Scleral Lenses for Ocular Surface Disease

CollaborativeEYE at the Intrepid Eye Society Meeting

The Intrepid Eye Society held its annual meeting in conjunction with the 2018 meeting of the American Optometric Association in Denver. This year’s symposium focused on audience participation, industry-led discussions, and presentations on inventive clinical applications at established practices.

Intrepid Eye Society treasurer and CollaborativeEYE Editorial Board member Melissa Barnett, OD, FAAO, FSLS, FBLCA prepared a talk for the Intrepid Eye Society symposium with John Gelles, OD, FIAO, FCLSA, FSLS, which she summarizes for our readers here. They discuss how scleral lenses can be used to treat a pathology that modern optometrists encounter more and more often: ocular surface disease.

Indications for scleral lenses include visual rehabilitation for patients with irregular corneas and therapeutic treatment of ocular surface disease. By providing ocular protection and continuous lubrication and by preventing mechanical damage and tissue desiccation, scleral lenses may promote healing and disrupt the pain cycle.

Scleral lenses have applications across myriad diseases. Patients with neurotrophic keratitis, exposure keratitis, dry eye disease (DED), graft-versus-host disease, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical burns, limbal stem cell deficiency, Sjögren syndrome, and persistent epithelial defect (PED) may benefit from scleral lens use. When conventional treatments are ineffective, scleral lenses are a viable management option. Scleral lenses have also been indicated for the treatment of conditions associated with neuropathic ocular pain.¹

The Tear Film & Ocular Surface Society Dry Eye WorkShop II report (also known as the TFOS DEWS II report) categorized scleral lenses as a tertiary therapy. In the TFOS DEWS II schema, primary treatments include prescription medications; secondary therapies include overnight treatments such as ointment or moisture goggles; and quaternary treatments include long-term steroid use, amniotic membrane grafts, surgical punctal occlusion, tarsorrhaphy, and salivary gland transplantation.²

Resources for Scleral Lens Practitioners

Dr. Barnett recommends several resources that scleral lens practitioners may wish to take advantage of.

She coedited, with Lynette K. Johns, OD, FAAO, FSLS, FBCLA, and authored (with the unique perspectives and contributions of international experts) the book Contemporary Scleral Lenses: Theory and Application, a resource for novice and experienced scleral lens practitioners. The text highlights the history of scleral lenses, their application in complex pathologies, scleral lens complications, collaborative care, and their innovative use in patients with diseases that are recalcitrant to primary and secondary treatments.¹

Dr. Barnett coauthored with Daddi Fadel, Dip Optom, FSLS, The Clinical Guide for Scleral Lens Success, a valuable, hands-on practical resource to use daily in clinical practice.²

Another resource for scleral lens information is the Scleral Lens Education Society website. Readers can visit the Society online at www.sclerallens.org.

This coming year, Dr. Barnett will be a chair of the 2019 International Congress of Scleral Contacts. Held in Fort Lauderdale, Florida, each summer, the meeting is dedicated exclusively to the art and science of scleral lenses. Lectures and hands-on wet labs provide a training ground for new practitioners to learn how to fit and handle scleral lenses, and for experienced practitioners to incorporate new techniques and new technologies into their practices. Dr. Barnett will cochair the meeting, to be held July 25 and 26, 2019, with the meeting’s cofounder, Thomas P. Arnold, OD, FSLS. You can register for the meeting at ICSCmeeting.com.

Barnett M, Johns LK, eds. Contemporary Scleral Lenses: Theory and Application. Vol. 4. Potomac, MD: Bentham Books; 2017.
Barnett M, Fadel D. Clinical Guide for Scleral Lens Success. SLS & AILeS; 2018.

SJÖGREN SYNDROME

Sjögren syndrome is a chronic systemic autoimmune disease characterized by lymphocytic infiltration and malfunction of the exocrine glands, resulting predominantly in symptoms of dry eye and dry mouth (xerostomia).³ Sjögren syndrome is one of the most common systemic rheumatic autoimmune diseases, affecting up to 1.4% of US adults and second only to rheumatoid arthritis in its prevalence in North America.⁴

Aqueous deficient DED and xerostomia are hallmarks of Sjögren syndrome. There are numerous other systemic manifestations of Sjögren syndrome, including mouth sores, dental decay, arthritis, muscle pain, and neurologic symptoms such as trouble with concentration, memory loss, and brain fog. Autoimmune thyroiditis and central nervous system disorders are also associated with this syndrome.

When taking a history in patients with DED, clinicians should inquire about xerostomia and arthritis. Prompt diagnosis is imperative due to the predominance of diffuse large B-cell lymphomas in patients with Sjögren syndrome.⁵

CASE STUDY

At the meeting in Denver, Dr. Gelles and I presented a case of a patient whose PED was managed with scleral lenses.

A 64-year-old man with diabetes presented with a PED that was present for 3 months after complicated cataract surgery in his right eye. He was monocular and had a prosthesis in his left eye. The right eye demonstrated evidence of neurotrophic keratitis secondary to a herpes simplex virus infection. Significant exposure keratitis and a PED were present in the right eye. Previous management strategies included topical moxifloxacin, three discrete treatments with cryopreserved amniotic membrane (Prokera, BioTissue), a bandage contact lens that frequently dislocated, autologous serum drops every 30 minutes, nighttime lubricant ointment, and a tape tarsorrhaphy at night.

Two scleral lenses were prescribed, and the patient was instructed to swap them every 12 hours. The patient was instructed to apply one drop of moxifloxacin and two drops of autologous serum in the bowl of the lens, and the remainder was filled with preservative-free unbuffered saline. Each lens was cleaned with 3% hydrogen peroxide solution (Clear Care, Alcon) when not worn.

With this regimen, the PED improved each day. The epithelial growth rate was measured, graded, and scored using AOS Anterior (Advanced Ophthalmic Systems), a novel software system that provides consistent, accurate, objective grading of ocular conditions.

On day 7, the epithelial defect had healed, vision improved to 20/25-, and scleral lens wear was continued for daily wear only. The regimen of extended scleral lens wear and moxifloxacin was discontinued; tape tarsorrhaphy and ointment application at night were continued. Based on AOS software analysis, ocular injection of the conjunctiva was significantly reduced from baseline measurement (23% of vessels injected at baseline compared with 10% of vessels injected day 7).

This lecture illustrated that scleral lenses are a viable option in the management of ocular surface disease.

Melissa Barnett OD, FAAO, FSLS, FBCLA

Editorial Board Member, CollaborativeEYE
Principal Optometrist, UC Davis Eye Center, Sacramento, California
drbarnett@ucdavis.edu; Twitter @drbarnett1
Financial disclosure: No relevant disclosures

Rosenthal P, Borsook D. Ocular neuropathic pain. Br J Ophthalmol. 2016;100(1):128-34.
Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575-628.
Bloch K, Buchanan W, Wohl M, Bunim J. Sjogren’s syndrome: a clinical, pathological and serological study of 62 cases. 1965. Medicine (Baltimore). 1992;71(6):386-401.
Helmick C, Felson D, Lawrence R, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Arthritis Rheum. 2008;58:15-25.
Navazesh M, Christensen C, Brightman V. Clinical criteria for the diagnosis of salivary gland hypofunction. J Dent Res. 1992;71:1363-9.