A C T A O P H T H A L M O L O G I C A 62 (1984) 566-576

Dcpnrtmcnt of Ophthnlmolop (Hcnd: T. I . Rrrtclsm). 1rniivrviQ of Rcrgm. Nomnv

HYDROPHILIC CONTACT LENSES IN CORNEAL DISORDERS

BY

GUNNAR H0VDlNG

Hvdrophilic ‘bandage’ lenses were fitted in 107 patients with corneal disorders not satisfactorily responding to conventional medical treatment. An over-all beneficial effect on both ocular discomfort. visual acuity and corneal disorder was found (P < 0.001). Regarding each group separately only patients with bullous keratopathv and those with corneal ulcers achieved a significant reduction of ocular discomfort ( P < 0.002) and a significant improvement of visual acuity (P < 0.05 - P 4 0.01). In bullous keratopathy corneal oedema was significantly reduced by concomittant use of contact lenses and 5% NaCl eve drops (P < 0.01). Significant improvement of corneal disorder occurred in patients with corneal ulcers and in those with corneal lacerations ( P < 0.002 and P < 0.0 1. respectively). Complications included corneal vascularization (7.5 Q ) and keratitislkeratoconjunctivitis (5.641). Prophylactic use of topical antibiotics appeared neccessary only in dry eye disease.

Kqv nwrls: hydrophilic ‘bandage lenses’ - corneal disorders - ocular dis- comfort - visual acuity - central corneal thickness - complications - lens removal.

The therapeutic use of hydrophilic contact lenses in corneal disorders was first described by Gasset & Kaufman (1970). Particularly in bullous keratopathy, slowly healing or recurring corneal ulcers/erosions and dry eye disease ‘bandage’ lens treatment was subsequently claimed to be a valuable therapeutic adjunct (Leibowitz & Rosenthal 1971; Dohlman et al. 1973; Could 1974; Brodrick 1976; Sundmacher et al. 1976). Unfortunately, several complications associated with bandage lens wear

Received on October 7th. 1983.

566

HBvding Hydrophilic ‘bandage’ lenses

have also been reported, the most serious being keratitis and corneal vascularization (Dohlman 1974: Brown et al. 1974; Schecter et al. 1975: Olson 1978).

This paper presents our experiences with continuous hydrophilic lens wear in corneal disorders not satisfactorily responding to conventional medical treatment. The influence of lens wear on the central corneal thickness, the complications occurring during lens treatment and the causes of contact lens removal are also reported. Finally, the effect of 5% NaCl eve drops used during lens wear in bullous keratopathv is discussed.

Material and Methods Material

A total of 141 patients were consecutively fitted with bandage lenses (134 patients) or re-examined after fitting (7 patients) by the author between February 1976 and June 1983. However, all patient groups with less than 6 subjects have been omitted in this report, because the information they offered was felt to be insufficient. Thus, the present study group included 107 patients (50 females and 57 males) aged 5-91 years. Sixteen patients wore lenses on both eyes, but only their right eyes were included in the study. The duration of wear ranged from 2 days to more than 11 years. Seventy-one patients suspected of having an external ocular infection or being highly susceptible to infection were intermittantly or continuously treated with topical antibiotics, usually chloramphenicol or polymyxine-neomycine- gramicidine eye drops. Table 1 presents the study group according to diagnoses, duration of lens wear and use or non-use of topical antibiotics. In the group with bullous keratopathy, 8 cases were classified as primary endothelial dystrophy (Fuch’s dystrophy), while the keratopathy in 38 cases was secondary to intraocular surgery (25), infections (7), trauma (4) or long-standing glaucoma (2). In 26 of the patients with corneal ulcers an infectious etiology was assumed. Except for the group with corneal lacerations, the patients had received conventional medical therapy without satisfactory results before lens fitting. The patients with kerato- conjunctivitis sicca used non-preserved 0.9% NaCl eye drops, while 34 of the patients with bullous keratopathy used non-preserved 5% NaCl eye drops. In addition, several patients used ordinary, preserved eye drops containing cortico- steroids, mydriatics or antiglaucomatous agents.

The contact lenses used at the initial fitting were ordinary hydroxyethylmetha- crylate (‘Wohlk, BDR) lenses produced by ‘Kontaktlinse Laboratoriet’ in Bergen (20 patients) and the more hydrophilic lenses Hydroflex 72 from ‘Wohlk, BDR (32 patients), Weflex from ‘Wohlk, BDR (1 patient), Sauflon PW from ‘Contact Lenses Ltd’, GB (46 patients) and Hydrocurve I1 from ‘Hydron’, GB (8 patients). The lens

567

Age

(yea

rs)

Patie

nts

No.

D

iagn

osis

M

ean

Ran

ge

Tot

al

107

60

5-91

7

31

34

18

17

71

Dur

atio

n of

lens

wea

r T

opic

al

t =

2

days

<t

2 w

eeks

<t

2 m

onth

s<t

antib

iotic

s t>

l ye

ar

2 da

ys

<2 w

eeks

<2

mon

ths

<I y

ear

Hmding Hydrophilic 'bandage' lenses

tvpe was sometimes changed during prolonged wear, particularly in those patients initiallv fitted with ordinary hydroxyethylmethacrylate lenses. Two aphakic patients with bullous keratopathy wore + 14D lenses, while the other patients wore lenses of zero or near-zero power. Lens diameter ranged from 12.5 mm to K.5 mm.

Methods

The evaluation of the therapeutic effect was based on the findings before lens fitting and at the last follow-up visit during lens wear. Thus initial, temporary changes occurring after lens fitting were omitted. Ocular discomfort, corrected visual acuity and the state of the corneal disorder requiring bandage lens treatment were recorded, as well as signs of adverse reactions to lens wear. The central corneal thickness was measured before and during lens wear in 6 patients with kerato- conjunctivitis sicca and in 26 patients with bullous keratopathy (18 using and 8 not using 5% NaCl eye drops). Only patients wearing Hydroflex 72 or Sauflon PW lenses of zero or near-zero power were included. The results were compared with those earlier obtained in a group of healthy subjects not wearing lenses, and those obtained after 2 weeks daily wear of ordinary hydroxyethylmethacrylate lenses for refractive errors (H@vding 1982a). The thickness measurements were made with a Haag-Streit pachometer No. 1 as described by Stone (1974). Only measurements obtained without the lens on the eye were included. All the readings were made by the author.

Statistical methods

1) The significance of a positive or negative effect of lens wear on ocular discomfort, visual acuity and corneal disorder was tested by the 50% probability test.

2) The significance of a change of central corneal thickness within a group of patients during lens wear was tested by the Wilcoxon's signed ranks test. Student's t-tests were used to compare the findings in the patient groups to the findings in the control groups.

3) Pairwise comparisons between the frequencies of infection in various groups of patients were carried out by using the Fisher exact test (Armitage 1971) or the +test with Yates correction.

Results

Lens effect on ocular discomfort (Table 2)

In the whole study group a statistically significant beneficial effect on ocular discomfort was found (P < 0.002). Within each group a statistically significant

569

Tabl

e 2.

The

influ

ence

of b

anda

ge le

ns w

ear o

n oc

ular

dis

com

fort

, cor

neal

dis

orde

r and

visu

al a

cuity

.

Dis

com

fort

D

iagn

osis

Im

- U

n-

prov

ed

chan

ged

Wor

se

Cor

neal

dis

orde

r V

isua

l acu

ity

Im-

Un-

Im

- U

n-

prov

ed

chan

ged

prov

ed

chan

ged

Wor

se

Wor

se

P

Stev

ens J

ohns

on

Ioni

zing

rad

iatio

n sy

ndro

me

1 4

1

kera

topa

th y

2 3

1

5 1

1 5

2 3

1 1

4 1

Tot

al

60

35

12

<0.

002

53

44

10

<0.

002

37

63

7 <

0.00

2

Hevding Hydrophilic 'bandage' lenses

positive effect was found in patients with corneal ulcers and in those with bullous keratopathy (P < 0.002). In the latter group ocular discomfort was not significantly influenced bv the use of 5% NaCl eve drops. No statistically significant effect of lens treatment was found in the other groups of patients. although an initial. temporarv beneficial effect was often reported.

Lens effect on visual acuity (Table 2)

Although a statistically significant positive effect was found in the whole study group (P < 0.002). the majority showed no change of visual acuity during the treatment. Eighteen patients with bullous keratopathy and 10 patients with corneal ulcers improved at least 1 line on Snellen's chart (P < 0.05 and P < 0.0 1 , respec- tively). In the first group improvement of vision was not significantly influenced by the use of 5% NaCl eye drops. In the latter group the frequency of improvement was significantly higher among those healing than among those not healing during lens treatment (P < 0.05). The visual acuity in the other groups of patients was apparently not significantly influenced by lens wear.

Lens effect on corneal disorders (Table 2)

In the whole study group a statistically significant improvement of corneal disorders occurred (P < 0.002). Within each group a statistically significant im- provement occurred in patients with corneal lacerations (P < 0.01) and corneal ulcers (P < 0.002). Twenty-one of the 22 patients improving in the latter group achieved complete epithelialization. Following lens removal, the ulcers recurred in 5 patients within 1 week, but healed rapidly after re-fitting.

Central corneal thickness during lens wear (Table 3)

T h e mean central corneal thickness before lens fitting and its mean changes during lens wear were very similar in keratoconjunctivitis sicca and in the control groups. In bullous keratopathy the pre-lens thickness was significantly increased (P < 0.002). In these patients the mean central corneal thinning recorded in both users and non-users of 5% NaCl eye drops differed significantly from the mean swelling in the control group of lens wearers ( P < 0.002 - P < 0.05). Compared with the pre-lens thickness, however, only the thinning obtained by concomittant use of lenses and hypertonic saline was statistically significant (P < 0.01).

Complications during lens wear

A markedly increased corneal vascularization was found in 8 patients (7.5%). At least 1 episode of acute keratitis/keratoconjunctivitis occurred in 6 patients (5.6%) (bullous keratopathy 2, keratoconjunctivitis sicca 3, Stevens Johnson syndrome 1).

57 I

Ker

atoc

onju

nctiv

itis

sicc

a 3

Bul

lous

ker

atop

athy

+

5% N

aCl

eye

drop

s

-5 %

NaC

l ey

e dr

ops

u1

Bul

lous

ker

atop

athy

No.

of

patie

nts

Cen

tral

cor

neal

thic

knes

s (m

m)

Cha

nge

of c

entr

al c

orne

al th

ickn

ess

(mm

)

Dif

fere

nce

from

D

iffe

renc

e fr

om

Mea

n SD

M

ean

SD

cont

rol g

roup

** (P

) co

ntro

l gro

up**

* (P

)

6 0.

52 1

0.03

04

n.s.

* 0.

020

0.05

8 1

ns.

18

0.71

4 0.

0922

<

0.00

2 -0

.050

0.

0524

<

0.00

2

8 0.

724

0.06

43

< 0.

002

4.0

13

0.

0405

<

0.05

* n.

s. =

not

sig

nifi

cant

. **

mea

n =

0.5

32 m

m, SD

= 0

.034

mm

, n =

74

(Hev

ding

198

2a).

*** m

ean

= 0

.025

mm

, SD

= 0

.015

mm

, n =

30

(H@

vdin

g 198

2a).

Hovding Hydrophilic 'bandage' lenses

T h e frequencv of infection was higher among non-users (4/36) than among users of topical antibiotics (2/71). but the difference was not statisticallv significant. In the first group infection occurred significantlv more frequentlv in patients with keratoconjunctivitis sicca (3/7) than in the rest of the patients ( 1 !29) ( P < 0.05). An apparentlv traumatic corneal ulceration developed in 1 patient (0.9%). Thirty-two patients (29.9%) lost at least 1 contact lens during the treatment.

Causes of lens removal

In 34 patients (31.8%) the contact lens was removed because the disorder initially requiring lens treatment had healed. Six patients (5.6%) preferred their moderate discomfort and /or visual impairment rather than permanent lens wear with regular control visits. The lens was removed in 26 patients (24.3%) because it appeared to have no therapeutic effect and in 14 patients (13.1%) because of increasing discomfort and/or progression of the corneal disorder. Complications necessitated lens removal in 7 patients (6.6%) (keratitislkeratoconjunctivitis 5 . corneal ulcer 1, corneal vascularization 1). Lens treatment was stopped in 1 patient (0.9%) due to frequent lens loss. Lens wear continued in 18 patients (16.8%). One patiens (0.9%) was lost to follow-up after about 1 month of wear.

Discussion

When evaluating the present therapeutic results, it must be remembered that these patients had not improved satisfactorily on previous conventional medical treat- ment. Thus, better results may be expected in a non-selected group of patients.

Corneal ulcers not healing on conventional medical therapy obviously represent one of the main indications for bandage lens treatment. In'these patients a significant reduction of ocular discomfort may be expected. The rapid epithelializa- tion of about 2/3 of the patients compared well with earlier reports (Dohlman et al. 1973; Brodrick 1976; Sundmacher et al. 1976; Leroux et al. 1982). The recurrence of corneal ulcers within the first week after lens removal in 5 of 21 patients may perhaps indicate the advisability of continuing lens wear for at least several weeks after epithelialization is achieved.

As earlier reported (Espy 1971 ; Dohlman et al. 1973; Ruben 1975). the principal benefit of bandage lens treatment in bullous keratopathy was the significant relief of ocular discomfort. Confirming the expected osmotic effect, corneal oedema was significantly reduced by concomittant use of contact lenses and 5% NaCl eye drops. T h e slight mean corneal thinning even in patients not using these drops may at least partly be due to a mechanical moulding of the oedematous, bullous corneal surface. Improvement of visual acuity was not significantly correlated to the use of

573

Hsvding Hydrophilic 'bandage' lenses

h\ pertonic saline. and must therefore be ascribed mainlv to the more smooth refracting surface created bv the lens.

Bandage lens treatment proved excellent in patients with small corneal lacera- tionc. which all healed with minimal scar formation and surface deformitv.

The present results indicated that the central corneal thickness is not significantly altered in keratoconjunctivitis sicca. The similar lens-induced mean central corneal welling recorded in these patients and in the control group suggested that continuous wear of lenses with a high water content leads to about the same degree of corneal oxvgen deprivation as dailv wear of lenses with a low fluid content. In accordance with Hasegawa et al. (1979) and Nesburn (1979). the long-term effect of bandage lens treatment in keratoconjunctivitis sicca appeared less favourable than indicated in initial reports (Gasset & Kaufman 1971 ; Gasset 1972). Following both wbjective and objective initial improvement in 8 of our 9 patients, lens wear was later stopped in 6 patients due to purulent keratoconjunctivitis (2 patients). increasing discomfort (2 patients) or lack of effect (2 patients). In the remaining 3 patients lens wear proved indispensible. Also in Stevens Johnson syndrome and ionizing radiation keratopathy bandage lens treatment appeared less effective than earlier reported (Gasset & Kaufman 1971; Buxton & Locke 1971; Dohlman et al. 1973: Could 1974). Lens wear was discontinued within 2 months in 10 of the 12 patients due to lack of effect (5 patients), increasing keratopathy (12 patients), purulent keratoconjunctivitis ( 1 patient), increasing discomfort ( 1 patient) or frequent lens loss (1 patient).

As reported bv Gnadinger & Birgelen (1973). Brown et al. (1974), Dohlman (1974) and Schecter et al. (1975). corneal vascularization and keratitis/keratocon- junctivitis were the most commonly occurring complications. The earlier reported increased risk of infection during bandage lens wear in dry eye disease (Dohlman et al. 1973; Brown et al. 1974; Mondino & Brown (1981) was also confirmed. This suggests that topical antibiotics should be used prophylactically when lenses are fitted to patients with dry eyes. Otherwise bandage lens wear per se does in our opinion not necessitate the use of topical antibiotics, although an increased frequency of infectious conjunctivitis during continuous aphakic lens wear has been reported by Barner et al. (1980). This is in accordance with studies of the conjunctival bacterial flora during continuous lens wear (Binder & Worthen 1973; Rydberg 1975; H6vding 1982b). Very frequent lens loss preventing further bandage lens treatment does usually not occur.

References

Barner S, Marner K & Fahmy J A (1980): Clinical experience with hydrophilic contact lenses in aphakia. Acta Ophthalmol (Copenh) 58: 83-89.

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Hsvding Hydrophilic 'bandage' lenses

Binder P S & Worthen D M (1976): A continuous-wear hvdrophilic lens. Arch Ophthalmol 94: 2109-21 1 1 .

Brodrick ,I D (1976): The Bausch and Immh 'T' lens in the treatment o f c.orne;il disease. Trans Ophthalmol Soc L'K 96: 330-333.

Brown S I. Bltn)mfield S. Pearce D B & Tragakis M (1974): Infections with the therapeutic soft lens. .4rch Ophthalmol91: 27.5-277.

Buxton,J N 8c Locke C R (1971): A therapeutic evaluation of hvdrophiliccontact lenses. Am,J Ophthalmol72: 532-535.

Dohlman C H. Boruchoff S A & Mobilia E F (1973): Complications in use of soft contact lenses in corneal disease. Arch Ophthalmol90: 367-371.

Dohlman C H (1974): Complications in therapeutic soft lens wear. Trans Am Acad Ophthalmol Otolarvngol78: 399-405.

Espy J W (1971): Management of corneal problems with hvdrophilic contact lenses. Am ,I Ophthalmol72: 52 1-526.

Gasset A R & Kaufman H E (1970): Therapeutic uses of hvdrophilic contact lenses. Am 1 Ophthalmol69: 252-259.

Gasset A R & Kaufman H E (1971): Hydrophilic lens therapy of severe keratoconjunctivitis sicca and conjunctival scarring. Am J Ophthalmol7 1 : 1185- 1189.

Gasset A R (1972): Gasset A R & Kaufman H E (eds). Soft Contact Lens. pp 210-223. Moshv. Saint Louis.

Gnadinger M C & Birgelen M (1973): Die 'therapeutische soft lens'. Ophthalmologica 170: 300 -305.

Could H L (1974): Therapeutic experience with soft contact lenses. Trans Am Acad Ophthalmol Otolarvngol78: 391 -398.

Hasegawa E. Matsuo N, Sarada K & Miyagawa K (1979): Studies on the treatment of keratoconjunctivitis sicca. Acta Med Okayama 33: 2 1-28.

H6vding G (1982a): Variations in central corneal thickness during the first year of contact lens wear. Acta Ophthalmol (Copenh) 60: 57-69.

Hovding G (1982b): Conjunctival and contact lens bacterial flora during continuous 'bandage' lens wear. Acta Ophthalmol (Copenh) 60: 439-448.

Leibowitz H M & Rosenthal P (1971): Hydrophilic contact lenses in corneal disease. I. Superficial, sterile, indolent ulcers. Arch Ophthalmol85: 163- 166.

Leroux C. Millard-Devauchelle C I, Turut P & Malthieu C (1982): Resultats des lentilles hydrophiles therapeutiques dans les ulceres corneens d'origine herpetique - a propos des 17 cas. Bull Soc Opht Fr 2: 245-250.

Mondino B J & Brown S I (1981): Ocular cicatricial pemphigoid. Ophthalmology 88:

Nesburn A B (1979): Complications associated with therapeutic soft contact lenses.

Olson R J (1978): Bilateral Hemophilus Influenzae corneal ulcers in a patient with bandage

Ruben M (1975): Soft contact lens treatment of bullous keratopathy. Trans Ophthal Soc UK

Rydberg M (1975): Bacteriology in continuous wearing of soft contact lenses. Contact Lens J

Schecter D R, Emery J M & Soper J W (1975): Corneal vascularization in therapeutic soft-lens

Stone J (1974): The measurement of corneal thickness. Contact Lens J 5: 14- 19.

95- 100.

Ophthalmology 86: 1130- 1137.

contact lenses. Contact Intraocul Lens Med J 4: 95-99.

95: 75-78.

1: 150-152.

wear. Contact Intraocul Lens Med J 1 : 14 1 - 145.

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Hevding Hydrophilic 'bandage' lenses

Sundmacher R, Junker C & Fanti P (1976): Erste Erfahrungen mit hochhydrophilen therapeutischen Weichlinsen. Klin Monatsbl Augenheilkd 169: 422 -430.

Author's address: Gunnar Hflvding, M.D., Department of Ophthalmology, N-5016 Haukeland sykehus, Norway.

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