Therapeutic Contact Lenses for Ocular Surface Disease Lynette K. Johns, OD, FAAO, FSLS, FBCLA.
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Transcript of Therapeutic Contact Lenses for Ocular Surface Disease Lynette K. Johns, OD, FAAO, FSLS, FBCLA.
Therapeutic Contact Lenses for Ocular Surface Disease
Lynette K. Johns, OD, FAAO, FSLS, FBCLA
Disclosure
• Clinical and education consultant for Bausch + Lomb Boston GP Division
• Adjunct Assistant Professor at the New England College of Optometry
Overview•Dry eye classification• Indications for bandage soft contact lenses• Indications for scleral lenses•Quality of Life•Long-term management•Limitations of CL and Scleral Lenses•Supplemental treatments
International Dry Eye Workshop•Expert committee including clinicians and
clinical scientists•Defined and classified dry eye disease•Epidemiology•Diagnosis, monitoring, treatment and
management•Research and clinical trials
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Dry Eye Disease• Multifactorial
• Tears• Ocular Surface
• Symptoms• Discomfort• Visual • Tear Film Instability
• Associated Features• Increased Tear Osmolarity• Inflammation of Ocular Surface
Dry Eye Disease• Aqueous deficient
• Sjogren’s syndrome• Non-Sjogren’s (age related)
• Evaporative• Meibomitis/Posterior Blepharitis• Environmental• Contact lens related
• Post-refractive surgery• Allergic keratoconjuntivitis• Blink abnormalities
Dry Eye and Ocular Surface Disease :Classification
From 2007 report of International Dry Eye WorkShop (DEWS)Ocular surface 2007; 5 65-198.
EarlyTimeline of Contact Lenses
•1st century A.D. Celsus applied honey soaked linen to conjunctiva s/p pterygium removal
•1888-1889 Fick, Kalt and Muller report using glass scleral lenses
•1960 First publication of soft hydrogel polymers for biologic use (Wichterle O, Lim D: Hydrophilic gels for biologic use. Nature 185: 117-118.)
•1963 Fredrick Ridley reports a review of 3,000 scleral fits over 13 years. (Ridley, F. Scleral Contact Lenses: Their Clinical Significance Arch of Ophthal 70: 740-745)
•1970 First report of bandage soft contact lens use (Gasset AR, Kaufman HE: Therapeutic uses of hydrophilic contact lenses. Am J Ophthal 69: 252-259.)
•1971 first soft contact lens was FDA approved
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Therapeutic Soft Contact Lenses
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Therapeutic Indications of Contact Lenses
Protection from the lid•Trichiasis•Distichiasis•Keratinized lid margins
Therapeutic Indications of Contact Lenses
Protection from exposure
• Bell’s /CN VII Palsy• Acoustic Neuroma• Möbius syndrome• s/p Blepharoplasty• Orbital Disease
Neurogenic & Mechanical Exposure
Therapeutic Indications of Contact Lenses
Keratoprosthesis Type 1•Lubrication of corneal graft host•Protection from ulceration
Re-epithelialization
http://www.visiomed.co.za/prk.php
•Persistent Epithelial Defects•Post-operative protection
Therapeutic Indications of Contact Lenses
Therapeutic Indications of Contact Lenses
Pain Relief
•Filamentary Keratitis•Bullous Keratopathy•Post-operative
Piggyback Therapeutic Contact Lenses
MLADEN ANTONOV/AFP/Getty Images
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Piggyback Contact Lens system
Therapeutic Indications of Contact Lenses
FDA Approved Silicone Hydrogel Bandage Contact LensesLotrafilcon A Balafilcon A
• AIR OPTIX® NIGHT & DAY® AQUA
• CIBA VISION®• Approved 2003• BC 8.4, 8.6• Dia 13.8• Dk 140, 24% H2O
• PureVision™• Bausch + Lomb• Approved 2005• BC 8.3, 8.6• Dia 14.0• Dk 91, 36% H2O
Senofilcon A
• ACUVUE® OASYS®
• VISTAKON®
• Approved 2007
• BC 8.4, 8.8
• Dia 14.0
• Dk 103, 38% H2O
Therapeutic Scleral Lenses
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Therapeutic Uses of Scleral Devices• Vision Rehabilitation• Protection from Lids• Protection from Exposure• Surface Lubrication• Pain relief• Re-epithelialization
Therapeutic Benefits of Scleral Lenses
Initial Presentation After 4.5 hours scleral lens wear
Constant Surface Lubrication
Improving Quality of LifeExamples in Literature
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Graft versus Host Disease
• Transplanted bone marrow/stem cells recognize recipient tissue as foreign
• Acute form within the first 90-100 days after transplant
• Affects skin, liver, mucosa, gastrointestinal tract• Dry eye affects 50% patients who had allogenic
bone marrow transplant
Graft versus Host Disease
Ocular Graft versus Host Disease• Keratoconjunctivitis sicca• Cicatricial lagophthalmos• Conjunctivitis• Corneal ulceration/melt• Uveitis• Ectropian• Cataract
Ogawa Y, Kuwana, M. Dry eye as a major complication of graft-versus-host disease after hematopoietic stem cell transplantation. Cornea 2003 (22) suppl. 1 S19-27
Ocular Surface Disease Index
• 12 question validated self-administerred psychometric tool
• 3 subscales▫Ocular Symptoms▫Visual Function▫Environmental Triggers
• Can be used as an endpoint in clinical trials• Aids monitoring of treatment outcomes• Available online via ALLERGAN• Scoring OSDI© = (sum of scores) x 25 (# of questions answered)Schiffman R, et al. Reliability and validity of the Ocular Surface Disease Index.
ArchOphthalmol 2000;118:615-621.
Ocular Surface Disease Index Scoring
Normal Mild Moderate Severe
0-12 13-22 23-32 33-100
Soft Contact Lenses and cGVHD
Eye & Contact Lens 33(3): 144–147, 2007
• Focus NIGHT & DAY®
• n = 8
• Continuous wear x 7 days over 1 month
• Improvement in VA
• Reduction in OSDI from 77 to 31
• Schirmer’s and Staining remained unchanged
Scleral Lenses and cGVHD
• Boston Scleral Lens
• n = 9
• Retrospective review
• Reduction in OSDI from 81 to 21 after 2 weeks
• Further reduced to 12 after 1 – 23 months
Biology of Blood and Bone Marrow Transplantation. 13: 1016-1021. 2007
Scleral Lenses and cGVHD
Eye & Contact Lens 2008 34(6): 302–305. 2008
Cornea 2007 (26) 10: 1193-1195
• n = 5
• retrospective review 2007
• 4-14 month follow-up
• Improvement in VA
• Subjective improvement in symptoms
• n = 33
• retrospective review 2002 -2005
• Survey regarding pain (52 % reduction), photophobia (63% reduction), quality of life (73 % improvement)
• 22 wearing devices for 3 months – 2 years
Long-Term Management
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Management of Recurrent Corneal Erosions
•Recurrent epithelial erosions•Associated with trauma and anterior corneal
dystrophies•Characterized by
▫Pain (worse in mornings)▫Injection▫Tearing▫Photophobia
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Management of Recurrent Corneal Erosions
Treatment of Recurrent Corneal Erosions
•Hyperosmotic agents•Lubricants•Bandage contact lenses•Tetracyclines•Superficial keratectomy•Anterior stromal puncture•Phototherapeutic keratectomy
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Cornea (30) 2: 164-166. 2011
•Retrospective review recalcitrant RCE•n = 12•Bandage soft CL worn for 3 months (replaced every 2 weeks) with antibiotic prophylaxis•75 % of patients had no recurrence of RCE after 1 year
Management of Recurrent Corneal Erosions
Management of Recurrent Corneal Erosions
•Randomized (unmasked) Controlled Study•n = 29•Bandage soft CL worn for 3 months (replaced every 30 days) •Ocular Lubricants (Lacrilube, Celluvisc) QID for 3 mos•No difference in recurrence between groups. CL provide better initial comfort
Cornea (32) 10: 1311-1314. 2013
Management of Persistent Epithelial Defects
•Photodocumentation•Extended wear of scleral device•Daily monitoring •Antibiotic prophylaxis•Daily disinfection of device and replenishment of
fluid•Longstanding PED’s can be managed with
exchange of 2 devices q12 hours•Weekend monitoring•DOCUMENTATION!!!!!!
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10/25/200710/27/200711/05/2007
Management of Persistent Epithelial Defects
Corneal Perforation: Symptoms, Signs
SymptomsPainImpaired vision“Excessive tearing”
SignsFlat Anterior ChamberPositive Seidel Sign (independent or with pressure)Iris Prolapse
CausesInfectiousAutoimmuneTrauma
Cases
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56 y.o. F referred for scleral lenses for exposure keratitis and lagophthalmos
• Blepharoplasty #1 at age 32 OU UL & LL, revision 4 lids, hard palate graft, canthoplasty, hard palate grafts removed, soft palate grafts, soft palate graft removal, cheek lifts, punctal cautery x4
• Total 38 facial and oculoplastic procedures
• Systemic history of Systemic Lupus Erythematosus, Fibromyalgia, Migraine
• Systemic meds: Namenda, Verapamil, Zolazepam, Vicodin
Ocular Surface Disease Case 1
• Ocular Meds: Tobradex 2x/week OU, Lacrilube OU qhs, Vigamox prn— “when eye is red”
• Chief complaint: dryness and pain OS>OD, inability to close OS, light sensitivity soft contact lens intolerant• VA entering (specs): OD: 20/25-2 OS: 20/20• 7th nerve paresis, lagophthalmos, 2+ PEE (Oxford staining scale)• TBUT: OD: 8 seconds OS: 7 seconds• Schirmer’s: OD: 9 mm, OS: 7 mm• Fitting goals: 1. Support ocular surface, 2. Improve comfort. 3. Improve vision
•Fit OU with scleral devices OD: 20/20-2 OS: 20/15-2 No corneal or conjunctival staining after 6 hours
Case 1
61 y.o. F referred for PROSE treatment for cicatrizing conjunctivitis and dry eye (x 10 years) associated with ocular cicatricial pemphigoid
• Systemic meds: Prednisone 5 mg q.o.d., Methotrexate injection 20 mg/week, Doxycycline 200 mg/day
•Ocular Meds: Restasis BID OU
• Past ocular treatments: Punctal plugs x4, cautery inferior OU, bandage contact lenses
• Chief Complaint: Pain, Dryness, Photophobia
Ocular Surface Disease Case 2
Case 2
• Entering VA (specs): OD: 20/40 OS: 20/40-2• Superior mild injection OD, inferonasal symblepharon OS
• Bilateral 1+ PEE (Oxford grading scale)
• Schirmer’s: OD: 7 mm, OS: 3 mm
• Fitting goals: 1. Improve Comfort, 2. Improve vision
•Fit and dispensed OU with VA 20/25 OD and 20/30+1
Case 2
• September 2005• OD: 16.5 OS: 16.5
• May 2006• OD: 18.0 OS: 18.0
• October 2007• OD: 18.0 OS: 18.0
• April 2008• OD: 17.5 OS: 18.0
• November 2008•Bandage soft CL OU
Example conditions and considerationsSjögren’s syndrome
Increased risk (44x) for Mucosa-Associated Lymphoid Tissue (MALT) lymphoma—non Hodgkin’s lymphoma
SclerodermaHandling Issues
Neurotrophic KeratitisRedness is the patient’s only cue something is wrongRequires a near-flawless scleral fit
Retinal surgeryScleral device diameter and haptic issuesLimit impingement and aggravation of irregular conjunctiva
Patch graft for perforationVisual rehabilitation
Ocular Surface Disease Case 3
61 y.o. F referred for resurfacing PED 1 month s/p patch for perforation • 3 eye surgeries in prior 6m • s/p Phaco CE, PCIOL• s/p PPV/AFx/EL/16% C3F8• s/p PK Patch graft for descemetocele• Secondary Sjögren’s syndrome • Neurotrophic cornea• ? Stem cell deficient
Case 3
Current TX by specialist : Vigamox QIDPF Pred Forte BIDSerum Tears q2hDoxy 50 mg p.o QDBandage CL
Case 3
Re-surfaced after 6 days continuous wear and Vigamox in the device
Figure 2
a
b c d
Novel Applications- Drug Delivery
Keating A., Jacobs D. Anti-VEGF Treatment of Corneal Neovascularization. The Ocular Surface. 2011 9 (4): 40-51.
October 20071w after continuous then daily wear of Boston Ocular Surface Prosthesis VA =CF 6’
March 2008: VA: 20/400s/p 3 months topical Avastin in BOSP , suture removal, systemic steroid. ?PK for vision
Case 3
July 2011s/p PKP January 2011VA 20/50
•Overnight wear with device and one drop Vigamox. •Resurfaced in 24 hours
Case 3
Limitations
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Limitations of Soft Contact Lenses
• Lens retention• Desiccation• Inability to correct irregular astigmatism• Dependency on doctor for applications• Microbial keratitis
Limitations of Scleral Lenses
• Daily wear• Surface Debris• Chamber debris• Bubbles• Suction• Handling• Microbial Keratitis
Microbial Keratitis: Risk for both soft lenses and scleral devices
Lens Management Considerations
Soft Lenses & Scleral Lenses
•Depends on patients condition•Application and removal•Overnight wear?•Prophylactic antibiotic?•Close management
Soft Lens Studies that we discussed•GVHD:
▫Continuous wear x 7 days ▫1 month▫no antibiotic
•RCE: ▫Continuous wear x 2 Weeks▫3 months▫Antibiotic prophylaxis
Supplemental Management
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Daytime Management with Lenses/Devices Lubricants over
lenses Medications with
lenses Refreshing lenses Punctal plugs Moisture goggles
Nighttime Management: To sleep or not to sleep in the lens/device?
•Overnight ointment•Tape tarsorrhaphy•Nighttime goggles
THANK YOU!THANK YOU!