dry eye dx and tx

Scleral Contact Lenses and Stevens-Johnson Syndrome

BY ANN LAURENZI, OD, FAAO

Stevens-Johnson Syndrome (SJS) is an acute inflammatory vesiculobullous disease characterized by cutaneous eruptions involving the skin and mucous membranes. It's commonly thought to be induced or incited by infection, radiation treatment, malignancy or collagen vascular disease. Although rare, ocular involvement occurs in about 50 percent of patients in the acute phase.

The aftermath of SJS may include symblepharon, entropion, trichiasis, keratinization, corneal neovascularization and severe tear film abnormality, which occurs in about 35 percent of patients. If complications do not resolve, chronic tear film insufficiency and insult from surrounding tissue abnormalities can devastate the ocular surface. As practitioners, we may play a vital role in the visual and physiological rehabilitation of patients as they recuperate from the acute phase of SJS.

Scleral contact lenses may be fit as therapeutic treatment for dry eye and ocular surface protection to avoid more invasive treatments such as tarrsoraphy or grafting in patients who have severe ocular effects from SJS.

Case Study

A 15-year-old female was referred after being hospitalized six weeks for SJS due to an antibiotic reaction. Symptoms included severe photophobia and foreign body sensation, burning and no tears even when crying. Chronic signs included conjunctival scarring, early symblepharon, no meibomian gland openings, lid margin thickening/scarring, mucus debris, punctate epithelial erosions and corneal scarring from recurrent epithelial defects.

Figure 1. Patient wearing scleral contact lens.

The patient was using prednisolone acetate ophthalmic suspension 1% (Alcon) q.i.d., artificial tears q 15 to 30 minutes and ointment overnight in both eyes.

The patient's best-corrected VA was 20/80 OU (MRx: OD –5.00D and OS –3.25D) due to the compromised corneal surface. Scleral contact lenses were fit in both eyes with an overall diameter of 18.2mm OU.

The patient continues to use preservative-free Systane (Alcon) q 30 to 60 minutes while wearing the lenses and ointment at night after lens removal. Her wear time is 16 hours a day.

Fitting Scleral Lenses

Scleral contact lenses provided therapeutic rehabilitation by protecting the cornea and sclera from mechanical irritation secondary to compromised lid margins.

The optimal fit of a scleral lens is to completely vault the cornea and limbus, placing the weight-bearing portion of the lens on the sclera and constantly maintaining an aqueous tear-fluid reservoir between the posterior lens surface and anterior corneal surface, which is critical to patients who have insufficient or an abnormal tear film.

The patient returned to the normal daily activities of a 15-year-old, which may not have been possible without the therapeutic benefits of scleral contact lenses. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #149.

Dr. Laurenzi practices at the Cole Eye Institute in Cleveland, Ohio, where she specializes in refractive surgery co-management, contact lenses and clinical research.