AOS State of Art Showcase July 19th 2019

AOS A N T E R I O R STATE OF THE ART SHOWCASE July 19 t h 2019

LIST OF SPEAKERS AND PRESENTATION TITLES

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PAGE 3: Dr John Gelles O.D., F.I.A.O.,F.C.L.S.A., F.S.L.S: Therapeutic scleral lenses and AOS in the management of persistent epithelial defects

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PAGE 31: Dr Giancarlo Montani Dip.Optom FBCLA: Ways to use image analysis software to evaluate the peripheral fitting of scleral contact lenses

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PAGE 53: Dr Byki Huntjens: PhD, MSc, MCOptom, FHEA and the title of her talk is Computer assisted diagnostics for contact lens practice

Objective Image Analytics: Epithelial Defect Healing July, 2019 John D. Gelles, O.D., F.I.A.O., F.C.L.S.A., F.S.L.S. Director, Specialty Contact Lens Division Cornea and Laser Eye Institute - Hersh Vision Group CLEI Center for Keratoconus Adjunct Clinical Professor New England College of Optometry State University of New York College of Optometry

Disclosures and Acknowledgments – Avedro – Avellino Labs – Advanced Ophthalmic Systems – BioTissue – BostonSight – Blanchard Lab – Bausch + Lomb – Contamac – EyecareLive – EyePhotoDoc – Formulens – Google – Gas Permeable Lens Institute (GPLI) – International Keratoconus Academy – PeerMed – STAPLE program – Scleral Lens Education Society – Synergeyes – Visionary Optics – Visionix

Peter S. Hersh, M.D.

David S. Chu, M.D.

Steven A. Greenstein, M.D.

AOS: Objective Image Analytics • Objective Image Analytics – Consistency, accuracy and repeatability across doctors and data set – Eliminate interclinical variability and subjectivity

Objective Analysis Impact on Care •

Growth Rates – Stable?

•

Healing Rates – Resolving?

– Technique superiority?

• Surgical – EBK vs Alcohol Debridement • Therapeutical – Dehydrated vs Cryopreserved

S/P removal of conjunctival intraepithelial neoplasia treated with 5Fu (Fluoroplex)

S/P PRK epithelial defect

CASE: SPK Evaluation

• Original

• NaFl Enhanced –

No light loss

• Graded –

Punctate Measured in 5 section grid

CASE: Epi Defect Evaluation

• Original

• HVID – –

Known measurement Select units

• Defect Area –

Measure the surface area of the defect

Scleral Lens PED Management • 12hr x 2 • Overnight wear until resolution then Daytime wear – Average 8.1 days • Avoid MK • First Try: – 4 MK • Revised with NPMoxifloxacin – No MK

CASE 1: Scleral Lens PED Management •

64 year old Caucasian male

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CC: Poor vision after complex Cataract Sx secondary to PED x 3m

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Referred by Ocular Immunology for Scleral Lens

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Medical history – Diabetes Type 2

•

Ocular history – Monocular c prosthesis OS – Neurotrophic S/P HSK –

Exposure keratitis

CASE 1: Scleral Lens PED Management • Previous Treatment – – – – – –

Moxifloxacin QID Prokera x 3 BCL- unable to retain Autologous Serum 20% Q30min Ointment QHS Tape tarsorrhaphy QHS

CASE 1: Scleral Lens PED Management •

Plan: – 12hr x 2 scleral lens wear • 1 gtt Moxifloxacin • Clear Care in deep well – Non-neutralized, must rinse thoroughly prior to insertion

CASE 1: Scleral Lens PED Management

• Pre Wear

• Day 3

CASE 1: Scleral Lens PED Management

• Pre Wear: – ED: 14.5mm2

• Day 3: – ED: 7.6mm2

• Epi Growth Rate: 2.3mm2/day

CASE 1: Scleral Lens PED Management •

Day 7 – ED healed – BCCLVA: 20/25– UCVA: 20/30

•

Software aids in follow up and resolution

CASE 1: Scleral Lens PED Management

• Pre Wear

• Day 7

CASE 1: Scleral Lens PED Management

• Pre Wear: – Inj: 1.1, 23% vessel

• Day 7: – Inj: 0.3, 10% vessel

• Injection Significantly Reduced

CASE 1: Scleral Lens PED Management •

Plan: – Daily wear scleral lens wear • D/C Moxifloxacin and Autologous Serum –

Serum 20% Q30 mins without lens

–

Water-based non-preserved gel ointment QHS

–

Tape Tarsorrhaphy OU QHS • Tegaderm RTC 2 weeks • no issues – D/C Scleral lens wear, tape and serum – PFAT QID and Gel QHS

–

CASE 2: Scleral Lens PED Management •

34 year old Asian male

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HPI: Neurotrophic and Exposure Keratitis secondary to 5th and 7th Nerve Palsy after emergency brain surgery

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Referred by Oculoplastics and Cornea for Scleral Lens

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Medical history –

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A/V Malformation

Ocular history –

None

CASE 2: Scleral Lens PED Management •

Previous Treatment – Moxifloxacin QID – BCL – Antibiotic UNG QHS – Temporary full tarsorrhaphy – Gold weight implant

CASE 2: Scleral Lens PED Management •

Plan: – 12hr x 2 scleral lens wear • 1 gtt Moxifloxacin, 2 gtt Autologous Serum – Clear Care in deep well • Non-neutralized, must rinse thoroughly prior to insertion

CASE 2: Scleral Lens PED Management

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Pre Wear: – ED: 13.2mm2 •

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Day 3: – ED: 8.6mm2

Epi Growth Rate: 1.5mm2/day

CASE 2: Scleral Lens PED Management

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Day 3: – ED: 8.6mm2 •

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Day 5: – ED: 5.9mm2

Epi Growth Rate: 1.3mm2/day

CASE 2: Scleral Lens PED Management

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Day 5: – ED: 5.9mm2 •

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Day 9: – ED: 3.2mm2

Epi Growth Rate: .7mm2/day

CASE 2: Scleral Lens PED Management

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Day 9

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Day 11

CASE 2: Scleral Lens PED Management

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Day 9: – ED: 3.2mm2 •

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Day 11: – ED: 1.8mm2

Epi Growth Rate: .7mm2/day

CASE 2: Scleral Lens PED Management •

Day 15 – ED healed

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Software aids in judging stagnation vs resolution

CASE 2: Scleral Lens PED Management •

Plan: – Daily wear scleral lens wear • D/C Moxifloxacin and Autologous Serum – Non-preserved artificial tears QID OU – Muro 128 5% gel ointment QHS – Tape Tarsorrhaphy OU QHS

Study Utilizing Objective Analysis •

Healing Rates after PRK – All patients undergoing bilateral PRK – Alcohol debridement – 9mm defect –

Randomized • Bandage CL vs Gel

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Time to resolution • Statistically significant difference?

QUESTIONS? John D. Gelles, O.D., F.I.A.O., F.C.L.S.A., F.S.L.S. Director, Specialty Contact Lens Division Cornea and Laser Eye Institute - Hersh Vision Group CLEI Center for Keratoconus johngellesod@gmail.com

Ways to use image analysis software to evaluate the peripheral fitting of scleral contact lenses GIANCARLO MONTANI Dip.Optom FBCLA

ANTERIOR WAYS TO USE IMAGE ANALYSIS SOFTWARE TO EVALUATE THE PERIPHERAL FITTING OF SCLERAL CONTACT LENSES GIANCARLO MONTANI Dip.Optom FBCLA

Introduction  The “landing” or “scleral” zone is one of the most important regions of a scleral lens since it is the region where the lens first contacts or “lands” on the ocular surface  For an optimal fit, the shape of the landing zone should have a close alignment with the overall scleral shape

Introduction

Introduction

Introduction  To select or design the “landing” zone can be used instruments as scleral topographers and optical coherence tomographers while their use in clinical practice is still limited  So slit lamp use remain the procedure most used to determinate the periphery of a scleral lens by the observation and evaluation of a diagnostic lens fitted.

Introduction  A majority of both 85% of new and 98%, experienced prescribers utilize slit lamp evaluation to assess conjunctival alignment of landing zone for areas of vascular compression or edge lift.

Introduction  Vascular compression can be evaluated considering the blanching of the conjunctival vessels induced by the pressure of the scleral lens peripheral curves  Compression may cause also hyperemia adjacent to the area of blanching with the lens in situ, and on lens removal, rebound hyperemia may occur where the vessels had previously been compressed

Introduction  To evaluate vascular compression/clearance induced by the periphery of a scleral contact lens a grading scale was proposed but at the moment there aren’t validated study on its efficacy

Introduction  On the same time using the subjective clinical grading of conjunctiva redness with grading scales can induce results highly variable.

Introduction

 To improve the precision, accuracy and reliability of results objective methods of image analysis were used and validated

Fieguth P.; Automated measurement of bulbar redness Invest Ophthalmol Vis Sci. 2002 Feb;43(2):340-7.

Downie LE et al.; Assessing ocular bulbar redness: a comparison of methods. Opht. Physiol Opt. 2016 Mar;36 (2):132-9 Sorbara L et al.; Comparison of an objective method of measuring bulbar redness to the use of traditional grading scales. Cont Lens Anterior Eye. 2007 Mar;30(1):53-9.

Peterson RC et al.;Objective grading of the anterior eye. Optom Vis Sci. 2009 Mar;86(3):273-8

AOS Anterior  The AOS ANTERIOR software allows images of the anterior eye to be analysed in a variety of ways that can then be more easily interpreted and recorded and reflect even the most subtle changes between imaging. In so doing it removes the subjective error that might otherwise risk misinterpretation and mismanagement of any individual presentation.

Harvey B., SOFTWARE Making the grade 8 December 2017 OPTICIAN 35

Purpose  The purpose of this pilot study was to evaluate the potential utility of AOS ANTERIOR to assess the effects of a scleral contact lens “landing” zone on the conjunctival vessels

Methods  Twelve eyes with healthy corneas were recruited for the study and a scleral lens design with the possibility to modify the landing zone (SLC Conica, Medlac, Avellino, IT) used for the measurements.

Methods  All lenses used had a limbal angle of 40°, an OAD of 16,80 mm and after settling time an apical clearance of ~250 µm.  The differences of landing zone behaviour were obtained changing the peripheral angles to control the level of peripheral contact lens bearing/compression.

Methods  The landing behavior of the CLs fitted were acquired in different four sections (Nasal,

S

Temporal, Superior and Inferior) with twodimensional cross-sectional images

N T

obtained with a Spectral Domain OCT system (Revo NX, Optopol Technology SA) with 110 000 A-scan/sec and an axial resolution of 2,6 μm

I

Methods

At insertion

 To consider the effect of optical artefact of apparent indentation induced by OCT images we measured the apparent

After settling

indentation at the insertion of CLs and the values measured subtracted from those found after a settling at least of two hours of wear. ∆= 5; 33; 12 µm Sorbara L et al. Optical edge effects create conjunctival indentation thickness artefacts. Ophthalmic Physiol Opt. 2015 May;35(3):283-92.

Methods

At insertion

 To repeat the measurements always in the same position:  The fixation target arm was positioned

After settling

in the different direction examined maintaining always the same distance from the instrument aperture  The periphery of the lens was divided in three different segments of 600 µm width

∆= 5; 33; 12 µm

Methods  In the same four sections images of the lens periphery were acquired using a digital slit lamp (SL203 + Digital Camera System DCS-700 Shin-Nippon) after lens settling using always the same magnification (16X) and the same lighting level.  Subsequently they were analysed using AOS ANTERIOR using the “bulbar redness” function in three different areas of conjunctiva using the automatic continuous grading from 0 to 4.

3

Results 180 160 166 140 154 120 100 113 80 60 40 20 23 31 15 0 S I 2.5 1.8 1.7 1.6

2 1.5 1 0.8

139 90 58 59

Conjunctival compression (Âľm)

5 N 2.1

12

S

T

1.6 1

1.4 1.2

N

I

12

90 65 10 T

N

2.1

2 1.6

1.3

0.5 0

S

I

N

0

1.91.9

0.8

1

T

79

66

1.91.8 2 1.81.7 1.5 1.5 Bulbar redness Scale 1 to 4

I

52

2.5

2

1 0.9

S

57

72 80

33

0.5 0

3 2 1

3 2 1

T

 From our results we found a very strong negative correlation (r=-0,834)

B u l b a r re d n e s s

Results

Chart Title 3

between the bulbar redness

2.5

and the compression

1.5

induced by different

0.5

peripheral design as evaluated using the OCT information.

2

f(x) = - 0.01x + 2.27 R² = 0.7

1 0 0

20

40

60

80 100 120 140 160 180

Conjunctival compression (µm)

Conclusions  In conclusion the objective evaluation of bulbar redness function obtained using an 3

ocular surface and image enhancement software can be an effective support for a better and objective evaluation of the behavior of scleral contact lens periphery on conjunctival tissue in different quadrants without OCT uses.

Thank you!

Computer assisted diagnostics for contact lens practice Dr Byki Huntjens PhD MSc FIACLE FBCLA

Computer assisted diagnostics for contact lens practice Evaluation of AOS software Dr Byki Huntjens

PhD MSc FIACLE FBCLA

Outline • Grading in practice Purpose: Evaluation AOS software for conjunctival hyperaemia – Repeatability – Agreement between grading scales – Agreement between practitioners (level of

Grading in practice  Assess deviations from normal  Record baseline measurements  Facilitate clinical decision making

Grading in practice

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3459675/

Grading in practice

https://www.aao.org/image/neiindustry-grading-system

Grading in practice

https://www.opticianonline.net/cet-archive/100

https://www.opticianonline.net/cet-archive/100

AOS software

Methods Images

 N=30 N=24  Variety of severities

Grading    

AOS, CCLRU and Efron N or T and Lid area 2 Randomised Two different days (1 week apart)

Comparison  Between days  Between grading methods  Between observers

v2

(optometrist versus student)

Repeatability (grading reliability) Bulbar hyperaemia

Palpebral hyperaemia

Sample size Mean ± SD

Efron 30 2.21 ± 1.14

CCLRU 30 3.13 ± 0.60

AOS 30 1.80 ± 1.37

CCLRU 24 2.41 ± 1.22

AOS 24 2.46 ± 1.18

session 1 Mean ± SD

2.16 ± 1.14

2.98 ± 0.72

1.81 ± 1.40

2.43 ± 1.05

2.46 ± 1.17

session 2 Mean

-0.05

-0.15

0.017

0.021

<0.001

difference Reliability Coefficient

0.31 0.62

0.26 0.50

0.06 0.13

0.40 0.78

0.05 0.10

0.57 to -0.66 P=0.423 0.926

0.35 to -0.65 P=0.004 0.885

0.14 to -0.11 P=0.169 0.998

0.80 to -0.76 P=0.800 0.9101

0.10 to -0.10 P=1.000 0.998

of Repeatability 95% LoA T-test R2 value

Repeatability (grading reliability) Bulbar hyperaemia

Palpebral hyperaemia

Sample size Mean ± SD

Efron 30 2.21 ± 1.14

CCLRU 30 3.13 ± 0.60

AOS 30 1.80 ± 1.37

CCLRU 24 2.41 ± 1.22

AOS 24 2.46 ± 1.18

session 1 Mean ± SD

2.16 ± 1.14

2.98 ± 0.72

1.81 ± 1.40

2.43 ± 1.05

2.46 ± 1.17

session 2 Mean

-0.05

-0.15

0.017

0.021

<0.001

difference Reliability Coefficient

0.31 0.62

0.26 0.50

0.06 0.13

0.40 0.78

0.05 0.10

0.57 to -0.66 P=0.423 0.926

0.35 to -0.65 P=0.004 0.885

0.14 to -0.11 P=0.169 0.998

0.80 to -0.76 P=0.800 0.9101

0.10 to -0.10 P=1.000 0.998







of Repeatability 95% LoA T-test R2 value



Subjective grading: 95% fall within 1 unit Objective grading: 95% fall within 0.25 units Subjective grading: 95% fall within 1.5 unit Objective grading: 95% fall within 0.20 units

Agreement between grading methods Palpebral Bulbar hyperaemia Method 1 Method 2 Sample size Mean ± SD method 1 Mean ± SD method 2 Mean difference 95% LoA CCC Confidence Intervals CCC T-test Effect size (partial eta squared) R2 value

Efron

Efron

hyperaemia CCLRU



F(2,28) = 40.34, P<0.0005 multivariate eta squared = 0.74



t(23)=-0.355, P=0.726

CCLRU

CCLRU AOS AOS AOS 30 30 30 24 2.16 ± 1.14 2.16 ± 1.14 2.98 ± 0.72 2.42 ± 1.12 2.98 ± 0.72 1.81 ± 1.40 1.81 ± 1.40 2.46 ± 1.17 0.82 -0.35 -1.25 0.04 1.90 to -0.26 0.86 to -1.56 0.56 to -2.90 1.11 to -1.03 0.603 0.850 0.436 0.899 0.444 to 0.725 0.730 to 0.919 0.273 to 0.575 0.787 to 0.954 P<0.0005 0.73

P=0.004 0.26

P<0.0005 0.67

P=0.726 0.005

(large effect) 0.856

(large effect) 0.810

(large effect) 0.614

(small effect) 0.788

Agreement between practitioners Bulbar hyperaemia

Palpebral hyperaemia

Sample size Mean ± SD

Efron 30 2.16 ± 1.14

CCLRU 30 2.98 ± 0.72

AOS 30 1.81 ± 1.40

CCLRU 24 2.43 ± 1.05

AOS 24 2.46 ± 1.17

experienced Mean ± SD

1.86 ± 1.2

2.52 ± 1.00

1.76 ± 1.32

2.21 ± 1.08

2.45 ± 1.15

0.30 0.37 0.73 1.03 to -0.42 0.959 P<0.0005 0.904

0.47 0.48 0.95 1.41 to -0.48 0.853 P<0.0005 0.802

0.05 0.20 0.39 0.44 to -0.34 0.995 P=0.177 0.982

0.08 0.78 1.54 1.61 to -1.46 0.944 P=0.023 0.829

0.017 0.06 0.11 0.13 to -0.09 0.999 P=0.162 0.998

student Difference Reliability CoR 95% LoA ICC T-test R2 value

Conclusion â&#x20AC;˘ For bulbar and palpebral hyperaemia, all three methods showed acceptable repeatability and agreement AOS system is substantially more reliable than the subjective methods of grading

Multiple systems cannot be used

Acknowledgements * AOS * my co-authors Mandeep Basi and Dr Manbir Nagra

And thank you for listening

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