The modern scleral GP lens can be life changing for patients suffering with eyelid and orbital malformations (Choi et al, 2016; Kashkouli et al, 2017). Particularly susceptible are individuals who undergo orbital reconstruction surgery, which can affect globe positioning, eyelid apposition, and efficiency of the blink itself.
Prior to the re-emergence of modern scleral lenses, treatment options for ocular exposure were limited. Patching and partial or complete tarsorrhaphy can be aesthetically devastating, while soft contact lenses, although cosmetically pleasing, are subject to desiccation and often provide inadequate coverage. Here, we provide an example of ocular exposure after reconstructive facial surgery that was successfully managed with scleral lenses with a scleral lens to mitigate severe ocular surface desiccation and pain due to corneal nerve exposure.
Our patient underwent surgical resection of cancerous tissue within her sinus cavity, resulting in a sunken, displaced orbit and a largely non-elastic, scarred lower eyelid that prevented lid closure (Figure 1). She reported constant, severe pain despite applying preservative-free artificial tears several times per hour and using an eye patch to reduce exposure.
The patient was fitted with a 16.5mm scleral lens with a 400µm corneal vault and adequate haptic landing (Figure 2). The lens provided full protection and tear film coverage, significantly improving her symptoms.
The Overnight Conundrum A primary obstacle in managing this patient was her need for 24-hour protection. For patients requiring overnight coverage, we recommend first attempting daily disposable, high-Dk soft lenses (Figure 3); however, if a scleral lens has a better benefit-to-risk ratio, patients must first thoroughly understand the risks and be monitored closely and frequently. They should have one pair of scleral lenses for daily wear and a second for overnight wear.
Additionally, because the lenses are prone to deposition due to ineffective blinking, an enzymatic cleaner should be used to reduce microbial adhesion and biofilm formation. Finally, regular disinfection and replacement of cases, plungers, and lenses is essential.
Informing the Specialists
It is important to communicate the effectiveness of scleral lenses for ocular surface exposure to specialists such as oculoplastic surgeons, endocrinologists, oncologists, and others. As these specialists become increasingly aware of the devices’ efficacy, the need for eyecare practitioners to manage medically necessary scleral lenses will increase. CLS
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