The Benefits of Scleral Lenses for Graft Versus Host Disease
BY ANN LAURENZI, OD, FAAO
Patients who develop chronic graft versus host disease (cGVHD) following allogeneic bone marrow transplantation suffer from severe skin, gastrointestinal tract, liver, lung, and ocular complications. The disease causes lacrimal and conjunctival dysfunction, creating severe dry eye and ocular inflammation.
Ocular Complications of cGVHD
The ocular complications begin as dry eye symptoms of tearing, discomfort, and photophobia and progress to keratoconjunctivitis sicca (KCS) (Figure 1) and pseudomembranous and cicatricial conjunctivitis. Sequelae to follow may include persistent epithelial defects, ulcerations, corneal scarring, neovascularization, secondary infectious keratitis, and possible corneal melting.
Figure 1. Superior limbal keratoconjunctivitis sicca with inflammation and conjunctival injection from graft versus host disease.
The patients are in constant pain and experience severe photophobia, burning, and reduced vision. Some are unresponsive to even aggressive dry eye therapy.
Relief With Scleral Lenses
An additional strategy to help cGVHD patients is to fit GP scleral lenses. A patient's oncologist or ophthalmologist will usually refer patients for a scleral lens fitting after other trials of conventional therapy have failed.
In my clinic I use the Jupiter (Essilor/Medlens Innovations) scleral lens. The starting overall diameter in the diagnostic fitting set is 18.2mm, with a standard 8.2mm optic zone. The peripheral curves are standardized for all the lenses in the diagnostic set but can be altered as necessary to achieve the best fit.
An ideal fit for a GP scleral lens is to completely vault the cornea and limbus and land on the scleral ocular surface. The peripheral curves should align with the scleral surface without excessive bearing. The scleral conjunctival blood vessels should be free of impingement and blanching under the weight of the lens. Examination with fluorescein after the lens has settled for 30 minutes should demonstrate definite clearance (Figure 2).
Figure 2. A scleral lens fit on a graft versus host patient showing complete corneal and limbal vault and scleral alignment of the peripheral curves.
The large overall diameter of these lenses protects the compromised corneal and conjunctival surfaces from exposure and from lid interaction during the blink. The post lens tear film acts to bathe the cornea in fluid and serves as a liquid corneal bandage. The limbal stem cells are also protected as the lens does not touch at the limbus, and these cells are also bathed in fluid.
Several studies have reported on the subjective benefits that some patients experience after GP scleral lens fitting, including reduced pain and irritation and improved quality of life. Scleral lens fits can be an effective therapy for cGVHD patients in relieving their dry eye symptoms. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #164.
Dr. Laurenzi practices at the Cole Eye Institute in Cleveland, Ohio where she specializes in refractive surgery co-management, contact lenses and clinical research.