Clinical benefits of the Boston Ocular Surface Prosthesis

Blood-Derived Eye Drops for the Treatment of Corneal Neuropathic Pain

Blood-derived preparations, including autologous or allogenic serum, umbilical cord serum/plasma, and platelet-rich plasma eye drops, contain various growth factors, cytokines, and immunoglobulins that resemble natural tears. These components play important roles in corneal cell migration, proliferation, and wound healing. Blood-derived eye drops have demonstrated clinical effectiveness across a spectrum of ocular surface conditions, encompassing dry eye disease, Sjögren's syndrome, graft-versus-host disease, and neuropathic corneal pain (NCP). Currently, management of NCP remains challenging. The emergence of blood-derived eye drops represents a promising therapeutic approach. In this review, we discuss the benefits and limitations of different blood-derived eye drops, their mechanisms of action, and treatment efficacy in patients with NCP. Several studies have demonstrated the clinical efficacy of autologous serum eye drops in relieving pain and pain-like symptoms, such as allodynia and photoallodynia. Corneal nerve parameters were also significantly improved, as evidenced by increased nerve fiber density, length, nerve reflectivity, and tortuosity, as well as a decreased occurrence of beading and neuromas after the treatment. The extent of nerve regeneration correlated with improvement in patient-reported photoallodynia. Cord plasma eye drops also show potential for symptom alleviation and corneal nerve regeneration. Future directions for clinical practice and research involve standardizing preparation protocols, establishing treatment guidelines, elucidating underlying mechanisms, conducting long-term clinical trials, and implementing cost-effective measures such as scaling up manufacturing. With ongoing advancements, blood-derived eye drops hold promise as a valuable therapeutic option for patients suffering from NCP.

New developments in the management of persistent corneal epithelial defects

A persistent epithelial defect (PED) is a corneal epithelial defect that failed to heal after 2weeks. It is a condition that carries much morbidity, and our understanding of PED remains poor, with current treatment methods often having unsatisfactory outcomes. With PEDs becoming more prevalent, more efforts are required to establish reliable treatment modalities. Our reviews describe the causes of PEDs and the different approaches developed to manage them, as well as their associated limitations. Emphasis is placed on understanding various advances in the development of new treatment modalities. We have also described a case of a woman with a background of graft-versus-host disease on long-term topical corticosteroids who developed complicated PED involving both eyes. The current approach to managing PEDs generally involves exclusion of an active infection, followed by treatment modalities that aim to encourage corneal epithelial healing. Success rates, however, remain far from desirable, as treatment remains challenging due to multiple underlying etiologies. In summary, advances in the development of new therapies may be able to facilitate progress in the understanding and treatment of PED.

Early Postoperative Therapeutic Scleral Lens Intervention for Penetrating Keratoplasty Complications in Atopic Keratoconjunctivitis

ABSTRACT

A 52-year-old white man with keratoconus and severe atopic keratoconjunctivitis underwent penetrating keratoplasty (PK) for visual rehabilitation in the left eye. Post-PK complications included a persistent epithelial defect. Therapeutic scleral lens wear was initiated 2 weeks post-PK. Customizations were incorporated into the lens design to prevent suction and corneal hypoxia during lens wear. Post-PK herpes epithelial keratitis developed shortly thereafter, causing recurrence of a nonhealing epithelial defect. The patient was treated with oral antiviral therapy, discontinuation of dupilumab, and daily waking-hour scleral lens wear, which was used as an antibiotic drug delivery device. The cornea fully epithelialized, and best-corrected visual acuity improved to 20/40-2. The patient continued with daily waking-hour scleral lens wear and was without recurrence of persistent epithelial defect or herpes keratitis at 18 months. No scleral lens-related complications were observed despite the unconventional early intervention with a therapeutic scleral lens.

Long-Term Benefits of Tear Exchangeable Limbal-Rigid Contact Lens Wear Therapy in Stevens-Johnson Syndrome Cases

OBJECTIVES

To evaluate the long-term benefits of tear-exchangeable, limbal-rigid contact lens (CL) wear therapy in patients with Stevens-Johnson syndrome (SJS)-associated ocular sequelae.

METHODS

This retrospective study evaluated 50 eyes of 41 SJS patients (15 men and 26 women) who underwent limbal-rigid CL wear therapy for more than 2 years post fitting. Ocular sequelae (i.e., conjunctival hyperemia, corneal neovascularization, and upper tarsus scarring) before fitting and at 3 months, 6 months, 12 months, and annually after initiating CL wear therapy were evaluated and then graded on a severity score (range: 0-3, maximum score: 3). Moreover, visual acuity (VA) at immediately post initiating CL wear therapy was evaluated.

RESULTS

The mean follow-up period was 4.3±1.1 years. Compared with before fitting, the mean conjunctival hyperemia score improved from 1.14 to 0.86 at 3 months of CL wear therapy ( P <0.01) and was maintained thereafter; the mean corneal neovascularization score improved from 2.10 to 1.98 at 3 months of CL wear therapy, with no deterioration of the score observed in all cases at the final follow-up examination, and mean VA (log of minimum angle of resolution) improved from 1.60 to 1.04 at immediately post initiating CL wear therapy ( P <0.01).

CONCLUSIONS

Limbal-rigid CL wear therapy can provide long-term ocular surface stabilization and improved VA in SJS patients.

Economic appraisal of prosthetic replacement of ocular surface ecosystem in Canada

OBJECTIVE

To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada.

DESIGN

Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses.

PARTICIPANTS

Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020.

METHODS

Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature.

RESULTS

Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (p = 2.68 × 10^-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (p = 5.42 × 10^-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (p = 1.30 × 10^-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients.

CONCLUSIONS

Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.

Current Trends in Scleral Lens Prescription, Management, and Evaluation

OBJECTIVES

To report current trends in scleral contact lens prescription and management, including lens designs prescribed, care products recommended, and procedures performed during routine scleral lens (SL) evaluation.

METHODS

An online survey was designed by the Scleral Lenses in Current Ophthalmic Practice Evaluation study team and administered to eye care practitioners attending a specialty contact lens meeting. The survey was available from November 8, 2019, through March 31, 2020. Participants' demographic data were collected, along with information on lens diameters, landing zone (LZ) designs, recommended care products, and components of routine SL evaluation.

RESULTS

In total, 715 participants responded to at least one of the survey items of interest. Most lenses prescribed (63%) were 16 mm or more in diameter. Lenses with toric LZs were the most frequently prescribed (48%), followed by spherical (40%), quadrant-specific (8%), and impression-based or image-based designs (3%). Most participants (61%) recommended hydrogen peroxide products for lens care. Nonpreserved saline in a single-use vial was most frequently recommended to fill the bowl of the lens before application. Intraocular pressure was measured during SL evaluation by 45% of participants; 38% of participants routinely measured corneal thickness.

CONCLUSIONS

Practitioners increasingly are prescribing SLs with advanced LZ designs. Most practitioners recommend hydrogen peroxide-based disinfection systems and single-use vials of nonpreserved saline for lens care and application. Because differences in components of routine SL evaluations were reported, clinicians may benefit from reaching a consensus on essential components of SL evaluation.

Prosthetic Replacement of the Ocular Surface Ecosystem for Limbal Stem Cell Deficiency: A Case Series

OBJECTIVES

To assess outcomes of limbal stem cell deficiency (LSCD) in patients treated with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE).

METHODS

Retrospective case series. Patients with LSCD who received PROSE treatment were included. Data including best-corrected visual acuity (BCVA) and LSCD staging before and after PROSE dispensing were collected to characterize each case.

RESULTS

Five eyes of four patients were included. All patients were female, with an age range of 21 to 80 years. Each patient received a PROSE device with diameters ranging from 16 to 18.5 mm. Follow-up ranged from 11 to 29 months. Tolerated wear times ranged from 3.5 to 10 hr daily. Four eyes showed improved BCVA and unchanged LSCD staging as per the global consensus after PROSE treatment. Three of these eyes had stage 3 and one had stage 1C LSCD at diagnosis. The fifth eye had worse BCVA and recurrence of stage 3 LSCD post-living-related conjunctival limbal allograft transplant despite PROSE treatment.

CONCLUSIONS

Prosthetic Replacement of the Ocular Surface Ecosystem may be a viable treatment for LSCD, including severe cases, because it can provide symptom relief and improve vision. Its customizability, as demonstrated in this study, is beneficial for troubleshooting issues with fitting. Future studies are needed to further assess PROSE as treatment for LSCD.

Regression of corneal opacity and neovascularization in Stevens-Johnson syndrome and Toxic Epidermal Necrolysis with the use of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment

Purpose

To report two cases demonstrating the regression of corneal neovascularization and clearing of corneal opacification in patients with Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) undergoing prosthetic replacement of the ocular surface ecosystem (PROSE) treatment.

Observations

Four eyes of 2 patients were analyzed. Regression of neovascularization and clearing of corneal opacification was observed in both patients. All 4 eyes demonstrated improvement in visual acuity with treatment. With treatment, both patients ultimately discontinued all prescribed topical therapies. It was discovered upon review of these cases that all 4 eyes were managed with PROSE devices designed with back-surface channeled haptics.

Conclusions and Importance

There currently is no known literature reporting on long-term regression of corneal neovascularization or clearing of corneal opacity in SJS or TEN patients with the use of scleral prosthetic devices. This report of 2 cases highlights the improvement in corneal function with PROSE treatment involving the use of channeled designs in patients with SJS or TEN. More research is needed to better understand how PROSE or scleral lens design features affect patient outcomes and why some patients may show regression in corneal neovascularization.

Case Report: Novel Patient Training Technique for the Application and Removal of Scleral Lenses

SIGNIFICANCE

This report shares a technique that can be utilized to assist training patients to properly and safely apply and remove prosthetic replacement of the ocular surface ecosystem devices (PD) or scleral lenses in order to reduce patient training nervousness, limit adverse events from training and limit training failures.

PURPOSE

To introduce a novel scleral lens application and removal training method.

CASE REPORT

A 28-year-old female with limbal stem cell deficiency secondary to contact lens overwear in the left eye greater than the right eye presented for prosthetic replacement of the ocular surface ecosystem treatment. Her ocular history included herpes simplex keratitis, fungal keratitis and acanthamoeba keratitis in the left eye which ultimately resulted in corneal perforation requiring repair with cyanoacrylate adhesive. The patient was initially fitted with a PD in 2015 in the left eye but had difficulty with application of the device on the eye which resulted in discontinuation of use. She returned to the clinic in 2021 for a re-evaluation and PD re-fitting. To address her past difficulties surrounding application and removal of the device, a novel piggyback technique (applying a second scleral lens on top of the primary customized scleral lens that is already on the eye) was utilized to successfully train the patient.

CONCLUSIONS

A novel piggyback training technique can be used to overcome obstacles during the scleral lens application and removal training process.

A multi-parameter grading system for optimal fitting of scleral contact lenses

Background: While scleral lens practise has improved over the years due to factors such as availability of lenses with better materials and designs as well as experience of practitioners, a lack of objectivity appears to remain in terms of assessment of scleral lens fitting. This prospective observational work aimed to achieve standardization on this front through proposing a grading system for scleral lens fitting.

Methods: After application of prosthetic replacement of ocular surface ecosystem (PROSE) devices on the participants’ eyes, four fundamental components for understanding scleral lens fitting such as central and limbal corneal clearance, mid-haptic compression, and alignment of lens edge over anterior sclera were assessed through a series of slit-lamp biomicroscopy imaging as well as with anterior segment optical coherence tomography. FitConnect® was used to modify the device parameters to simulate different grading patterns on the proposed scale. Serial imaging was done for all the different lenses to compose the grading scale.

Results: A clinically relevant grading scale was constructed that pictorially demonstrated grades for the different aspect of scleral lens fitting. The grades were conveniently scaled within three categories: “optimal”, “acceptable” and “not acceptable”.

Conclusion: The gradation of scleral lens fitting parameters would take a step towards objectifying the assessment patterns in practise. This will also help reducing the gap between a novice and an experienced practitioner in terms of understanding of scleral lens fitting.

Contact Lenses for Ocular Surface Disease

ABSTRACT

Ocular surface disease can be difficult to manage, causing patients discomfort and vision loss. Therapeutic contact lenses are an important treatment option that is often neglected because it is conventional wisdom that eyes that are dry or irritated are not good candidates for contact lens. In this focused review, we consider the substantial literature on the use of bandage soft contact lenses (BSCL), scleral lenses, and customized prosthetic devices in the management of ocular graft-vs-host disease. Reports on BSCLs for recurrent corneal erosion are reviewed, as is literature on scleral lenses and prosthetic replacement of the ocular surface ecosystem treatment for Stevens-Johnson syndrome. Clinical pearls for fitting BSCLs are presented, and the issue of antibiotic prophylaxis is considered.

Glaucoma Prevalence and Glaucoma Surgical Considerations in Prosthetic Replacement of the Ocular Surface Ecosystem Device Use

OBJECTIVES

The purpose of this study was to identify patients with glaucoma and corneal/ocular surface disease who have been fit with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE; BostonSight, Needham, MA) devices and to understand the PROSE device fit experience in patients with glaucoma at Weill Cornell Medicine (WCM).

METHODS

This is a retrospective chart review of patients older than 18 years who underwent PROSE device fitting at WCM. Records were reviewed for demographic information and ophthalmic variables. Descriptive statistics were performed.

RESULTS

Between 2011 and 2017, 281 patients underwent PROSE device fitting at WCM, of whom 24 patients (8.5%) had a glaucoma diagnosis and 17 patients (6.0%) were identified as glaucoma suspect. Ocular surface disease was the most common indication for PROSE device wear (58.3%). Five patients had a history of incisional glaucoma surgery in the eye undergoing PROSE device fitting: three valved glaucoma drainage implants and two trabeculectomies. Three of these eyes were successfully fit with PROSE devices.

CONCLUSIONS

Patients fitted with Prosthetic Replacement of the Ocular Surface Ecosystem devices at WCM had a higher prevalence of glaucoma than in the general population. Among patients with incisional glaucoma surgery, PROSE device fitting was challenging, with a 40% failure rate.

Oral Mucosal Epithelial Transplantation and Limbal-Rigid Contact Lens: A Therapeutic Modality for the Treatment of Severe Ocular Surface Disorders

Stevens-Johnson syndrome, ocular cicatricial pemphigoid, and severe thermal or chemical injury are considered severe ocular surface disorders (OSDs) because they affect the entire ocular surface, including corneal and conjunctival epithelial stem cells. In patients with severe OSDs, the long-term prognosis for limbal transplantation is poor, and the related corneal opacity and cicatrization lead to devastating visual impairment. To date, there is no standardized treatment to improve vision in cases with severe OSD. Investigating novel treatment methods for severe OSDs, our group began cultivated oral mucosal epithelial transplantation in 2002 and developed a limbal-supported rigid-type contact lens that can be applied as a nonsurgical treatment. When used in combination, these treatment methods make it possible to successfully restore vision in cases with severe OSDs.

Quality-of-Life Improvement After Scleral Lens Fitting in Patients With Keratoconus

OBJECTIVES

To assess the quality-of-life improvement after scleral lens fitting in patients with keratoconus.

METHODS

We conducted a prospective observational study of all consecutive patients with keratoconus starting scleral lens fitting in 2019, from January 2 to December 27, at the Dijon University Hospital, France. Quality of life was assessed before and after wearing scleral lenses for 3 months through the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ 25) questionnaire. We investigated factors potentially influencing quality of life: final visual acuity, keratoconus stage, and maximum keratometry reading.

RESULTS

In total, 41 eyes of 24 patients were successfully fitted with scleral lenses, 92.9% were 18 mm in diameter and 7.1% were 17 mm. The visual acuity improved by -0.4±0.3 logarithm of the minimum angle of resolution (P<0.001) after scleral lens fitting. Visual gain increased with keratometry and keratoconus severity (P<0.001; P<0.01). The NEI-VFQ 25 score increased by 19.5±19.1 points on average (P<0.001). No association was found between the factors under study and improvement in quality of life.

CONCLUSION

Our study confirms the functional improvement in patients with keratoconus fitted with scleral lenses, especially in patients with more advanced disease. Moreover, it suggests a major role of these lenses in improving quality of life, independently of the severity of the disease and the visual gain.

Diagnoses and Outcomes of Prosthetic Replacement of the Ocular Surface Ecosystem Treatment-A Canadian Experience

OBJECTIVES

To investigate underlying diagnoses and outcomes of patients undergoing Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment at the first Canadian PROSE center.

METHODS

A retrospective chart review was conducted on patients referred for PROSE treatment and fitted with PROSE devices from 2018 to 2020. Data were collected on diagnoses, presenting symptoms, previous lens modalities attempted, best-corrected visual acuities (BCVAs) pre-PROSE and post-PROSE, daily wear time, and failure rates. Best-corrected visual acuities pre-PROSE and post-PROSE were compared to evaluate visual improvement.

RESULTS

In total, 78 patients (126 eyes) were analyzed. The most common diagnoses were keratoconus (n=39 eyes) and postcorneal graft (n=15) in the distorted cornea group, and limbal stem cell deficiency (n=17) and graft versus host disease (n=15) in the ocular surface disease (OSD) group. Most frequent symptoms included blur, photophobia, and pain. Most common lens modalities attempted pre-PROSE were conventional scleral lenses and glasses. The overall mean BCVA improvement was 0.40 logarithm of the minimal angle of resolution (logMAR) (4-lines Snellen) (P<0.0001). Best-corrected visual acuities improvement in the distorted cornea group (0.52 logMAR, 5-lines) was significantly greater than in the OSD group (0.29 logMAR, 3-lines) (P=0.004).

CONCLUSIONS

Prosthetic replacement of the ocular surface ecosystem treatment can provide significant visual improvement for patients with distorted corneal surfaces and OSDs who failed other lens modalities.

CLEAR - Medical use of contact lenses

The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.

CLEAR - Scleral lenses

Scleral lenses were the first type of contact lens, developed in the late nineteenth century to restore vision and protect the ocular surface. With the advent of rigid corneal lenses in the middle of the twentieth century and soft lenses in the 1970's, the use of scleral lenses diminished; in recent times there has been a resurgence in their use driven by advances in manufacturing and ocular imaging technology. Scleral lenses are often the only viable form of contact lens wear across a range of clinical indications and can potentially delay the need for corneal surgery. This report provides a brief historical review of scleral lenses and a detailed account of contemporary scleral lens practice including common indications and recommended terminology. Recent research on ocular surface shape is presented, in addition to a comprehensive account of modern scleral lens fitting and on-eye evaluation. A range of optical and physiological challenges associated with scleral lenses are presented, including options for the clinical management of a range of ocular conditions. Future applications which take advantage of the stability of scleral lenses are also discussed. In summary, this report presents evidence-based recommendations to optimise patient outcomes in modern scleral lens practice.

Scleral contact lenses: Visual outcomes and tolerance. A prospective study about 98 eyes

PURPOSE

To assess the improvement in visual acuity (VA), tolerance and quality of life of patients after scleral contact lens (SCL) fitting.

MATERIAL AND METHODS

We carried out a prospective observational study conducted from April 2016 to August 2017. Patients fitted with SCL were included. For the purpose of this study, we analyzed VA and quality of life score (NEI-VFQ25) after 6 months of use.

RESULTS

We identified 98 eyes of 56 patients; the major indication for SCL fitting was keratoconus in 64.3%; the other indications were post-penetrating keratoplasty, other irregular astigmatism, severe ametropia and ocular surface disease. The mean follow-up was 10.71 months. The mean daily wearing time was 9.89±1.63 hours. Best corrected Visual acuity "BCVA" (baseline 1.11±0.37 in the right eye and 1.13±0.42 LogMar in the left eye) improved to 0.19±0.20 and 0.23±0.38 LogMar respectively in the right and left eyes after SCL wear (P=0.000). The scores on the various subscales of the NEI-VFQ 25 questionnaire were significantly higher 6 months after SCL fitting, with a mean score of 87.28±9.87 with SCL versus 39.94±11.33 without these lenses (P=0.000). In our group, no complications related to the SCL wear occurred, except for the occurrence of "loose conjunctival tissue" at the inferior limbus in one patient.

DISCUSSION

Our results complement those of several large series published on this subject. The best visual acuities were reported after correction of irregular astigmatism, in particular keratoconus. Therefore, SCL fitting has become an alternative or a precursor to penetrating keratoplasty in patients with advanced keratoconus. In the case of ocular surface disease, in addition to the improvement in VA, the comfort and recovery of the homeostasis of the ocular surface is greater, with fewer wearing complications. Hence, their inclusion in the therapeutic arsenal for severe ocular surface disease alongside the conventional treatment options.

CONCLUSION

SCL have proven their efficacy and safety in the optical correction of irregular corneas and in the management of ocular surface problems. Additional studies are needed to compare the many lenses currently available and assess optimal fitting strategies for each type of scleral lens for easier fitting procedures and better wearing comfort.

Impact of corneal refractive surgery on the precorneal tear film

Corneal refractive surgeries are one of the commonly performed procedures for correction of refractive errors. Tear film abnormality is the most common postoperative complication of corneal refractive surgeries. Consequently, these procedures represent a clinically significant cause of dry eye disease. The mechanisms which lead to dry eye disease include corneal sensory nerve dysfunction, ocular surface desiccation, glandular apoptosis and ocular surface inflammation. Although transient tear film abnormalities occur in almost all patients following surgery, patients with pre-existing dry eye symptoms or dry eye disease are at significant risk of developing more severe or long-term ocular surface disease. As such, careful patient selection and preoperative evaluation is essential to ensuring successful surgical outcomes. This is particularly important with LASIK which has the strongest association with dry eye disease. Appropriate surface lubrication and anti-inflammatory therapy remains the cornerstone treatment. Timely and effective management is important to facilitate visual rehabilitation and reduce the risk of secondary complications. In this review we describe the causes, pathophysiology, risk factors, manifestations, and management of tear film dysfunction and dry eye disease following corneal refractive surgery.

Indications for Wear, Visual Outcomes, and Complications of Custom Imprint 3D Scanned Scleral Contact Lens Use

PURPOSE

To report indications for wear, visual outcomes, and complications of EyePrintPRO (EPP) scleral contact lens (SCL) use.

METHODS

A retrospective review identified all patients fitted with this device between December 2013 and March 2018. Baseline demographics, wear indication, and contact lens history were determined. Habitual-corrected visual acuity was measured at baseline and follow-up. Adverse wear symptoms and signs, reprinting, and device cessation were tracked.

RESULTS

Ninety-five eyes from 69 patients were followed for a median of 12.1 months (interquartile range 4.4-19.6). Indications for wear included vision improvement and/or ocular surface stabilization in the setting of irregular corneal shape (n = 68 eyes, 72%), ocular surface disease (n = 17, 18%), exposure keratopathy (n = 7, 7%), neurotrophic keratitis (n = 5, 5%), and extracorneal topographical abnormalities preventing noncustom lens fitting such as glaucoma drainage devices (n = 8, 8%). Median habitual-corrected visual acuity improved from 0.67 to 0.08 (P = 0.0003). One-third of eyes (33.1%) developed adverse wear symptoms. Fifteen of 95 eyes (16%) developed adverse wear signs. Device cessation occurred in 10 eyes (10.5%) and reprinting occurred in 14 eyes (14.7%) unrelated to prior lens wear or indication (P = 0.67 and 0.15, respectively). In eyes that previously failed SCLs (n = 56), 12 eyes required reprinting and 49 eyes continued use.

CONCLUSIONS

Indications for EPP wear include irregular corneal shape, ocular surface disease, and extracorneal topographic abnormalities. Visual acuity improves with the use of EPP. Clinicians and patients should be aware of potential adverse wear symptoms/signs and device cessation that may occur with EPP use. EPP is a viable salvage therapy in eyes that previously failed SCLs.

Current U.S. based optometric scleral lens curricula and fitting recommendations: SCOPE educators survey

OBJECTIVES

To describe current components of scleral lens curricula at U.S. based optometry colleges and universities.

METHODS

Contact lens educators were surveyed between June 2019 and August 2019 regarding their optometric scleral lens curriculum. Respondents were asked to describe their experience and involvement in optometric scleral lens education as well as to describe components of scleral lens curricula. Educators were also asked to identify sources of information upon which they rely on in order to stay informed about new developments and best practices in scleral lens prescription and management.

RESULTS

Most programs begin scleral lens education during the 3rd year of optometric education (71.2 %; n = 52). Students complete an estimated 18.0 ± 18.1 (range 2-100) scleral lens evaluations during training (n = 36). Ideal fitting characteristics taught include central corneal clearance of 206.3 ± 44 microns (range 150-350, n = 40), limbal clearance of 62.1 ± 23.6 microns (range 20-100, n = 36) with one clock hour or less of conjunctival vascular compression (n = 41). Educators ranked in-person continuing education (61 %, 22/36) followed by contact lens laboratory consults (22 %, 8/36) as the two most important sources of information on best practices in scleral lens prescription and management.

CONCLUSIONS

Educators are uniquely positioned to guide the next generation of eyecare providers by incorporating and disseminating new research findings into their scleral lens curricula.

Mini-Scleral Lenses Improve Vision-Related Quality of Life in Keratoconus

PURPOSE

To evaluate the effects of mini-scleral lenses on visual acuity (VA) and visual functioning in patients with keratoconus.

METHODS

This prospective, interventional study examined the effects of mini-scleral lenses on VA and visual functioning in patients with keratoconus. Patients younger than 18 years or with a history of refractive surgery or corneal graft surgery were excluded. Patients were fitted with mini-Misa lenses, Senso mini-scleral lenses, or Zenlens mini-scleral lenses. Outcome measures were scleral lens-corrected VA and vision-related quality of life as assessed with the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-39).

RESULTS

Eighty-nine eyes of 50 keratoconus patients were included in the study. Median baseline logarithm of the minimal angle of resolution VA with habitual correction was 0.22 (range 0.02-1.04). Mini-scleral lens fitting resulted in a statistically significant visual improvement (median 0; P < 0.0001). At the 6-month follow-up, 11 patients (22%) had abandoned mini-scleral lens wear, primarily because of difficulties with lens handling (7 patients). Of the 39 patients with continued wear, 33 patients (84.6%) wore their lenses for a daily average of 12 hours. NEI-VFQ scoring in these patients showed significantly improved results for both visual functioning and socioemotional scales after scleral lens fitting (P < 0.0001).

CONCLUSIONS

Mini-scleral lenses significantly improve VA and visual functioning on NEI-VFQ in patients with keratoconus. Difficulties with lens insertion and removal are the principal reason for lens dropout.

Clinical trial to evaluate the therapeutic benefits of limbal-supported contact lens wear for ocular sequelae due to Stevens-Johnson syndrome/toxic epidermal necrolysis

PURPOSE

To analyze the therapeutic benefits of limbal-supported contact lens (CL) wear in patients with ocular sequelae due to Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN).

METHODS

This interventional study enrolled 10 chronic SJS/TEN eyes with a spectacle best-corrected visual acuity (BCVA) of between 0.01 and 0.7 that were fitted with a limbal-supported CL. At baseline and at after 3-months CL use, CL-wear BCVA and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) scores were measured, and then compared. Incidence rates and severities of adverse events were also analyzed.

RESULTS

At after 3-months CL use, BCVA with the fitted CL significantly improved compared to that with spectacle correction at baseline (LogMAR: 0.76-0.15) (P = 0.0039), all NEI VFQ-25 scores improved, however, only in ocular pain and mental health showed statistically significant improvement (P = 0.0078 and 0.0039). No serious adverse events were observed during the follow-up.

CONCLUSION

Wearing of the limbal-supported CL improved vision compared to spectacles and reduced ocular pain in patients with ocular sequelae due to SJS/TEN.

Prosthetic Replacement of the Ocular Surface Ecosystem Treatment for Ocular Surface Disease in Pediatric Patients With Stevens-Johnson Syndrome

PURPOSE

To report the outcomes of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in pediatric patients with chronic ocular surface disease associated with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

DESIGN

Retrospective, interventional case series.

METHODS

Patients aged 18 years or younger seen in consultation for PROSE treatment at a single center between January 1992 and December 2016 with a history of SJS/TEN were reviewed. Demographics, etiology of SJS/TEN, age at treatment milestones, best-corrected visual acuity (BCVA) at treatment milestones, and treatment failures were recorded. BCVA at the initial presentation visit was compared to BCVA at the time of PROSE device dispense and at the last recorded visit.

RESULTS

Twenty-seven female and 22 male patients were reviewed. Reported etiology was antibiotic (n = 19), antiepileptic (n = 9), antipyretic (n = 9), other (n = 3), and unknown (n = 9). The mean age was 6.4 years at disease onset and 9.3 years at time of initial presentation. The mean duration of follow-up was 5.45 years. The median BCVA at the initial presentation was 0.6 logMAR (20/80 Snellen), and was significantly improved to 0.18 logMAR (20/30 Snellen) at the time a PROSE device was dispensed (P < .0001). The median BCVA at the last recorded visit was significantly improved to 0.18 logMAR (20/30 Snellen, P = .0004). There were 15 patients who failed PROSE treatment (30.6%).

CONCLUSIONS

PROSE treatment is feasible in over two thirds of pediatric patients with chronic ocular surface disease related to SJS/TEN and results in significant improvement in vision that is durable over a period of many years.

Advances in dry eye disease treatment

PURPOSE OF REVIEW

The prevalence and burden of dry eye disease continues to grow at a rapid pace, creating an increased need for new therapies. In a sector once limited to only a handful of treatments, clinicians now have multiple options available for patients who fail traditional therapies. This review summarizes the various treatment options available to clinicians treating complex dry eye disease patients.

RECENT FINDINGS

As we better understand the multifactorial mechanisms leading to dry eye disease, treatments increasingly focus on the amelioration of the underlying deficiencies and inflammation, rather than on transient symptomatic relief alone. Most topical medications seek to replace deficient growth factors and/or decrease inflammation on the ocular surface. The majority of new devices and procedures seek to treat meibomian gland dysfunction, with one new device stimulating tear production through utilizing the nasolacrimal reflex pathway.

SUMMARY

Clinicians have more options at their disposal in the treatment of dry eye disease than ever before, including topical medications and devices.

Long-term outcome of using Prosthetic Replacement of Ocular Surface Ecosystem (PROSE) as a drug delivery system for bevacizumab in the treatment of corneal neovascularization

PURPOSE

To report the long-term outcome of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) for delivery of bevacizumab in the treatment of corneal neovascularization (KNV).

METHODS

Retrospective, non-comparative, interventional case series of 13 sequential patients treated for KNV at the BostonSight between 2006 and 2017. In all cases, PROSE treatment was initiated for management of ocular surface disease and patients wore PROSE consistently on a daily wear basis prior to bevacizumab treatment. Patients applied a drop of 1% preservative free bevacizumab to the reservoir of PROSE device twice daily. Patients continued with daily wear of the device during treatment and afterwards.

RESULTS

13 patients (8 female and mean age of 45 years) are included with a mean follow-up of 5.1 years (range 6 months-11 years). Underlying ocular diagnoses included Stevens-Johnson syndrome (7), ocular chronic graft-versus-host disease (2), corneal transplant (2), contact lens-related corneal ulcer and limbal stem cell deficiency (1), and familial dysautonomia (1). Median duration of bevacizumab use was 6 months (range 3 months-10 years). Twelve cases (92%) had regression of KNV and 10 cases (77%) had improved best-corrected visual acuity (BCVA) with treatment. Median BCVA improved from -1.1 (LogMAR) at baseline, to -0.66 at end of bevacizumab treatment, and remained -0.63 at last follow-up (P = 0.047). KNV progressed in one eye after discontinuation of bevacizumab. There were no ophthalmic or systemic complications.

CONCLUSIONS

Topical bevacizumab used in PROSE is effective in treating KNV and improving vision. Long-term follow-up reveals durable response and no complications.

Resolution of fluoroquinolone-resistant Escherichia coli keratitis with a PROSE device for enhanced targeted antibiotic delivery

Purpose

To report the resolution of a fluoroquinolone-resistant Escherichia coli keratitis with use of a prosthetic replacement of the ocular surface ecosystem (PROSE) device for enhanced targeted delivery of moxifloxiacin.

Observations

A 62-year-old female presented with a 3-day history of pain, photophobia, and declining vision in left eye. The patient had a 2-year history of binocular PROSE treatment for ocular chronic graft-vs-host disease (cGVHD). A corneal ulcer was diagnosed and treated with topical 0.5% moxifloxacin solution 6 times per day, with continued wear of the PROSE device. After 4 days, worsening symptoms led to an increase in application of moxifloxicin to every 2 hours while awake. The drug was administered by removal of the device, cleaning and replenishing the reservoir with sterile saline, and adding one drop of the drug to the reservoir prior to reinsertion. Four days later, the corneal surface was epithelialized with only small subepithelial infiltrate remaining. The corneal culture grew an E. coli isolate carrying multiple mutations in the topoisomerase genes. These mutations were correlated with varying levels of resistance to ciprofloxacin (256 μg/mL), levofloxacin (8 μg/mL), and moxifloxacin (16 μg/mL).

Conclusions and Importance

Although the infecting E. coli strain exhibited resistance to fluoroquinolones, the infection resolved when moxifloxacin was combined with PROSE therapy. Frequent dosing to the PROSE reservoir is likely to increase fluoroquinolone bioavailability and may represent a valuable approach to overcome antibiotic resistance.

[Evaluation of the quality of life of patients fitted with scleral lenses using a Moroccan version of NEI-VFQ 25]

PURPOSE

To evaluate the contribution of scleral lenses in terms of improving quality of life and vision.

METHODS

We conducted a retrospective study of the quality of life (QOL) of patients fitted with scleral lenses, between November 2015 and November 2016 in the Marrakech university hospital department of ophthalmology. QOL was assessed before and after scleral lens (ICD) adaptation using a version of the National Eye Institute Visual Function Questionnaire 25 translated into the Moroccan dialect of Arabic.

RESULTS

We included 48 patients (68 eyes). The main indications included severe corneal ectasia followed by post-keratoplasty eyes, post-traumatic corneas and patients with ocular surface disease. The average duration of scleral lens wear was 6 months, and the average wearing time was 12hours per day. BCVA increased from 0.8 to 0.2±0.5 LOGMAR. The average scores on the NEI-VFQ 25 of patients after scleral lens fitting were significantly higher, 80.5 versus 42.6 before wearing scleral lenses, thus an increase of 38.1.

DISCUSSION

Quality of life has become a major issue in the healthcare field, which has seen a renewed interest in ophthalmology lately. The results of our study support the data from previous studies regarding the impact of scleral lenses on the quality of life of patients.

CONCLUSION

High oxygen permeability scleral lenses are a satisfying therapeutic alternative, allowing a significant improvement in the quality of life of patients for whom the usual therapeutic means are limited.

Improvement of chronic corneal opacity in ocular surface disease with prosthetic replacement of the ocular surface ecosystem (PROSE) treatment

Purpose

To demonstrate clearing of chronic corneal opacities and improvement of visual acuity with the use of BostonSight prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in ocular surface disease.

Observations

We undertook retrospective analysis of the medical records of a series of patients who underwent PROSE treatment from August 2006 to December 2014. Patients were referred for ocular surface disease of various etiologies. Primary inclusion criterion was corneal opacity that improved with PROSE treatment. Patients were excluded if topical steroids or adjuvant therapy used once PROSE treatment was initiated. Underlying disease, prior treatment, clinical presentation, and clinical course were extracted from the medical record. Four patients are included in this series. There were three females and one male; median age at time of treatment initiation was 30 years (range = 0.5–58 years). Median duration of PROSE treatment at time of retrospective analysis was 3.5 years (range = 1–8 years). Two cases had corneal opacification in the context of neurotrophic keratopathy: a unilateral case due to presumed herpes simplex keratitis and a bilateral case due to congenital corneal anesthesia associated with familial dysautonomia. One case had corneal opacity from exposure related to seventh nerve palsy, and one had corneal opacification associated with recurrent surface breakdown, neurotrophic keratopathy, and limbal stem deficiency of uncertain etiology. After consistent wear of prosthetic devices used in PROSE treatment for support of the ocular surface, visual acuity improved and clearing of the opacities was observed, without use of topical steroids or adjuvant therapy.

Conclusions and importance

These cases demonstrate clearing of chronic corneal opacity with PROSE treatment for ocular surface disease. This clearing can occur with no adjuvant therapy, suggesting that restoration of ocular surface function and integrity allows for corneal remodeling.

Fitting Tips and Visual Rehabilitation of Irregular Cornea with a New Design of Corneoscleral Contact Lens: Objective and Subjective Evaluation

OBJECTIVES

To study the fitting and the visual rehabilitation obtained with a corneoscleral contact lens, namely, Rose K2 XL in patients with irregular cornea.

METHODS

This prospective study included 36 eyes of 36 patients with irregular cornea fitted with Rose K2 XL. Refractive and visual outcomes and mesopic and aberrometric parameters of fitted eyes were assessed at 2 weeks, 3 months, and 6 months after the initial lens use. Objective and subjective parameters of patient satisfaction and lens comfort were noted. Causes of lens discontinuation and complications were also recorded.

RESULTS

Average logMAR VA improved significantly from 0.95 ± 0.09 without correction to 0.04 ± 0.05 six months after lens wear. Similarly, mesopic and aberrometric measures were significantly improved. Statistical analysis of the subjective patients' responses showed a significant acceptance of the lens by most of them. At the end of follow-up, the mean wearing time was 9.9 ± 2.9 hours per day. The most common cause of wearing discontinuation was persistent discomfort (16.7%) and high lens expenses(16.7%). Self-assessed questionnaire showed statistically significant improvement in nearly all measured subjective parameters.

CONCLUSION

Rose K2 XL lenses provide patients with irregular cornea with both quantitative and qualitative optimal visual function with high degree of patient comfort and satisfaction.

Dry Eye Post-Laser-Assisted In Situ Keratomileusis: Major Review and Latest Updates

Dry eye is one of the most common complications occurring after laser-assisted in situ keratomileusis (LASIK), with virtually all patients experiencing some degree of postoperative dry eye symptoms. Enhanced understanding of the pathophysiology and mechanism of dry eye development in addition to preoperative screening of patients who are prone to dry eye is essential for better patient satisfaction and for improving short-term visual outcome postoperatively. This article reviews the latest studies published on LASIK-associated dry eye, including epidemiology, pathophysiology, risk factors, preoperative assessment, and management.