SCLERAL LENSES CREATE a semi-sealed environment with negative pressure that may induce suction-related complications on the ocular surface (Walker et al, 2020; Walker et al, 2016). The mantra behind safe contact lens wear often centers around educating patients to promptly remove the lenses and discontinue their use if any ocular injection occurs.

Recently, however, I have a few patients who would like to wear scleral lenses but report a history of lens-related injection that does not appear infectious in nature. The following case report describes a patient who initially seemed like a straightforward scleral lens candidate but has me stumped.

HISTORY

A 34-year-old Hispanic male with keratoconus presented with a chief complaint of blurry vision and desired to be fit in scleral lenses that did not cause injection. His entering visual acuities with spectacles were 20/100 OD and 20/30⁺² OS. Refraction, corneal tomography, and slit lamp examination all revealed findings consistent with keratoconus that was more advanced in the right eye.

After discussing alternate treatment options, a scleral lens fitting was attempted. Given the patient’s history, a large, 18.0mm diameter, highly customizable lens design was utilized in hopes of achieving even weight distribution and minimal conjunctival compression (Esen and Toker, 2017; Kauffman et al, 2014). Minimal injection was noted during routine diagnostic scleral lens fitting and acuities were correctable to 20/20 in both eyes with an over-refraction.

The initial lens design incorporated milled channels in each major meridian to prevent scleral lens suction (Schornack et al, 2008) (Figure 1). At time of dispense, both adequate central clearance and haptic alignment were observed in both eyes (Figure 2). The patient reported having used brand name, multipurpose, GP lens solution for cleaning and soaking, and filling with off-label, preservative-free, multidose, bottled saline. Although the patient reported clear vision and good comfort, a slow onset diffuse conjunctival injection did occur that was greater in severity in the right eye after four hours of lens wear (Figure 3).

DISCUSSION

Although scleral lens suction can induce conjunctival injection, I suspect there may be more than meets the eye in this particular case. Systemic testing revealed asymptomatic chronic hypertension (180/160 mmHg) that is now managed with medication. General blood work did not indicate the possibility of an underlying systemic inflammatory disorder.

The patient has been switched to an oxidative solution and U.S. Food and Drug Administration-approved scleral lens filling saline solution that contains buffer and five essential electrolytes. Having an allergy to GP lens plastics is rare but may need to be ruled out in this case. CLS

REFERENCES

1. Walker MK, Pardon LP, Redfern R, Patel N. IOP and Optic Nerve Head Morphology during Scleral Lens Wear. Optom Vis Sci. 2020 Sep;97:661-668.
2. 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.
3. Esen F, Toker E. Influence of Apical Clearance on Mini-Scleral Lens Settling, Clinical Performance, and Corneal Thickness Changes. Eye Contact Lens. 2017 Jul;43:230-235.
4. Kauffman MJ, Gilmartin CA, Bennett ES, Bassi CJ. A comparison of the short-term settling of three scleral lens designs. Optom Vis Sci. 2014 Dec;91:1462-1466.
5. Schornack MM, Baratz KH, Patel SV, Maguire LJ. Jupiter scleral lenses in the management of chronic graft versus host disease. Eye Contact Lens. 2008 Nov;34:302-305.