Contact Lenses for Ocular Surface Disease

Abstract

Ocular surface disease can be difficult to manage, causing patients discomfort and vision loss. Therapeutic contact lenses are an important treatment option that is often neglected because it is conventional wisdom that eyes that are dry or irritated are not good candidates for contact lens. In this focused review, we consider the substantial literature on the use of bandage soft contact lenses (BSCL), scleral lenses, and customized prosthetic devices in the management of ocular graft-vs-host disease. Reports on BSCLs for recurrent corneal erosion are reviewed, as is literature on scleral lenses and prosthetic replacement of the ocular surface ecosystem treatment for Stevens–Johnson syndrome. Clinical pearls for fitting BSCLs are presented, and the issue of antibiotic prophylaxis is considered.

Ocular surface disease (OSD) typically requires a multimodal treatment approach. Therapeutic contact lens, including bandage soft lenses and rigid gas-permeable (RGP) scleral lenses, can be effective tools in the management of OSD. There are no studies comparing bandage soft contact lenses (BSCLs) and RGP scleral lenses. Table 1 is a summary of the advantages and disadvantages of therapeutic contact lens types. In most reports on scleral lenses, OSD patients are a small minority of those described. In this brief review, we examine the utility of contact lenses in the treatment of OSD, with focus on the lessons learned from the literature and personal experience related to ocular graft-versus-host disease (oGVHD), recurrent corneal erosion syndrome (RCE), exposure keratitis, and Stevens–Johnson syndrome. We conclude with clinical pearls for the use of BSCLs in OSD. For exhaustive reviews and detailed fitting guides, these more comprehensive resources can be consulted.^1–4

TABLE 1. - Therapeutic Contact Lens Types: Advantages and Disadvantages

	Bandage Soft Lens Weekly, Biweekly, Monthly Replacement	Bandage Soft Lens Daily Disposable	Standard Scleral Lens (15- to 18-mm Diameter) Limbal Lens (13- to 14-mm Diameter)	Highly Customized Scleral Lens (18-mm Diameter or Larger)
Local availability	Excellent	Excellent	Good (except limbal lens, in Japan only)	Fair
Cost	Low	Low	High	Very high
Patient ease of use	Excellent	Poor (unless prior cosmetic wear)	Good	Fair
Compatibility with fragile epithelium	Good	Fair (because of requirement for daily insertion/removal)	Good	Excellent

OCULAR GRAFT-VERSUS-HOST DISEASE

Ocular graft-versus-host disease can be thought of as the preeminent example of the utility of therapeutic contact lens given there are good data presented in many different publications on several types of contact lens. Among these articles,^5–9 there is excellent response to contact lens use by many metrics, including those that patients report (e.g., National Eye Institute Visual Function Questionnaire 25 [NEI VFQ-25],¹⁰ Ocular Surface Disease Index [OSDI]¹¹) and those that physicians measure or observe (e.g., best-corrected visual acuity [BCVA], staining, and resolution of filaments and persistent epithelial defects). It is worth noting that no medical interventions for oGVHD achieve the standards met by therapeutic contact lens. The lesson learned in the management of oGVHD can be applied to OSD of other types.

Russo et al. reported in 2007 on the safety and efficacy of the Focus night & day (CIBA Vision, Duluth, GA) silicone hydrogel contact lens in the management of oGVHD. Patients with oGVHD who were fitted with this soft contact lens, which was worn on a 7-night continuous-wear basis for 1 month had significant improvement in the subjective assessment of their dry eye symptoms. Their OSDI score decreased from 76.8 at the initial assessment to 31.2 at 1 month. Their log of minimum angle of resolution BCVA improved from 0.22 to 0.23 to 0.04 after 1 month. Interestingly, and perhaps, not surprisingly, there were no significant changes in Schirmer I results, fluorescein staining, or tear breakup time. No complications of contact lens wear were observed.⁵

The safety and efficacy of BSCLs in patients with oGVHD was studied further in a phase II clinical trial published in 2015. Twenty patients were fitted in various extended-wear BSCLs (Bausch & Lomb PureVision, Bausch & Lomb SofLens 38, Ideal Optics Flexlens, Kontur lens) for a maximum of 1 month at a time. All patients were placed on prophylactic antibiotic drops and continued their other eye drops, including steroids, cyclosporine, and serum tears. Patients were assessed at 2 weeks, 4 weeks, and 3 months. The OSDI and 11-point eye symptom ratings improved significantly. Clinically meaningful improvement as measured by the Lee eye subscale¹² was observed in 47% of the patients at 2 weeks, in 58% at 4 weeks, and 47% at 3 months. At 2 weeks, visual acuity was significantly improved, and punctate erosions improved in 58% of the patients. No ocular infections occurred in any of the patients.⁹

A case series from Boston Foundation for Sight reported on 33 consecutive patients with severe dry eye with oGVHD unresponsive to conventional therapy. All the patients were fitted with the Boston Scleral Lens Prosthetic Device (BSLPD), a custom-designed, large-diameter, RGP scleral lens that vaults the cornea and limbus, resting entirely on the sclera (Figure 1). The space created by the vault is occupied by artificial tears that are retained and exchanged gradually with tears during wear. Patients were surveyed after lenses were dispensed and worn. More than half reported the highest improvement in pain and photophobia, and 90% had improvement in reading and driving.⁷ Similar success with BSLPD was reported by a group from the Fred Hutchinson Cancer Research Center, who referred nine patients with oGVHD-related severe keratoconjunctivitis sicca (KCS) refractory to standard treatments to Boston Foundation for Sight. All patients reported improvement in ocular symptoms, with the median OSDI improving from 81 to 21 within 2 weeks after BSLPD fitting. The OSDI further decreased to 12 at the time of last follow-up, median 8 months after fitting. Disability related to KCS resolved in seven patients, and no patients had serious adverse events or infections attributable to BSLPD use.⁶ The Mayo Clinic reported similar impact with the Jupiter scleral lens (Medlens Innovations, Front Royal, VA or Essilor Contact Lens, Inc., Dallas, TX) in five patients. These were commercially available and fitted using a preformed diagnostic set of lenses. In this retrospective case series, five patients with severe KCS associated with oGVHD unsuccessfully treated with conventional therapy were fitted with the Jupiter scleral lens and followed for 4 to 14 months. All 10 eyes were successfully fit, and all patients reported subjective improvement in comfort. Seven of the 10 eyes had improvement in BCVA, with the other 3 eyes maintaining prelens BCVA. The 4 eyes that initially had BCVA of 20/60 or worse all improved to 20/40 or better following treatment with scleral lenses. There were no complications associated with contact lens wear.⁸

FIG. 1.: PROSE device, successor to the Boston scleral lens prosthetic device, on a patient with a 10-year history of oGVHD. (a) Slitlamp photograph showing white eye with 19-mm-diameter lens in place and quiescent inferior corneal neovascularization. (b) Anterior segment optical coherence tomograph (AS-OCT) illustrating vault of the lens over the apical cornea. (c) AS-OCT illustrating an ideal broad bearing zone of the haptic with no conjunctival impingement or compression, and the peripheral vault beginning over the sclera. oGVHD, ocular graft-versus-host disease; PROSE, prosthetic replacement of the ocular surface ecosystem.

With scleral lenses now widely available and falling into the repertoire of specialty lens fitters globally, and myriad soft lenses available, we contend that every patient with symptomatic chronic oGVHD should be offered trial and the prescription of therapeutic contact lens. It is clear that despite relative contraindication to contact lens wear, including sicca, underlying medical disease, older age, and use of topical and systemic immunosuppressants, therapeutic contact lenses can have substantial impact on the quality of life for these patients, with little risk of complications.

RECURRENT CORNEAL EROSION SYNDROME

Recurrent corneal erosion is usually treated in a stepwise fashion with initial use of antibiotic, preservative-free lubricating drops, and nighttime ointments. Bandage soft contact lenses can be applied to protect the affected cornea from the eyelid and provide a scaffold for healing. This can provide immediate relief for the patient.^13–15 A retrospective study of 12 patients with RCE who failed at least 6 weeks of medical lubrication therapy showed that 75% of the patients had no recurrence of RCE with extended-wear BSCL therapy. Patients wore a BSCL for 3 months with a change of lens every 2 weeks. In the 1-year follow-up period, only one patient had objective findings of an RCE.¹⁶ A randomized controlled trial in the United Kingdom compared the efficacy of BSCLs with ocular lubricants in the initial management of RCE. For 3 months, patients were assigned to either wear BSCLs with monthly replacement or use ocular lubricants four times daily and ointment nightly. The two groups had similar rates of resolution of corneal erosion (about 70%) after 3 months. However, patients using BSCLs had resolution of symptoms at 5 weeks versus 9 weeks for patients treated with ocular lubricants. The study concluded that BSCLs are comparable to ocular lubricants in the resolution of RCE, but BSCL treatment seems safe and can provide earlier relief for some patients.¹⁷ Although superficial keratectomy±diamond burr polishing, anterior stromal micropuncture, and phototherapeutic keratectomy are often undertaken for RCE,¹³ it is our experience that these interventions are rarely needed with judicious use of BSCL.

EXPOSURE KERATOPATHY

Scleral lenses and Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) lenses have been used to successfully treatment patients with exposure keratopathy.^18–20 A retrospective case series of 18 patients with exposure keratopathy treated from 2009 to 2014 at a single center reported on the utility of the PROSE device. Patients had exposure keratoconjunctivitis, lagophthalmos, ectropion, or lid retraction. Visual acuity significantly improved from about 20/80 to 20/35 with PROSE treatment. Ocular surface disease index improved by more than 50% from pre-PROSE to post-PROSE. Corneal staining values also significantly decreased after PROSE treatment.²⁰ The Boston Ocular Surface Prosthesis (BOSP), a precursor to the device used in PROSE treatment, was used in a case series of 10 patients with exposure keratopathy from severe periorbital thermal injuries during combat missions. Patients wore BOSP devices on average 16 hr per day, and the BOSP device was also used as a drug-delivery vehicle to treat corneal ulcers. Visual acuity improved to 20/70 or better in 10 of the 16 eyes, with 5 eyes achieving 20/40 or better.¹⁹ Other investigators report that scleral lens is therapeutic for exposure and neurotrophic keratopathy from cranial nerve palsies.¹⁸

STEVENS–JOHNSON SYNDROME

Stevens–Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are life-threatening hypersensitivity skin reactions associated with destruction of the epidermis. Ocular complications can occur both acutely and in the late phase. Scleral lens, BOSP/PROSE, and tear exchanging limbal lens can be used to treat OSD from SJS/TEN. Tougeron-Brousseau et al. reported a retrospective study of 39 patients fitted with scleral lenses for OSD from SJS/TEN, with a mean follow-up of 33 months. Among fitted patients (3 patients failed fitting), BCVA improved by approximately 31% after 6 months. The mean OSDI was reduced by half, and the mean NEI VFQ-25 composite score improved by almost 300%.²¹ The BOSP scleral lens has also been reported to improve visual acuity, symptoms, and visual function in patients with SJS in the United States²² and in India.²³

A retrospective case series of 19 patients with chronic SJS and OSD showed that PROSE treatment could be an effective therapy. Twenty-seven eyes of 16 patients were fitted with PROSE. Log of minimum angle of resolution BCVA improved from 0.43 pre-PROSE to 0.14 post-PROSE. Ocular surface disease index scores improved from 70.4 pre-PROSE to 37.4 post-PROSE.²⁴ Another case series reported that overnight wear of PROSE can be effective in promoting healing of persistent corneal epithelial defect in SJS patients. Reepithelization occurred in 17 of 20 eyes with a median duration of treatment of 8.5 days.²⁵ Pediatric patients with SJS/TEN are candidates for PROSE treatment. In a series of 49 patients younger than 18 years, the median BCVA in patients treated with PROSE was significantly improved, with a mean duration follow-up of 5.45 years. Fifteen patients (30.6%) failed PROSE treatment.²⁶

Limbal contact lens (limbal CL) is a fluid-ventilated 13- to 14-mm-diameter RGP contact lens developed in Japan that can be used in eyes with a short fornix or symblepharon. It is designed to allow tear exchange under the CL during the blinking process. This tear-exchangeable limbal CL was reported to improve visual acuity, and the NEI VFQ-25 composite score in 53 eyes of 42 SJS/TEN patients fitted. No serious adverse events occurred.²⁷

LIMITATIONS OF THERAPEUTIC CONTACT LENS IN OCULAR SURFACE DISEASE

Interestingly, there is limited success of contact lens therapy in Sjögren syndrome, nonspecific dry eye, and post-LASIK dry eye. Patients are often intolerant to PROSE or other scleral lens because of corneal neuralgia or secondary hyperalgesia. Beneficial effect has been reported for silicone hydrogel BSCLs in Sjögren syndrome²⁸; these lenses have high Dk and high modulus, which may both contribute to tolerance.

CLINICAL PEARLS FOR THE USE OF BANDAGE SOFT CONTACT LENSES

Scleral lenses and PROSE are a substantial investment of clinician training and clinician and patient resources. We argue that the investment yields a high return, but for clinicians and patients who do not have access to such resources, it is worthwhile to consider trial of BSCLs for appropriate cases of OSD. Many clinicians are familiar with the use of BSCLs after corneal surgery or procedures. Ocular surface disease is not an absolute contraindication to use, and there can be substantial benefits. The following points may be useful.

Get to Know One Lens

Silicone hydrogel lenses are recommended because they have high Dk and rigid modulus making for easier handling and larger posterior tear lens. Options include AirOptix Night & Day (Alcon, Fort Worth, TX), Acuvue Oasys (Johnson & Johnson, Jacksonville, FL), and PureVision (Bausch & Lomb, Rochester, NY). We advise avoidance of daily disposable lenses because many low Dk hydrogel lenses and daily disposable lenses, regardless of material, are not manufactured or marketed for extended wear.

In-Office Trial

It is important to confirm good centration and movement of the lens. Different base curves and diameters can be trialed for optimal lens/eye relationship. After 30 min of lens wear, lens retention should be confirmed, and patients should report relief of symptoms when queried, with no ongoing blinking, rubbing, or spasm.

Follow-Up

If a patient has no contact lens experience, it is recommended that the patient be checked after 1 day and again at 1 week. If the lens is not retained, a larger diameter lens or Kontur lens, which comes in an extended range of high diameters with variable base curves, may be needed.

Consider Daily Versus Extended Wear

Patients should ideally be eventually converted to daily wear, which is safer with less risk of infection. However, this can be more difficult for a novice patient and may challenge a fragile epithelium. Daily disposable is the safest daily wear soft lens option, rather than a lens that needs to be disinfected overnight. Although extended wear lenses have high patient acceptance, there is higher risk of microbial keratitis. Patients who use extended wear lenses may also need weekly, biweekly, or monthly office visits for exchange to a new lens.

Consider Antibiotic Prophylaxis

Some providers prescribe prophylactic topical antibiotics only when there is geographic epithelial defect at the time of fitting, whereas others prescribe prophylaxis to any high-risk patients, such as those on topical steroid or with prior ulceration. Some prescribe prophylaxis to all BSCL patients. Our practice is to prescribe only in the presence of a geographic epithelial defect.

CONCLUSION

The guiding principles of treating OSD include treating the underlying local and systemic processes. Therapeutic contact lenses can help optimize the environment at the ocular surface, improving patient comfort and allowing for recovery of vision. There is now a substantial body of experience and evidence that contact lenses are useful in the management of OSD. It is important to consider using therapeutic contact lenses in patients with severe OSD who fail conventional therapies before consideration of, and perhaps to avoid, tarsorrhaphy.