Contact Lens Case Reports

Sclerals Benefit OSD Patients

BY PATRICK J. CAROLINE, FAAO, & MARK P. ANDRÉ, FAAO

In our practice over the past 10 years, modern scleral lenses have become a primary medical treatment for pathologic ocular surface diseases (Figure 1). One condition, Stevens-Johnson syndrome (SJS), is a rare anomaly that occurs most commonly in young or middle-aged adults. The condition is the result of an individual’s hyper-reactivity after exposure to a variety of substances or conditions that include systemic drug reaction, recurrent herpes simplex infection, or measles.

Figure 1. Common ocular surface disease conditions.

The onset of SJS is usually sudden and stormy, with fever, malaise, sore throat, and respiratory symptoms. This is followed by the appearance of skin lesions of alternating red and white rings and bullae on the hands, feet, arms, legs, trunk, and face. The mucous membranes (especially those of the eyes, mouth, and genitalia) may be particularly affected by the erosive lesions. Individual skin lesions tend to have life cycles of approximately two weeks, and the entire disease usually has a duration of six weeks.

At the onset of the disease, the ocular course is difficult to predict. However, not infrequently, the most serious long-term sequelae are the ocular complications.

The ocular manifestations of SJS vary markedly and include severe keratoconjunctivitis sicca, total conjunctival and corneal scarring, keratinization of all ocular membranes and lid margins, corneal vascularization, entropion, trichiasis, symblepharon, perforation, and blindness.

A Case of SJS

A 63-year-old female was diagnosed with SJS at age 10 following systemic use of a sulfonamide. Her right eye was enucleated at age 21 following multiple corneal graft failures. She presented to our clinic with a left eye visual acuity of 20/400 and extensive corneal neovascularization, scarring, and the presence of a non-healing epithelial defect (Figure 2).

Figure 2. The patient’s left eye at initial presentation.

We immediately fit the patient with a high-Dk, 16.5mm scleral lens that she wore 24/7 for two weeks, until the underlying epithelial defect had healed. During that two-week period, the patient was followed closely by us and her cornea specialist. She was instructed to remove the lens to exchange the preservative-free saline solution four times a day.

Today, the patient wears the lens on an all-day wearing schedule with 20/25 vision and no recurrence of the epithelial defect. Figure 3 shows her eye six months after beginning scleral lens wear.

Figure 3. The patient’s left eye following six months of scleral lens wear.

Modern scleral lenses provide a number of benefits to patients who have severe ocular surface disease. These benefits include improved visual correction; protection of the ocular surface from scarred lid margins, entropion, and trichiasis; ongoing lysis of symblepharon to maintain the conjunctival fornices; and protection of the ocular surface from the debilitating effects of tear evaporation. CLS

Patrick Caroline is an associate professor of optometry at Pacific University. He is also a consultant to Contamac. Mark André is an associate professor of optometry at Pacific University. He is also a consultant to CooperVision.