Gloria B. Chiu

Functional and visual improvement with prosthetic replacement of the ocular surface ecosystem scleral lenses for irregular corneas.

Purpose: To evaluate the Doheny Eye Institute Experience with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) scleral lenses for the management of irregular corneas with outcomes based on visual acuity (VA) and visual function. Methods: A retrospective chart review of 58 subjects (90 eyes) with irregular corneal surfaces referred to the Doheny Eye Institute for PROSE treatment between July 2009 and December 2011 was performed. The best-corrected VA before and after PROSE fitting was recorded. A functional assessment before and after PROSE fitting was also performed using the Ocular Surface Disease Index, a 12-item questionnaire that grades the severity of ocular discomfort and vision-related function. Results: Keratoconus (43%) represented the largest group, and post-PK astigmatism (31%) represented the second largest group of patients with irregular corneas who had completed the PROSE treatment. Patients with keratoconus had the greatest improvement in VA after PROSE fitting with an 88% improvement in the logarithm of the minimal angle of resolution vision. Patients with post-PK astigmatism had the greatest improvement in Ocular Surface Disease Index scores with a 79% improvement observed after PROSE fitting. Conclusions: PROSE scleral lenses offer improvements in the VA and function, and they could be an option for patients with irregular corneas who have failed conventional treatments before considering additional surgery.

Prosthetic Replacement of the Ocular Surface Ecosystem Scleral Lens Therapy for Patients With Ocular Symptoms of Chronic Stevens-Johnson Syndrome

PURPOSE To evaluate the results of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) scleral lens treatment on visual acuity and function in patients with ocular symptoms of chronic Stevens-Johnson syndrome (SJS). DESIGN Retrospective interventional case series. METHODS setting: Single multi-specialty institutional practice. study population: A chart review from July 2009 to July 2013 identified 19 patients with ocular symptoms from chronic SJS who were referred for PROSE fitting evaluation. Three patients deemed appropriate candidates were excluded because they were lost to follow-up during the fitting process. Only 1 eye was fitted in 4 patients because anatomic changes prohibited PROSE fitting in the fellow eye. Another patient chose to have PROSE fitting only in 1 eye. A total of 27 eyes of 16 patients who completed PROSE fitting were included in this study. intervention: PROSE scleral lens fitting. outcome measures: Visual acuity and visual function were assessed before and after PROSE fitting using Snellen acuity and Ocular Surface Disease Index (OSDI) survey. The OSDI survey is a validated questionnaire that assesses ocular surface disease in the context of vision-related function, ocular symptoms, and environmental triggers. RESULTS Visual acuity improved from 0.43 ± 0.35 logMAR pre-PROSE to 0.14 ± 0.22 logMAR post-PROSE (P = .0007) in SJS patients. OSDI scores improved from 70.4 ± 19.0 pre-PROSE to 37.4 ± 23.2 post-PROSE (P = .0002) in the same cohort. CONCLUSION The results of this study show that PROSE treatment is a viable option for improving visual acuity and function in SJS patients who failed conventional treatment.

PROSE Treatment for Ocular Chronic Graft-Versus-Host Disease as a Clinical Network Expands

Background: Keratoconjunctivitis sicca occurs in 40% to 90% of patients with ocular chronic graft-versus-host disease (cGVHD). Ocular symptoms can have profound effects in both the visual function and quality of life of patients with GVHD. We report the impact of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in patients with cGVHD as a clinical network expands. Methods: We queried the BostonSight PROSE manufacturing database from January 2002 to December 2011. Patients treated for ocular cGVHD were reported by age, gender, year, and network site where the treatment was undertaken. The baseline and six-month follow-up scores of visual function using a standardized validated instrument, the National Eye Institute Visual Function Questionnaire (NEI VFQ-25), were evaluated for a period in 2006 and again in 2010 after network expansion had occurred. Results: A total of 407 patients with a male:female ratio of 226:181, mean age was 51 years with ocular cGVHD underwent PROSE treatment from January 2002 to December 2011. By 2011, 67% of all cases were treated at network clinics. Baseline characteristics of patients treated throughout the network in 2010 were similar to that of 2006 and 2010 cohorts from the main center. There was a significant improvement of 41 points (P<0.001) in composite NEI VFQ score among patients treated across the network in 2010, similar to the improvement of 30 points (P<0.001) seen among the patients treated at the main center in 2010. There was a trend toward lower baseline self-reported general health status (SRGHS) and VFQ scores among patients treated at network clinics, suggesting that expansion of the network allows treatment of sicker patients (lower general health status) or those more severely affected by ocular cGVHD. Conclusions: PROSE treatment of ocular cGVHD has increased in the last decade with the establishment of BostonSight network clinics across the United States. Patients treated at network clinics showed similar levels of baseline visual function and SRGHS, and achieved a similar high level of improvement in visual function as those treated at the main center. Patient-reported measures of functional status are useful in evaluating treatment options for patients with cGVHD. PROSE treatment has significant positive impact on the visual function of patients with ocular cGVHD regardless of whether the patient is treated at the main center or at a network site.

Transient corneal epithelial bullae associated with large diameter scleral lens wear: A case series

With the increased fitting of scleral lenses by eye care practitioners, complications with lens wear need to be considered. Several prior studies have addressed complications specific to scleral lens wear and the incidence of hypoxia with extended wear, but few report the presence of epithelial bullae. This case series investigates three patients with differing ocular surface diseases, yet all developed transient epithelial bullae with concurrent large diameter scleral lens wear. These bullae appear to form due to weakened connections in the corneal epithelium at the level of basement membrane and Bowmans layer and flatten within minutes of lens removal. These bullae need to be further studied, as they can increase the patients risk of epithelial defects, infections, and other complications in already compromised corneas.

Prosthetic Replacement of the Ocular Surface Ecosystem Scleral Lens Therapy for Exposure Keratopathy.

Objectives: To investigate the utility of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) scleral lenses in patients with exposure keratopathy, with outcomes based on changes in visual acuity, visual function, and corneal staining. Methods: A retrospective interventional case series of patients evaluated and treated from September 2009 through June 2014 at a single multi-specialty institutional practice. Eighteen of 29 patients with exposure keratoconjunctivitis, lagophthalmos, ectropion, or lid retraction, referred to USC Eye Institute after failing conventional therapies completed PROSE scleral lens fitting and were included in the study. Visual function was assessed before and after PROSE fitting with the Ocular Surface Disease Index (OSDI) survey. Visual acuity (VA) and corneal staining changes were also evaluated before and after treatment. Results: Visual acuity improved from 0.60±0.68 logMAR pre-PROSE to 0.25±0.34 logMAR (Z=−3.81, P=0.00014) post-PROSE, which corresponds to an improvement of about 20/80 to 20/35 on Snellen VA. Ocular Surface Disease Index scores improved from 56.54±29.75 pre-PROSE to 24.98±21.23 post-PROSE (Z=−2.98, P=0.0029), and corneal staining values decreased from 2.17±0.84 pre-PROSE to 0.64±0.70 post-PROSE (Z=−3.27, P=0.011). Conclusions: The results suggest that PROSE scleral lens therapy is effective in patients with exposure keratopathy who had failed conventional therapies and can serve as an alternative to lid surgery.

PROSE Treatment in Atypical Ocular Graft-Versus-Host Disease.

Purpose To report a case of persistent epithelial defects in a patient with ocular chronic graft-versus-host disease that required coordinated modulation of systemic immunosuppressive treatment and overnight wear of Prosthetic Replacement of the Ocular Surface Ecosystem (BostonSight PROSE, Needham, MA) devices to achieve ocular surface healing. Case Report The case of a 38-year-old male patient who presented with a 2-year history of ocular chronic graft-versus-host disease, ocular burning, pain, light sensitivity, and a 3-week history of bilateral corneal epithelial defects is presented. Standard therapies and an initial PROSE treatment utilizing customized scleral lenses were unsuccessful in resolving his ocular complications. A second trial of PROSE treatment involving overnight wear of the devices in combination with increased systemic immunosuppressant therapy ultimately allowed ocular surface healing and improved his discomfort, vision, and quality of life. Conclusions Sight-threatening complications of ocular chronic graft-versus-host disease often require a multidisciplinary approach. Persistent corneal epithelial defects may require increased systemic immunosuppression and extension of PROSE treatment to overnight wear.

PROSE scleral lens: a novel aid for staged eyelid reconstruction.

A 50-year-old man presented with a papillomatous tarsoconjunctival tumor involving the medial two-thirds of the left upper eyelid. Office biopsy revealed papillary squamous cell carcinoma (SCCA). Rapid tumor growth with caruncular and forniceal conjunctival involvement continued, despite a trial of weekly interferon-α2b intralesional injection therapy. Surgical excision with clear margins resulted in a large upper eyelid defect. The suspicion for recurrence remained, given the aggressive nature of the tumor. A temporary prosthetic replacement of the ocular surface ecosystem (PROSE) scleral lens was fit for preservation of the ocular surface and visual function during a 1-month observation period. No evidence of recurrence was noted, and the eyelid defect was successfully reconstructed with a Cutler-Beard procedure. Local disease was controlled; unfortunately, metastatic disease was found in the ipsilateral parotid gland 1 year later. Aggressive surgical removal is recommended in interferon-α2b nonresponsive SCCA tumors. The PROSE scleral contact lens may serve as a useful adjunct for the maintenance of a healthy ocular surface and visual function during delayed eyelid defect repair.

Utility of Prosthetic Replacement of the Ocular Surface Ecosystem Treatment in the Management of Patients with Refractory Intrinsic Evaporative Dry Eye Disease

Background: Dry eye disease is a multifactorial disease whose pathogenic mechanisms have not been investigated rigorously. The objective of this study was to evaluate the utility of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in the management of patients with intrinsic evaporative dry eye refractory to conventional therapies. Design: A retrospective clinical cohort study of patients with intrinsic evaporative dry eye disease refractory to conventional therapies seen between July 1, 2009 and May 31, 2012 at USC Eye Institute, a tertiary referral center. Participants: 36 eyes of 21 patients with intrinsic evaporative dry eye that completed PROSE fitting were included. Main outcomes measures: Outcomes based on pre and post PROSE visual acuity and visual function. Bestcorrected visual acuities were measured using a Snellen chart under standardized conditions. Visual function was assessed using the Ocular Surface Disease Index survey, a 12-item questionnaire that quantifies the severity of ocular discomfort and level of vision-related function. Results: Mean visual acuity improved from 0.33 ± 0.40 logMAR pre-PROSE to 0.10 ± 0.16 logMAR post-PROSE (Z=-4.3, p<0.0001, n=36). Thirteen of 21 patients completed pre-PROSE and post-PROSE surveys. Survey scores improved from 63.61 ± 15.76 pre-PROSE to 24.84 ± 29.58 post-PROSE (Z=-2.9, p=0.004, n=13). Conclusion: The results of our study strongly suggest PROSE treatment improves visual acuity and function in patients with refractory intrinsic evaporative dry eye disease and could serve as a viable alternative to more invasive procedures.

Glaucoma surgical considerations for PROSE lens use in patients with ocular surface disease.

PURPOSE To examine challenges of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with glaucoma drainage implants (GDI) and the surgical management of patients where both GDI and PROSE treatment are indicated. METHODS A retrospective noncomparative observational study was performed to investigate the outcomes of 7 eyes of 6 patients that required PROSE lens wear and GDI implantation. RESULTS Group A consisted of 2 cases where PROSE lens wear was problematic due to scleral surface irregularities following GDI placement. These included changes in surface morphology caused by the elevated scleral patch graft tissue adjacent to the corneal limbus in one case and the presence of two anteriorly located shunts in the other. Group B consisted of 3 eyes where the previously placed GDI led to poor lens alignment due to the proximity of the lens edge to the scleral graft. Group C consisted of 2 cases where both patients underwent placement of the GDI in the pars plana and insertion of the drainage tube 3-3.5mm from the limbus in order to facilitate PROSE lens use. The posterior location of the tube and patch allowed for proper PROSE device alignment over the ocular surface. CONCLUSIONS Surgical considerations and prior planning for GDI placement allows PROSE lens use for management of ocular surface disease. Pars plana tube placement with a posteriorly placed patch graft, instead of anterior chamber tube positioning with more anterior graft, enables adequate lens wear in scleral-lens-dependent patients.