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Anterior ocular pathology and ocular surface disease

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Margaret Lam
BOptom UNSW CCLSA OSO IAO
NSW State President, Cornea and Contact Lens Society of Australia (CCLSA)
Adjunct Senior Lecturer, School of Optometry and Vision Science UNSW

 

The 2007 Report of the International Dry Eye Work Shop (DEWS) discussed the role of contact lenses to protect and hydrate the corneal surface in severe dry eye conditions. Several different contact lens materials and designs have been evaluated, including the use of silicone lenses and scleral contact lenses.1,2,3,4,5,6

The advantages include resolving corneal desiccation, improved visual acuity and comfort, decreased corneal epitheliopathy, and healing of persistent corneal epithelial defects.7,8,9,10,11

In some circumstances, for very extensive corneal epitheliopathy, the use of an appropriate high dK lens for overnight extended wear may be appropriate to allow the corneal surface to heal optimally and the fragile epithelium to best recover from mild to severe long-standing anterior ocular pathology, including superficial punctate keratitis, bullous keratopathy and many other conditions, as long as the risk of adverse infectious events is minimised through appropriate precautions around hygiene and contact lens care.

There is acknowledgement that these are corneas at higher risk for contact lens-related adverse events such as inflammatory and infectious events and ocular complications such as corneal neovascularisation. However, the symptoms of pain and visual impairment due to severe dry eye signs and symptoms can warrant the use of a bandage contact lens. This allows a considerable degree of improvement to the patient’s quality of life.

 

Case report 1

 

Bandage contact lens use for superficial punctate keratitis and reduction in visual acuity and ocular surface disease management of dry eye with Dailies Total1

Triska* is a 30-year-old female and has been a patient in our practice since 2011. Her chief concern is her constant blurry vision, her RE much more than LE. She has no dry eye symptoms.

She was initially wearing Acuvue  1-Day TruEye occasionally, one to two days a week. Triska had no Roaccutane history, no autoimmune conditions and no ocular rosacea history.

Refraction: RE -1.75  6/9+2, LE -2.75  6/6.

Slitlamp signs: considerable central corneal superficial punctate keratitis staining. Moderate to marked conjunctival staining.

Tear break up time was four seconds both eyes.

There were no signs of meibomian gland disease, no ocular rosacea and no teleangiectasia. However, the patient did have low tear volume and evaporative dry eye signs with vertical breaks in tear film.

Diagnosis: dry eye disease with constant, moderate to marked effect on vision, DEWS Category 3.

Strangely, the patient reported no pain or soreness. The incongruity of ocular signs and symptoms was noted in dry eye ocular surface disease.

 

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Figure 1. CASE REPORT 1. BEFORE: Triska was prescribed TheraTears nutrition twice a day and Systane Hydration as needed but minimum four times a day

 

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Figure 2. CASE REPORT 1. AFTER: Triska was prescribed TheraTears nutrition twice a day and because she had no dryness symptoms was advised to apply Systane Hydration when noticing blurriness but also minimum four times a day

 

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Figure 3. CASE REPORT 1. BEFORE: The patient was given Alcon Dailies Total1 as a bandage contact lens and advised to wear predominantly contact lenses instead of glasses

 

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Figure 4. CASE REPORT 1. AFTER: The patient was given Alcon Dailies Total1 as a bandage contact lens and advised to wear predominantly contact lenses instead of glasses

 

Management

Triska was prescribed TheraTears nutrition twice a day and Systane Hydration as needed but minimum four times a day.

The patient was given Alcon Dailies Total1 as a bandage contact lens and advised to wear predominantly contact lenses instead of glasses.

Daily wear only of Dailies Total1 for two weeks showed considerable improvement in superficial punctate keratitis.

RE 8.5/14.1/-1.75; improved from 6/9+2 to 6/6 with considerable improvement in corneal epithelial surface staining.

LE 8.5/14.1/-2.75; maintained 6/6 vision with full resolution of corneal epithelial staining.

Results on two-week follow-up showed considerable reduction in superficial punctate keratitis and subsequent improvement in visual acuity from considerable ocular surface resolution with RE improving from 6/9+2 to 6/6.

 

Case Report 2

 

Bullous keratopathy, advanced bilateral keratoconus, infectious crystalline keratopathy, bandage contact lens RE and speciality scleral contact lenses

Barry* is a 70-year-old male who presented with bilateral keratoconus, and bullous keratopathy secondary to a long-standing full-thickness penetrating keratoplasty corneal graft starting to fail. His condition had been managed by bandage contact lens; however, the condition had escalated into infectious crystalline keratopathy, which meant that he would require another penetrating keratoplasty graft soon.

Signs in the RE were consistent with bullous keratopathy, which included corneal stromal haze secondary to corneal endothelial compromise in an ageing (approximately 15-year-old) full-thickness corneal penetrating keratoplasty graft, and subsequent corneal oedema and painful erupting bullae. As a temporary fix, he was wearing an extended-wear, high-dK monthly bandage contact lens, and co-managed by an ophthalmologist. His bullous keratopathy was consistent with signs of graft failure.

The patient’s RE started to develop infectious crystalline keratopathy, which was very challenging to differentially diagnose against the painful, subepithelial erupting bullae on the right cornea coming from the bullous keratopathy. The subepithelial fluid-filled bullae that erupt on the surface cause symptoms of pain similar to those caused by the new infectious crystalline keratopathy.

Infectious crystalline keratopathy as defined by Sharma and colleagues is a corneal infection in which thin, branching crystalline opacities are seen within the corneal stroma, yet no corneal or anterior segment inflammation occurs.12 In most cases, it occurs as a secondary complication of corneal surgery and keratitis, where streptococcus is a highly suspected microbial causative pathogen.12

Management can be aggressive antibiotic therapy and adjunctive discontinuation of topical steroids, but in more serious cases where there is continued infection (corneal vascularisation or scar formation that adversely affects visual acuity)it requires treatment by penetrating keratoplasty.12

The patient was referred for a speciality contact lens fitting on his LE. He had advanced bilateral keratoconus, a longstanding penetrating keratoplasty corneal graft, and LE iris atrophy. In addition, he had had a LE retinal detachment and subsequent retinal surgery. The current LE rigid contact lens was more than four years old and the lens was displaying apical bearing on the corneal graft. This raised concerns of future apical scarring on the LE. The lens also displaced frequently off the eye due to a suboptimal fitting. Barry was prescribed a custom scleral contact lens for his LE.

Entering visual acuity RE was counting fingers at 30 cm, LE 6/9- but the lens needed changing due to heavy apical bearing and risk of future apical scarring.

 

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Figure 5. CASE REPORT 2. RE bullous keratopathy, infectious crystalline keratopathy

 

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Figure 6. CASE REPORT 2. LE iris atrophy, full thickness penetrating keratoplasty corneal graft and advanced keratoconus

 

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Figure 7. CASE REPORT 2. RE escalating crystalline keratopathy and early signs of graft rejection

 

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Figure 8. CASE REPORT 2. LE post graft speciality scleral contact lens fitting

 

Management

RE: full thickness penetrating keratoplasty corneal transplant was prioritised on surgical list at Sydney Eye Hospital due to extensive bullous keratopathy as well as recent development of infectious crystalline keratopathy. LE: prescribed Innovative Contacts scleral contact lens.

Habitual visual acuity RE counting fingers at 30 cm, LE 6/9-

Innovative Contacts Custom scleral contact lens prescribed LE 8.40/3900/Increased Flat/16.5/+1.75 

Outcome: Post scleral contact lens, VA LE 6/7.5+2.

Lens displaying no conjunctival indentation or subconjunctival vessel blanching and nicely centred (as per Figure 8).

LE lens: the patient commented after the two-week follow-up: ‘The left eye lens is comfortable. I am really enjoying the crisp vision and the lens is no longer falling off easily, unlike the previous lens.’

*Names have been changed for patient anonymity

 

1.  2007 Report of the Dry Eye WorkShop. Ocul Surf 2007; 5: 2: 65-204.

2.  Bacon AS, Astin C, Dart JK. Silicone rubber contact lenses for the compromised cornea. Cornea 1994; 13: 422-428.

3.  Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: the expanding role. Cornea 2005; 24: 269-277.

4.  Tappin MJ, Pullum KW, Buckley RJ. Scleral contact lenses for overnight wear in the management of ocular surface disorders. Eye 2001; 15(Pt 2): 168-172.

5.  Romero-Rangel T, Stavrou P, Cotter J, et al. Gas-permeable scleral contact lens therapy in ocular surface disease. Am J Ophthalmol 2000; 130: 25-32.

6.  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; 130: 33-41.

7.  Bacon AS, Astin C, Dart JK. Silicone rubber contact lenses for the compromised cornea. Cornea 1994; 13: 422-428.

8.  Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: the expanding role. Cornea 2005; 24: 269-277.

9.  Tappin MJ, Pullum KW, Buckley RJ. Scleral contact lenses for overnight wear in the management of ocular surface disorders. Eye 2001; 15(Pt 2): 168-172.

10.  Romero-Rangel T, Stavrou P, Cotter J, et al. Gas-permeable scleral contact lens therapy in ocular surface disease. Am J Ophthalmol 2000; 130: 25-32.

11.  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; 130: 33-41.

12.  Sharma N, Vajpayee RB, Pushker N, Vajpayee M. Infectious crystalline keratopathy. CLAO J 2000; 26: 1: 40-43.



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