Mayo Clinic Global Health Program: Ghana Mayo Clinic has developed a wide international footprint through its Global Health Program. In this lecture, Eric D. Bothun, M.D. discusses his work in Kumasi, Ghana, where 29 Mayo Clinic physicians participated in a program with a local teaching hospital: Kumasi Academic Teaching Hospital.
All right, I have the um opportunity of presenting a little different uh format to our educational um session. Uh, this is meant to be educational, um, just like Grand Rounds is normally, um, an opportunity for us to be challenged clinically and be prompted to care for patients differently, to learn more things. This is, uh, meant to present a new opportunity for our department, um, actually for the Mayo Clinic. Uh, that we want you all to be aware of, um, so again, my name is Eric Bothan, uh, pediatric ophthalmology here, as you know, and had the opportunity to be involved in our global health program, uh, recently to Ghana, and I'd like to explain, um, what it. Um, what the trip is about and what this opportunity is about for our department just for this morning. Number 1 is recognize the glowing international footprint that Mayo Clinic Global Health Program has initiated, um, over time. Number 2, describe what Ch means. Uh, number 3, review the ophthalmology academic opportunities at CAF in Kumasi, Ghana. The multiple choice question of the day is what are the three international sites that the Mayo Clinic has chosen for our global health humanitarian teaching, and I listed 5 locations here, and by the end I would hope you'd be able to recognize the 3. Mayo Clinic Global Ophthalmology Program Health Program. You can um learn about this online. Uh, the opportunities continue to expand, and I'd like to just um just talk through this on the other slides. Um, Doctor uh Bernheiser, Doctor Scruggs, and I probably both are resources for you and maybe others in this department have had interactions with this program. I do want, on that note, just say that, um, many people on this call are involved in international global health and truly global as Brittany's shared us, you know, encouraged us to think about it all and Ashley also is all is all over. Global is here in Rochester, global is somewhere else around the world, um, these 3, this program is meant to be all encompassing. Um, and I just, you know, as you recognize too, for those that aren't fully aware that we have a global ophthalmology track for our residents now that Ashley has been leading and creating, um, with other support, um, my background, just why was I asked to be involved in this or why was my interest, I've, uh, been involved in medical teaching in a variety of countries over my career, um, program development, some a post, uh, international work, um, but the opportunity to be involved in, uh, the global health program here at Mayo is quite broad, uh, the. Mayo has chosen three sites to invest in. Um, the first was Da Nang, uh, Vietnam. Uh, that's been, uh, really active for many, many years, uh, and multiple departments continue to go to Vietnam in a, in an educational, uh, cross-learning experiences and, uh, and, and setting up programs. There are surgical uh departments in my understanding, going to Vietnam. We have not yet, um, um, been active in Vietnam. And that may soon change. Um, the next one that was hot off the press was this, uh, uh, ask that people that had an international or global, uh, history of activity and program development, um, were asked to come to the table. Uh, Doctor Bernheisel and I were both gonna go to Ghana, and then I was the one that she had a conflict, so I was able to attend. And then the last that's just been chosen in the last two months is Bolivia, and that trip will be pending soon. Um, in over the summer, so what is CT, and we'll get to that in a second, but, um, CT is, is a, I'll just say is a, is a Kumasi academic teaching hospital, and you're gonna hear about Kumasi in a second. So as of last month, 29 physicians from different departments were asked to go to Ch and build relationships, teach throughout the week, um. Invest and start launching this new program with uh this program in Kumasi, Ghana. Ironically or interestingly, I found I was the only surgeon, um, but certainly there was a whole boat boatload of us that went to Ghana. Here again is where Ghana is located, flew to Europe, and then down to Ghana. Uh, both were about 8 hour flights, that's so 2 flights to get to Ghana. We flew into Accra, which is right down here on the coast. That's the capital city. And then the location that's been chosen by Mayo after years and months of studying and um and seeing proposals is in Kumasi and you'll see Kumasi is a little bit in the center of the country um horizontally and just, you know, but everything's a little more in on the south um Kumasi draws. Patients from all over Ghana, um, maybe a little bit less from the south cause Accra is there. The two big teaching hospitals are in Accra, that's called Corlibu and Kumasi, um, which is this again, Kumasi Academic Teaching Hospital, CAT. And so I, when in going there, I was quickly aware and Doctor Bernheisel helped me in this regard and partnered, there's a fair bit of ophthalmology footprint in Ghana, both in pediatric development, ROP but also cataract and other services, um, those of you that have been. Been involved um with the Himalayan Cataract project um and uh in Nepal recognized that that is such a strong training program now they now have developed programs around the world including in Africa and Kumasi is where they've center or uh Ghana is where they've centered their focus. So I connected with um Cure Blindness. I don't have their slide for their organization here, but, um, knowing that they had such a footprint, they have staff in country in Ghana and are networked in the academic training programs. So I figured if our department ophthalmology was gonna. Connect with the ophthalmology educational programs in at CT we should connect with cure blindness and this was such wise um counsel by Ashley and my own investment that we we put into um understanding and partnering with CAT. One of the unique things they said, if you're going to cure to Kumasi, please bring corneas. And I thought, uh, OK, but the cataract, they don't have eye banking, as Ashley Bernheiser's had rich experience in research in in in Africa very thoroughly, and so they rely on people to bring in corneas. And so I said, sure, I'll go to Ghana and I will bring in corneas. I've never done this before. Um, our local Minnesota, we're all, our department is Minnesota Lions, um, and our Lions Eye Bank in the city just stepped up up the Twin Cities stepped up massively along with multiple other eye banks in the country. Um, cheer blindness organized this request. I just was the mule that carried corneas. My shock was knowing that these all had to be hand-carried. Um, I got home on a on a Thursday night leaving on Friday, and I had this many boxes of corneas in my front going, how in the world am I going to carry this onto an airplane? And um with the support of Minnesota Lions, I had 3 of these nanocoolers that each could store 8 corneas, so at home, I had to put them in these nanocor coolers. They're chemically cooled for 96 hours, and I was able to get them in 2 boxes and 2 sets of carry-on um with me. And this was quite anxiety provoking. I got to the airport. Um, I, I will admit I didn't know how that was going to go. It actually was seamless. The airport security was phenomenal and saying, yes, we're used to this. We support you, and you go. Um, landed in Kumasi after this flight. This is Dr. Bauer on the far right, um, and then. The, um, the cure blindness staff in country, um, we landed there, got through security easily with these corneas, and then gave them what was essentially a record was 28 corneas that we brought in for transplantation in the next, it had to be within the next 10 days, and, you know, that'll be part of the story here. So Accra, um, uh, is a fairly large city on the coast. Very quickly though, you realize you're no longer in Rochester. I did put a video in of what a city street might be like, not we're in the downtown, but, um, it is, it is an experience that for any of you that do go. Coconuts on the right. Um, so this is just traveling to, uh, Corlibu Hospital in Ghana, where I went to at the end here you'll see, but, um, again, this is not, uh, it, it's a definitely, uh, a dev uh, a country in development, um, and, and educationally there are aspects of it that you realize, um, it just would, it is a rich complement to be involved in. Our accommodations were chosen by Mayo ahead of time. We stayed at the Marriott right by the airport in Accra, and then either went land or flight to, um. Oh, this was a neat, I in the Marriott, I, there's a, an art display that I got a kick out of cause this artist that's a Ghanaian artist really likes eyes, and I thought the left looked like a good example of ptosis. The middle was thyroid eye and the right is just universal. I, I was struck by his, his, his, uh, the, the display even at the Marriott. But Mayo arrived. As I said, there were 29 of us that um flew in to be educationally active throughout the week. I really bonded with many of these people and and appreciated the entire effort. Um, we stayed at the Lancaster, which if anybody would, it's fairly close to the Kumasi Cath Center. Um, and this is where Mayo's chosen to have our staff stay. It was a, a nice hotel. Um, here is the Ch Teaching Hospital again. Um, actually I had mis mispronouncing, I'm forgetting. It's the KOpo, um, Oka Teaching Hospital, but I, I think of it as a Kumasi Academic teaching hospital anyway, that's what Cath is. And then the eye hospitals in the back that is. On an unpopulated day on a Sunday when we arrived, normally the parking lot is full, and that is the eye center. We then spent a number of days in a, in a teaching conferences, breaking out into our own, um, into our own groups. Um, I gotta be a speed up a little bit. They had music that celebrated this massive, um, conference, and then we, um, spent time in centers doing individual teaching. This is Doctor Awasi Ahmed. Uh, Doctor Bernheiser knows him from residency. He's a phenomenal surgeon. He's the retina surgeon at CT. Um, this is the staff they had. Most departments are recommend, are, are, are, you know, are here on site. Um, really striking to, um, get to know many of these individuals and what they are doing. Um, this was the, the, um, early in the morning, the patients come and have a, a sort of musical worship time, um, uh, the, the The environment there, the, the, you know, dominantly Christian, um, environment in, I think it's like 70% Christian and about 25%, um, uh, Islam, uh, background, and the lobby though had its unique characteristics here. I thought the sign was quite striking there at Kunfo, um, not, not, not a sign we see in ours. One of the things I did not know, I didn't pick the week, but when I got to the C is Orbis was also there, and I will admit Orbis is, I've been involved in teaching and development in Africa for some time. I was struck by the phenomenal enterprise that this was. They, the, the plane was in Accra, but the teaching staff doing surgeries were in, um, at Ch with me doing educational programs, and they, uh, I, they brought in anesthesiologist. They brought in staff, um, really in a team. Effort that I just showed teaching that's happening at for anesthesia and on the table, um, in a variety of ways. It's simulation now that's present, um, the, um, both ROP simulation, cataract simulation, uh, there, and then, uh, um, the, the surgical program, um, was, was, uh, quite apparent, um, the corneas, so the corneas landed in in in Ghana and got divided up. 2/3 came to, um, um. Kumasi in, in a third state in, in Accra, and I was able to um be part of witnessing watching these corneas go in. Um, I think in the end, 26 corneas got implanted within the next week. It was striking for me to see these patients, to meet these patients. Um, I've never been part of a corneal transplant, um, process, but, you know, internationally, but it was, um, incredible to me. These are different cases. I got, my phone had too many videos and stories. Um, the lions, um, shined in Ghana. And gave back sight, um, both, many of them were, uh, like about a third of them were DEC, um, and many of them were PKs, um, and I just would share with you for those that have a corneal background, the team there is phenomenal. These are some of the patients that Underwent it, but the team is, was unbelievable in my opinion at at their corneal technique. I watched cataract surgery and cornea, um, had educational things about peds and shared, uh, but I, I really have phenomenal colleagues to connect with. Oculoplastics was the same. Um, that's uh Doctor Peter Armah, that's standing watching the monitors. There's a monitor on the left in the walls. The retina process was striking. I was told by Ashley Bernheiser ahead of time that Awassi Ahmed was a gifted surgeon, and I, um, um, was able to watch the Orbis process with him, um, doing different macular hole repairs, um, doing vitrectomies, retinal, uh, giant retinal tears, um, in our, uh, educational time. Oculoplastics, glaucoma, uh, neuro-op, again, they don't have a dedicated neuro op, uh, uh, all have opportunities, uh, for growth and connecting. The clinics were busy, um, and a couple last things before I wrap up, um, the king of Asante, uh, is the, uh, regional king of the tribe of Asante in that part of Africa. Um, just the impact of how important this relationship is locally. They, he invited the Mayo docs to, um, his palace. These are pictures from that event. We all had to line up, give an introduction to herself before we went and greeted the king. Relationships. I was there a week, and I will tell you is Phenomenal, um, to appreciate the opportunities in education, the abilities they have there, the technology they have there, um, the appreciation they have, uh, in this academic partnership with Mayo Clinic. And the impact The, the weak had, um, this is Doctor Ahmed, uh, with one of his patients, but, um, in the lobby, but were meaningful. And so I think the Mayo Clinic left all the more encouraged about this particular site, um, as we're investing in it. I then also though I shared with you, this was all up at Kumasi, and cure blindness was very clear of how important, um, the two training programs are and the ophthalmology training program in Accra. And Kumasi share educational. They, they share speaking, um, by virtual connection. So I said I need to go see the team in Accra. So I was the only went to that spent one day in Accra doing some collaboration, teaching, um, observation. And so we went to the Corlebu Teaching Hospital in Accra. I did, I did for one day. I was the only male doc that did that and witness care connected, did a teaching session. Um, appreciated their technology, their teams, uh, highly impressed with them, um, in their education, and, uh, their team here, um, strong but mighty, um, what is listed at that this is a really busy clinic. I don't need to go through the every room has 2 or 3 patients happening at the same time, um, just this is the Peds clinic. It is busy, but I was impressed with the quality of care, and there the leadership at that location sending their greeting, saying, Please don't forget us. If Mayo's coming to the country, can you at least come to us sometimes? I did watch some very complex sutureless extra cap. Most they have faco and sutureless at both sites, mostly extra cap. And then I was struck by the teaching and simulators. Uh, this was a brand new simulator. I was actually the first one to demo it, um, at Accra that does both faco and, um, uh, sutureless extra cap surgery. I ruptured the globe. If I would, that was comical, but then I was able to watch, you know, a, a master who'd been trained in India on this technique. Um, I did not do any sightseeing. This was not an educational trip or a, a fun, uh, uh, a non-academic fun trip. Um, I did come back very moved by the events of what, including this a corneal transplant process across the globe. Since we're all lions, we just had the big celebration. And so I was able to carve a Minnesota Lions pumpkin celebrating this, uh, Ghanaian effort by, um, the, the Minnesota Lions. So what are the next trips? The next trips are scheduled here. There's one in Vietnam. I've been strongly asked to attend. Um, that's still being weighed on my schedule, um, but Bolivia will be in June. I will not be going, and I would love to have someone else be a, a lead if we, if there's interest. And then the next, um, calf trip is in. Um, cath, meaning in Kumasi, is in October, um, but we can go on our own. People can have their own schedule, and I'll just say if you're going to a cath, uh, let's, I think there's rationale to consider, um, also going to Corlebu in Accra. Um, takeaways, this is a priority for the Mayo Clinic. It is a sort of a strong push that the Mayo Clinic um has physicians collaborate for teaching and research across the world at these three sites. You can do things all over the place. I'll continue to go to Zimbabwe, but they're asking. Us and departments to really think about collaborating in these areas. Consider virtual platforms. Many of the other 29 physicians are already active in setting up, uh, virtual platforms or facilitating that in teaching and then again academic trips that are available for consultants, fellows, and residents. Um, fellows and residents can go to, um, international locations. The, you know, my plug there is don't say you're going with another doc and saying we're gonna go to lots of surgery, because that's not the case. We're going to learn from them. You are and going to observe and, and truly, um, you know, be stimulated for your own future engagement, and that's what the support that Mayo gives residents and fellows, uh, um, it comes with that sort of priority or theme. Um, again, so what are the three sites, uh, Da Nang, Vietnam, Kumasi, Ghana, and I don't have even the city because it's just been chosen, but I know, uh, Bolivia is the last location. Um, and, and just would, uh, open it up for conversation questions, uh, as I think we have this opportunity, um, at Mayo in our department to either not choose to participate in some sites we could pick one or multiple, uh, but it's certainly an opportunity that Mayo wants us to consider going forward, and I'll stop there. Ashley or Brittany, who's also been a great voice in this arena, our voices in this arena can comment too. Yeah, thanks, Eric, so much. This is Ashley Bernheisel for, um, thanks for presenting this. I think it really is a great opportunity to have Mayo support behind these kind of trips. Um, they're opportunities for For residents and like you said, fellows as well, one thing to keep in mind, I mean, one question that might come up, well, oh gosh, they have all of these, um, you know, simulators, and cure blindness is there. But what's cool about about Ghana in particular and Kumasi is that it really has an opportunity to be a center of excellence in West Africa. And, and, you know, we, as, you know, our ophthalmology department at Mayo. We don't have a ton of manpower to like go choose our own spot and and and go, you know, once a month. We just don't, we just don't have that at this point. So I think this is a really great opportunity for someone who maybe wants to go once every 2 years somewhere when there's support from NGOs, other academic institutions, it just really gives you that opportunity. So I just wanted to encourage those of you who maybe don't like this isn't like your thing that you do all the time, but there's, there's opportunity here. That's a great comment. I think that's one of the drivers why Mayo Clinic chose the sites that did is they're definitely teaching programs. Um, I, I will comment too on your, these other, uh, NGOs that are already in Ghana. I found it incredibly appealing. Um, sometimes when I go to Zimbabwe, I feel like I'm doing all the heavy lifting myself and, in, in teaching. And you know, here, Mayo's equipping across the departments, #1, and, and also research collaborations, but #2, these other organizations, I really, I really felt like they've gotten momentum and, and yet the, the, the opportunity to go and teach and expand the care is just rich. So the teaching priority is why they were chosen, and I, I, I thank you for that comment, Ashley. All right, with that, I will stop sharing and uh let the next. Journey start. Thank you. Thank you, doctor Bothan. That's gonna be a a hard talk to follow up. Um, we will change gears completely. So I am Sherry now. I'm one of the uh optometrists here at Mayo. Rochester. And I will be discussing scleral lenses and some current concerns with scleral lenses. Learning objectives will be threefold. We will discuss corneal thickness with scleral lens wear, midday fogging, and concern with intraocular pressure and scleral lens wear. Label discussion. Scleral lenses, hopefully, you're all at least familiar with them. We use them mostly for corneal irregularities to help vision. Secondarily, they're used for ocular surface diseases to help protect the surface of the eye. Here's an example of a sclero lens sitting on the eye. Part of the concerns that have been popular recently with scleral lenses are cornea swelling with sclero lens wear. I will get into that shortly. Midday fogging. So when we talk about that, think about the fact that there is a fluid reservoir here between the cornea and the contact lens. And then finally, intraocular pressure. Concern with that is mostly where the contact lens lands that it could be putting some pressure on the aqueous humerus outflow. Corneal thickness. What does an average cornea do? So corneas do swell. They're, they are an active Part of the body that changes. It's not static. There's going to be changes throughout the day. Overnight, the cornea swells because the lid is closed. Concern then with the scleroin is, is that we have something else over the cornea preventing oxygen from getting to the cornea. So this picture here is thinking the more layers you put on top of something, the harder it is gonna be for oxygen to get through. With the sclero lens, you have the thickness of the contact lens, which is fairly thick. You have The fluid reservoir, which adds thickness and barriers to the cornea for getting oxygen. What else is involved in getting oxygen to the cornea? Well, it depends on how healthy the cornea is and how long are patients wearing these lenses. There was a theoretical model published in 2012 that suggested that scleral lenses should be fit with a high oxygen permeable material, that lenses should be small, 15 millimeters, to help keep the cornea clearance thinner, to help keep the scleral lens thinner. And that the fluid reservoir clearance should be 200 microns or less. Well, that sounds like a good idea until you start fitting an irregular cornea like you see in this picture, which you might have an area here of less than 100 or less than 200 microns clearance. But you have such an irregular cornea that you have hundreds of microns of clearance on different parts of the cornea. That is the nature of it. We're not gonna hit this ideal model of how to fit a scleral lens, especially when we're fitting these on irregular corneal surfaces. And this is just a reminder, this is a recently published study looking at standard soft lens wearers. So don't forget that there is corneal thickness, corneal swelling with soft lens wear compared to controls. This is not just a phenomenon in sclero lens wearers, and I think sometimes that gets forgotten in the sclero lens world. We'll go back again then to this idea of fluid reservoir thickness and cornea swelling. Part of the scleral lens fitting process is how does this lens cut off potential fluid from interacting with the surface. So, The, the sclero lens can have tear exchange under the surface of the lens. So it is possible for oxygen to come through, through the circulation underneath the edge of the sclero lens. There is some support from the limbus of the cornea to help support cornea from swelling. But what happens with lens wear? There's not a lot of studies out there about long term swelling. A lot of the studies out there are on healthy eyes, different modalities changing to see what happens in the first few bits of lens wear. So here's a study that only has 10 eyes, healthy eyes. They only have 90 minutes of lens wear, and it's a smaller diameter lens, well, small in my world. It's a 16.5, which is pretty average for most scleral lenses out there. We fit up to 19 millimeter lenses, so 16 is a little bit on the small side. What they did in this study was they looked at different clearances of that fluid reservoir, a low clearance, a medium clearance, a high clearance. They measured scleral or corneal thickness centrally, and then in the far periphery. And they found with just 90 minutes of lens where they did get, this is percent of corneal. Uh, thickness increase. So things did increase and more so with a higher fluid reservoir clearance. Peripheral, peripherally, there was some more swelling in the low and medium lenses than in the high, but there's swelling everywhere. Similarly, we did a study here, not looking at different lens clearances, but looking at different lens diameters. So 15 millimeter lens, I think is on the smaller side. We do a lot of 18 and 18 too. We looked at central thickness, superior, inferior temporal, and nasal. Now, in the periphery, it wasn't that far of a peripheral clearance because we use the Pentaca and it doesn't do quite as good as getting that far periphery. So these are maybe paracentral clearances for thickness. And again, we see that there is a percentage of corneal swelling after 2 hours of lens wear. In our study, we found that the greatest swelling was in the smallest diameter lens, the 15 millimeter. And that had almost a, almost a 5% swelling after two hours. Again, these were healthy eyes, but we see the swelling after lens wear. Another study looked at overnight lens wear with scleral lenses. This is a very rare phenomenon. The point of this study was really looking at, well, what happens if we put these eyes in high stress, how much do they swell? This study excluded those that had more than 5% 5% swelling during three hours of lens wear during the day. So they kept this to maybe low swellers, mild swellers. But what happened with overnight lens wear After wearing a scleral lens with an eye closed. These are the results. So daytime lens wear with these folks that had more minimal swelling was up to 3.5% swelling with 3 hours of lens wear. Overnight, they had up to a 10% swelling. Again, there's only a few subjects here. Some of these subjects did report haze from the cornea swelling in the morning. Interestingly, they did take a look at one of those high swellers that had 5% swelling during the day, and that person had 17% cornea swelling with overnight wear. They did measure um endothelial cell density with these patients and found a correlation with higher endothelial cell density and less overnight swelling. Are we gonna measure endothelial cell density with every patient though? I, I don't think so. I'll get more into that. My favorite part of this paper was that they said this degree of swelling should not rule out overnight therapeutic sclero lenswear if the disease process is deemed to be more damaging than the hypoxic effect of the RGP sclero lens wear overnight. This is what I completely agree with. There's some cornea swelling. Most of these studies are less than 5% swelling for sclero lenswear. Most of the patients that we're fitting have a reason to be fit with these scleral lenses which outweighs the potential of some swelling. So is there a certain patient that shouldn't be fit with a, with a sclero lens because of the cornea? Perhaps. Um, but I don't think we have to look at The, the doing like an endothelial cell count for patients to be wearing sclero lenses. We have a research study that looked at 869 uh sclero lens wearers. Only 1% of those patients stopped sclero lens wear because of corneal swelling. We've also asked Sclero lens fitters, how often do you measure corneal thickness in your patients. In 2020, it was only 38%. This topic has gotten hotter, so it's almost 50% that are, are measuring, but still, it's around half that measure corneal thickness. So how concerned are fitters really? I think there are cases to be concerned, and that is cases where maybe the cornea is not very healthy, and Doctor Shornak and Doctor Bernheiser have a published paper of what they call the sclero lens challenge. So this is taking a patient that comes in with some Problems with their sclero lens. Usually vision gets very cloudy. And what we do is we take a look at before any lens where, what does their cornea look like. We challenge them with a well-fit sclero lens. Maybe it's not best for their vision, but we make sure that it's not the Fit of the cornea that's changing or the fit of the sclero lens that's causing trouble to the cornea. Put on a well-fit sclera lens for 2 hours and then have them come back and see if there's cornea swelling. So, can we induce cornea swelling in 2 hours of lens wear? If so, then maybe we need to change um The cornea and not the sclero lens. So this is a patient that ended up failing this corneal uh lens challenge and ended up having endothelial surgery, which then they were able to wear a well-fit sclero lens, perfectly fine, no swelling. The next topic that kind of goes along is that we can notice some, some fog with cornea swelling, but there is a symptom called midday fogging in scleral lenses. What is it? When you ask patients or practitioners, you're gonna find studies have found that 20 to 58% of sclero lens wearers report this midday fogging. Vision starts off clear, but then it gets foggy as the day goes on. But where is that fogginess coming from? Is it the cornea swelling? One possibility. Many lens fitters think of it as debris in that fluid reservoir of the sclero lens, but that's not the only place you might be getting blur. You could also have a, a non-wetting surface of the contact lens, which also creates blur. Many potential factors that can contribute to this, and some studies have been done to look at this. But again, It's not just sclero lens wearers that report mid midday fogging. We did a study of some dry eye patients. We didn't ask, it wasn't specifically sclero lens wearers, it was all comers for dry eye. And we found that when we asked the question of midday fogging, 62% of soft lens wearers complained of midday fogging. So, again, it's not just sclero lens wear, but we've become hyper-aware of this condition with sclero lens wearers. And I will say in all the things I'm discussing this morning. The most frustrating and practical to me is the midday fogging. That is frustrating to a patient that they put the lens on to have better vision, and then the vision gets worse as they wear the lens, and there's not a great way to fix it because where is it coming from? uh habitual lens wearers, we asked a bunch of lens fitters to report on their last square lens patient that they saw in clinic to get just a sampling of data. In this sampling, we had nearly 250 practitioners reporting on patients. 26% of these patients reported midday fogging. Most of them had worn lenses for a couple of years. When we looked at the data, there was no difference in lens diameter between what we would call foggers and non-foggers. There was no difference in haptic design or the landing zone of that lens on the eye. No differences in storage solution, no differences in What you use to fill the bowl of the lens. What did come up was if there was redness or irritation reported with lens wear, that happened more frequently with midday foggers. Is it potential that there is an inflammatory portion going on causing this fogging wherever it might be coming from? Another study Looked with 5 different sites and we just took a sclera lens wear that came into the clinic that had lens on for at least 2 hours that day. They've worn the same lens for 6 months. Um, and had pretty continuous wear, at least 6 days a week, 5 hours a day. And we just put them behind a slit lamp, and what did we find with these folks? We found a fairly high amount of fogging reported in these patients. And again, most of these patients were fit for uh corneal irregularity, a higher than usual portion for ocular surface disease, but these five sites that are included here are sites that fit a lot of diseased eyes. So that's why we have a higher ocular surface disease in this patient group. When we looked at self-reported Fogging and the clearance or fluid reservoir depth. Those that had fogging had slightly less clearance than those that didn't. A lot of people think, again, if you have a smaller clearance over the night, you're gonna have less fogging. Maybe not necessarily true. Where else there might the fogging be coming from? Front surface non-wetting, so looking at the front surface of the contact lens, where was where we saw a lot of problems with midday foggers, a lot more than those that didn't fog. The other thing we found was some haze or particles in the fluid reservoir. But a lot of things that I think sclero lens fitters don't look at is that front surface of the lens. Is it wetting well? We, we've got a trick to help with that. But again, with, with these things, we're finding maybe why patients are getting midday fogging, but there's not a great solution to it yet. There have been studies on what exactly is in that fluid reservoir for patients. This is in a group of, of healthy subjects in just 4 hours of runs where patients that are, those that reported fogging did have more cells in their fluid reservoir than those that didn't fog. So maybe there is a component of inflammatory cells action that's causing some of this haze in the vision. And also, this study found that maybe clearance is related, but again, only 4 hours of lens wear. Not stable results in here. What do you do then if someone complains of mid midday fogging? Idea is to adjust the lens diameter, landing zone or clearance, but that hasn't been found to solve anything. Sometimes we do suggest a more viscous solution like a Soluvisc in the bowl of the lens to help slow that fogging down. For dry eye patients, sometimes we use a drop of serum in the bowl of the lens to help that ocular surface be a little healthier. We also suggest for those that have this fogging on the surface of the lens, what we call a squeegee technique. So if that surface of the lens has some non-wetting and gunk in it, we advise patients to take their little removal device and instead of using it to remove the lens, use the edge of that device with a little bit of preservative-free saline, wipe it across the surface of the lens to clean up the vision, and that can work. A lot of this can come from some mybomian gland disease, so we do try to address that to make a healthier surface for this lens to be in. But it shouldn't be forgotten that maybe patients are having some corneal edema that's significant enough to cause fogging. In that case, maybe we put in a, a channel to help oxygenation for the cornea. Fenestrations are used occasionally or we need to send them to have a, a surgical treatment for their cornea. The final thing I'll discuss in this group of concerns with sclero lenses is intraocular pressure. This has been around as a hot topic. Part of the problem with wearing a sclera lens and checking pressure is how do you do a pressure check when the lens is on the eye. There are two different ways we can potentially check pressure on the eye. One is with pneumotonometry. This is a small diameter lens. You can see the edge of it here. This is a 15 millimeter lens. You can take a measurement off to the side on the conjunctiva to, to measure intraocular pressure. There's a other device called the diatton that measures corneal or pressure through the lid of the eye. This is a large diameter lens here. This is a fairly easy eye to get outside of the lens onto the lid. Part of the problem measuring um with the diatton, one, it's not very reliable. And two, if you don't have this lid up above that contact lens, you're gonna do this measurement over the contact lens, and that gives it erroneous high reading. Many studies have tried to look at this and figure out, well, do scleral lenses cause problems with intraocular pressure. A lot of these are on, again, healthy eyes, not people that are wearing the lenses full-time. Uh, so some of them are, are just a few hours of lens wear, various lens sizes, and we've got various results. Also depends on what are you using to measure that pressure. So, jury is still out on this as well. What do we see in the clinic? In one of our studies that looked at 522 subjects, we found that only one reported that they had um increased pressure with spiral lens wear. How often are practitioners checking pressure in the eye with scleral lenses? In our study of practitioners in 2020, 45%. In our recent study from this year, it's up to 60% are checking pressure. But how often are we seeing a high pressure in these patients? I, I am not sending the majority of my scular lens patients over to glaucoma, so I think it is low. One of the new things that we're, that research is starting to look at is measuring the optic nerve with the sclero lens on the eye. So this is new research that's coming out, trying to look at changes in uh Birch's membrane with the sclero lens on, seeing that there are changes with sclero lens wear compared to without lens wear. So potentially there's changes to the optic nerve. Again, this is healthy eyes, um, only a few hours of lens wear, so hard to know what is going to happen as we study this more. Key points here are patients with scleral lenses need to be monitored. We need to listen to what their concerns are and look for them. Is there Fogging coming from a, a fluid reservoir, poor wetting surface, and don't forget the health of the eye. Are we checking for things like intraocular pressure? Are we checking the surface of the eye without the lens on? So these are great for, for certain patients, not for every patient, and sometimes the lens won't fix all of their issues. So we're gonna go back to what um initial question, what percent of sclera lens wearers report midday fogging. That is 20 to 58%. 58% was, was higher in a recent study and that, that was with more diseased eyes. And I think we're out of time, but I'm happy to take any questions if anyone has any.
