The Use of Scleral Lenses for Persistent Epithelial Defects
The scleral lens controversies session at the Global Specialty Lens Symposium included many fascinating topics and excellent speakers. One area of discussion was the use of scleral lenses for persistent epithelial defects.
The epithelium is susceptible to breaking down in advanced ocular surface disease such as limbal stem cell deficiencies and neurotrophic corneas. A continuing epithelial breakdown is known as a persistent epithelial defect (PED). Several management strategies for PED include patching, intensive lubrication, soft bandage contact lenses and amniotic membrane grafts. In severe cases, tarsorrhaphy may be used. A tarsorrhaphy is a method to surgically close the palpebral fissure by suturing the superior and inferior lateral eyelids. Alternatives to tarsorrhaphy include Stamler lid splint, an adhesive on one side of the eyelid with enough rigidity to hold the eyelid in the closed position. A different alternative is the TLC appliqué from ostomy barrier, a heavy ostomy material that adds weight to aid in eyelid closure, much like a gold weight. Different alternatives for eyelid closure are Tagederm, a transparent medical dressing manufactured by 3M or nasal dilator strips used in the vertical position to keep the eyelid closed.
The use of scleral lenses for PED may be an ideal treatment modality from the patient’s perspective. Scleral lenses provide vision and the patient is not disfigured by a tarsorrhaphy or another option. Of upmost importance when using a scleral lens for PED is to carefully evaluate anterior segment ocular health and rule out microbial keratitis. A PED may permit opportunistic microbial infection of the cornea. Contact lenses worn overnight is strongly associated with an increased risk of microbial keratitis.
There have been several case studies and publications regarding the use of scleral lenses for PED. The post lens fluid reservoir continuously bathes the cornea. Schornack’s 2014 review article described the resolution of PED with scleral lenses1. Katzman described scleral lens therapy in his overview of management strategies for PED2. Typically, scleral lenses are not worn for sleeping, or extended wear. However, in PED management, the protection provided by scleral lenses may also be required during sleeping as well as waking hours.
In 2014, Ciralsky et al. published a standardized protocol for continuous wear of scleral lenses for the management of persistent epithelial defects3.
The protocol is described below4:
1. Wear of the scleral lens 24 hours a day until complete re-epithelialization was achieved.
2. Brief daily removal of the device for cleaning, disinfection with Clear Care (Alcon, Fort Worth, TX, USA) and Optimum CDS or ESC (Lobob Laboratories, San Jose, CA, USA), and rinsing with Unisol 4 Saline (Alcon, Fort Worth, TX, USA). Of note, Unisol 4 is no longer available. Alternative products include LaciPure (Menicon America, Inc., Waltham, MA, USA) or Purilens Plus (The Lifestyle Company, Inc., Freehold, NJ, USA).
3. Replacement of the reservoir fluid with one drop of moxifloxacin 0.5% (VigamoxTM, Alcon, Fort Worth, TX, USA) followed by Unisol 4 saline (see above).
4. Prompt transition from continuous to long-term, daytime only scleral lens wear following epithelial defect resolution.
Daily monitoring is needed to evaluate the PED. According to Johns, resuming daily wear of the scleral lens immediately after the defect resurfaces may cause the PED to return5. The recommendation is to continue one more night of extended wear after the defect has resolved to strengthen the epithelium5. The first night after daily wear of the lens, the eye is aggressively lubricated with ointment and a tape tarsorrhaphy is used if lagophthalmos is present. Extreme caution must be utilized in these situations. After a PED is resolved, scleral lenses for daily wear may be used. All patients with a history of a PED should be monitored closely.
Image 1. Example of a persistent epithelial defect prior to scleral lens wear. Image courtesy of Lynette Johns.
Image 2. Image of a resolved PED after five days of extended wear with a scleral lens and prophylactic antibiotic. Note the epithelial bullae present. Image courtesy of Lynette Johns.
1. Schornack MM, Pyle J, Patel SV. Scleral lenses in the management of ocular surface disease. Ophthalmology 2014; 121(7): 1398-405. [http://dx.doi.org/10.1016/j.ophtha.2014.01.028] [PMID: 24630687]
2. Katzman LR, Jeng BH. Management strategies for persistent epithelial defects of the cornea. Saudi journal of ophthalmology: official journal of the Saudi Ophthalmological Society 2014; 28(3): 168-72.
3. Ciralsky JB, Chapman KO, Rosenblatt MI, et al. Treatment of refractory persistent corneal epithelial defects: A standardized approach using continuous wear PROSE therapy. Ocul Immunol Inflamm 2015. Jun;23(3):219-24. doi: 10.3109/09273948.2014.894084. Epub 2014 Mar 21.
4. Barnett M, Johns LK. Contemporary Scleral Lenses: Theory and Application. Bentham Science 2017. Volume 4 ISBN: 978-1-68108-567-8. Ch 5: 120.
5. Barnett M, Johns LK. Contemporary Scleral Lenses: Theory and Application. Bentham Science 2017. Volume 4 ISBN: 978-1-68108-567-8. Ch 14: 427-429.
Dr. Melissa Barnett is a Principal Optometrist at the UC Davis Eye Center in Sacramento, specializing in anterior segment disease and specialty contact lenses. Dr. Barnett is the Past President of The Scleral Lens Education Society. She lectures and publishes extensively on topics including dry eye, anterior segment disease, contact lenses and creating a healthy balance between work and home life for women in optometry.