SAMER AL-TITI Bsc E&E –FBDO(HONS)-CL(HONS)

1. SAMER AL-TITI Bsc E&E –FBDO(HONS)-CL(HONS) • Bsc(Honours) E&E NOTTINGHAM UNIVERSITY • Diploma D.O. BRADFORD & ILKLEY COLLEGE • Honours Diploma with merit REF & C/L CITY AND EAST LONDON COLLEGE • Honours Diploma spect lens &low vision • F.B.D.O(Honours) CL(Honours) S. S. AL-TITI

2. Management of irregular corneal cases • The first step in managing these cases is to refer them to ophthalmologist as they are these days they are many sols starting from cross linkage to penetrating keratoplasty • The OPTICAL management of irregular corneal varies from spectacle e.g early kertoconus who has been treated and obtain good V/A …to contact lenses fitting (all types) the choice OF C/L varies we take case by case and the requirement of this case S. S. AL-TITI

3. What are the contact lens choices 1-Soft & Soft toric: adequate vision can be obtain in early cases of kertoconus who had been treated to halt the progress of the irregular changes in corneal shape known as ectasia 2-Soft Lenses for irregular cornea: when a pt. is unable to tolerate any kind of rigid lens it is worth while trying a soft lens it should be more comfortable and may give surprisingly good vision in some cases such lenses so S. S. AL-TITI

4. SOFT K & SOFT K TORIC these lenses gives better V/A than other soft because it has a special system( incorporates Pressure Balancing Holes) to equalize the pressure between the front and back of the lens, to improve • Optic stability • Oxygen transmissibility • Eliminate air bubbles & tear exchange S. S. AL-TITI

5. 3-Combination or piggyback lenses: as Silicone hydrogels offered a potential solution to PS’s hypoxic complications a combination of a soft contact lens with an RGP lens fitted on top the rigid lens can be free on the soft lens surface or may fit into a circular cut out portion, in the centre of the front surface at the soft lens 1- rigid lens free the are many types of soft lenses can be used with HGP such as OASYS, BIOMEDICS AND AIR OPTIX AQUA 2- TOPLENS is one of the brand for The other type of the piggyback center cut 8.50mm about 0.20mm RGP about 0.2-.3mm Smaller than cut S. S. AL-TITI

6. 4-Scleral Lenses :are very large RGP lenses that can provide adequate vision but often require very precise and skilled fitting and may be made by taking an impression of the eye alternatively by performed lens method using trial lenses separate lenses needed to assess the scleral and corneal fits Sclerals occasionally have to be removed and reinserted with fresh saline during the day to keep your vision clear and comfortable. 5-RGP Lenses can provide good V/A if it is possible to center the lens on the visual axis good oxygen transmission longer wearing time but uncomfortable, allow dirt to be trapped under the lens and may pop out S. S. AL-TITI

7. 6-Hybrid Contact Lenses combine a soft and RGP lens together to provide 1-superior visual acuity 2-all-day comfort 3-and freedom from having to worry about dirt getting under your lenses or the lenses popping out 4-good centration 5- stability S. S. AL-TITI

8. Soft perm was one this lens we were aware this lens manufactured by Ciba vision they stopped producing this lens for the following : PS developed hyperemia and over a year some revascularization also seen . When over wear happened, of oedema these problems occur because the HGP imbedded inside soft lens that except low DK in conjunction with thickness also the soft lens followed the contour of the HGP OF BOZR 7.00 TO 8.00 mm which made the soft contour immobile A NEW SERIES OF LENSES BEEN DEVELOPED USING HIGH DK HGP AND SILICON HYDROGEL LENSES OVER COME THESE PROBLEMS S. S. AL-TITI

9. THE TYPES OF SYNERGEYES 1-SynergEyes A Hybrid :This lens produced for regular corneal it does not interest us as they are many practical sols in our hands 2-SynergEyes K Hybrid : this lens developed for keratoconus which we are not going to discuss this now 3-SynergEyes PS Hybrid : this lens been developed for post surgical ectasia which we are not going to discuss this now 4-SynergEyes Duette Hybrid this lens been developed for regular and early irregular corneal 5-Synerg CLEARKONE Hybrid: this lens can work for all the above conditions which we are going to study it today S. S. AL-TITI

10. Approved on 31/8/2010 FDA Approves New SynergEyes Silicone Hydrogel Hybrid Contacts S. S. AL-TITI

11. Lens DesignPATENTED HYPERBOND TM S. S. AL-TITI

12. Vault and Skirt Curvature The vault diameter is ~7.4mm and includes the spherical optic zone and reverse curve The fit of the vault is independent of the fit of the skirt curve. Each should be fitted separately S. S. AL-TITI

13. Vault design 1-The vault value describes the overall relative depth of the lens on the cornea. 2-The goal is to determine the appropriate vault that provides complete apical clearance. 3-Design gives the ability to “vault” over the vast majority of ectasias without bearing 4-Design results in substantially lower lens power: -Closer lens alignment to the cornea in conjunction with the lacrimal lens results in significantly lower powers -Enhances optical quality and improves Visual Acuity for the patient -Lower lens power in conjunction with superior centration substantially reduces coma and minification S. S. AL-TITI

14. New Hybrid Skirt Design ClearKone incorporates a new reverse geometry hybrid design that: -Promotes all-day tear flow and movement -Facilitates ease of removal -Provides all-day comfort and corneal health The lens lands on both the soft, defined as Outer Landing Zone (OLZ)and rigid, defined as Inner Landing Zone (ILZ)materials. The landing area is divided by the junction of the hybrid lens. S. S. AL-TITI

15. Fitting Process • Linear vault fitting process minimizes chair time • Power of Dx lenses are calibrated to change at the same rate as the vault • All lenses within the fitting set will require the same over-refraion • Calculations that are normally needed with other lenses are unnecessary • Once the over-refraction of a Diagnostic lens has been determined, every other lens in the set will take the same over-refraction • Requires no topography S. S. AL-TITI

16. Patient Candidates • ClearKone is Ideal for: • Oval/nipple keratoconus (emerging to advanced) • Central and the majority of decentered cones Fitting success may be possible for: • Globus (depending on the specifies of the case) • Pellucid irregular corneas • RK(REFRACIVE KERATOTOMY), PRK(PHOTO REFARCTIVE KERATOMY), LASIK induced ectasia,post PK • Most irregular corneas(TRAUMATIC OR ANY OTHER REASON) • Patients that aren’t satisfied with the vision or comfort of their current lens. S. S. AL-TITI

17. ClearKone TerminologyVault-The vault value describes the overall relative depth of the lensOuter Landing Zone (OLZ)-Portion of the lens that lands on the soft materialInner Landing Zone (ILZ)–Portion of the lens that lands on the RGP S. S. AL-TITI

18. NaFL Thinning–refers to the appearance of a NaFL pattern in a lens with apical clearance to the cornea. A decrease of thickness of the tear layer will cause a decrease in fluorescence, resulting in an area of NaFL having a darker appearance than the area around it (Not black as with bearing) S. S. AL-TITI

19. Bearing–a black appearance as a result of contact of the cornea with the posterior of the lens, eliminating the presence of NaFL and the possibility of any fluorescence. S. S. AL-TITI

20. Pooling–complete uniform appearance of the NaFL layer (no variation in brightness) S. S. AL-TITI

21. Areas within the optic zone could result in trapped air bubbles if lens not inserted properlyAir bubbles affect the appearance of NaFL pattern -critical to eliminate them prior to evaluating fitBubbles are ALWAYSrepresentative of an insertion error –NOT a fitting errorMust remove lens and re-insert –making certain bowl of lens is filled to the TOP with solutionBubbles cannot be displaced by lens manipulation –must remove and re-insert S. S. AL-TITI

22. ProperInsertionProcess To increase the comfort of the fluorescein and to minimize insertion bubbles, fill the bowl of the lens with 1 drop of fluorescein (1 or2% sol)and fill the remainder of the bowl completely to the top with non-preserved saline. or fill it with diluted NAFL impregnated paper strip in non preserved unidoses saline S. S. AL-TITI

23. Proper Insertion ProcessFill the lens while holding it horizontally on the DMV scleral cup (included in the Dx set).Have the patient lean forward and tuck their chin to chest. Nose perpendicular to the floor.Bubbles are less likely to occur if patient maintains fixated gaze straight to the floor. S. S. AL-TITI

24. Retract the upper and lower lids and elevate the lens onto the center of the cornea, displacing the saline.Be careful not to push the lens too forcefully upon insertion.This can induce corneal suction resulting in edema S. S. AL-TITI

25. Key Fitting Principles • The fitting of ClearKone is based on the concept of fitting on overall sagittal depth rather than varying the base curve in relation to the irregular cornea. The fit of ClearKone depends upon the depth of the lens clearing the elevation of the cone, rather than a match in curvature • The fitting process involves individually fitting two different areas of the cornea: Central – determining the appropriate vault needed to clear the cone and provide complete apical clearance. Peripheral – determining the skirt curvature that places the proper distribution of support within the landing zones. S. S. AL-TITI

26. Evaluating NaFL Patterns • The key to determine the proper ClearKonefit is to evaluate the lens/cornea relationship using high molecular weight NaFL(i.e. FluoreSoft®) • NaFL evaluation must be done within 3-5 minutes after insertion, because the tear flow will thin the NaFL and give a false appearance/interpretation. (Should not let patient sit in waiting room for 15+ minutes) • Critical to eliminate any central touch when fitting. Even the lightest touch or “feather touch”can cause patient discomfort. • Critical to use a Wratten filter (provided in Dxset) to enhance the contrast of the NaFL pattern. Makes fine tuning the skirt curve much easier and will save chair time. S. S. AL-TITI

27. Wratten filter S. S. AL-TITI

28. Corneal Changes • For patients who are being re-fit from RGPs, SynergEyesA, KC or PS (and sometimes even soft/soft torics)Once the pressure of the predicate lens is removed, the cornea will most likely return to its natural shape • You should expect topographical changes • Critical to have complete apical clearance on first fit lenses • On follow-up if patient complains of discomfort or reduced wear time – check for central bearing May need to re-order deeper ClearKonelenses • May need to re-order deeper ClearKonelenses this problem can overcome by crosslinkage treatment S. S. AL-TITI

29. Ideal ClearKone FitOLZ (BEARING)--ILZ (THINNING)-- APICAL CLEARENCE S. S. AL-TITI

30. Step 1: Determine VaultCENRAL BEARING(TOUCH) OR POOL • To determine the proper vault, begin with the 250μ Vault value in the Medium skirt curve and check for: S. S. AL-TITI

31. STEP 1 If central bearing is seen, increase the vault in 50 TO 100μ increments, until apical clearance is achieved. VAULT TOO SHALOW S. S. AL-TITI

32. STEP1Ideal vault fit = 100μ over first bearingComplete apical clearanceRemember: Even the lightest touch or “feather touch”can cause patient discomfort • Ideal Vault Fit APICAL CLEARENCE→ S. S. AL-TITI

33. STEP1 If pooling is seen, decrease the vault in 100μ increments until the first bearing is observed. At the 250μ Medium starting point. Vault too deep S. S. AL-TITI

34. STEP 1 When first bearing is observed – increase the vault by 100μ and re- evaluate the corneal clearance for apical clearance. • Vault decreased 100μ Vault too shallow S. S. AL-TITI

35. STEP1 If the increased vault now results in apical clearance, you have reached the endpoint.If the increased vault still results in bearing, increase the vault 100μ to reach the fitting end- point. Vault increased 100μ Ideal Vault Fit S. S. AL-TITI

36. Step 2: Determine Skirt Curvature Ideal Skirt Curve Fit Evaluate skirt only after proper vault determined and is on eye GOAL: on most patients, best fit landing area achieved when NaFL thinning is observed in ILZ and bearing in the OLZ. Lens will exhibit movement very similar to soft lens. S. S. AL-TITI

37. Step 2: Determine Skirt Curvature (con’t) • Start with the Medium skirt curve • Evaluate landing area at 3 and 9 o’clock positions with the slit beam perpendicular to the area being observed It is critical to have the slit beam positioned perpendicular to the area being observed in order to properly illuminate the area for evaluation • Slit beam is positioned perpendicular to the 9 o’clock position to effectively evaluate the landing zone S. S. AL-TITI

38. Skirt Curve too Flat • If bearing observed under ILZ and thinning observed under OLZ – change to the STEEP skirt curve S. S. AL-TITI

39. Skirt Curve too Flat If equal bearing observed under both ILZ and OLZ change to the STEEP skirt curve S. S. AL-TITI

40. Skirt Curve too Flat • If pooling observed under the OLZ, and bearing is observed under ILZ – change to the STEEP skirt S. S. AL-TITI

41. Skirt Curve too Steep • If pooling observed under the ILZ–order the FLAT skirt curve S. S. AL-TITI

42. Determining Proper Skirt Curvature • Patient comfort is optimized when NaFL pattern shows slight diffusing beneath the rigid/soft junction S. S. AL-TITI

43. In summary after determining the min vault that gives clearance we look for the skirt fit which will be as follow OLZ ILZREMEDY T(bearing) T(bearing) S (SKIRT) P(pooling) T(bearing) S A(thinning) T S T P F A P F P P F T A IDEAL P A good A A good S. S. AL-TITI

44. Step 3: Determine Final Lens Power • When an ideal NaFL pattern is achieved, over-refract to determine final lens power • If the over-refraction is greater than 4.00/5.00D, adjust for vertex distance. • Lenses in the fitting set vary in power from -1.00D to -14.50D sphere power depending on the vault depth selection . A laminated card is provided in the Dx set indicating the power of each lens S. S. AL-TITI

45. Tips for Achieving Success • Evaluating NaFL Patterns – Timing is Critical! • 1 MINUTE STILL SETTLING 3 MINUTES IDEAL S. S. AL-TITI

46. differences in NaFL patterns affect lens fit. Which of the following is the ideal skirt curve? EX-1↓ EX-2→ EX-3↓ S. S. AL-TITI

47. Example 3: Ideal Skirt Curve OLZ BEARING ILZ THINNING S. S. AL-TITI

48. 16 MINUTES 31 MINUTES S. S. AL-TITI

49. Things to remember • Critical to eliminate any central touch when fitting. Even the lightest “feather touch”can cause patient discomfort. • For patients being re-fit from RGPs, SynergEyes KC, A, PS or even soft lenses Cornea will most likely return to it’s natural shape once the pressure of the predicate lens is removed • May need to re-order deeper lenses after the cornea re-normalizes this disadvantage can be eliminate by cross linkage and life time now is short it is expensive as the lens new Patient comfort greatly validates final fit in ClearKone Patient training is critical Proper insertion • Removal easier than KC lens but still requires training • Proper lens care critical (ONLY Non-preserved products) • Proper wear time - daily NOT extended • Build wear time over 5-7 days S. S. AL-TITI

50. ClearKone Diagnostic Set • 22 lens diagnostic set: • 11 Vaults: 100 –600μin 50μsteps • 2 Skirt Curvatures for each Vault: Medium and Steep • DMV scleral cup inserter • NaFL illuminating cobalt pen light • Wratten filter • Fitting Guide • Each Dx lens has laser markings that indicate its lens type, vault and skirt curvature S. S. AL-TITI