Article

THE SCLERAL LENS VAULT

OCULAR SURFACE DISEASE: SCLERAL LENS KEY POINTS

I see patients every week who have a variety of ocular surface disease (OSD) diagnoses and have failed with traditional palliative and medical management. A few recent cases revealed some key points for successful scleral lens management.

Succeeding with Three OSD Cases

Graft-Versus-Host Disease (GVHD) #1 A 40-year-old male who had GVHD reported for scleral lens fitting of his right eye. His left eye had previously been fit with a scleral lens, but his right eye hadn’t been fit due to a partial tarsorrhaphy and poorly controlled glaucoma. After removal of the tarsorrhaphy and successful tube shunt surgery, I fit his right eye with a 16.5mm scleral lens with a customized back-surface haptic to accommodate conjunctival surface irregularity (Figure 1). The conjunctival injection resolved after several weeks of wear. Minimal clearance was noted post-lens settling; therefore, a second steeper lens was ordered that resulted in 150 microns of central clearance.

Figure 1. Scleral lens at dispense for GVHD.

KEY POINTS: A tarsorrhaphy can be avoided or removed if the patient can wear a scleral lens. Although the amount of vault doesn’t affect the therapeutic benefit of scleral lenses (Sonsino and Mathe, 2013), don’t risk the lens eventually bearing on compromised corneal epithelial cells.

GVHD #2 A 43-year-old female patient who had GVHD had previously been fit with scleral lenses and had ordered a new set of replacement lenses. At examination, she complained of intermittent visual disruption that resulted from poor surface wetting (Figure 2A). Lenses were reordered with a polyethylene glycol (PEG)-based coating that provided surface wetting (Figure 2B), which improved visual acuity.

Figure 2. (A) Non-wetting scleral lens in a patient who has GVHD. (B) Surface wetting achieved with PEG-based coating.

KEY POINTS: Patients who have OSD often aren’t able to properly wet a scleral lens, which can significantly affect comfort and vision. Many of these patients will benefit from plasma treatment and surface coatings for improved wetting. However, some patients who wet standard lenses well find the added surface coating disruptive and prefer their lenses without it.

Chronic Dry Eye A 23-year-old female patient who had severe chronic dry eye and had successfully worn scleral lenses for three years complained of recent irritation of her left eye with lens wear. The patient had developed a nasal pinguecula since the original fit that resulted in haptic impingement (Figure 3). A customized lens that vaulted the pinguecula allowed her to comfortably resume scleral lens wear.

Figure 3. Nasal impingement secondary to newly formed pinguecula.

KEY POINT: Patients who wear scleral lenses to manage OSD will wear them long-term. Changes to the anterior ocular surface can require lens redesign to maintain wearing success. CLS

For references, please visit www.clspectrum.com/references and click on document #284.