Ellen Shorter

Contact lens surveillance cultures in boston type 1 keratoprosthesis patients

Objectives: To describe surveillance cultures of bandage contact lenses (BCL) in patients with a history of Boston type 1 keratoprosthesis (KPro) surgery. Methods: An institutional review board–approved retrospective review of patients with a history of Boston type 1 KPro surgery and BCL cultures between July 2008 and June 2010. Data on demographics, preoperative diagnosis, topical corticosteroid and antibiotic use, duration of BCL wear, clinical diagnosis of microbial keratitis or endophthalmitis, and culture results were recorded. Results: There were 14 patients (15 eyes) who underwent Boston type 1 KPro between July 2008 and June 2010 with BCL culture data. Ten eyes showed positive growth and one eye developed an infection. Thirty-four cultures were performed and 12 were positive. The most common organism cultured was coagulase-negative staphylococcus (CoNS). Positive cultures, colonization by non-CoNS pathogens, and infection occurred more frequently in patients with an ocular history of autoimmune disease or chemical burn. The growth of 15 or more CoNS colonies occurred only in patients not on vancomycin. An antibiotic was added to the regimen in response to positive cultures for three patients. Conclusions: Contact lens surveillance cultures may provide valuable information on the characteristics of microbial colonization, particularly in highlighting inflammatory disease and disuse of vancomycin as possible risk factors. Bandage contact lenses cultures also have the potential to be useful adjuncts in the clinical management of antibiotic therapy.

Contact Lens Use in Patients With Boston Keratoprosthesis Type 1: Fitting, Management, and Complications.

Abstract: The Boston type 1 keratoprosthesis (KPro) is the most commonly used artificial cornea worldwide. Long-term bandage contact lenses are the standard of care for patients with these devices. The goal of bandage contact lenses is to maintain hydration and to protect the corneal tissue that surrounds the anterior plate of the keratoprosthesis which is vulnerable to desiccation, epithelial breakdown, dellen formation, and corneal melt. Contact lenses can also improve comfort, correct refractive errors, and improve the cosmesis of patients with artificial corneas. However, the continuous use of contact lenses places these patients at risk for complications such as lens loss, lens deposits, chronic conjunctivitis, and infection. In addition, obtaining an adequate fit in a patient with a compromised ocular surface and history of multiple surgeries including glaucoma drainage devices can present a challenge. This review discusses the types of contact lenses used, special fitting considerations, and common complications in patients with previous KPro surgery.

Demographic Characteristics and Prescribing Patterns of Scleral Lens Fitters: The SCOPE Study

Objectives: This study reports demographic characteristics of scleral lens providers and indications for scleral lens prescription as assessed by a worldwide online survey. Methods: The Scleral Lenses in Current Ophthalmic Practice: an Evaluation (SCOPE) study group designed the online survey regarding current scleral lens prescription and management practices. The Mayo Clinic Survey Research Center administered the survey, which was open from January 15 to March 31, 2015. Data from 989 responses were collated by the Survey Research Center and deidentified before analysis. Responses of individuals who had fit at least five patients with scleral lenses were analyzed in detail. Results: Most lens fitters were men (61%, n=800). Of survey respondents, 29% were 25 to 34 years; 22%, 35 to 44 years; 22%, 45 to 54 years; and 26%, more than 55 years (n=806). For 29% of all respondents, professional training was completed between 2009 and 2014 (n=804). Most (54%) fit their first patient between 2010 and 2015, with the earliest lens fit reported in 1956 (n=634). Most respondents (63%) worked primarily in private, group, or retail practice (n=811). Scleral lenses were most often prescribed for corneal irregularity (74%), followed by ocular surface disease (16%) and uncomplicated refractive error (10%) (n=673). Conclusions: Eye care providers of all ages are fitting scleral lenses. The number of individuals who fit this lens modality has increased during the past decade. Scleral lenses are being fit by providers in a wide range of practice settings. Most scleral lenses are prescribed for corneal irregularity.

Scleral Lens Prescription and Management Practices: The SCOPE Study

Objectives: To assess current scleral lens prescription and management practices by conducting an international online survey of eye care providers. Methods: The SCOPE (Scleral Lenses in Current Ophthalmic Practice: an Evaluation) study group designed and administered an online survey regarding current scleral lens prescription and management practices. The survey was open from January 15 to March 31, 2015, and generated 723 responses from individuals who had fit at least 5 patients with scleral lenses. Results: Respondents (n=663) prescribed scleral lenses that ranged from 15 to 17 mm in diameter (65%), smaller than 15 mm (18%), and larger than 18 mm (17%). More than 50 lens designs were identified. Average daily wearing time of 11.8 hr was consistent across 651 respondents, and 475/651 (73%) recommended midday removal on some, most, or all days. Most respondents recommended nonpreserved saline to fill the bowl of the lens before application (single-use vials, 392/653 [60%]; bottled products, 372/653 [57%]). A hydrogen peroxide-based disinfection system was the most commonly recommended care product (397/651 [61%]). Conclusions: A reasonable degree of consensus exists regarding some aspects of scleral lens prescription and management (average lens diameter, daily wearing time, and use of nonpreserved products for lens application). Further study is needed to develop evidence-based guidelines for scleral lens prescription and management.

Scleral Lenses in the Management of Ocular Surface Disease

Scleral devices can play a vital role in the treatment of ocular surface disease, both as an adjunct to traditional therapy and as an alternative when traditional therapies fail. With proper utilization, gas-permeable scleral lenses can promote healing of the ocular surface and improve debilitating symptoms related to severe dry eye syndrome secondary to conditions such as GVHD or Sjogren’s syndrome as well as persistent epithelial defects. Scleral lenses can also provide a safer alternative to surgery for patients with corneal irregularity who can no longer tolerate traditional gas-permeable corneal lenses. Scleral lenses and PROSE devices should be considered in all of these situations when traditional treatment modalities have failed.

Visual and physiological outcomes of scleral lens wear

PURPOSE To describe patient-specific outcomes of scleral lens wear utilizing a variety of lens designs across multiple practice settings as reported in an international practitioner survey. METHODS An electronic survey was administered to eye care providers who prescribe scleral lenses in which they were asked to describe their most recently examined established scleral lens patient. Data was collected on patient characteristics, lens designs, wearing schedules, care products, and visual and physiological outcomes of lens wear. Descriptive analysis of data was performed. RESULTS A total of 292 responses were received. Participants represented 26 countries. The most commonly reported indication for scleral lens wear was corneal irregularity (87%) followed by ocular surface disease (8%), refractive error (4%) and 1% with multiple indications. Visual acuity improved from 0.4 ± 0.4 (mean ± SD) to 0.1 ± 0.2 in eyes with corneal irregularity (p < 0.001), from 0.3 ± 0.3 to 0.1 ± 0.3 in eyes with ocular surface disease (p < 0.001), and from 0.1 ± 0.1 to 0.0± [0.1] in eye with refractive error (p = 0.01). Prior to scleral lens wear, corneal staining was present in 55% of patients; staining was present in only 35% of patients following scleral lens wear. The number of topical ophthalmic drops needed decreased from 1.7 ± 0.9 to 0.8 ± 0.8 in patients with corneal irregularity (p < 0.001) and from 3.5 ± 1.7 to 1.1 ± 1.0 in patients with ocular surface disease (p < 0.001). The number of drops used by patients with refractive error remained stable, with these patients using an average of 2.0 ± 1.0 drops prior to scleral lens wear and 1.7 ± 1.5 drops following scleral lens wear. CONCLUSIONS Patients with corneal irregularity experienced the greatest improvement in visual acuity, but patients with ocular surface disease and refractive error also achieved better visual acuity with scleral lenses. Ocular surface condition improved in patients with both corneal irregularity and ocular surface disease; patients with ocular surface disease experienced the most dramatic improvement. Patients who wore scleral lenses to correct uncomplicated refractive error did not experience an improvement in signs or symptoms of ocular surface disease.

Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations

Scleral lenses are being prescribed for the management of corneal irregularity, uncomplicated refractive error, and ocular surface disease. There are many potential therapeutic uses of scleral lenses in addition to providing similar benefits as corneal gas permeable lenses. Scleral contact lenses are a valuable therapeutic tool for patients with ocular surface disease as these lenses protect the ocular surface, provide continuous corneal hydration while providing optimal visual correction, and are often used in conjunction with other therapies.

Man with blurry vision.

A 53-year-old man presented with progressively worsening blurry vision of the left eye. The patient reported redness in his eye for 2 days. He denied pain, itchiness, or recent ocular trauma. He had a distant history of contact lens wear but terminated use owing to recurrent corneal abrasions. His medical history was significant for uncontrolled type 2 diabetes mellitus, leading to bilateral below-the-knee amputations, and osteomyelitis. The patient was unemployed and denied cigarette smoking, alcohol use, or drug use. Current medications included insulin, nasal spray, and aspirin. Review of systems was positive for stiff joints of the hands and back pain. The patient reported that results from a workup for Crohn disease were negative. On examination, uncorrected visual acuity was 20/40 in the right eye and 20/100 in the left eye. Findings from Schirmer testing without anesthesia for 2 minutes were 20 mm OD and 15 mm OS. Corneal sensation was bilaterally decreased to a level of 2/4. There were inferior corneal epithelial defects, with significant corneal thinning bilaterally, and an inferonasal Descemetocele of the right eye. The anterior chambers possessed 3 to 4+ cells, with bilateral hypopyons (Figure). Serology was sent owing to concern regarding the patient’s joint pain, need for a Crohn disease workup, and presence of bilateral corneal thinning with anterior uveitis. Significant results included an elevated rheumatoid factor of 27 IU/mL (normal, 0-14 IU/mL), while all other laboratory results were within normal limits. Results from corneal cultures were positive for pansensitive coagulase-negative Staphylococcus, which was likely a contaminant from the eyelids. Quiz at jamaophthalmology.com WHAT WOULD YOU DO NEXT?