At the 2014 ESCRS Dr. Smoradkova introduces Esclera at Mediphacos speaker corner

1. ESCLERA
Scleral lens - news for irregular corneas
Dr. Adriana Smorádková, Slovakia
ESCRS, London 2014
www.neovizia.sk

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Clinic NeoVízia
• our clinic specialize in cataract and refractive surgery, glaucoma, retina and
keratoconus
• my specialization is refractive surgery (FemtoLasik, PRK), glaucoma (SLT, LI)
and keratoconus (CXL, implantation Kerarings, Esclera)
Keratoconus
• we started implantation of kerarings in 2011
• we are implanting kerarings with femtosecond laser Visumax since March
2013
• we started application of ESCLERA in March this year

3. ESCLERA – scleral lens
ESCLERA is a scleral lens with semi – scleral design
It performs new possibilities for correction of irregular cornea such as:
• keratoconus, pellucid marginal degeneration
• post implantation intracorneal rings segment
• post penetrating keratoplasties, corneal trauma, LASIK, PRK, Radial
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Keratectomy
• dry eye
• Salzmann’s degeneration, Stevens – Johnson’s syndrome
• intolerance of soft contact lenses (myopia, hyperopia, astigmatism)

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Characteristic
• material is fluoro-silikon akrylat copolymer
• it has excellent optical properties, good stability
and oxygen permeability
• surface is plasma treated which makes lens wetter and cleaner
• surface is resistant to protein deposition
• the lens is bearing on the sclera without touching cornea
• between the cornea and the lens is a 100 microns
space, filled with saline fluid

5. Mechanism of action
• liquid between cornea and ESCLERA
removes corneal irregularity
• Esclera optically replaced the front surface
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of the cornea
• operates on the principle of optical substitutions

6. Why is ESCLERA comfortable ?
• it has excellent stability on irregular
cornea
• lens is large and always in center
• it reduced movement
• it has excellent visual acuity
• exceptional comfort compared with
hard corneal lenses
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History
Makro lens, Esclera 1 – 6
Esclera 7
This ESLERA is seventh generation of scleral
lenses with new material, new surface modified
by plasma, new sizes and curvature.

8. Size and models
• each lens has a customized design
• we have a trial set which consists 20 basic models with different sizes and
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corneal curvatures
• when we are choosing the right model we are
looking for lateral bowing curvature and
corneal diameter WTW - white to white
• the models have different....
 diameter 16.0, 16.5, 17.5, 18.2 mm
 diopter − 20 .... + 20 D
 curvature 6.49 mm .... 8.44 mm

9. Trial set – 20 lens
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Moderate cone
(A,B)
Instruction
Advanced cone
(C,D)
Post surgical
Sunken
Post surgical
Bulging
Keratoconus Post LASIK, PRK, RK, PMD
Group A Group A Group B Group A
7,50 / 16,0 / 4,47 7,03 / 16,0 / 4,64 7,85 / 16,5 / 4,75 6,49 / 16,0 / 4,89
Group C Group C Group D Group D
7,85 / 17,5 / 5,20 6,89 / 17,5 / 5,64 7,85 / 17,5 / 5,20 6,89 / 17,5 / 5,64
Specification of lens

10. Choosing the right model
• patient open eye lids
• we look from side and check corneal elevation
• than check white to white
• we are choosing predictive model from the trial set
• put saline solution + fluorescein into the lens
• apply the lens with face down
• and control it under the slit lamp
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Ideal fit
Has 4 simple steps
• Size – ESCLERA must be 2 mm larger than the limbus
• Vault – is without touching
• SAG - Saggital Depth Value is 100 microns space
• Edge – without pressure vessels and
without movement

12. Trouble Shooting
too large SAG 250 um –
steep fit
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central bearing 2 mm-flat
fit
flat lens, central bearing,
bubbles, edge lift
Rules:
1. central bearing 1 mm -
increase SAG about 0,1 mm
2. Vault more than 100 um -
decrease SAG... 50
um=0,1mm
peripheral bearing

13. Choosing the next model
• if it was an incorrect model, we must remove the lens
• than try another model
• again control under the slit lamp
• if it is correct model....
• patient has it inserted in the eye for 30 minutes
• we are doing manifest refraction - final lens power
• write all information to the order form
• patient’s lens is manufactured and delivered
• ESLERA is produced in 4 weeks
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Lens care
• we must teach the patient how to use Esclera
• lens wear during day approximate 8 - 10 hours
• patients need cleaning solution, saline solution for rinse and application
and GP (gas permeable) lens solution for conditioning in the box
• highlight possible complications associated with Esclera, which are such as
other types of contact lenses
Esclera can last up 2 years if good care is taken

15. Keratoconus in our clinic
EYE 288
CXL 11
Keraring 85
penetrating keratoplasties 2
CLE + AIOL Toric 6
Oper. cataract + IOL Toric 6
ESCLERA 17
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now 8 patients wear

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Case 1
man, 33 years , keratoconus on both eyes
• myopia gravis, wearing glasses from 6 y. (o.dx: -7,25, -2,0/ 91, o.sin: -6,0, -0,5/85)
• we implanted keraring to the left eye and we proposed penetrating keratoplasties or to try
ESLERA to the right eye. He wanted to try ESCLERA
eye UCVA BCVA AR CCT CCT -
thinnest
K1 K2 K max
OD 0,01 0,2 -21,5,-2,0/171 418 381 53,0 59,0 66,5
OS 0,05 0,6 -9,5,-4,25/78 474 439 49,0 52,5 60,8
penetrating
keratoplasties or
ESCLERA
Keraring
Transplantation Keraring

17. Case 1 - conclusion
Method: OD: ESCLERA ( fitting 2/2014, wear from 5/2014)
OS: implantation of keraring (surgery 1/2014)
before after
eye UCVA BCVA AR BCVA MR
0D 0,01 0,2 -21,5,-2,0/171 ESCLERA 0,9
OS 0,05 0,6 -9,5,-4,25/78 Keraring 0,7 -5,0
the patient is satisfied
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Case 2
man, 38 years old, keratoconus on both eye, doctor – cardiologist, keratoconus both eyes
• myopia gravis, wearing glasses from 4 y. (o.dx: -3,0, o.sin: -4,0)
• we implanted kerarings to both eyes, after surgery the vision improved significantly
eye UCVA BCVA AR CCT K1 K2 K max AL
OD 0,5 0,9 -5,0,-9,75/26 469 46,5 53,75 61,1 24,38
OS 0,05 0,3 -13,5,-10,0/178 474 53,25 59,0 65,7 24,59
Keraring
Keraring ESLERA

19. Case 2 - conclusion
Method: OD: implantation of keraring (1/2014)
OS : implantation of keraring (7/2013)...ESCLERA (fitting 2/2014, wear from 6/2014)
• but the left eye had low vision, so we decided to try ESCLERA
before after
eye UCVA BCVA AR method BCVA MR/AR
OD 0,5 0,9 -5,0,-9,75/26 Keraring 1,0 -3,0
OS 0,05 0,3 -13,5,-10,0/178 Keraring 0,5 -10,0-1,25/152 ESCLERA 1,0
the patient is satisfied
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Case 3
woman, 47 years, keratoconus on both eye
• right eye with myopia gravis, ambylopia, fundus myopicus, cataract scutelaris, strabizmus,
• left eye with myopia medii
• she is wearing hard corneal lens on the left eye (now she has problem with tolerance)
• wearing glasses from 20 y. (o.dx: -3,5, o.sin: -3,0,-1,0/156)
eye UCVA BCVA AR CCT K1 K2 K max AL
OD 0,01 0,05 -16,25,-5,75/70 484 46,25 49,75 51,4 29,91
OS 0,1 1,0 -4,5,-3,75/156 458 48,5 51,25 55,5 23,7
ESCLERA
ESCLERA

21. Case 3 - conclusion
Method: OD: ESCLERA (fitting 5/2014)
OS: ESCLERA (fitting 5/2014)
We proposed to try ESCLERA to both eyes.
UCVA BCVA AR BCVA
before after
OD 0,01 0,05 -16,25,-5,75/70 ESCLERA 0,05
OS 0,1 1,0 -4,5,-1,0/149 ESCLERA 1,0
the patient is satisfied
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Case 4
man, 35 years, keratoconus on both eye, wearing glasses from 11 y. (o.dx: -6,75, -2,5/48, o.sin: -8,0,-3,5/105)
• he had implantation of myoring combined with CXL to the left eye at another clinic in 2013
• after surgery was his vision still very low, with halo and glare effect
He wanted keraring to the right eye, but he was afraid of surgery and finally he decided to try ESCLERA.
eye UCVA BCVA AR CCT K1 K2 K max AL
OD 0,05 0,8 -12,75,-4,75/38 447 48,75 51,25 51,4 26,10
OS - myoring 0,1 0,4 -8,0,-6,25/1 370 45,5 46,75 55,5 26,48
ESCLERA
ESCLERA

23. Case 4 - conclusion
Method: OD: ESCLERA (fitting 6/2014)
OS: ESCLERA (fitting 6/2014)
UCVA BCVA AR BCVA
before after
OD 0,05 0,8 -12,75,-4,75/38 ESCLERA 0,9
OS 0,1 0,3 -8,0,-6,25/1 ESCLERA 0,3
He ordered ESCLERA to both eyes.
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Case 5
man, 46 years, keratokonus on left eye, he doesn’t have glasses
• we proposed implantation of kerarings to the left eye. After surgery the vision was 0.5, so we decided to try
ESCLERA
Keraring ESCLERA
eye UCVA BCVA AR CCT K1 K2 Kmax
OD 0,9 1,0 +1,0,-0,5/63 571 44,25 45,00 45,5
OS 0,16 0,4 -3,75, -12,5/96 537 48,75 57,25 58,7
Kerarings 10/2013
SI5 160/300 - sup.
SI5 90/250 - infer
UCVA post keraring 0,5 AR -3,5, -3,0/84

25. Case 5 - conclusion
Method: OS: ESCLERA (fitting 7/2014)
UCVA AR BCVA
post implantation keraring after
OS 0,5 -3,5, -3,0/84 ESCLERA 0,8
He ordered ESCLERA to the left eye.
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26. Final conclusion
• has excellent stability
• excellent visual acuity
• it is comfortable to wear
And this is a new type of correction for patients
with keratoconus and irregular cornea.
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27. www.neovizia.sk 27 Thank you for your attention!