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ONLINE PHOTO DIAGNOSIS

Conjunctival Hyperemia with Scleral Lenses

This image shows a case of conjunctival hyperemia due to use of a scleral lens.

Case History

This patient has a history of keratoconus with corneal ring implants. He was fit in another clinic with a scleral lens that is not available in Brazil, so I presume that the clinic imported it. The patient visited us in May 2018 with the pictured condition in both eyes. He is a medical doctor and works as an on-duty physician with occasional overnight wear.

Both lenses had similar parameters of base curve 45.00D (7.50mm), power -5.00D, overall diameter (OAD) 16.5mm, and 0.27mm central thickness. During slit-lamp examination, we found that the lenses were too tight, both compressing the sclera and causing blanching and impingement (Figure 2).

Figure 2. Impingement and blanching with the scleral lens at presentation.

We also observed that the scleral lens vault was excessive, due to an overestimated sagittal height (sag) value.

A higher vault may be tolerated in some cases, especially when you fit the larger, full scleral lenses that have diameters of 18mm and greater. But an excessive vault may also result in corneal hypoxia and subsequent corneal edema. Figure 3 shows the lens vault at presentation.

Figure 3. Scleral lens vault OD and OS with the scleral lenses at presentation.

Figure 4 shows the fluorescein pattern at presentation using biomicroscopy with a cobalt blue filter OS.

Figure 4. OS slit-lamp observation with fluorescein.

In this case, the patient mentioned seeing a rainbow, indicating that corneal edema was present. The limbus was affected, and we noted superficial keratitis in both eyes.

Management of the Case

We instructed the patient to suspend scleral lens wear for at least three days and to instill nonpreserved artificial tears q.i.d. and then return for re-evaluation and a new scleral lens trial.

We refit the patient with a customized scleral lens design to achieve better alignment with the anterior eye. The scleral lens parameters were 48D (7.03mm) central posterior curve with optical zone (OZ) of 10.0mm, 44D (7.67mm) secondary posterior curve with OZ of 13.7mm, OAD 17.7mm, powers of -8.75 (OD) and -7.75 (OS), and sag value 5.964.

Figures 5 to 7 show the fit with the new scleral lenses.

Figure 5. Temporal and nasal views of the haptic and sclera.

Figure 6. Inferior view of the haptic and sclera.

Figure 7. The lens vault with the new scleral lens.

At the 30-day follow-up visit, the patient had calm eyes, good lens tolerance, and restored corneal physiological health in both eyes. Figure 8 shows an image taken and sent by the patient with the new lenses, which he wears for 14 to 16 hours a day.

Figure 8. The patient took this photo and sent it to us recently.

Conclusion

In this case, we identified the possible problems and complications from the previous scleral lens fit, instructed the patient to suspend lens wear, and refitted him with a customized scleral lens that would not insult the scleral conjunctiva and also better aligned to the anterior eye. The result is excellent comfort as well as great visual acuity and ocular health.

Luciano Bastos is the director and clinical instructor of specialty contact lenses at the Instituto de Olhos Dr. Saul Bastos (IOSB) and is the director and specialty lens consultant of Ultralentes, a small laboratory specializing in GP and scleral lens designs in Porto Alegre, RS, Brazil.