Indications and outcomes of scleral contact lens for severe ocular surface disease in the acute inpatient setting

Maylon Hsu, M.D.; Michael Nolan; Pooja Jamnadas, M.D., Amy Lin, M.D.Loyola University Chicago Stritch School of Medicine, Department of Ophthalmology

Introduction

References

Results

Conclusion

Table 1. Indications and Outcomes of Scleral Lens Therapy

Scleral lenses are rigid, gas permeable contact lenses that are usually custom fitted to an individual’s eye and used to manage a variety of ocular surface conditions. Recently they have been applied to the inpatient setting, using a preservative-free lubricating gel in the fluid reservoir. The (PROSE) Posthetic replacement of the ocular surface ecosystem device, formerly known as the Boston Ocular Surface Prosthesis (BOSP) and Jupiter Lens are custom-designed in the inpatient setting, but the thicker gel allows for the fit of the lens to be more forgiving against the shape of the ocular surface. This study reports the clinical courses and outcomes of a series of patients who were treated with the BOSP and Jupiter scleral lenses as inpatients.

Data was collected by retrospective chart review of all patients who had insertion of the PROSE device or Jupiter scleral lens as inpatients since 2008. The indication for sclera lens placement and duration of use was recorded. The health of the cornea, development of any complications, and severity of other clinical findings such as lagophthalmos, trichiasis, symblephara, and scarring was recorded.

Scleral Lenses were used in 14 patients. Some patients required bilateral lenses, and one patient with severe periocular burns required repeated rounds of sclera lens therapy, resulting in a total of 30 cases. The age range was 2 weeks to 81 years old. All patients had some degree of exposure ranging from intermittent lag and poor lid closure to over 1 cm of lagophthalmos. 6 patients had cicatricial change; 5 due to flame burns and 1 due to pemphigus vulgaris. 4 patients had lagophthalmos secondary to sedation/ altered mental status. One patient had complete exposure of the globe due to agenesis of the eyelids at birth. The duration of sclera lens use ranged from 1 day to 40 days (Mean = 10.3 days, Median = 7 days). 5 patients expired while being treated with scleral lenses. In 8 out of the 30 cases, the sclera lens was discontinued when a tarsorraphy was placed. In all cases the corneal defects improved or remained stable.

The use of sclera lenses in the inpatient setting is a safe and effective means of protecting the cornea from damage due to exposure. The lenses provide a more stable precorneal tear film and decrease the frequency of eyedrop administration by nursing staff.

1. Rosenthal P, Cotter J. The Boston Scleral Lens in the management of severe ocular surface disease. Ophthalmol Clin N Am. 2003;16:89-93.2. Romero-Rangel T, Stavrou P, Cotter J et al. Gas-permeable scleral contact lens therapy in ocular surface disease. Am J Ophthalmol. 2000;130:25-32.3. Rosenthal P, Cotter J, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol. 2000;130:33-41.4. Rosenthal P, Croteau A. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye and Contact Lens. 2005;31(3):130-134.5. Jacobs DS. Update on scleral lenses. Curr Opin Ophthalmol. 2008;19:298-301.6. http://www.bostonsight.org

1960/D941

Patient ID Age Time (days) Eye Reason for Hospital Admission Cause of Corneal Exposure Lids / Lashes Cornea Outcome / Reason discontinued

1.1 20 2 OS septic shock sedation and AMS 5 mm lag 7x2mm epi defect cornea unchanged, tarsorrapy placed

1.2 20 1 OD septic shock sedation and AMS 2 mm lag, poor Bell's cornea clear cornea unchanged, Pt expired

1.3 20 1 OS septic shock sedation and AMS 2 mm lag, Poor Bell's cornea clear cornea unchanged, Pt expired

2.1 61 1 OD PICA aneurysm rupture sedation and AMS LL ectropion 2x3 mm epi defect cornea unchanged, lateral tarsorrhaphy placed

3.1 52 4 OD pemphigus vulgaris lid damage 3 mm lag 6x5 mm epi defect and corneal abrasion cornea healed, lag improved

4.1 24 15 OS MVA - head trauma sedation and AMS 3 mm lag 8x3 mm epi defect epi defect decreased, tarsorrhaphy placed

5.1 70 13 OD MG crisis sedation and AMS 1 mm lag, poor blink reflex 1 mm epi defect and PEE epi defect healed

5.2 70 13 OS MG crisis sedation and AMS 1 mm lag, poor blink reflex 1 mm epi defect and PEE epi defect healed

6.1 52 2 OD flame burn 50% TBSA lid damage, sedation, AMS singed lashes, lid edema, 3mm lag epithelial haze cornea unchanged, Pt expired

6.2 52 2 OS flame burn 50% TBSA lid damage, sedation, AMS singed lashes, lid edema, 3mm lag epithelial haze cornea unchanged, Pt expired

7.1 42 3 OS flame burn 48% TBSA lid damage, sedation, AMS burn damage to lids, intermittent lag PEE epi defect healed, tarsorrhaphy placed

7.2 42 4 OD flame burn 48% TBSA lid damage, sedation, AMS 3 mm lag, poor Bell's clear cornea improved lag

7.3 42 21 OD flame burn 48% TBSA i lid damage, sedation, AMS 3 mm lag, poor Bell's clear cornea cornea unchanged, tarsorrapy placed

7.4 42 21 OS flame burn 48% TBSA lid damage, sedation, AMS tarsorrhaphy cheesewired, 4 mm lag, LL ectropion clear cornea cornea unchanged, tarsorrapy placed

7.5 42 24 OD flame burn 48% TBSA lid damage, sedation, AMS 7 mm lag, poor Bell's, LL ectropion 2 mm epi defect at margin cornea unchanged, Pt expired

7.6 42 19 OS flame burn 48% TBSA lid damage, sedation, AMS 4 mm lag, poor Bell's, LL ectropion 1 mm ulcer, acinetobacter cornea unchanged, Pt expired

8.1 21 10 OD flame burn 20% TBSA lid damage UL edema, intermittent lag 6x3 mm epi defect cornea clear, improved blink reflex

8.2 21 10 OS flame burn 20% TBSA lid damage intermittent lag 5x3 mm epi defect cornea clear, improved blink reflex

9.1 23 40 OS flame burn lid damage burn damage to lids, intermittent lag corneal abrasion cornea improved, skin graft to lids

9.2 23 37 OD flame burn lid damage burn damage to lids, intermittent lag irregular epithelium cornea improved, skin graft to lids

10.1 81 4 OD flame burn to head lid damage sloughed epithelium, singed lashes large central epi defect epi defect decreased, lag resolved

10.2 81 1 OS flame burn to head lid damage sloughed epithelium, singed lashes 3x1 mm epi defect cornea unchanged, Pt expired

11.1 2 weeks 8 OShydrocephalus, possible Fraser syndrome lid agenesis lid agenesis 4x2 mm epi defect epi defect decreased, Switched to soft BCL

12.1 19 7 OD MVA with facial degloving lid damage and AMS lid edema epi defect inferior 1/2 of cornea cornea unchanged, tarsorrapy placed

13.1 37 6 OD MVA sedation and AMS sutured lid laceration, poor Bell's 4x2 mm epi defect epi defect healed

13.2 37 6 OS MVA sedation and AMS intermittent lag, poor Bell's 6x1 epi defect epi defect healed

14.1 53 14 OD flame burn 53% BSA lid damage singed lashes confluent PEE nasally epi defects resolved, no lag

14.2 53 14 OS flame burn 53% BSA lid damage burn damage to lids, singed lashes 4x2 mm epi defect epi defects resolved, no lag

14.3 53 3 OD flame burn 53% BSA lid damage 8mm lag, skin sloughing 3x2 mm epi defect and central PEE cornea unchanged, Pt expired

14.4 53 3 OS flame burn 53% BSA lid damage 10 mm lag, skin sloughing 2x1 mm epi defect cornea unchanged, Pt expired

Methods

Figures 1-4: Various conditions requiring a scleral lens: 1) lagophthalmos secondary to sedation 2) severe facial and eye lid burns with cicatricial lag 3) lagophthalmos with epithelial defect and corneal scarrin 4) severe facial and eyelid malformation in 2 week old

1 2 3 4

http://www.bostonsight.org

Acknowledgement: Grant Support: The Richard A. Perritt Charitable Foundation.