Schornack, Muriel

ABSTRACT Purpose Substantial endothelial cell loss (∼80%) occurs after keratoplasty. Corneal rigid and scleral lenses are frequently prescribed to manage irregular astigmatism and high refractive error, but lens wear may contribute to hypoxic stress. The relationship between various lens wear and corneal stress after penetrating keratoplasty remains unclear. This study characterizes cell density distribution in post‐keratoplasty corneas and evaluates its influence on swelling during lens wear. Methods Participants ≥5 years post‐surgery, with or without habitual lens wear, were enrolled. Specular microscopy measured endothelial cell density in central, superior, inferior, superotemporal, and superonasal corneal quadrants (@3 mm). Baseline corneal thickness maps (>2 h after waking without lens wear) were acquired using Scheimpflug imaging (Pentacam). Wearers applied habitual lenses and all participants returned 6–8 h later for imaging. Nonparametric tests assessed cell density variation by quadrant and lens designs. Linear mixed models evaluated associations between endothelial parameters and corneal swelling while accounting for within‐subject correlation, repeated measures, lens type, location, and interactions. Results Twenty‐five participants (31 eyes) from three centers were included; 90% had keratoconus preoperatively. Four wore large‐diameter scleral lenses (13%), nine wore small‐diameter scleral lenses (29%), 12 wore corneal rigid lenses (39%), and six did not wear lenses (19%). Cell density across quadrants averaged 780 ± 240 cells/mm 2 . Central thickness decreased slightly in non‐lens‐wearing eyes (−0.3%) but increased in lens‐wearing eyes (1.9% ± 3.1%). Central cell density showed a weak negative correlation with swelling ( r = −0.39, p = 0.03). Compared with non‐lens wearers, corneal rigid ( p = 0.02) and large diameter scleral lenses ( p = 0.05) generated greater swelling; smaller diameter scleral lenses did not. Conclusions Although all eyes fitted with various lens designs were clear, lower central cell density correlated with increased swelling during lens wear, except when smaller diameter scleral lenses were worn. Clinically, however, cell density does not seem to be a robust predictor of corneal swelling induced by lens wear post‐keratoplasty.

Background/Objectives: As scleral lens (SL) use continues to expand, particularly for medically necessary management of corneal irregularity and ocular surface disease, it is important to determine if wear of these lenses is associated with eyelid disease. This study evaluated habitual SL wearers for meibomian gland obstruction, meibum quality, and signs of lid margin inflammation. Methods: Eligible participants wore scleral lenses in one or both eyes for any indication and had been wearing their current lens design(s) for at least six months, with habitual wear of ≥5 h per day, six days per week. Eyelid inflammation metrics were specifically assessed. Results: Forty-nine scleral lens wearers (32 females) were enrolled. Upper lid wiper epitheliopathy (LWE) was present in 21 eyes (43%), and lower LWE was present in 15 eyes (31%). Thirty-nine eyes (80%) had expressible meibomian glands. Eyes with no expressible meibum were significantly higher in ocular surface disease (39%, 7/18) than corneal irregularity (11%, 3/27) (p = 0.03). Lid margin telangiectasia was present in wearers with ocular surface disease (61%, 11/18) and corneal irregularity (19%, 5/26) (p = 0.005). Conclusions: Eyelid disease was common among habitual scleral wearers regardless of indication for lens use. Eyes with ocular surface disease demonstrated a higher prevalence of meibomian gland obstruction and lid margin telangiectasia compared to those with corneal irregularity.

Abstract Introduction Midday fogging is a complication of scleral lens (SL) wear that interrupts clear vision during the course of wear. SLs can be made with a variety of gas permeable materials, sizes and surface treatments, and various solutions are available for storing the lenses and for filling them before application on the eye. Many of these factors have been implicated as possible contributors to midday fogging. This study explored the lens and solution properties in habitual SL wearers with and without midday fogging. Methods In this prospective study, 48 habitual SL wearers were evaluated and asked to report whether they experienced midday fogging and if they removed their lenses during the day. They completed the Ocular Surface Disease Index (OSDI), which is a validated tool for dry eye assessment. Lens parameters (material, coatings and diameter) and lens storage and filling solutions were documented. Backward elimination of regression terms evaluated the lens and solution properties in those with and without fogging. OSDI scores were compared using the Mann–Whitney analysis. Results Collectively, the lens properties and solutions accounted for 27.7% of the variance related to midday fogging. None of the factors alone had a significant impact upon midday fogging. The median (interquartile range) OSDI score for those with fogging [37 (35)] was significantly different from those without fogging [10 (15)], with the scores corresponding to severe dry eye and normal eyes, respectively. Conclusion SL wearers with midday fogging exhibited similar symptoms to patients with severe dry eye. Lens and solution characteristics may play a small role in patients with midday fogging, although changing just a single factor is not likely to impact its presence.

SIGNIFICANCE Scleral lenses (SLs) are increasingly being considered as the initial correction for patients with keratoconus. In this study, keratoconus patients report higher levels of comfort and visual satisfaction with SL compared with corneal gas‐permeable lenses (GPs). PURPOSE This study aimed to compare patient satisfaction and care burden associated with GP and SL for the management of keratoconus. METHODS An electronic survey was distributed by the National Keratoconus Foundation from October 2016 to March 2017. Age at diagnosis, initial and current treatment, lens complications, access to care, lens handling time, and annual out‐of‐pocket treatment costs were collected. Vision, lens comfort, and ease of use satisfaction were rated from 1 to 5. RESULTS A total of 422 responses were received, including 75 bilateral GP and 76 bilateral SL wearers. Scleral lens wearers had greater satisfaction with vision (3.2 ± 1.1 [SL] vs. 2.6 ± 1.1 [GP]; P <. 001) and comfort (3.3 ± 1.0 [SL] vs. 2.2 ± 1.2 [GP]; P <. 001) but similar ease of use satisfaction in both groups (2.8 ± 1.1 [SL] vs. 2.7 ± 1.1 [GP]; P <. 90). Both groups reported issues with cloudy or foggy vision (GP, 63%; SL, 58%) and contact lens discomfort (GP, 77%; SL, 67%). Although GP wearers reported more issues with lens movement or loss (40 [GP] vs. 18% [SL]), they had fewer difficulties with halos (53 vs. 72% [SL]) and lens handling (40%) compared with SL wearers (63%). Gas‐permeable lens (48%) and SL (45%) wearers spend 6 to 10 minutes daily handling their lenses. Sixty percent of GP wearers reported annual out‐of‐pocket cost expenses less than U.S.$1000, whereas only 41% of SL wearers reported the same. CONCLUSIONS Scleral lens wearers with keratoconus report greater satisfaction with vision and comfort than do GP wearers, although both groups reported cloudy vision and lens discomfort.

ABSTRACT SIGNIFICANCE As scleral lens wear becomes more common, understanding the impact of these lenses upon ocular physiology is critically important. Studies on the effect of scleral lens wear upon intraocular pressure (IOP) have used different instruments and have reported conflicting results. PURPOSE The purpose of this study was to compare assessment of IOP during scleral lens wear using pneumatonometry and transpalpebral tonometry. METHODS Twenty healthy subjects wore a small‐diameter (15.2 mm) and a large‐diameter (18.0 mm) scleral lens on the right eye, each for 1 hour in randomized order. IOP was assessed with pneumatonometry and transpalpebral tonometry on both eyes before lens application, immediately after lens application, after 1 hour of lens wear, and immediately after lens removal. Paired t test compared mean IOP in the study eye to the control eye. Repeated‐measures ANOVA was performed to take instrumentation, lens diameter, and their interaction into account in an analysis of the change in IOP in the study eye. RESULTS Mean peripheral IOP measured with pneumatonometry was not significantly different from baseline at any subsequent measurement. Measurements with transpalpebral tonometry, however, were significantly different during scleral lens wear immediately after application and after 1 hour of wear with both diameter lenses ( P <. 005), but were not significantly different after either sized lens was removed. Repeated‐measures ANOVA revealed that the instrument used to measure IOP was a significant factor in IOP changes found during lens wear ( P ≤. 001). CONCLUSIONS Assessment of IOP during scleral lens wear varies based upon the instrument that is used. Although further studies are clearly needed to further elucidate this issue, clinicians should continue to monitor optic nerve structure and function in scleral lens wearers, as they do in all patients.

SIGNIFICANCE Alignment of the scleral lens haptic with the anterior ocular surface is of critical importance when fitting scleral lenses. The concept of leveraging big‐data analysis to drive lens design is explored in this study. This retrospective study evaluated fitting outcomes of a data‐driven, quadrant‐specific scleral lens design and found that most patients (76%) were successfully fit with this design. PURPOSE The purpose of this study was to evaluate clinical outcomes with a data‐driven, quadrant‐specific scleral lens design compared with traditional lens designs. METHODS For this multicenter retrospective observational study, A REDCap (Research Electronic Data Capture) survey was distributed to scleral lens practitioners who participated in β testing of a data‐driven, quadrant‐specific scleral lens design (study lens) between June 1, 2016, and January 31, 2017. Descriptive data were collected, and patient‐reported outcomes, visual acuity, and lens design outcomes achieved with the study lens were described. RESULTS Seventy‐five patients (85 eyes) were fit with the study lens design between June 2016 and January 2017. Mean patient age was 47 years (range, 17 to 77 years). Forty‐six were male, and 29 were female. Seventy‐six eyes (89%) were fit for corneal irregularity, whereas nine eyes (11%) were fit for management of ocular surface disease. Compared with habitual correction, 22% more eyes achieved 20/20 or better, and 21% more eyes achieved 20/40 or better. There was also a 60% decrease in the need for midday removal with the study lens. An average of two lenses were manufactured per eye to complete the fitting process. CONCLUSIONS Using a data‐driven, quadrant‐specific scleral lens resulted in visual improvement, a reduced need for midday removal, and an average of two lenses needed to complete the fitting process. Longer‐term clinical outcomes and the use of big‐data analysis to inform scleral lens design should be further explored.

Introduction This manuscript describes data from an original study, simulating a tele-glaucoma programme in an established clinic practice with an interdisciplinary team. This is a ‘real life’ trial of a telemedicine approach to see a follow-up patient. The goal is to evaluate the accuracy of such a programme to detect worsening and/or unstable disease. Such a programme is attractive since in-clinic time could be reduced for both the patient and provider. This study evaluates agreement between in-person and remote assessment of glaucoma progression. Methods A total of 200 adult glaucoma patients were enrolled at a single institution. The in-person assessment by an optometrist or glaucoma specialist at time of enrolment was used as the gold standard for defining progression. Collated clinical data were then reviewed by four masked providers who classified glaucoma as progression or non-progression in each eye by comparing data from enrolment visit to data from the visit immediately prior to enrolment. Agreement of glaucoma progression between the masked observer and the in-person assessment was determined using Kappa statistics. Intra-observer agreement was calculated using Kappa to compare in-person to remote assessment when both assessments were performed by the same provider ( n = 279 eyes). Results A total of 399 eyes in 200 subjects were analysed. Agreement between in-person versus remote assessment for the determination of glaucoma progression was 63%, 62%, 69% and 68% for each reader 1–4 (kappa values = 0.19, 0.20, 0.35 and 0.33, respectively). For intra-observer agreement, reader 1 agreed with their own in-person assessment for 65% of visits (kappa = 0.18). Discussion Intra-observer agreement was similar to the agreement for each provider who did not see the patient in person. This similarity suggests that telemedicine may be equally effective at identifying glaucomatous disease progression, regardless of whether the same provider performed both in-clinic and remote assessments. However, fair agreement levels highlight a limitation of using only telemedicine data to determine progression compared with clinical detail available during in-patient assessment.

Purpose: Glaucoma specialists and optometrists who work in a team model at a single institution utilize a common definition of glaucoma progression and treatment algorithm. The purpose of this study was to assess the consistency of agreement in identifying glaucoma progression among glaucoma specialists and optometrists of 1 team. Methods: In total, 399 eyes of 200 patients age 18 or older with glaucoma were enrolled over 2 years. Clinical data, disc photographs, optical coherence tomography (OCT), and visual fields were independently reviewed by 2 masked optometrists and 2 masked fellowship-trained glaucoma specialists. Each eye was judged as progression or no progression of glaucomatous disease. The following were assessed: (1) agreement among optometrists; (2) agreement among glaucoma specialists; and (3) agreement among optometrists and glaucoma specialists. The frequency of use of testing modality to determine progression was also studied. κ statistics were used to evaluate agreements. Results: Optometrists agreed with each other for 74.2% of the eyes assessed (κ=0.42), whereas glaucoma specialists agreed with each other for 78.7% of eyes (κ=0.39). All 4 providers agreed with each other for 54.4% of the eyes evaluated (κ=0.37). Providers had the highest agreement when the progression decision was based on disc hemorrhage (92%) and the lowest agreement when based on OCT progression analysis (36%). Compared with optometrists, glaucoma specialists used OCT (P≤0.01) more frequently to determine disease progression. Conclusions: Fair to moderate agreement levels were found among providers in their assessment of glaucoma progression, suggesting that a team approach to glaucoma management may be effective. Further work is needed to investigate ways to optimize consistency within the glaucoma team.