WHAT SHOULD ONE do when every tool in the toolbox has been used to heal a nonhealing epithelial defect on a neurotrophic cornea? Reach for a loose-fitting scleral contact lens and give the patient immediate protection and the ability for their cornea to heal.

CASE REPORT

A 76-year-old patient presented with a persistent epithelial defect (PED), along with a significant ocular and medical history. The patient had a systemic history of a peripheral stem cell transplant for large cell lymphoma, lupus, and Sjögren’s. His ocular history included herpes zoster ophthalmicus OS with two reoccurrences resulting in a neurotrophic keratoconjunctivitis causing an epithelial defect.

In four months, punctal plugs, bandage contact lens, amniotic membrane, anti-inflammatory drops, serum tears, and an eye drop to treat the neurotrophic keratitis all failed to resolve the defect. His current medications related to his ocular condition include moxifloxacin q.i.d. OS, prednisolone q.d. OS, cyclosporine b.i.d. OS, serum tears q.i.d. OS, preservative-free tears six times a day, and 1 gram of valaciclovir every day.

Entering uncorrected acuity OS was counting fingers at 1 foot. Slit lamp exam revealed significant meibomian gland dysfunction, palpebral and bulbar conjunctival injection, a 3.5mm vertical and 5.5mm horizontal epithelial defect with rolled edges, and underlying edema. There were no signs of an infiltrate or keratic precipitates. The patient was post-cataract extraction and the anterior chamber was quiet.

At this initial encounter, a 19.0mm scleral lens was placed on the patient’s eye and evaluated for fit and comfort. The initial lens fit was adequate, but not ideal; however, we wanted to get a lens on the patient as soon as possible. An over-refraction was performed, and the patient’s best-corrected visual acuity was 20/200. Application and removal were taught, and the patient left with the trial lens.

After two weeks of daytime 12- to 15-hour wear, the patient’s epithelial defect measured 3.5mm vertical and 2.5mm horizontal. There was reduced edema, intact diffuse hazy epithelial surrounding.

One month after, the entering acuity was improved to 20/200 and the patient reported a noticed improvement in vision. The epithelial defect was 2.75mm vertical and 1.5mm horizontal; superficial neovascularization was seen.

DISCUSSION

According to the British Contact Lens Association Contact Lens Evidence-based Academic Report (CLEAR) on the medical use of contact lenses, sclerals promote reepithelization of the defect in the majority of cases (Jacobs et al, 2021). Lim and colleagues (2013) reported most eyes had complete resolution with no adverse advent.

Another report of patients using fluid ventilated scleral lenses for this purpose showed the majority of patients having resolution (Rosenthal et al, 2000), however 29% developed microbial keratitis. A large difference is that in Lim and co-workers (2013) study, the patients all used prophylactic preservative-free antibiotics.

It is difficult to estimate the exact time a patient’s defect will resolve, and it varies. In a paper by Khan and colleagues (2019), out of eight eyes that had PEDs, complete resolution was observed in all eyes with a mean time of 11 days. This is consistent with the case series done on PROSE lenses by He and coworkers (2018) that found resolution within two to four weeks.

It is important to watch for signs that the cornea cannot tolerate the scleral lens, such as worsening of corneal edema, visual acuity, symptoms, and redness.

CONCLUSION

Scleral lenses provide the corneal epithelium with hydration and oxygen permeation, while at the same time protecting it from mechanical forces. This is why sclerals also facilitate the healing of a PED. CLS

References

1. Jacobs DS, Carrasquillo KG, Cottrell PD, et al. BCLA CLEAR - Medical use of contact lenses. Cont Lens Anterior Eye. 2021 Apr;44:289-329.
2. Lim P, Ridges R, Jacobs DS, Rosenthal P. Treatment of persistent corneal epithelial defect with overnight wear of a prosthetic device for the ocular surface. Am J Ophthalmol. 2013 Dec;156:1095-1101.
3. Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol. 2000 Jul;130:33-41.
4. Khan M, Manuel K, Vegas B, Yadav S, Hemmati R, Al-Mohtaseb Z. Case series: Extended wear of rigid gas permeable scleral contact lenses for the treatment of persistent corneal epithelial defects. Cont Lens Anterior Eye. 2019 Feb;42:117-122.
5. He X, Donaldson KE, Perez VL, Sotomayor P. Case Series: Overnight Wear of Scleral Lens for Persistent Epithelial Defects. Optom Vis Sci. 2018 Jan;95:70-75.