Transcript Conjunctival Hyperemia With Scleral Lens Wear: A Clinic

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Conjunctival Hyperemia With Scleral Lens Wear: A
Clinic-Microbiological Correlation and Management
Varsha M Rathi
Somasheila I Murthy
L V Prasad Eye Institute
Hyderabad, India
The authors have no financial interest to disclose
Introduction
• Scleral contact lenses are large diameter
rigid gas permeable (RGP) lenses which
rest on sclera and vault the cornea ( no
touch)
•Scleral lenses are filled with fluid (normal
saline – preserved or unpreserved) before
placing on the eye
•Usually worn as daily wear lenses
•PROSE i.e. Prosthetic Replacement of
the Ocular Surface Ecosystem
(PROSE from Boston Foundation for
Sight, Needham Heights, MA, USA) is
FDA. approved scleral contact lens
Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface
prosthesis: an Indian experience. Indian J Ophthalmol 2011;59(4):279-81.
Jacobs DS. Update on scleral lenses. Curr Opin Ophthalmol 2008;19(4):298-301.
Indications for Scleral lenses
• Scleral lenses have been shown to be effective in
various ocular conditions
• To improve vision in corneal ectasias
–
–
–
–
Keratoconus
Pellucid marginal degeneration,
Intolerant to RGP lens wear
Unable to get an acceptable fitting of corneal RGP lenses
because of advanced ectasia
• To improve comfort in ocular surface disease
– Stevens Johnson Syndrome (SJS)
– Limbal stem cell deficiency (LSCD)
Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: the expanding role. Cornea
2005;24(3):269-77.
Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface prosthesis:
an Indian experience. Indian J Ophthalmol 2011;59(4):279-81.
Rathi VM, Sudharman Mandathara P, Vaddavalli PK, Dumpati S, Chakrabarti T, Sangwan VS. Fluidfilled scleral contact lenses in vernal keratoconjunctivitis. Eye Contact Lens 2012;38(3):203-6.
Safety of Scleral contact lens
wear
• The scleral contact lenses are considered to be safer
with fewer complications
• Rosenthal et al had shown infectious keratitis with
scleral lens wear when the lenses were worn on
continuous wear modality for persistent defect
• Acute Red eyes have been reported with miniscleral
lenses when worn for keratoconus
Purpose:
• The aim of this study is to report the occurrence of red
eyes when the scleral lenses were worn as daily wear
modality and the management.
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(1):33-41.
Methods
• Retrospective analysis of 10 eyes of 5 patients who
had red eyes while using PROSE
• Fitting of scleral lens is described in literature Training for lens insertion, removal, cleaning of the
lenses and the plungers was explained
• Demographics, presenting symptoms, primary
indication for fitting these lenses, duration of lens
wear, cleaning regimen of the lenses, lens case,
plungers that are used for lens insertion and removal,
solution used, change of saline bottle, cleaning of
were noted
Rathi VM, Sudharman Mandathara P, Vaddavalli PK, Dumpati S, Chakrabarti T, Sangwan VS. Fluidfilled scleral contact lenses in vernal keratoconjunctivitis. Eye Contact Lens 2012;38(3):203-6.
Solution and Saline
• Saline used was normal saline to fill the lens prior to
the application in the eye.
– Saline bottle was used for three days and then discarded
• Solution used for lens care – single step RGP lens
solution used in care and maintenance of RGP
• Plungers for insertion and removal – to be cleaned
with Alcohol wipes prior to using for lens insertion
and removal
• The insertion plunger (DMRV corp) is the one with the
hole and the removal plunger is one without hole
Methods - continued
• When patients presented to clinic
– Symptoms were noted and Slit lamp biomicroscopy was done for all
eyes – Lenses and plungers were observed for deposits, scratches,
edges. The fit was assessed
– Conjunctival swab was taken
• From the lid margin and bulbar conjunctiva,
• From the scleral lens inner surface and plungers.
– Patients were asked to discontinue the lens wear
– Antibiotic eye drops (Moxifloxacin eye drops 0.5%, four times a day)
were prescribed
– Patients continued with lubricating eye drops or saline eye drops as
lubricants
• Antibiotic sensitivity testing was done by Disc diffusion method
Results
• None of the patients was cleaning the plungers
with alcohol swabs
• Lens broke – two during follow - up while
cleaning
Conjunctival hyperemia with
lens wear
1 week later -Reduction in hyperemia
with lens discontinuation & antibiotic
eye drops
Case
Eye
Indication
Same lens
worn for
Surface of
the lens
Average
daily wear
Case1
OD
SJS
3 years
Deposits
12h ( gap in Redness
between
and pain
20/80
3 years
Deposits
12h ( gap in Redness
between
and pain
20/100
OS
Case 2
OD
SJS
OS
Results
1year ( lens Deposits
wear for
3years)
3years
Case 3
OD
OS
KC with SJS 2 years
2 years
Case 4
OD
SJS
OS
Case 5
OD
OS
SJS
1.5 years
12h(gap)
Multiple
12 h
depositis on
lens surface
Few deposits12h
Few
Visual acuity
with lens
Redness
20/50
discomfort
Redness
20/40
discomfort
Deposit
14h(gap)
No deposit
10 months ( Good
lens wear
surface
for 7 years)
7 years
6-7 hours
Symptoms
12h
redness
20/25
20/30
No
complaints
CF1m
No
complaints
CF2m –
20/126 over
follow up
Redness, no
discomfort
Redness, no
Culture and Sensitivity
• Microorganisms grown –
• Conjunctival swab - Staphylococcus xylosis, Serratia
marcescans
• PROSE - Nocardia, Klebsiella pneumoniae,
Pseudomonas aeuroginosa, Unidentified fungus
• All plungers grew micro-organisms -Bacillus species,
Staphylococcus xylosis, Propinobacterium acnes
• Sensitivity – The organisms were sensitive to all
drugs – with intermediate sensitivity to Ceftazidime
Risk factors
• Poor compliance to the cleaning regimen despite
using single multipurpose lens solution as two
patients had lenses broken during the cleaning
• Not using alcohol wipes to clean plungers
• These lenses are worn on compromised ocular
surface
• As scleral lenses cover the cornea, do not move on
the eye, there is a built of debris in the fluid
compartment,which can further increase the risk of
inflammatory events
Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface prosthesis: an Indian
experience. Indian J Ophthalmol 2011;59(4):279-81.
Discussion
• This is the first case series which shows the various
organisms isolated from the Scleral contact lenses
and the plungers
• The red eyes can be reduced when scleral lenses are
worn
– By adequate teaching of the care regimen
– Cleaning of plungers with alcohol wipes
– Replacing the lens case and the plungers frequently
•