Ocular cicatricial pemphigoid (OCP) is an autoimmune disease that has a mean age of diagnosis between 58-to-69 years old. It results in antibodies binding to the basement membranes of mucous membrane tissue, including the conjunctiva (Elder and Lightman, 1994). OCP is a progressive condition that has four stages: 1) chronic conjunctivitis and subepithelial fibrosis, 2) fornix foreshortening, 3) symblepharon formation, and 4) end-stage keratinization (Foster, 2014). Keratopathy significantly contributes to pain and visual loss.

Diagnosis is made with biopsy; pharmacological treatment is directed at reducing inflammation (Foster, 2014; Taurone et al, 2019). Ocular cicatrization progresses in 75% of patients not receiving treatment (Elder and Lightman, 1994). Contact lenses are often a critical management strategy during middle and later stages of disease. Prescribing soft bandage lenses for extended wear will reduce discomfort for those who experience chronic erosions and are unable to successfully handle contact lenses. Scleral lenses can also protect the compromised surface and bandage the eye for relief as well as improve vision in cases of corneal irregularity.

Case Examples

Case 1 An 85-year old female who had OCP was referred for bandage contact lenses. She reported extreme discomfort and wasn’t able to open her eyes. Uncorrected visual acuity was OD 20/400 and OS hand motion. Slit lamp examination showed trichiasis, symblepharon, corneal erosions, corneal scarring, and neovascularization (Figure 1). She was using Restasis (Allergan) b.i.d. Scleral lenses were not an option because she was unable to handle contact lenses and she had extremely small apertures.

Alternatively, she was fit with U.S. Food and Drug Administration-approved silicone hydrogel soft lenses for extended wear. The bandage lenses provided significant relief. She returned every week or two for in-office replacement. Unfortunately, fornix foreshortening and symblepharon eventually prevented application of the bandage lenses, and she was returned to full-time care with her cornea specialist.

Case 2 A 69-year-old female who had OCP reported for scleral lens fitting. Current treatment included Restasis, autologous serum tears, artificial tears, and bacitracin ointment. She was wearing soft contact lenses, with visual acuity of OD 20/70 and OS 20/30. Her chief complaint was increased burning and redness. Slit lamp exam showed punctate erosions, trichiasis, and fornix foreshortening OD and OS. The patient was fit with scleral lenses, right eye 16mm (Figure 2) and left eye 16.5mm. She was able to see 20/30 OD and OS, and symptoms improved significantly. The patient is stable after three years and has discontinued the autologous serum.

Contact lenses provide patients who have OCP with significant relief as an additive strategy to their systemic and ocular pharmacological treatment. For the majority of cases, sclerals provide the most benefit. Fornix foreshortening, symblepharon, or ocular comorbidities can result in contact lens failure. CLS

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