Successfully Managing Ocular Surface Disease
By Gregory W. DeNaeyer, OD, FAAO
The effects of severe ocular surface disease (OSD) resulting from Stevens-Johnson syndrome and chronic graft-versus-host disease can be disabling. OSD symptoms can prevent patients from working and participating in activities of daily living. Fortunately, as contact lens practitioners we are able to offer these patients some relief by managing them therapeutically with scleral GP lenses (Schornack, 2008; Rosenthal, 2003). The fluid reservoir of a scleral lens acts as a liquid bandage for the anterior ocular surface. This column will review scleral contact lens strategies that will improve your success at managing OSD.
Scleral Lens Choice and Care
There is some debate about which scleral-type lens can manage OSD. Keep in mind that to treat these patients successfully, the lens must completely vault the corneal surface and provide approximately 100 microns of fluid reservoir. With that said, in some cases a mini-scleral contact lens (15mm to 18mm diameter) may adequately protect and bathe the corneal surface. However, eyes that have larger corneas or more disfigurement may require a full scleral contact lens (18mm to 24mm) to be successfully fit.
Scleral contact lenses have slow tear exchange secondary to their relatively large size and semi-sealing properties. Therefore, fluid that is used to fill the lens before application has significant contact time with the fragile anterior surface of a patient who has OSD. It is therefore critical to prescribe nonpreserved saline solution to fill the lens to prevent preservative toxicity and/or hypersensitivity. Unfortunately, a few patients may have toxicity to borate buffers in some nonpreserved saline solutions. Prescribing off-label use of 0.9% sodium chloride inhalation solution or off-label balanced salt solution (BSS) are alternatives.
Hydrogen peroxide or alcohol-based care systems are recommended for patients wearing scleral lenses to manage OSD. Their advantage, as compared to other systems, is that they are a preservative-free option. You can prescribe extra strength cleaners to periodically keep lenses free of deposits and debris.
Most OSD patients produce increased amounts of mucin, which can get trapped beneath the lenses. Educate patients that they will probably have to remove their contact lenses a few times a day to rinse and fill them to maintain good vision and comfortable wear. Visser et al (2007) reported that 67 percent of patients who had keratitis sicca required one or more breaks during scleral lens wear.
Before being fit with scleral lenses, most patients who have severe OSD will be on multiple ophthalmic medications in an attempt to manage their condition. Examples include artificial tears, steroids, cyclosporine, antibiotics, and autologous tears. After successful scleral lens fitting, some of these medicines may be reduced in frequency or eliminated. Make sure to coordinate care if a patient is also under the supervision of an anterior segment specialist.
Some patients who have OSD may be managed successfully with soft contact lenses (Russo et al, 2007). Reserve this option for patients who have mild OSD, for patients who may not be able apply scleral lenses, or for patients who fail in scleral lens therapy.
A Worthwhile Challenge
Managing patients who have OSD can be challenging, but a successful outcome will return a patient to an active lifestyle. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #188.
Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio. His primary interests include specialty contact lenses. He is also a consultant to Visionary Optics. Contact him at firstname.lastname@example.org.