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CLINICAL RELEVANCE This study identifies key signs and symptoms of acute conjunctivitis, that when combined with a point-of-care test, can improve clinician accuracy of diagnosing adenoviral conjunctivitis. BACKGROUND Adenoviral conjunctivitis is a common ocular infection with the potential for high economic impact due to widespread outbreaks and subsequent furloughs from work and school. In this report, we describe clinical signs and participant-reported symptoms that most accurately identify polymerase chain reaction (PCR)-confirmed adenoviral conjunctivitis. METHODS Adults with 'red eye' symptoms of four days or less were enrolled. Participants rated 10 ocular symptoms from 0 (not bothersome) to 10 (very bothersome), and indicated the presence or absence of systemic flu-like symptoms. Clinicians determined the presence or absence of swollen lymph nodes and rated the severity of eight ocular signs using a 5-point scale. An immunoassay targeting adenovirus antigen was utilised for the point-of-care test, and conjunctival swab samples were obtained for subsequent adenovirus detection by PCR analyses. Univariate and multivariate logistic regression models were used to identify symptoms and signs associated with PCR-confirmed adenoviral conjunctivitis. The diagnostic accuracy of these clinical findings, and the potential benefit of incorporating point-of-care test results, was assessed by calculating areas under the receiver operating characteristic curves (AUC). RESULTS Clinician-rated bulbar conjunctival redness, participant-rated eyelid swelling and overall ocular discomfort had the best predictive value in the multivariate logistic regression model with an AUC of 0.83. The addition of the point-of-care test results to these three clinical sign/symptom scores improved diagnostic accuracy, increasing the AUC to 0.94. CONCLUSIONS Conjunctival redness severity and participant-reported eyelid swelling and overall discomfort, along with adenoviral point-of-care test results, were highly predictive in identifying individuals with PCR-confirmed adenoviral conjunctivitis. Improved diagnostic accuracy by clinicians at the initial presenting visit could prevent unnecessary work furloughs and facilitate earlier treatment decisions.

The benefits of scleral lens (SL) wear have been described in cross-sectional and retrospective studies; however, the frequency of complications associated with SL wear has not, to the best of our knowledge, been determined. From a survey of SL practitioners, we estimated the period prevalence over 1 year of corneal complications that required SL wearers to discontinue lens wear. In a sample of 72,605 wearers, SL wear was discontinued for the following complications: corneal edema, 1.2%; corneal neovascularization, 0.53%; microbial keratitis, 0.45%; and limbal stem cell deficiency, 0.20%. This study design allowed for calculation of period prevalence of these complications rather than complication incidence rates. Information presented in this report may be useful in clinical decision-making and for future study design.

To describe contact lens prescription trends for patients with keratoconus.Demographics, corneal curvature, visual acuity, and type of contact lens prescribed were reviewed for all patients with keratoconus evaluated in the contact lens service in 2010 and 2020.There were 292 patients in 2010 and 217 in 2020. In 2010, 69% were using corneal gas-permeable lenses (GP), 16% soft toric, 13% hybrid, and 2% soft sphere with no scleral lens (SL). In 2020, 60% were using corneal GP, 22% SL, 12% soft toric, 5% hybrid, and 1% soft sphere. Mean log of minimum angle of resolution visual acuities with manifest refraction were (represented in mean [SD, range]) 0.42 (0.33, 0-1.3) in 2010 and 0.35 (0.33, 0-1.6) in 2020 improving to 0.19 (0.18, 0-1.3; P≤0.01) and 0.13 (0.14, 0-0.60; P0.01) with contact lenses. Mean keratometry measurement in patients using SLs was 53.0 diopters (D) (9.9, 42.1-84.5), which was steeper than 46.6 D in patient's using all other lens types in 2010 and 2020 (3.9, 40.9-57.9; P0.01).Scleral lens prescription increased during the past decade; however, corneal GP lenses remain the most frequent lens prescribed for patients with keratoconus in this cohort. Despite being prescribed for patients with the most advanced disease, SLs provide good visual acuity.

To describe prescribing patterns of therapeutic scleral lenses (SLs) in the management of corneal irregularity and ocular surface disease among practitioners who prescribe SLs.Participants ranked treatment options for corneal irregularity and ocular surface disease in the order they would generally consider using them in an electronic survey. Median rank score for each option is reported, along with the percentage of participants assigning first place ranking to each option. The percentage of participants assigning first, second, or third place ranking to each option is also reported.Seven hundred and seventy-eight practitioners participated. Scleral lenses are most frequently considered as the first choice for the management of corneal irregularity based on overall median rank, followed by corneal rigid lenses (rigid gas-permeable [RGPs]). Scleral lenses were the first choice of 42% of participants, followed by RGPs (20%). For ocular surface disease, lubricant drops are most frequently used first, followed by meibomian gland expression, topical cyclosporine or lifitegrast, topical steroids, punctal plugs, and SLs, respectively. Lubricant drops were the first therapeutic option considered for ocular surface disease by 63% of participants and 45% ranked SLs as their sixth, seventh or eighth treatment based on median overall rank.Scleral lenses were identified as the first option for management of corneal irregularity more frequently than RGPs. Scleral lenses are considered for management of ocular surface disease before surgical intervention but after meibomian gland expression, punctal occlusion, and topical medical therapy are attempted.

Significance The effectiveness of masking is rarely evaluated or reported in single- or double-masked clinical trials. Knowledge of treatment assignment by participants and clinicians can bias the assessment of treatment efficacy. Purpose This study aimed to evaluate the effectiveness of masking in a double-masked trial of 5% povidone-iodine for the treatment of adenoviral conjunctivitis. Methods The Reducing Adenoviral Patient Infected Days study is a double-masked, randomized trial comparing a one-time, in-office administration of 5% povidone-iodine with artificial tears for the treatment of adenoviral conjunctivitis. Masking was assessed by asking participants and masked clinicians at designated time points if they believed the treatment administered was povidone-iodine or artificial tears, or if they were unsure. Adequacy of masking was quantified using a modified Bang Blinding Index. Results Immediately after treatment, 34% of participants who received povidone-iodine and 69% of those who received artificial tears guessed incorrectly or were unsure of their treatment (modified Bang Indices of 0.31 and -0.38, respectively). On day 4, 38% of the povidone-iodine participants and 52% of the artificial tear participants guessed incorrectly or were unsure of their treatment (modified Bang Indices of 0.24 and -0.05, respectively), indicating adequate and ideal masking. On days 1, 4, 7, 14, and 21, masked clinicians guessed incorrectly or were unsure of treatment in 53%, 50%, 40%, 39%, and 42% among povidone-iodine participants compared with 44%, 35%, 38%, 35%, and 39% among artificial tears participants, respectively. The modified Bang Indices for clinician masking in the povidone-iodine group ranged from -0.05 to 0.25 and from 0.13 to 0.29 in the artificial tears group. Conclusions Masking of participants and clinicians was adequate. Successful masking increases confidence that subjective measurements are not biased. We recommend quantitative assessment and reporting the effectiveness of masking in ophthalmic clinical trials.

Severe chemical burns can damage the periocular area causing exposure keratopathy and resulting in ocular pain, foreign body sensation, epiphora, photophobia, and vision loss. A custom fit large diameter therapeutic scleral lens can protect the ocular surface by preventing desiccation and providing immediate improvement in comfort. This case describes the management of a patient with extensive chemical burn with complete lid loss and exposure keratopathy who has maintained excellent visual acuity and comfort with therapeutic scleral lens use.

Purpose To estimate the prevalence of patient-reported midday fogging and to identify risk factors for midday fogging. Method A multicenter, cross-sectional study was conducted with an electronic survey that was distributed to scleral lens practitioners. The survey asked them to describe their most recently examined established scleral lens patient. Respondents provided data about patient-reported midday fogging, patient demographic characteristics, indication for lens wear, lens-wearing schedule, lens design, and care products. Results Of the 248 survey respondents who indicated whether their patients had midday fogging, 64 (25.8 %) had patients who self-reported such issues. Midday fogging was not associated with demographic characteristics (age, sex, race/ethnicity), indications for scleral lens wear, mean lens diameter (P = .30), haptic design (P = .29), use of a daily cleaner (P = .12), disinfection/storage solution used (P = .71), or filling solution (P = .65). Patients who reported midday fogging more commonly reported redness or irritation associated with scleral lens wear compared with those who did not experience midday fogging (P = .03). Conclusions Prevalence of midday fogging in this study was similar to previously reported rates. No specific lens design or care product was associated with patient-reported midday fogging. If inflammatory mediators are elevated in the postlens fluid reservoir of patients with midday fogging, as previously described, the redness or irritation associated with scleral lens wear suggests that ocular surface inflammation may be contributing to this phenomenon.

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.

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.

Purpose To describe international scleral lens prescription and management practices across multiple practice types. Methods For this cross-sectional study, scleral lens practitioners were asked to complete an electronic survey that requested information about a single scleral lens patient. Data collected included practitioner demographics (practice type, country, years of experience) and patient indications for scleral lens wear, fitting process, lens design, and care products. Results Data were collected for 259 patients (419 eyes). Most participants (60%) practiced in the US, 75% worked primarily in community practice, and 58% claimed more than 5 years’ experience fitting scleral lenses. Indications for scleral lens wear were corneal irregularity (87%), ocular surface disease (9%), and uncomplicated refractive error (4%). During the fitting process, the mean (SD) number of lenses ordered was 2.4 (1.6) (range, 1–16 lenses) during 3.8 (2.4) visits (range, 1–18 visits). Of patients, 62% used a daily surfactant cleaner, 47% used hydrogen peroxide disinfection, and 67% used single-use vials of nonpreserved saline. Mean lens diameter was 16.2 (1.1) mm (range, 11.8–23.0 mm). The landing zones were spherical (64%), toric (26%), quadrant-specific (7%), and custom (3%) designs. Optical power was spherical in 70%, toric in 27%, and higher-order aberration correcting in 3% of lenses. Only 5 lenses had multifocal optics. Conclusions General consensus regarding prescribing patterns (lens design, wearing schedules, care products) between US vs non-US, community vs academic, and new vs established providers is reported in this study. Relatively low percentages of patients wearing lenses with advanced landing zones or optical designs suggest that these new options have not been widely adopted.

Purpose Accurate diagnosis of adenoviral conjunctivitis (Ad-Cs) is important for timely and appropriate patient management to reduce disease transmission. This study assessed the diagnostic accuracy of a commercially available point-of-care adenovirus immunoassay and determined whether its predictive accuracy is influenced by signal intensities of test result bands. Methods Point-of-care immunoassay (AdenoPlus) testing and quantitative polymerase chain reaction (qPCR) testing was performed on conjunctival swab samples obtained from eyes of 186 eligible adult participants with presumed infectious conjunctivitis and symptoms of ≤4 days. Masked observers assessed signal intensities of the immunoassay test and control bands using densitometry. Results Ad-Cs was confirmed by qPCR in 28 of the 56 eyes that tested positive on the AdenoPlus, a 50% positive predictive value (95% confidence interval [CI] = 36.9, 63.1). No adenovirus was detected by qPCR in 128 of 130 eyes that tested negative on AdenoPlus, a 98.5% negative predictive value (CI = 96.3, 100). Sensitivity and specificity were 93% (CI = 84.4, 100) and 82% (CI = 76.0, 88.1), respectively. Viral titers significantly correlated with ratio of test band signal intensities (R2 = 0.32, P = 0.002). Higher positive predictive value was associated with higher densitometry ratios (receiver operating characteristic [ROC] area = 0.71; 95% CI = 0.59, 0.83). Conclusions Densitometric analyses suggest that the diagnostic accuracy of AdenoPlus is influenced by the signal intensity of the test result bands. Visual comparison of the test band intensities by clinicians could reduce the false positive rate of point-of-care immunoassays and aid in the diagnosis of viral infections. Translational Relevance Ratiometric densitometry of point-of-care immunoassays could aid clinicians' decision making in diagnosing infectious diseases, including Ad-Cs.

Purpose To report safety and tolerability of a one-time administration of ophthalmic 5% povidone-iodine (5% PVP-I) in a double-masked randomized trial for the treatment of adenoviral conjunctivitis (Ad-Cs). Methods Of 212 participants screened, 56 eligible participants with red eye symptoms ≤4 days and a positive adenoviral rapid immunoassay were randomized to a one-time administration of ophthalmic 5% PVP-I or preservative free artificial tears (AT). Safety was assessed by corneal fluorescein staining (baseline, immediate post-administration and Day 1) and visual acuity (VA) (baseline and Day 1). Tolerability was assessed using participant-rated overall ocular discomfort (baseline, immediately post-administration and on Day 1. Results In the 5% PVP-I group, corneal staining increased immediately post-administration but returned to baseline levels by Day 1. There was no change in VA between baseline and Day 1 in either 5% PVP-I or AT groups (p = 0.87). In the 5% PVP-I group, there was no change in participant-rated overall discomfort immediately post-administration (p = 0.78) or on day 1 (p = 0.10) compared to baseline. In the AT group, participant-rated overall discomfort was lower immediately post-administration but returned to baseline levels by Day 1. One adverse event was reported in the 5% PVP-I group on Day 1–2 that was classified as not related to treatment. Conclusion These results suggest ophthalmic 5% PVP-I used as a one-time treatment is safe and well tolerated by patients with Ad-Cs.

The application of artificial intelligence (AI) in diagnosing and managing ocular disease has gained popularity as research highlights the utilization of AI to improve personalized medicine and healthcare outcomes. The objective of this study is to describe current optometric perspectives of AI in eye care.Members of the American Academy of Optometry were sent an electronic invitation to complete a 17-item survey. Survey items assessed perceived advantages and concerns regarding AI using a 5-point Likert scale ranging from "strongly agree" to "strongly disagree."A total of 400 optometrists completed the survey. The mean number of years since optometry school completion was 25 ± 15.1. Most respondents reported familiarity with AI (66.8%). Though half of optometrists had concerns about the diagnostic accuracy of AI (53.0%), most believed it would improve the practice of optometry (72.0%). Optometrists reported their willingness to incorporate AI into practice increased from 53.3% before the COVID-19 pandemic to 65.5% after onset of the pandemic (p0.001).In this study, optometrists are optimistic about the use of AI in eye care, and willingness to incorporate AI in clinical practice also increased after the onset of the COVID-19 pandemic.

Objectives To assess dry eye symptoms associated with different contact lens modalities in patients with keratoconus using a dry eye questionnaire. Methods An online survey was distributed by the National Keratoconus Foundation. The survey asked participants to report demographic characteristics, current optical correction, age at the time of diagnosis of keratoconus, and contact lens history. The 12-item Ocular Surface Disease Index (OSDI) questionnaire was also completed. Data from participants wearing the same contact lens modality bilaterally were analyzed. Results The survey was completed by 197 individuals wearing the same contact lens modality bilaterally. The average age of participants at the time of the survey was 47.2±14.8 years (range: 15-87 years), and the average age at which keratoconus was diagnosed was 26.1±9.9 years (range: 8-55 years). The mean overall OSDI score of all participants was 40.2±22.8 (range: 0-100). There was no difference in the mean OSDI scores based on current contact lens modality type (F=1.79; n=187; P=0.13). Based on an OSDI score of 33 or higher, 90% of participants reported symptoms indicative of dry eye disease. Scleral lens wearers reported less discomfort on the individual items related to windy and low-humidity conditions. Conclusions Individuals with keratoconus, irrespective of contact lens modality, report a high incidence of dry eye symptoms.

Objectives: To describe visual outcomes with various contact lens modalities in patients with a history of ocular trauma who underwent surgical open globe repair. Methods: Records of all patients with a history of open globe injury and repair at a tertiary care hospital between January 1, 2010, and December 31, 2016, were reviewed. Demographics, type of injury, and visual acuity were assessed before and after contact lens evaluation. Results: Of 214 patients who underwent open globe repair, 29 (13.6%) were evaluated with a contact lens. Visual acuity improved in 97% (28 of 29) of patients from 1.47±0.75 to 0.67±0.71 logarithm of the minimal angle of resolution (logMAR) with manifest refraction to 0.28±0.45 logMAR with contact lenses (n=29; P

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).This study aimed to compare patient satisfaction and care burden associated with GP and SL for the management of keratoconus.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.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.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.

To describe outcomes using impression based-scleral devices for the management of anterior segment disease.Retrospective chart review identified all patients who were fitted with impression-based scleral devices between January 1, 2013 and June 30, 2019 at three specialty contact lens practices. Patient demographic data, indication for device use, visual and physiological outcomes, as well as details of the fitting process and survival of device use were determined.Forty-four patients (70 eyes) were included in the study. Primary indications for device use included corneal irregularity (28 patients, 44 eyes) and ocular surface disease (16 patients, 26 eyes). Fifty-four percent of patients had more than one ocular surface condition, and 39 % of patients had undergone at least one anterior segment surgical procedure. Twenty-nine patients had unsuccessfully attempted to wear standard scleral lenses prior to being fit with impression-based devices. Visual acuity improved significantly with impression-based devices compared to habitual correction (p0.001). Completion of the fitting process (including visit to acquire the impression and post-fitting assessments) required an average of 4 [1.5] visits.Ideal haptic alignment was achieved with 74 % and complete limbal clearance was achieved in 83 % of fits. Device use was discontinued due to complications in two eyes.Patients with complex eye disease who are unable to successfully wear standard scleral lenses successfully may achieve visual and therapeutic success with impression-based devices.

PURPOSE The Boston keratoprosthesis (KPro) is the most commonly used artificial cornea. It has been proven to be successful for severe corneal disease not amenable to keratoplasty. We have observed our patients reporting debilitating glare despite attaining good visual acuities. This motivated us to objectively measure light scatter in eyes with a KPro. METHODS Light scatter was measured in 21 eyes with the Boston type 1 KPro with a VA of 20/150 or better and was compared with 13 healthy control eyes using the Oculus C-Quant device (Arlington, WA). Eyes were also measured using an occluder contact lens. RESULTS Light scatter (quantified as the logS value) was significantly higher in the KPro group than in the control (2.34 ± 0.15 vs. 1.29 ± 0.17, P < 0.001). The polymethylmethacrylate (PMMA) KPro group (16 eyes, logS 2.49 ± 0.19) but not the titanium group (5 eyes, logS 1.87 ± 0.15) had significantly higher light scattering than the control. The use of an occluder contact lens significantly decreased light scatter in eyes with a PMMA backplate (n = 11, logS 1.71 vs. 2.42, P = 0.028). CONCLUSION This study confirms that intraocular light scatter is increased in KPro eyes. Possibly because of its opaque nature, the titanium backplate model seems to produce less light scatter than does the PMMA model. Occluder contact lenses reduced light scatter significantly in the PMMA KPro and could be a treatment option for symptomatic patients.

Scleral lenses are being prescribed for the management of corneal irregularity, uncomplicated refractive error, and ocular surface disease. There are many potential therapeutic uses of scleral lenses in addition to providing similar benefits as corneal gas permeable lenses. Scleral contact lenses are a valuable therapeutic tool for patients with ocular surface disease as these lenses protect the ocular surface, provide continuous corneal hydration while providing optimal visual correction, and are often used in conjunction with other therapies.

Objectives To describe indications for scleral contact lens (ScCL) evaluation, previous treatments, and outcomes of patients prescribed ScCL at a tertiary referral center. Methods This retrospective study reviewed 133 patients evaluated for ScCL between January 1, 2010, and December 31, 2015, at the University of Illinois at Chicago (UIC) Contact Lens Service. Patient demographics, ocular history, indications for evaluation, previous treatments, presence of punctate epithelial erosions, number of lenses ordered, follow-up visits, best-corrected visual acuity before ScCL, and visual acuity with ScCL were evaluated. Patients were categorized based on primary indication for ScCL evaluation as ocular surface disease (OSD) or corneal irregularity (CI). The primary outcome was visual acuity. Results Visual acuity improved from logarithm of the minimal angle of resolution 0.3±0.4 at presentation to 0.1±0.2 with ScCL in all eyes (n=223, P=0.0001), and from 0.3±0.5 to 0.1±0.2 (n=164, P=0.001) in the OSD group and 0.5±0.4 to 0.2±0.2 (n=59, P=0.0001) in the CI group. Seventy percent of patients were evaluated for bilateral ScCL evaluation. Indication for ScCL evaluation was OSD in 71% (n=95) of patients, with 20% having a secondary diagnosis of CI. Corneal irregularity was the primary diagnosis in 29% of patients (n=38), with 50% having a secondary diagnosis of OSD. Conclusions Ocular surface disease was common in this tertiary referral patient population and was a primary or secondary indication for ScCL evaluation in 85.7% (n=114) of patients evaluated for ScCL. Scleral contact lenses improved visual outcomes in patients with both primary diagnoses of CI and OSD.

Patients with a keratoprosthesis often develop complications including glaucoma, requiring glaucoma drainage devices. In most of these patients, glaucoma drainage devices have been shown to be safe and effective. However, occasionally, a glaucoma drainage device in the setting of a keratoprosthesis can lead to conjunctival erosion with mechanical trauma. While repeat surgical intervention may appear necessary, we report a case of a patient who had improved conjunctival erosion and glaucoma drainage device exposure after refitting of a therapeutic contact lens. Therapeutic contact lenses can be used to maintain hydration and decrease exposure while improving cosmesis and refractive error. Complications following keratoprosthesis surgery are an understudied area, particularly regarding glaucoma drainage devices, and we seek to show that careful fitting of therapeutic contact lenses may avoid the risks of repeat surgical intervention.

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.

Significance Familial dysautonomia is a rare genetic disorder that affects the sensory and autonomic nervous systems. Affected individuals have decreased corneal sensation and can develop serious complications from neurotrophic keratitis. Scleral devices are an excellent option for the long-term management of patients with familial dysautonomia and neurotrophic keratitis. Purpose In this series, we describe three patients with familial dysautonomia and classic ocular complications fit with scleral devices. No identifiable health information is included in this case report. Case reports Case 1: A 35-year-old white male presented with blurred vision without complaint of pain or dryness. He had moderate punctate corneal staining and central stromal corneal scarring in both eyes despite use of artificial tears, punctal plugs, and therapeutic soft lenses. He was fit with 18.2-mm commercial scleral devices, which improved vision and protected the ocular surface. Case 2: A 20-year-old cognitively impaired white female presented with history of frequent eye rubbing and self-mutilation. She had recurrent corneal abrasions with corneal scarring in both eyes and was fit with 16-mm gas-permeable prosthetic replacement of the ocular surface ecosystem devices. Case 3: An 18-year-old white male with history of frequent corneal abrasions and blurred vision was referred by his medical doctor. He and his mother were trained in the safe handling of 16- and 16.5-mm gas-permeable prosthetic replacement of the ocular surface ecosystem devices in the right and left eyes. Corneal epithelial defects healed and vision improved with daily use. Conclusions Individuals with familial dysautonomia present unique clinical challenges owing to severe ocular surface disease and inability to perceive pain. Initial therapy for neurotrophic keratitis includes lubrication, punctal occlusion, and therapeutic lenses. Additional therapies include autologous serum tears, amniotic membrane treatment, scleral devices, and tarsorrhaphy. In this series, scleral devices are an excellent option to protect the ocular surface and prevent common ocular complications.

To describe patient-specific outcomes of scleral lens wear utilizing a variety of lens designs across multiple practice settings as reported in an international practitioner survey.An electronic survey was administered to eye care providers who prescribe scleral lenses in which they were asked to describe their most recently examined established scleral lens patient. Data was collected on patient characteristics, lens designs, wearing schedules, care products, and visual and physiological outcomes of lens wear. Descriptive analysis of data was performed.A total of 292 responses were received. Participants represented 26 countries. The most commonly reported indication for scleral lens wear was corneal irregularity (87%) followed by ocular surface disease (8%), refractive error (4%) and 1% with multiple indications. Visual acuity improved from 0.4 ± 0.4 (mean ± SD) to 0.1 ± 0.2 in eyes with corneal irregularity (p 0.001), from 0.3 ± 0.3 to 0.1 ± 0.3 in eyes with ocular surface disease (p 0.001), and from 0.1 ± 0.1 to 0.0± [0.1] in eye with refractive error (p = 0.01). Prior to scleral lens wear, corneal staining was present in 55% of patients; staining was present in only 35% of patients following scleral lens wear. The number of topical ophthalmic drops needed decreased from 1.7 ± 0.9 to 0.8 ± 0.8 in patients with corneal irregularity (p 0.001) and from 3.5 ± 1.7 to 1.1 ± 1.0 in patients with ocular surface disease (p 0.001). The number of drops used by patients with refractive error remained stable, with these patients using an average of 2.0 ± 1.0 drops prior to scleral lens wear and 1.7 ± 1.5 drops following scleral lens wear.Patients with corneal irregularity experienced the greatest improvement in visual acuity, but patients with ocular surface disease and refractive error also achieved better visual acuity with scleral lenses. Ocular surface condition improved in patients with both corneal irregularity and ocular surface disease; patients with ocular surface disease experienced the most dramatic improvement. Patients who wore scleral lenses to correct uncomplicated refractive error did not experience an improvement in signs or symptoms of ocular surface disease.

Purpose To describe prescriber reported scleral lens fitting and assessment strategies. Methods The SCOPE (Scleral Lenses in Current Ophthalmic Practice Evaluation) study group designed and administered an IRB approved, electronic survey (REDCap) regarding current scleral lens fitting and assessment methods. The survey was distributed to attendees of the 2017 Global Specialty Lens Symposium. Results 95 practitioners responded to the survey. Over half of the respondents, 58% (55/95) reported fitting scleral lenses for less than five years (new prescribers), and 42% (40/95) reported fitting scleral lenses for more than five years (experienced prescribers). There was a statistically significant difference between their initial use of technology (χ2 = 21.117, p Conclusions Practitioners with varying backgrounds and experience have added sclerals to their lens inventories. However, definite guidelines for fitting have not been developed. The results of a survey are provided; demonstrating that among practitioners with greater than 5 years of scleral lens experience, a consensus has emerged for best practices. Strategies for lens evaluation, which may inform future efforts at generating scleral fitting standards are described.

Purpose To describe current practice patterns regarding the use of scleral lens therapy in the management of corneal irregularity and ocular surface disease among eye care providers who fit scleral lenses. Methods The Scleral Lenses in Current Ophthalmic Practice: an Evaluation (SCOPE) study group conducted an electronic survey of eye care providers from January 15 to March 31, 2015. Respondents ranked management options for corneal irregularity in the order in which they would generally consider their use. Respondents also ranked options for the management of ocular surface disease in the order in which they would use each of the treatments. Results for each option were analyzed as percentage first-place ranking; percentage first-, second-, or third-place ranking; and mean rank score. Results Survey responses were obtained from 723 providers who had fit 5 or more scleral lenses. Of these respondents, 629 ranked options for management of corneal irregularity and 612 ranked options for management of ocular surface disease. Corneal rigid gas-permeable lenses were the first option for management of corneal irregularity for 44% of respondents, and scleral lenses were the first option for 34% of respondents. Lubricant drops were the first therapeutic recommendation for ocular surface disease for 84% of respondents, and scleral lenses were ranked first by 6% of respondents. Conclusion Scleral lenses rank second only to corneal rigid gas-permeable lenses for management of corneal irregularity. Scleral lenses are generally considered after other medical intervention and before surgery for the management of ocular surface disease.

Scleral devices can play a vital role in the treatment of ocular surface disease, both as an adjunct to traditional therapy and as an alternative when traditional therapies fail. With proper utilization, gas-permeable scleral lenses can promote healing of the ocular surface and improve debilitating symptoms related to severe dry eye syndrome secondary to conditions such as GVHD or Sjogren’s syndrome as well as persistent epithelial defects. Scleral lenses can also provide a safer alternative to surgery for patients with corneal irregularity who can no longer tolerate traditional gas-permeable corneal lenses. Scleral lenses and PROSE devices should be considered in all of these situations when traditional treatment modalities have failed.

Objectives To assess current scleral lens prescription and management practices by conducting an international online survey of eye care providers. Methods The SCOPE (Scleral Lenses in Current Ophthalmic Practice: an Evaluation) study group designed and administered an online survey regarding current scleral lens prescription and management practices. The survey was open from January 15 to March 31, 2015, and generated 723 responses from individuals who had fit at least 5 patients with scleral lenses. Results Respondents (n=663) prescribed scleral lenses that ranged from 15 to 17 mm in diameter (65%), smaller than 15 mm (18%), and larger than 18 mm (17%). More than 50 lens designs were identified. Average daily wearing time of 11.8 hr was consistent across 651 respondents, and 475/651 (73%) recommended midday removal on some, most, or all days. Most respondents recommended nonpreserved saline to fill the bowl of the lens before application (single-use vials, 392/653 [60%]; bottled products, 372/653 [57%]). A hydrogen peroxide-based disinfection system was the most commonly recommended care product (397/651 [61%]). Conclusions A reasonable degree of consensus exists regarding some aspects of scleral lens prescription and management (average lens diameter, daily wearing time, and use of nonpreserved products for lens application). Further study is needed to develop evidence-based guidelines for scleral lens prescription and management.

OBJECTIVES To describe surveillance cultures of bandage contact lenses (BCL) in patients with a history of Boston type 1 keratoprosthesis (KPro) surgery. METHODS An institutional review board-approved retrospective review of patients with a history of Boston type 1 KPro surgery and BCL cultures between July 2008 and June 2010. Data on demographics, preoperative diagnosis, topical corticosteroid and antibiotic use, duration of BCL wear, clinical diagnosis of microbial keratitis or endophthalmitis, and culture results were recorded. RESULTS There were 14 patients (15 eyes) who underwent Boston type 1 KPro between July 2008 and June 2010 with BCL culture data. Ten eyes showed positive growth and one eye developed an infection. Thirty-four cultures were performed and 12 were positive. The most common organism cultured was coagulase-negative staphylococcus (CoNS). Positive cultures, colonization by non-CoNS pathogens, and infection occurred more frequently in patients with an ocular history of autoimmune disease or chemical burn. The growth of 15 or more CoNS colonies occurred only in patients not on vancomycin. An antibiotic was added to the regimen in response to positive cultures for three patients. CONCLUSIONS Contact lens surveillance cultures may provide valuable information on the characteristics of microbial colonization, particularly in highlighting inflammatory disease and disuse of vancomycin as possible risk factors. Bandage contact lenses cultures also have the potential to be useful adjuncts in the clinical management of antibiotic therapy.

Purpose Describe the presentation and management of superior limbic keratoconjunctivitis (SLK)-like inflammation and secondary limbal stem cell dysfunction in the setting of ocular chronic graft-versus-host disease (cGVHD). Methods Retrospective observational case series in a multicenter clinical practice. Participants were 13 patients (26 eyes) with ocular cGVHD and SLK-like inflammation presenting to the University of Illinois at Chicago and BostonSight® between January 1, 2009 and July 1, 2013. Main outcome measures 1) Reversal or worsening of SLK, and 2) development of limbal stem cell dysfunction. Results All eyes showed evidence of SLK-like inflammation and superior limbal stem cell dysfunction manifested by conjunctival injection and superior conjunctival and corneal staining. In addition to aggressive lubrication, management strategies for SLK included topical steroids (20/26), punctal occlusion (18/26), topical cyclosporine (24/26), autologous serum tears (12/26), therapeutic soft contact lens (13/26 eyes) and scleral lenses (4/26 eyes). SLK and limbal stem cell dysfunction were reversed in 23/26 eyes. Three eyes of two patients with long-standing disease demonstrated frank limbal stem cell deficiency (LSCD) and corneal pannus, with one patient requiring multiple reconstructive surgical procedures. Conclusions SLK-like inflammation is an under-recognized condition in patients with severe dry eyes secondary to ocular cGVHD. Untreated SLK can potentially lead to permanent LSCD over time. Early recognition and management of SLK in ocular cGVHD can improve vision, reverse signs, and may prevent these long-term consequences.

The Boston type 1 keratoprosthesis (KPro) is the most commonly used artificial cornea worldwide. Long-term bandage contact lenses are the standard of care for patients with these devices. The goal of bandage contact lenses is to maintain hydration and to protect the corneal tissue that surrounds the anterior plate of the keratoprosthesis which is vulnerable to desiccation, epithelial breakdown, dellen formation, and corneal melt. Contact lenses can also improve comfort, correct refractive errors, and improve the cosmesis of patients with artificial corneas. However, the continuous use of contact lenses places these patients at risk for complications such as lens loss, lens deposits, chronic conjunctivitis, and infection. In addition, obtaining an adequate fit in a patient with a compromised ocular surface and history of multiple surgeries including glaucoma drainage devices can present a challenge. This review discusses the types of contact lenses used, special fitting considerations, and common complications in patients with previous KPro surgery.

After Boston KPro Type 1 surgery, a soft bandage contact lens has an important role in protecting the ocular surface. The initial contact lens placed after surgery is a Kontur© Precision Sphere with a 16.0 mm diameter, 9.8 mm base curve, and plano power. Proper centration of the lens and complete corneal coverage are essential for a proper fit, lens retention, and ocular protection. Over-refraction should be measured at each visit and power changes may be incorporated in the bandage lens. Lenses should be worn on an extended wear basis with frequent follow-up visits for lens disinfection or replacement. In some situations, patients benefit from refitting to prosthetic contact lenses, large-diameter gas-permeable lenses, or hybrid contact lenses.