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Contact Lens Spectrum

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THE SCLERAL LENS VAULT

More Conjunctival Injection and SL Wear

By: KAREN LEE, OD
Contact Lens Spectrum August 1, 2023 Vol 38, Issue August 2023 Page(s): 40

THE CASE OF the persistent injection previously described in May’s “The Scleral Lens Vault” column continues. There has been steady progress with this patient and his scleral lens wear-related injection has improved significantly in both eyes. His visual acuity through the most recent pair of lenses was 20/20- OD and 20/20- OS. No further improvement was observed with a sphero-cylindrical over-refraction and the suction previously experienced during lens removal was no longer present.

Overall, the patient was very satisfied and reported gradual symptom resolution that was attributed to scleral lens modifications and concomitant topical medication use. Due to the patient’s history as a steroid responder, fluorometholone acetate ophthalmic suspension, which has been shown to have greater penetrance and fewer side effects as a soft steroid, was prescribed for a short period of time with a taper (Fung et al, 2020).

A mast cell stabilizer, which inhibits the release of inflammatory mediators such as histamine and can prevent both immediate and late reactions, was prescribed for indefinite use (Sharma et al, 2023). The road taken to achieve this endpoint involved multiple scleral lens iterations and would not have been possible without the expertise of knowledgeable lens laboratory consultants. Table 1 summarizes the changes and topical prescriptions of significance.

TABLE 1. Pertinent Scleral Lens Parameters
TRIAL PAIR # PERTINENT SCLERAL LENS PARAMETERS (IN BOTH EYES) SUBJECTIVE AND OBJECTIVE OBSERVATIONS THEORETICAL JUSTIFICATION BEHIND LENS CHANGES CONCOMITANT TOPICAL MEDICATION (IN BOTH EYES)
1 High-Dk 18.0mm diameter scleral lens with a quadrant-specific landing zone * Adequate fit* Lens suction during removal
* Severe injection after 25 minutes of lens wear		 Most patients exhibit rotational asymmetric scleral shapes (DeNaeyer et al, 2017) Cromolyn sodium ophthalmic solution: one drop four times a day; fluorometholone: one drop two times a day for 10 days
2 Lens parameters above plus four milled channels 250μm in depth, stretching from the limbal zone to lens edge in each quadrant (Figure 1) * Trace blanching along channel borders* Mild suction with lens removal
* Injection after three hours of lens wear		 Peripheral channels can prevent or minimize lens suction and promote tear exchange (Michaud, 2020) Cromolyn sodium ophthalmic solution: one drop four times a day; fluorometholone: one drop one time a day for 10 days
3 Lens parameters above; however, depth of channels decreased to 100μm, one fenestration incorporated in the superior quadrant * Adequate fit* Trace resistance noted with lens removal
* Injection noted after eight hours of lens wear		 Scleral lens fenestrations relieve lens suction (Johns, 2011) Cromolyn sodium ophthalmic solution: one drop four times a day; fluorometholone: one drop one time a day for 10 days
4 Lens parameters above plus three additional fenestrations (one fenestration within each channel) * Adequate fit* Minimal resistance noted with lens removal
* Injection noted after 12 hours of lens wear		 Further decrease in lens suction by increasing the number of fenestrations Cromolyn sodium ophthalmic solution: one drop four times a day; fluorometholone: one drop every other day for 10 days

Figure 1. 18mm diameter scleral lens with four milled channels and four fenestrations along the major meridians. Photo courtesy of Karen L. Lee, OD
Figure 1. 18mm diameter scleral lens with four milled channels and four fenestrations along the major meridians. Photo courtesy of Karen L. Lee, OD

It is prudent for practitioners to rule out common causes of scleral lens wear-related injection such as poor alignment, ocular toxicity, or hypersensitivity reactions to solutions and materials before incorporating advanced customizations (Walker et al, 2016). Practitioners must also use their best judgment and consider the benefits and risks when combining ophthalmic corticosteroids use with contact lens wear. CLS

References

  1. Fung AT, Tran T, Lim LL, et al. Local delivery of corticosteroids in clinical ophthalmology: A review. Clin Exp Ophthalmol. 2020 Apr;48:366-401.
  2. Sharma S, Hashmi MF, Chakraborty RK. Asthma Medications. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2023 Feb.
  3. Walker MK, Bergmanson JP, Miller WL, Marsack JD, Johnson LA. Complications and fitting challenges associated with scleral contact lenses: A review. Cont Lens Anterior Eye. 2016 Apr;39:88-96.
  4. DeNaeyer G, Sanders DR, van der Worp E, Jedlicka J, Michaud L, Morrison S. Qualitative Assessment of Scleral Shape Patterns Using a New Wide Field Ocular Surface Elevation Topographer: The SSSG Study. J Cont Lens Res Sci. 2017 Nov;1:12-22.
  5. Michaud L, Lipson M, Kramer E, Walker M. The official guide to scleral lens terminology. Cont Lens Anterior Eye. 2020 Dec;43:529-534.
  6. Johns L. Frustration or Fenestration? I-site. 2011 Jul.

Dr. Lee is the past president of the Scleral Lens Education Society. She has received travel funding and lecture or authorship honoraria from AccuLens, Alcon, Bausch + Lomb, BostonSight, Essilor, and Woo University.

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