Bandage contact lenses in ocular disorders

Clinical Article

Bandage Contact Murali

Lenses in Ocular K. Aasuri,

MD,

We performed a retrospective analysis of 129 patients (138 eyes) fitted with bandage contact lenses (BCL) between 1992 and 1997 for various ocular disorders at the L.V. Prasad Eye Institute, India. Included were 105 malesand 24 femaleswith a mean age of 36.3 years. Lenses were worn on an extended basis for a mean duration of 32.5 t- 45. I 8 days (range, 1-385 days). Prophylactic antibiotics were used in the majority (87.7%) of eyes. In 108 (78.3%) eyes, BCL wear was successful. Sewenty-one of the 87 eyes with persistent epithelial defects healed. Visual acuity improved by one or more lines in 55 eyes. Three eyes deweloped infiltrates--one sterile and two infectious. Infectious keratitis resolved in both patients after appropriate management. With a close follow-up, BCLs are safe and effective in alleviating symptoms and promoting healing of many ocular surface disorders. The role of prophylactic antibiotics is kbatable. 0 Elsewier Science Inc. 1998 Bandage contact lens; persistent epithelial defect; bullous keratc>pathy; infectious keratitis; prophylactic antibiotics

Keywords:

Introduction Since the introduction of hydrogels by Wichterle and Lim’ in 1960, their role as soft contact lenses for refractive correction has been well established. Due to their large diameter, comfort, ability to conform to the shape of the cornea, and relatively good oxygen permeability, they have been tried successfully in treating a variety of ocular surface Address correspondence and reprint requests to Dr. Murali K. Aasuri, Consultant, Cornea and Contact Lens Services, L.V. Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500 034, India. Presented as a poster at ARVO meeting, 1997, Fort Lauderdale, USA. Accepted for publication December 8, 1997. ICLC, Vol. 24, November/December, 1997 0 Elsevier Science Inc. 1998 655 Avenue of the Americas, New York, NY 10010

and Sreedhar

M.S.,

Disorders

MD

disorders. Currently, bandage contact lenses (BCL) are very popular as a therapeutic modality for recurrent cornea1 erosions,*,’ persistent epithelial defects,4,5 bullous keratopathylh and post-photorefractive keratectomy (PRK)/phototherapeutic keratectomy (PTK).’ Since these lenses are worn on an extended wear basis on corneas that are compromised, complications can result if adequate precautions are not taken.s Adverse effects of BCL wear could range from minimal lens intolerance to severe infectious keratitis. We evaluated the efficacy and safety of BCL wear in a variety of ocular surface disorders treated at our institute.

Materials and Methods We retrospectively studied the medical records of patients fitted with BCL between February 1992 and February 1997. We analyzed the indications, different types of lenses used, duration of lens wear, clinical outcome, and complications. Clinical outcome was either success (purpose served) or failure (purpose not served) with BCL wear. Success was defined as fulfillment of the purpose for which the lens was fitted, varying from symptomatic relief to healing of the underlying condition. Any complication that could be attributed to BCL wear was considered to be lens induced. Patients who had infective etiology or received concomitant tissue adhesive application were excluded from the study, since it would be impossible to identify the specific cause for any complications arising in this group of patients. Also, records with inadequate data or follow-up were excluded. Adequate follow-up was a minimum of one day for patients fitted for symptomatic relief and one week for other indications; however, patients discontinued prior to adequate follow-up by the treating ophthalmologist were included in the study. 0892-8967/97/$17.00 PII SO892-8967(97)00084-9

Results A total of 129 patients (138 eyes), including 105 males and 24 females, were evaluated. The mean age was 36.3 years (range, 4-75 years; Tahlr 1). The various indications for BCL application are shown in T&e 2. A majority (6 3.0%) of the eyes had k3crsistcnt epithelial defects (PED). PEL) was diagnosed clinically when the epithelial defect failed to heal with frequent instillation of lubricants and/or revealed heaped up epithelium at the edges, with or without assclciated inflammation. A majority of the eyes in the miscellane<>us group (n = 25) had epithelial defects due to various reasons, including 9 eyes (seven patients) that underwent PRK. The different types of BCLs used were Plan+T (71 = 33), U4 (11 = 34), and SeeQuence-2 (n = 12) of Bausch & Lomb and Acuvue (n = 4) of Vistakon (Johnson &I. Johnson vision products, Inc). Lens details were incomplete in 55 eyes. Lens fit was assessed l-2 hours her insertion and 24 hours later. Thereafter the patients were checked as required by the underlying disease process. Parameters for fit assessment included centration, movement, and tightness of the lens (Table 3). Lens tightness, assessed by a push-up test, was avoided in the majority of patients in view of the underlying pathology. Good centration was achieved in most eyes (91.5%). The lens decentration noted in 11 eyes was felt to be within tolerable limits and did not require a change of lenses. Details of the topical medication received are shown in T&e 4. Topical antibiotics were given for prophylaxis in the majority (87.7%) of eyes. When required, cycloplegics and topical steroids were used for controlling the underlying inflammation. Fifteen eyes were refitted for lens loss. Lens damage or significant deposit formation requiring lens exchange was not noted. The lenses were used on an extended-wear basis for an average duration of 32.5 t45.18 days (range, l-385 days). One hundred and eight eyes (78.3%) were treated successfully with BCL wear (Table 2). Thirty eyes failed to respond to BCL wear. When the duration of BCL wear was analyzed, it was noted that the eyes in the “Success” group wore lenses for a significantly longer duration (36.3 ? 48.4 days) as compared to those in the “Failed” group (19.1 -C

Table 1. Age Distribution Age (years)

No. of Patients 1 8 17 32 19 12 22 15 3

(5 5-10 1 l-20 21-X 3 l-40 41-50 51-60 61-70 71-m

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27.5 Jays) (1) = c7.001). WI irn the trc:ttil-iz ~~pt~th,~lni~~t~i gists’ impreshionx were anaIy:e~l, tiohx>\.ci-, it \v;ih IIC I~I.II t liar “Failed” eyes wcrc’ not responding ;rnJ/clr dctcrlor,tnng dcspite the prcsenc-c of BCL. Vistial acuify improved 1~ s)IIC’ 01 more lines in 55 eyes. In the rc’yt, \sisioii thither rci11;Itnc’cI th<. same, decreased marginally, or was not I-cc~~JcJ. Eyc‘5 u2tti hubs kerattectic)n of the graft from the trichiatic lashes. In addition, tarsorrhaphy and electrolysis of the trichiatic lashes was performed. The graft remained clear for 6 months. Subsequently, the patient presented with a sterile infiltrate in the bed c>fa PED in the inferior quadrant of the graft, corresponding to the area of limhal ischemia from the original chemical burn. The condition remained unaltered despite performing a limbat autograft. Patient 2 developed fungat keratitis in the right eye with overnight wear of BCL. He had recurrent attacks of viral keratitis and was fitted with a BCL for a suspected mrtaherpetic keratitis. He was on topical hetamethasone sodium phosphate (1%) eye drops, twice daily, which was discontinued after insertion of the BCL. He was asked to use chloramphenicol 0.4% eye drops fcour times a day- with follow-up the next day. The patient presented with severe pain, redness, and irritation in the right eye, which started the previous night. Examination revealed a full thickness cornea1 infiltrate with endothelial exudates and anterior chamber reaction. The BCL was noted tco be of normal tightness and exhibited a movement of 0.5 mm. Fungal filaments were noted on smears (Crams and potassium hydroxide) obtained from cornea1 scrapings. Fusarium solani was isolated from cultures of material obtained from cornea1 scrapings and the BCL. The ulcer worsened despite the use of intensive antifungal therapy and compelled us to perform a therapeutic graft. The infection was successfull\ eliminated, and a clear graft was achieved. Patient 3 was a unilateral high myope who underwent PRK in his right eye and was fitted with a BCL. He was seen the following day and was advised to use a prophylactic antibiotic (gentamicin sulphate 0.3%, four times daily) and a topical nonsteroidal anti-inflammatory agent (diclofenac sodium l%, four times daily). The BCL was noted to be in place. The patient presented for an unscheduled check-up, with complaints of severe pain, redness, watering, and photophobia in the right eye of four days duration. A central

Bmtdagr Contact Table

2. 0culx

l)iseases

and Their

Response

to BCL

Lensrs in Ocular

Disor&rs:

Aasttri and Srcedhar M.S.

Wear Purpose Mean

17iwilac

No.

PED ABKjPBK Lrakm:! blt&/wounJ L’JI pnd&x~ Filamcntxy keratitis Exposed knots Miscellane -l-m11 PEI)

= Persistent

Table 3.

uf Eyes (%)

87 12 6 1 6 1 25 138 epithelial

defect;

Wear 31.94 70.42 25.17 6.0 52.50 35.0 14.64 32.59

(63%) (8.7%) (4.3%) (0.71%) (4.3%) (0.7%) (18.1%) (100%)

ABK/PBK

= Aphakic/Pscudophakic

of Lens Serveci

(232.) (235.52) (2 107.89) (227.56)

71 9 3 I 6 1 17 108

(k33.72) (t 14.27) (?45.18) hullnus

No.

Not

(81.6%) ( 7 5 ‘% ) (50%) (lO@‘rn, (lo@%) (100%) (68%) (78.3%)

130 119 II 138 121 14 3 20 1 16 3

(%) (91.5%) (8.5%) (100%) (87.7%) (10.1%) (2.2%) (14.5%) (5.0%) (80.0%~) (15.0%)

cornea1 infiltrate with hypopyon was noted. The BCL was removed with sterile, disposable surgical gloves and sent for culture along with the material obtained from cornea1 scrapings and the contact lens solution used. Sta&lococcus aureus was isolated from all the cultures. Intensive treatment with fortified cefazolin and gentamicin for two months resulted in the resolution of the infiltrate, leaving behind a cornea1 scar with best corrected visual acuity of 20/100. There were no episodes of contact lens acute red eye or lens binding. Also, none of the patients were detected to have papillary conjunctivitis or cornea1 neovascularisation; however, a detailed documentation of the lid changes was lacking in some visits.

Discussion The concept of bandaging the ocular surface dates back to C&us, who applied honey-soaked linen to the inferior fornix in an attempt to prevent symblepharon formation following pterygium excision. o Scleral shells made of methylmethacrylate were popularized by Ridley and coworkers,‘” and were followed by glued-on contact lenses. After the introduction of the hydrogels in 1960, Gassett

Served

(W))

I6 (18.4’%) ?J(25%) 3 (50%)

8 i 32’:;1) 30 (21.7%)

Medication

of Eyes (%) Nature

Centrntion Well ccntcreil t~rcwtered M clvcrnent CO.2 mm 17.2-0.5 mm >0.5 mm Tightness L0OSlZ Normal Tight

( ‘%, )

keratoyathy.

Table 4. Topical

Lens Fit Assessment

Parameter

Duration

of Medication

AntibIotic> Yes Chloramphenicol (0.4%) Gentamicin Sulphate (0.3’%)) Others No Cycloplegics Yes No Steroids Yes No

No.

Frequency of Eyes (‘)/I’) (time\/daily) zm-4

12 1 35 58 28 17

(87.7%) (25.4%) (42.0%) (20.3%) (12.3%) 2-4

45 (32.6%) 03 (67.4%) 3-12 45 (32.6%) 93 (67.4%)

and Kaufman (1970)’ I first reported the therapeutic use of soft contact lenses in a variety of ocular surface disorders. In this series, the majority of patients benefitted from BCL wear. PED was the most common (63% of eyes) indication for BCL fitting. Most of these patients did not benefit from medical treatment, which they received prior to the insertion of the BCL. In PED, epithelium fails to slide across the defect and adhere to the basement membrane. Frequently, these eyes are chronically inflamed and may require anti-inflammatory agents. Irrespective of the etiology, PED can be extremely difficult to treat. A BCL reduces the shearing action of the lids on the epithelium and allows the epithelium to slide over the defect and adhere to the hasement membrane. Metaherpetic ulcer is a common form of PED seen in eyes treated for a prolonged time for Herpes simplex virus epithelial disease. BCL wear has been shown to promote healing in these patients.+,5 In our series, a majority (81.6%) of the eyes with PEL>responded favorably to BCL wear; however, one patient (patient 2) with PED, suspected to have a metaherpetic ulcer, developed fungal keratitis with overnight BCL wear. Chronic use of steroids could have reduced the ocular resistance, while the BCL precipitated the attack.

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Table

5. Comeal

Infiltrates

with

BCL

Wear

Patient NO.

BCV

Therapeutic graft for cornea1 perforation secondary to alkali hum (OD)

U4/B

PED (OD) (Metaherpetic keratitis)

U4,‘B & L

Post PRK epithelial defect in unilateral high myopia (OD)

SeeQuence-2

= best corrected

vision;

& L

180 days

Yes (Chloramphenico 1 eye Jrops/4 times daily)

Sterile infdtrate with PED; comeal scrapingssterile

Limhal .lutc7gratt plw elcitroly~is Rlr trichixlc lashes

Per\I~\tIn~

One

Yes (Chloramphenico 1 eye drops/4 times daily)

Infectiws keratitis; culture: cornea1 scrapings-F. solani, A. flaws; BCL-F. solani; eye drops-sterile

Antifungal treatment;

Clear graft; BCV---20150

Yes (Gentamicin drops/4 times

Infectious keratitis stuplylococ~u aurtlu.~ in corneal scrapings, lens solution, and BCL

Fortified

Jay

5 days

(B 6. L)

daily)

PED

= persistent

epithelial

ICLC, Vol. 24, November/December

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therapeutic penetrating keratoplasty

antibiotics

Vasculansed corncal xx; BCV-20/l@@

defect

BCL wear can provide dramatic relief from symptoms and may also improve vision by flattening bullae in patients with bullous keratopathy. A combination of cornea1 edema, diseased epithelium, and overnight lens wear, however, predisposes these patienrs to a greater risk of infectious keratitis. ‘2 In our series, a majority (75%) of the eyes with bullous keratopathy were successfully treated for symptomatic relief. We reserve BCLs, however, only to patients awaiting penetrating keratoplasty (PK), since it needs only a limited period of lens wear. Patients who are unlikely to undergo PK would benefit from palliative procedures like anterior stromal puncture. Melamed et al. ‘3 successfully treated leaking filtration blebs with “glaucoma shells.” In our series, all three eyes with leaking filtration blebs failed to respond to BCL treatment. In all these patients, the site of leak was about 2 mm from the limbus and was inadequately covered by a 14.5 mm lens. In PRK, healing of the epithelial defect can be promoted by ocular bandaging or BCL wear. Although extremely rare, infectious keratitis has been reported following PRK. In a review of 48 studies on PRK, six cases of infectious keratitis were identified.7 Disposable soft contact lenses were used in all these patients during the postoperative period. In our series, of the 9 eyes (post-PRK) treated, one eye developed microbial keratitis. The organism (Sta~hyk~ucus albus) was

210

eye

[‘El )

also isolated from the contact lens solution. The extremely low incidence of microbial keratitis and the symptomatic relief and promotion of epithelial healing by BCL do not warrant discontinuation of lens wear; however, caution must be exercised until the epithelium heals and the BCL is removed. Thirty eyes in our series failed to respond to BCL wear. Apparently the duration of wear and the nature of the underlying pathology played a role in these eyes. The shorter duration of BCL wear in these eyes could be explained by the early termination of lens wear by the treating ophthalmologist for nonresponse. It is possible that some of these eyes could have benefitted from longer periods of lens wear. In a retrospective study, however, it would not be possible to arrive at a definitive answer. Prophylactic antibiotics are recommended for safety during BCL wear. The majority (87.7%) of eyes in our study received

one

or

the

other

prophylactic

antibiotic

during

BCL wear, including all three that developed infiltrates. Although the safety afforded by the antibiotics is unclear, we continue to use them. Although BCL wear is considered to be safe, complications are increasingly noted with longer follow-up times and growing patient numbers. ‘4,15Three patients developed infiltrates in our study-one sterile and two infectious. The sterile infiltrate (patient 1) seems unrelated to BCL wear.

Bandage Contact Lenses in Ocular Disorders: Ansuri and Sreedhar M.S. The primary pathology appeared to he a limbal stem cell failure in the quadrant that developed the PED. In patient 2, who developed fungal keratitis with overnight BCL wear, the chronic use of steroids, the nature of the underlying disease (metaherpetic ulcer), and the BCL played a role. Such an acute attack should caution practitioners to observe a close follow-up in high-risk patients, especially in the presence of steroids. Patient 3, a post-PRK keratitis, developed the ulcer within 4 days of PRK, possibly related to a contaminated lens care solution in the presence of an epithelial defect. Incidentally, all three of thesepatients were given prophylactic antihiotics, whose role seems questionable. Other complications, such as acute red eye, giant papillary conjunctivitis, and cornea1 neovascularisation, were not noted. Although lack of detailed documentation of some of these ocular changes possibly played a role, it is unlikely that anything serious could have been missed. We conclude that current hydrogel lenses are highly effective as therapeutic bandage lenses in a variety of corneal surface disorders. Though the rate of complications may not be high, a close follow-up is mandatory to avoid a mishap. Prospective, masked clinical trials are required to determine the role of prophylactic antibiotics.

RM, Macahamer apy for recurrent erosion

D:

Hydrophilic

gels

for

biologIca

use.

CJ, Norman syndrom. Ann

CW: Soft Ophth&nol

lens ther197P;lO:

875. 3. Williams 4. 5. 6. 7. 8. 9. 10. 11. 12.

13.

14.

References 1. Wichterle 0, Llm Nuture lY60;185:117.

2. Langston

15.

R, Buckley R: Pathagenesis and treatment of recurrent erosion. Br J Ophthltnol 1985;69:435. Cavangh HD: Herpetic ocular disea: Therapy of persistent epithelial defect. Int Ophthalmol Clin 1975;) 567. Hording G: Hydrophilic contact lenses in curneal disorders. Actu Ophthnlmoi 1984;62:566. Ruben M: Soft contact lens treatment ot b&us keratopathy. Tram Ophchalmot Sot UK l975;Y5:75. Seiler T, Mcdonnell l’l: Excimer laser photo&active kerntectomy. Sure Ophthaimol 1995;40:89. McDermott ML, Chandler JW: Therapeutic u>eb of contact lenses. Stlrv Oohthcllmol 1989;33:381. Arrington GE: A Hlstoq of Ophtulmology. New York, MD publishers, 1959. Ridley F: Therapeutic uses of hcleral contact lenses. Int Ophthalmol Clm 1969;2:687. Gasset AR. Kaufman HE: Therapeutic uses of hydn,philic contact lens. Am J Ophthalmol 1970;69:252. Kent HD, Cohen EJ. La&son PR, Arentsen JJ: Microbial keratitis and cornea1 ulceration associated with therapeutic soft contact lenses. CLAOJ 1990;16:4Y. Melamed S, Hersh P, Kersten D, et nl.: The USC of giaucoma shell tamponade in leaking filtration blehs. O@halmoloffy 1986;93:839. Kaufman HE: Problems associated with prolonged wear of soft contact lenses. Ophthalmoloa 1979;86:411. Ormerod LD, Smith RE: Contact lens-associated microhlal keratitis. Arch Ophthatmoi 1986; 104:79.

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Murali Krishnamachary Aasuri, MD, completed his junior residency in ophthalmology from the R.P. Centre, All India Institute of Medical Sciences, New Delhi, India, in 1992, where he was also a senior resident in the Cornea Unit. He underwent fellowship training in Cornea & Anterior Segment in 1994 and worked as a research ophthalmologist in 1995 at L.V. Prasad Eye Institute, Hyderahad, India. He is currently working as a consultant in the Cornea and Contact Lens Department at L.V. Prasad Eye Institute. He is a diplomate of the National Board in Ophthalmology. He has also been awarded a Fellowship in the International Association of Contact Lens Educators (IACLE) in 1997. He is in charge of the Indian Contact Lens Education Programme (ICLEP). His interests include cornea1 diseases, contact lenses, and cataract surgery.

Sridhar M.S., MD, graduated from Mysore University in 1992. He did his post-graduate studies in ophthalmology at the R.P. Centre, All India Institute of Medical Sciences, New Delhi, between 1993 and 1996. He completed a one-year fellowship in Cornea and Anterior Segment in 1997 at the L.V. Prasad Eye Institute, Hyderabad, India. Presently he is on the faculty of the Cornea Service at Sankara Nethralaya, Unit of Medical Research Foundation, Chennai, India.

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