New Options for Keratoconus, Cross linking and Corneal transplant patients!
Keratoconus is an eye condition where the normally round dome shaped cornea progressively thins, the front surface the eye becomes distorted, causes poor vision and can often lead to a corneal transplant.
In the past, small corneal hard lenses were fitted for these cases, but these lenses were very often uncomfortable to wear. Patients battled with symptoms of reflex tearing, lens decentration and constant lens awareness when blinking.
Pieterse Oogkundiges which form part of The Keratoconus and Scleral centre in Johannesburg has invested in new exciting technology to treat and manage Keratoconus. Our Optometrist Mr Willem Pieterse has a special interest in Keratoconic patients and assists with patients across the country who present with this unfamiliar eye problem.
According to Mr Pieterse scleral lenses are the newest development for corneal irregularities and are exceptionally comfortable, provide great vision and have transformed the quality of life for patients with Keratoconus even after corneal transplant surgery. Most patients would agree that the comfort of these lenses is similar to toric soft contact lenses and are especially fitted for all those patients who battled with hard contact lenses in the past.
Mr Pieterse did an advanced contact lens fellowship and worked with Mr. Ken Pullum at the Moorefield’s Eye Hospital in London UK, to expand and refine his knowledge in scleral lenses. Mr Pieterse has now fitted hundreds of patients with advanced contact lenes and had some excellent results with problem cases where these lenses proved to be the only solution. His interest and passion for advanced contact lenses has helped to modify South African’s first modern scleral RGP contact lens fit set.
The secret of scleral lenses is that they do not touch on the sensitive corneal tissue, but rather vaults the cornea with fluid resting on the “white” of the eye called the sclera. There is an absence of friction; constant moisture on the eye and adequate oxygen levels, which leads to higher visual function and comfort.
South Africa is at the forefront of this technology which has taken the world by storm with incredible results and happy patients. Mr Pieterse and Mr Nettmann are qualified in complex lens fitting and use new generation Scleral lenses like the ICD lens from Canada, the 5Z lens from Australia and the new Modern DF lens from South Africa.
It is essential that keratoconus is identified at a young age and since corneal ectasia has a large genetic component, all family members should have a corneal Topography screening done in the practice to identify corneal changes.
The following videos explain Keratoconus and how Corneal topography is affected.
Cross-linking (CXL) can help to stop progression of Keratoconus
Corneal cross-linking the procedure, often also named CXL, strengthens corneal tissue to stop the bulging of the cornea in patients with Keratoconus. Cross-linking is not a cure, but will stop the progression of the corneal cone shape and the thinning of the cornea. It is important for patients that have Keratoconus to consider corneal cross-linking since vision loss can lead to the need for a corneal transplant.
The procedure of corneal cross-linking is done with riboflavin. The riboflavin solution is applied to the corneal surface and is activated by illumination with UV-A light for approximately 5-8 minutes to strengthen the corneal structure. The riboflavin helps new stronger bonds to form between corneal collagen strands in the deeper stromal layer of the eye.
Studies done and published in the early 2000’s showed a 100% stabilization in all the cases done and a slight visual improvement in a larger group of patients.
Scleral lenses, hybrid or other corneal RGP contact lenses can be offered before and after cross linking to patients to correct and improve vision where spectacles visual correction is limited.
Frequently asked questions (FAQ) about Keratoconus, Corneal graft ,severe Dry eye and Scleral lenses:
Newest Technology available for Corneal cases, Keratoconus and Severe Dry eye?
Eye Fit/Print haptic scleral
The scleral haptic option is made from a quick impression taken on the patient’s eye and is scanned with a high resolution 3D scanner. This allows us to fit any ocular shape especially those cases when ocular surgery has dramatically affected the eye shape as seen with trauma cases or after corneal transplant surgery. Large pterygiums or pinguecula might also cause conventional scleral lenses to fit poorly.
There are many advantages of this new technology and at last we can now help patients who we could not assist previously, this option is not constrained to the typical fabrication and we are able to exactly follow the contour of the eye. This haptic shell IS HOPE for OUR PATIENTS!
What is the best option to improve vision with Keratoconus or irregular corneal cases?
There are many options that can help however only a few do make a significant visual improvement.
Spectacles often do not give great vision but can be helpful to use as a backup option at night or over weekends. Scleral lenses are the newest development for corneal irregularities, are exceptionally comfortable, provide great vision and have transformed the quality of life for patients with Keratoconus even after cross linking or even corneal transplant surgery. Most patients would agree that the comfort of these lenses is similar to toric soft contact lenses and are especially fitted for all those patients who battled with hard contact lenses in the past.
However every patient case at Pieterse optometrist is unique and should be reviewed to decide on the best option for the patient’s ocular health and lifestyle. The fact that we now have 7 options of various designs and the latest equipment for scleral fitting equip us to improve vision when corneal problems present. These options gives us at the practice extra tools in the toolbox until we find a good option for vision, health and comfort.
What does scleral contact lenses Cost?
It’s a bit difficult to give an exact amount since there are many variables.
It’s important to understand that the different lens options and complexity affects the price, Scleral lens in South Africa prices can be between R 5200- R 6200 per lens depending on where the lens needs to be imported from( Weak performance of the Rand/Dollar prices will change) . Impression guided scleral haptic shells are significantly more and due to the complexity of the option we will quote you on the options.
Patients in our practice are quoted for the following:
- Initial examination and follow up costs (Which include an examination and all the Topography and OCT scans) ,
- The scleral lens or lenses if both eyes fitted
- Contact lens instruction
It is important that patients are informed and that communication is transparent to avoid surprises especially when it comes to the financial cost to the patient.
What is the comfort of customized scleral lenses?
General long-term success of scleral lenses options are excellent, it is however important to review and select the correct scleral design and order a custom contact lens for the patient. In general we find that most patients present with a comfort level similar to soft contact lenses on the eye.
The key in this is to select the correct scleral lens design for each patient and we take time to select from all the different scleral designs until we find the best possible options. Most scleral lenses designs originate from Europe, Australia, USA and Canada. Some suppliers can now finish a custom Canadian scleral lens locally.
How long should scleral lenses be worn per day?
Patients with early to moderate Keratoconus cases should be able to use their scleral lenses comfortably for 14 hours per day. Severe allergies, hypersensitivity, severe dry eye problems or significant ocular inflammation after corneal surgery affect the patients wearing time of contact lenses. Fortunately there are options available to control these presentations.
It is important to note that you are in control of your eye health, poor hygiene, extreme long wearing times and incorrect solutions use can lead to contact lens exhaustion syndrome as seen with soft contact lenses.
Are scleral lenses used after corneal cross-linking, corneal transplant or corneal graft surgery?
Studies have shown that corneal cross linking is the best way to stop corneal changes, corneal ectasia or keratoconus progression.
Often if patients get poor vision due to severe Keratoconus progression where cross linking was not offered or it was too late, corneal graft surgery would then be recommended. Scleral lenses have changed the stats significantly since many patients will still get good vision with RGP scleral lenses before surgery. Central scaring or corneal hydrop formation is another reason for corneal graft surgery, and studies suggest that 70% of patients will need RGP options such as Scleral lens fitting to correct the vision after surgery.
What is the best contact lens fluid to fill my RGP scleral lens?
Re-look at pH when filling my scleral lens or hybrid lens for Dry eye.
Studies by Patrick J,Caroline and Mark P.André show that different saline 0.9% NaCl scleral solutions can have significant different pH measurements. Overall the preservative free solutions assist with dry eye, post-surgical corneal cross linking (CXL) and Keratoconus management in scleral lenses. It has been found that patients who have dry eye tend to do better with a slightly more buffered solution, showing more comfort with the initial application and at the end of the day.
What was interesting for us to discover was that most patients felt that using a combination of the solutions below gave much less dryness sensation and resolved corneal haze. When reviewing these patients we were removing the lenses and looking at the cornea’s and it seems that the cornea health is also much happier with this option BELOW! The higher viscosity of the Celluvisc UD that is placed first into the scleral lens when filling the lens makes a huge difference.
Our recommended saline combination at Pieterse Optometrist for filling scleral lenses is the following:
Start with Celluvisc UD (2-3 drops ) + top up with preservative free such as saline Purilens/ or Lens plus (4 drops) .
Are scleral lenses hard or soft?
Scleral lenses are Rigid Gas permeable which means O2 can travel through the lens. The lens keeps its own shape and does not touch the corneal surface when placed on the eye. Scleral lenses touch and rest upon the white sclera of the eye giving great comfort if fitted correctly since there should be almost no lid interaction. The hard lens design now offers the same comfort of soft contact lenses however the vision is often by far the best compared to any other option available.
How to clean your scleral lenses?
There are a few new good contact lens cleaning solutions for scleral lenses on the market.It must be said that selecting the correct cleaning solution is crucial, since patients often present with allergic responses to preservatives and protein build up on lenses should not occur.
We highly recommend the patient to incorporate a Peroxide cleaning solution into their weekly cleaning regime. It is important to review the corneal health, lens deposits, patient hygiene compliance and dry eye status before it is decided on what solution is recommended to use. It is our experience that most patients can use the same set of lenses for 3 years, however the correct cleaning solution and storing solution plays a vital role.