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Contact Lens Spectrum

Article

DRY EYE DX AND TX

SCLERAL LENSES FOR EXPOSURE KERATOPATHY AFTER SURGERY

Contact Lens Spectrum February 1, 2018 Vol 33, Issue February 2018 Page(s): 18

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.

The Case

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.

Figure 1. Our patient had poor eyelid apposition, with fluorescein pooling in the unopposed inferior lid.
Figure 1. Our patient had poor eyelid apposition, with fluorescein pooling in the unopposed inferior lid.

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.

Figure 2. With scleral lenses, the patient was comfortable and able to resist forced closure.
Figure 2. With scleral lenses, the patient was comfortable and able to resist forced closure.

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.

Figure 3. The patient wears high-Dk disposable soft lenses at night for corneal coverage and to reduce ocular desiccation.
Figure 3. The patient wears high-Dk disposable soft lenses at night for corneal coverage and to reduce ocular desiccation.

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

For references, please visit www.clspectrum.com/references and click on document #267.

Dr. Walker is currently a clinical instructor at the University of Houston College of Optometry, where she is also pursuing her PhD in scleral lens effects on the eye.

Dr. Gaume Giannoni is a clinical professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting. She is a consultant or advisor to Alcon, Allergan, and Johnson & Johnson Vision Care.

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