The Scleral Lens Vault
BY GREGORY W. DENAEYER, OD, FAAO
Hematopoietic stem cell transplantation (HSCT) includes bone marrow, peripheral blood stem cell, and cord blood transplantation. More than 25,000 HSCTs are performed annually to treat diseases including leukemia and lymphoma (Ogawa et al, 2013). Acute or chronic graft-versus-host disease (GVHD) is a complication of allogeneic stem cell transplantation (allo SCT). Chronic graft-versus-host disease (cGVHD) can affect various organs such as the skin, gut, lungs, and eyes (Nassiri et al, 2013).
Westeneng et al (2010) reported that 54% of patients developed ocular GVHD after allo SCT that resulted in dry eye and conjunctivitis. Inflammation secondary to GVHD causes destruction of the conjunctiva and lacrimal glands, which leads to fibrosis as well as decreased goblet cell density and tear production (Nassiri et al, 2013; Hessen and Akpek, 2012). Other contributing factors to dry eye can include irradiation, chemotherapy, immunosuppressive therapy, and infection (Nassiri et al, 2013).
GVHD-Induced Dry Eye Care
Patients who suffer from ocular GVHD often have disabling dryness that significantly affects their quality of life and impedes activities of daily living. Initial ophthalmological care involves supplementation of the tears, controlling inflammation, and maintaining mucosal integrity (Nassiri et al, 2013). Patients are often prescribed a wide variety of ophthalmic medications including non-preserved artificial tears, antibiotics, cyclosporine, steroids, and autologous serum.
Despite aggressive management, some patients will experience little relief from their symptoms. Additionally, patients who have ocular GVHD can have reduced vision secondary to keratoconjunctivitis sicca (Nassiri et al, 2013). Often, these patients will have to give up driving and will struggle with other distance-related activities.
Scleral Lenses Provide Relief
Scleral lenses are often able to successfully manage symptoms secondary to ocular GVHD. The liquid reservoir beneath a well-fit scleral lens continuously bathes the compromised anterior ocular surface of a patient suffering from ocular GVHD.
Additionally, a scleral lens can dramatically improve vision by masking dry eye-related irregularity. Jacobs and Rosenthal (2007) demonstrated improvement in pain, photophobia, and general quality of life in nearly all of 33 consecutive patients who had severe dry eye from cGVHD and were fit with scleral lenses.
In another study, Schornack et al (2008) reported that five patients who had ocular GVHD all experienced improved comfort, and vision improved in seven of the 10 eyes after several months of scleral contact lens wear.
Completely vaulting the corneal surface is important to avoid corneal bearing that may disrupt an already compromised ocular surface. However, Sonsino and Mathe concluded in a 2013 study that amount of vault is not a critical factor for successfully fitting scleral lenses for dry eye patients.
In my personal experience, patients who have ocular GVHD and are fit with scleral lenses are often able to significantly decrease their regimen of ocular medicines. Educate them that they may accumulate reservoir debris during wear, as they produce excessive mucus.
Eyecare practitioners should follow up with these patients frequently to monitor scleral lens fit and the status of their ocular surface.
Patients who have ocular GVHD and are fit with scleral lenses will often have immediate relief of dry eye-related symptoms and improvement in their vision. Their family members are usually surprised to see such patients able to open their eyes. CLS
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Dr. DeNaeyer is the clinical director for Arena Eye Surgeons in Columbus, Ohio, and a consultant to Visionary Optics, B+L, and Aciont. You can contact him at email@example.com.