Contact Lens Case Reports
Therapeutic Benefits of Sclerals
BY PATRICK J. CAROLINE, FAAO, & MARK P. ANDRÉ, FAAO
Our patient is a 49-year-old female with a history of bilateral keratoconus. The patient had always managed her condition with contact lenses; in 2012, she began to experience increasing intolerance with her right lens. At the time, her practitioner was unable to manage her symptoms and referred her to an ophthalmologist for corneal collagen cross-linking (CXL) and intrastromal ring implantation (Figure 1).
Figure 1. A patient with a single inferior intrastromal ring for keratoconus.
Intrastromal rings were first proposed by Gene Reynolds, MD, OD, PhD, in the 1980s. The original concept was that of a 360º ring that could be implanted into the periphery of the cornea. Expansion of the ring would flatten the central cornea, while constriction of the ring would steepen it. This evolved into two 150º arches of varying thickness to control the amount of central corneal flattening.
In May 1999, the product received FDA clearance as a refractive surgery device/technique for correction of mild myopia from –1.00D to –3.00D. In August 2004, its clearance was expanded to include keratoconus.
CXL (developed at the Technische University in Dresden, Germany in the mid-1990s) uses ultraviolet (UV) light and a photosensitizer, riboflavin, to strengthen chemical bonds within the cornea. Its goal is to halt or slow the progressive corneal thinning that occurs in conditions such as keratoconus, PMD, and post-refractive surgery ectasia. Human studies of CXL began in 2003.
Reported complications with CXL have primarily involved the epithelium and stroma. Epithelial complications are often temporary and predominately involve a corneal staining secondary to the UV exposure. Stromal complications are also often temporary and include edema and anterior stromal haze that can last from two to six months.
Ten days postoperatively, our patient experienced severe dry eye symptoms and corneal staining, which were probably related to a residual UV toxicity. The ophthalmologist placed the patient on maximum dry eye treatment, yet her symptoms persisted. We fitted the patient with a scleral contact lens, and immediately her dry eye symptoms improved (Figures 2 and 3). Her visual acuity with the scleral lens was 20/25, and over the next week, her wearing time increased to all-day lens wear.
Figure 2. Scleral contact lenses following intrastromal ring implantation and corneal cross-linking.
Figure 3. Corneal staining pre- and post-scleral lens wear.
This case shows the therapeutic benefits of a scleral lens in patients who have ocular surface disease. While the corneal staining would have most likely resolved on its own, the scleral contact lens provided both an immediate resolution of the patient’s dry eye symptoms and a long-term optical treatment of her keratoconus. CLS
Patrick Caroline is an associate professor of optometry at Pacific University. He is also a consultant to Contamac. Mark André is an associate professor of optometry at Pacific University. He is also a consultant for CooperVision.