed lenses for
  each 3 configurations.

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Fitting Process

• Standard RGPs and Soft CLs rely heavily on Base
  Curve and Diameter to fit them properly.
• Scleral CLs rely heavily on Corneal Sagittal
  Depth and Diameter.
• With the use of an anterior segment OCT scan one
  can easily calculate the sagittal depth of the
  cornea and what the sagittal depth of the contact
  would be needed for that patient.

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Sagittal Depth
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Sagittal Depth
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How Sagittal Depth Affects Corneal Diameter
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Why is this important?

• When fitting you need to ensure adequate corneal
  clearance.
• What is adequate?
• For 18 mm design 40 to 200 um
• For 15 mm design 50 to 200 um

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OCT of Corneal Clearance
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What if you dont have an OCT?

• An OCT makes fitting Scleral CLs easier however
  it is not necessary.
• If you have the pachymetry reading of your
  patients cornea you can use that as a guide to
  estimate the corneal clearance of the scleral
  contact in the slit lamp.
• If clearance is too low you need to either
  increase sagittal depth by steeping the base
  curve or increasing the diameter.
• For example

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Slit lamp example
Fluoress clearance ½ the corneal thickness
Corneal thickness 540
Corneal Clearance 270 um
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Where do you start?

• I always start steep and back down from there
  approximately 1.00 D STEEPER than patients
  STEEPEST curvature.
• I have learned from me own fitting experience
  that it is important on initial fit that you
  leave about 400 um clearance.
• The reason for this is the scleral elasticity of
  every person is different.
• These lens can settle any where between 50 um to
  250 um in a 4h period and can continue to settle
  up to 8h.

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Inadequate Corneal Clearance
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Excessive Corneal Clearance
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Perfect Corneal Clearance
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What is next?

• Limbal clearance complete and generous limbal
  clearance insures good tear circulation.
• If there is very little limbal clearance you must
  pick a large diameter lens.
• If there is too much limbal clearance large
  bubbles will form and a smaller diameter should
  be uses.
• Examples

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Limbal Clearance
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OCT of Limbal Clearance
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Next Step

• Peripheral Curves need to be adjusted to either
  tighten or loosen the fit of the CL.
• If the PCs are to tight this can lead to vessel
  blanching, hyperemia, difficulty removing the
  lens, fogging and discomfort for the patient.
• If the PCs are to loose seal off can not be
  maintained and the lens will not stay on the
  cornea.
• Examples

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Good Edge Fit
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OCT good edge landing
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Blanching of the vessels
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OCT poor edge landing
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Why would we use Scleral Contacts

• Dry Eye
• Ocular Surface disease
• Keratoconus
• High refractive error
• Irregular Corneas
• Post Lasik
• Post RK
• Post PKP
• Injury/Scarring

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Dry Eye/Ocular Surface Disease

• Advantage since the scleral contact is filled
  with preservative free saline the cornea is
  constantly bathed in fluid throughout the day.
• Advantage since the scleral contact is vaulted
  over the cornea instead of touching the cornea it
  does not compromise the integrity of the corneal
  surface.
• Disadvantage lenses are large and difficult to
  handle.
• Disadvantage cost 300 dollars per lens

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Keratoconus

• Keratoconus is a progressive thinning of the
  cornea secondary to the loss of the collagen
  fiber integrity. Thinning causes a bulging of
  the cornea resulting in an irregular corneal
  surface.
• Treatment for keratoconus
• Rigid Gas Permeable contacts
• Hybrid Contacts (Duette)
• Specialty Contacts (Rose K, Rose K2IC, Rose K
  Post)
• Scleral Contacts
• Surgery (Corneal Cross-linking, Intacs, PKP)

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Keratoconus
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Keratoconus
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OCT of Keratoconus
Keratocnusooooooooooo
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Keratoconus

• Advantage corneal vaulting reduce risk of
  corneal scarring since the lens does not touch
  the cornea.
• Advantage excellent visual outcome even with
  advanced keratoconic patients.
• Disadvantage difficult to handle
• Disadvantage - cost

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High Refractive Error

• Advantage wide range of available powers
• BV power - 50.00 D to -75.00 D in 0.25 steps
• Cylinder power - -0.25 D to 15.00 D in 0.25 steps
• Axis 1 to 180 in 1 steps
• Disadvantage difficult to handle
• Disadvantage - Cost

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Post Surgerical

• Advantage wide range of powers
• Advantage does not compromise corneal integrity
• Advantage gives excellent visual outcome
• Disadvantage difficult to handle
• Disadvantage - Cost

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Summary

• Scleral lenses are not difficult to fit if you
  follow some simple rules.
• Scleral lenses have improved materials and oxygen
  permeability to make them safe to fit.
• They can be a life saver for that difficult dry
  eye patient or irregular cornea.
• They are difficult to handle due to their large
  size
• They are no inexpensive, but worth it for the
  right patient.

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Any Questions