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Therapeutic contact lenses


This area of contact lens work can be one of the most satisfying, writes
Daniel P Ehrlich, Head of Optometry at Moorfields Eye Hospital

Daniel P Ehrlich BSc (Hons) MCOptom DCLP

Therapeutic contact lens management can be one of the most rewarding


areas of contact lens practice. The current armoury of contact lenses has
simplified therapeutic lens management for the majority of cases, but all
CONFUSED ABOUT
lens types play a role for some patients with severe ocular disease.
CET REQUIREMENTS?
See www.cetoptics.com/ Patients with ocular disease may have several contra-indications to lens
cetusers/faqs/ wear. This together with the potential therapeutic benefit must be consid-
IMPORTANT INFORMATION ered when selecting the optimal therapeutic lens. Furthermore, therapeu-
Under the new Vantage rules, all
OT CET points awarded will be tic lens use must be considered in the context of the medical and surgical
uploaded to its website by us. All management alternatives.
participants must confirm these
results on www.cetoptics.com
so that they can move their points
from the “Pending Points record” Contact lenses have been used in ophthal- Mechanical factors: both lens related
into their “Final CET points
record”. Full instructions on how mology for therapeutic purposes for more (e.g. rigidity or poor fit) and ocular
to do this are available on their than a century and are now the standard (e.g. restricted fornices, irregular
website.
treatment for a variety of ocular condi- corneal shape, swollen conjunctiva).
tions.1 Over the years, the therapeutic indi- Toxicity from eye drops and their preser-
cations for contact lenses and the materials vatives accumulating in the lens or
from which they are manufactured have from contact lens care systems. This
changed. The primary aim of therapeutic can be minimised by the use of rigid
contact lenses is to maintain ocular tissue or thin soft lenses or those with low
integrity; any improvement in vision is sec- water content (e.g. silicone hydrogels).
ondary. Appropriate lens selection is derived Corneal desiccation from pervaporation
from an understanding of how the lens through a hydrogel, or poor corneal
interacts with diseased and normal eyes.2 coverage of a corneal lens, impaired
tear production or increased tear
Mechanisms of action evaporation (for example, secondary
to eyelid abnormality).
A number of mechanisms of therapeutic Corneal hypoxia, from continuous/
lens action have been proposed2,3 includ- overnight lenses wear and pre-existing
ing: compromised corneal function. This
Protection of the corneal surface from may be of more significance as oxygen
shearing forces of the eyelid during demand may be increased in the pres-
normal blinking ence of wound healing.
The retention of a stable ocular tear film Allergic/inflammatory response e.g.
The creation of a barrier between the contact lens related papillary conjunc-
tears and the cornea, reducing tivitis or corneal infiltrates. Also co-
neutrophil infiltrate from the tears incident ocular inflammation can lead
Module 5 Part 1 The retention of a fibrin matrix on an to an increase in tear film proteins
PAYL injured corneal surface. It is believed causing increased deposition on the
About the author that this can form a scaffold to assist lens.
Dan Ehrlich is Head of epithelial cell growth over a corneal This contact lens wearing group has a
ulcer. 4 high reported risk of microbial keratitis
Optometry at Moorfields Eye
of 52/10,000 per year.5
Hospital, London, where he
Inevitably several negative mechanisms
was formerly Head of
occur with therapeutic lenses that practi- Lens selection
Contact Lens Clinic and tioners must first consider and, where possi-
Optometric Training and ble try to minimise by prudent lens 1.Determine the primary (and any
Development. selection. These include: secondary) therapeutic goals to be

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Courtesy of Illustration Dept., Moorfields Hospital


Contact Lenses

Soft Lenses Rigid Lenses

Figure 2
Hydrogel lens provides pain relief in
filamentary keratitis

Courtesy of Illustration Dept., Moorfields Hospital


Corneal Scleral

Hydrogel Silicone Hydrogel Silicone Rubber


Figure 3
(obsolete)
Hydrogel lens required to provide pain
Figure 1 relief and protection from glue on corneal
Therapeutic contact lens types perforation.

achieved with the contact lens. large range of parameters and materials. later.
2. Identify the contra-indications to The oxygen transmission, shape, flexibility Applications of hydrogel lenses include
contact lens wear. and ‘soft’ property of hydrogel lenses is pain relief, promotion of epithelial healing,
3. Select which lens type provides the largely determined by the water content. apposition of wound edges and short-term
best compromise. The advent of disposable lenses has mechanical protection.2,3,7,8
4. Note any ocular features which will reduced the cost of standard lenses. When
require a modified insertion technique there is a prosthetic or cosmetic considera- Selecting a therapeutic
(e.g. corneal perforation, restricted tion the lenses can be tinted. If the eye is hydrogel lens
fornices, re-entrant corneal profile). dry or there is corneal exposure a hydrogel
5. After inserting the lens immediately, lens may dehydrate while it is on the eye Lens fit, oxygen transmission, surface prop-
check the fit, ensure mucus or loose altering its shape, reducing its flexibility and erties, and resistance to dehydration all
epithelium is not trapped beneath the reducing the oxygen transmission through need to be considered. The corneal cover-
lens and the fit is satisfactory. the lens. “Pervaporation” of tears through age, centration and stability are mainly con-
6. Recheck the fit and comfort at regular the lens may exacerbate a dry eye and result trolled by changing the total diameter,
intervals (note that once a flat anterior in increased surface deposition on the lens although the BOZR must be altered for
chamber reforms a soft lens fit may and its therapeutic action may be compro- exceptionally steep or flat corneas. Often a
become loose). Raised conjunctiva mised. Protein deposition may occur rapidly thin lens will drape better over an irregular
may be indented by a contact lens, in inflamed eyes thus non-ionic hydrogel shape of cornea or bulbar conjunctiva. If the
the tonicity of the tears alters as lenses are preferred. Overnight lens wear is eye is dry or there is exposure, a non-ionic
lacrimation subsides. required for most therapeutic cases and the material with low water content, increased
7. Refit as required, although it is prefer- associated risks of the limited oxygen trans- thickness, and high bound water may be
able to minimise the numbers of lens- mission with all traditional hydrogel lenses6 preferable. No one lens meets all these cri-
es inserted onto often-vulnerable eyes. may limit the success of these lenses. terion but, for example, the monthly
The lens surface is especially prone to Proclear lens from CooperVision meets most
Hydrogel lenses: therapeutic spoilage if there is exposure, dry eye or any of the requirements. If the therapeutic site is
properties and applications ocular inflammation present. Some of these scleral - e.g. leaking trabeculectomy -
disadvantages may be overcome by a thin bespoke lenses with a large total diameter
These lenses are soft, easy to fit, readily non-ionic lens with high bound water or by are required, typically from 16.50mm up to
available and can be made to order in a a silicone hydrogel, which will be discussed 22.0mm.9 If the fornices are restricted a

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Courtesy of Illustration Dept., Moorfields Hospital


Table1 Hydrogel bandage contact lenses: examples

LENS Dk/tave tave Dk Water content Comments


Proclear 28.7 0.063 18.1 60% High bound water,
drapes well
Bespoke lens
“D75/ ED4” 27.6 0.12 33.1 75% Large range of
total diameters
and radii possible,
drapes well Figure 4
Acuvue 26.8 0.076 20.4 63% Ionic First silicone hydrogel contact lens used as
CSI - T 21.4 0.035 7.5 38% Drapes well a bandage lens at Moorfields. Persistent
Permalens 18.0 0.15 27.0 71% Spun cast epithelial defect on corneal graft healed
Precision UV 17.5 0.148 25.8 74% Thick high water when previous hydrogel lenses had been
content lens unsuccessful
Sequence, O4 14.0 0.054 7.5 38% Low Dk/t
B&L B4 6.3 0.12 7.5 38% Very low Dk/t small lens diameter may be required. It is
useful to compare the oxygen transmission,
No hydrogel lens meets minimum recommended overnight oxygen transmission thickness and other properties of lenses that
(Dk/t) of 87. c.f. silicone hydrogel 86 to 170 are advocated for therapeutic lens use, see
All non-ionic unless specified Table 1.
*Water content, calculated Hydrogel Dk and Dk/t for -3.00 D.Spn - derived from
Morgan & Efron (1998) CLAE 21. 3-6. Silicone hydrogel

The original two silicone hydrogel lenses:


Table 2 Silicone hydrogel bandage contact lenses: examples Purevision from Bausch & Lomb, and Night
and Day from CIBA Vision, offer theoretical
LENS Dk/tc tc Water Modulus Lowest Base Diameter advantages over traditional hydrogel lenses
content (MPa) BVP curve with an oxygen transmissibility which is less
NIGHT & DAY® 175 0.08 24% 1.4 Plano 8.4 & 8.6 13.8 likely to impede wound healing and epithe-
ACUVUE® OASYS™ 147 38% 0.7 -0.50 8.4 14.0 lial cell reproduction, and is theoretically
O2OPTIX ™ 138 33% 1.2 -0.25 8.6 14.2 more suitable for overnight wear.10 They
PureVision™ 110 0.09 36% 1.1 Plano 8.6 14.0 also have a low water content so this theo-
ACUVUE® 86 47% 0.4 -0.50 8.3 & 8.7 14.0 retically reduces the dependence of the lens
ADVANCE™ on tear quality and quantity. The disadvan-
tages include the increased rigidity (modu-
lus of elasticity) poor surface wettability, and
limited parameters. Epidemiological studies
Manufacturers data have not shown a significant difference in
reduction in microbial keratitis with these
Table 3: Suggestions for improving corneal coverage, centration and lenses in a normal population.
stability As bandage contact lenses are often
required for painful eyes with irregular
First Last corneas, the more soft or flexible the lens
Poor corneal Increase total Steepen the more likely an acceptable and comfort-
coverage diameter BOZR able fit will be achieved. Lens deposition
Excess lens Reduce Steepen Increase may be a problem in dry eyes especially as
movement thickness radius diameter mucus balls have been reported in a normal
Lens too tight Reduce thickness Flatten radius Decrease population of silicon hydrogel wearers.11
diameter The increased rigidity may also be expected
Irregular ocular Low modulus of Thin lens to increase the risk of CL related papillary
surface elasticity conjunctivitis and SEALS. The development
Dry eye/ High bound water Reduce water Non-ionic Increase of the so-called second generation of sili-
exposure content thickness. cone hydrogels addresses some of the limi-
Restricted Reduced diameter, tations of the earlier lenses. The two
Fornices typically 13.00mm Johnson & Johnson lenses have a lower
modulus (see table2) and claim improved
wettability. Although this has been at the

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Table 4: Indications of therapeutic contact lenses: Summary

Lens Type Primary indications Examples/ Manufacturer

Courtesy of Illustration Dept.,


1) Hydrogels Pain relief
a) Thin mid water  First choice incl. - Proclear Biocompatibles,

Moorfields Hospital
content with high bound irregular corneas, mild to Coopervision, UK.
water moderate dry eye 8.60:14.20:plano (60%,
ct = 0.065)
b) Steep hydrogel lenses For steep corneas - D75 (75% water content, Figure 5
standard disposable ct = 0.12) Limbal diameter RGP lens used to maintain
lenses too loose 7.80:13.50:plano corneal hydration in combination with
8.00:15.00:plano unpreserved topical lubricants in a patient
c) Large hydrogel lenses For limbal or scleral 8.50:15.00:plano with cicatricial conjunctivitis,
defects and buphthalmos 9.50:16.50:plano descemetocele, corneal scarring and
8.60: 7.00/ 11.00: 18.00 neovascularisation secondary to Steven
(ct = 0.19) Johnson’s Syndrome.
8.80: 7.00/ 11.00: 20.00
(ct = 0.19) although flexible, they do not drape over
2) Silicone hydrogels For wound healing (per- See Table 2 irregular corneal profiles. Some movement
sistent epithelial defects) and tear exchange is essential and uniform
apposition of wound edge clearance and central corneal align-
edges, short term ment is desirable but rarely achieved. The
mechanical protection lenses often steepen unpredictably and can
3) Rigid gas permeable Corneal protection, S-Lim, Jack Allen UK. bind to the cornea. Thus the fit should be
(RGP/Limbal) maintain corneal Limbal lens, Moorfields, UK. checked immediately following insertion,
hydration, promotion of (To order) then again after a few minutes, and after
epithelial healing one to two hours and also the following
4) Scleral Mechanical protection of Innovative Sclerals, UK. day. Lens removal can be difficult, especially
ocular surface, maintain (To order) on a dry eye. First irrigate with saline, then
corneal hydration on a soft eye, in the presence of a desceme-
tocele or a perforation, the lens is best
removed by sliding forceps under the edge
expense of oxygen permeability, this still the maintenance of epithelial hydration of the lens and lifting it off, after instillation
compares favourably to hydrogel lenses. together with ocular lubricants. They are of topical anaesthetic. Otherwise a corneal
One of the most common applications for used for the apposition of wound edges lens technique should be used (with or
therapeutic lenses is for recurrent erosions. and pain relief (see hydrogels). However, without a sucker). Several attempts may be
Typically the acute episodes of pain and the applications may be constrained by the required to break the suction. If using a
epithelial breakdown occur during sleep in limited range of total diameters and limited sucker, it should be placed on the periphery
the earlier hours of the morning. So there- choice of BOZR. Also, as some lenses are of the lens (not the centre) to help break the
fore both overnight wear and wound heal- not available in plano power, some patients surface tension. The B&L Silsoft has a limit-
ing are required, yet some patients have with good visual acuity may not tolerate the ed BVP > +12.00Sph, total diameter 12.5
been unable to tolerate the first generation change in induced ametropia, such as RCE and 11.3; radii: 7.5 - 8.3 (0.2mm steps).
of silicone hydrogels, presumably due to patients with a VA of 6/5 (see table 2).
their rigidity; thus the new generation of sil- Properties and applications
icone hydrogel lenses may well have a role. Silicone rubber
Silicone rubber has a high oxygen transmis-
Application of silicone For historical purposes a brief overview of sibility12 (Dk 200-400), and absorbs no
hydrogels these lenses is included. Production of the water so lens parameters are independent
Silflex lens (Wohlk) stopped several years of hydration, tear quality or exposure. The
Currently the main application is for wound ago and the Bausch & Lomb Silsoft lens has lenses are also robust and flexible but they
healing (persistent epithelial defect, corneal been largely unsuccessful as a therapeutic must be coated to improve surface wetting.
laceration etc), or where corneal neovascu- lens. Although silicone hydrogel, corneal Until recently they were the first choice for
larisation could be disastrous (on corneal RGP and scleral RGP lenses can often suc- the maintenance of corneal hydration, e.g.
transplants or where a transplant is likely to cessfully replace SR lenses, in some cases Sjögrens syndrome, exposure and neu-
be considered). Since the Wohlk silicone they can no longer be managed with a con- rotrophic keratitis.13 They also offered pro-
rubber lens has been withdrawn (see tact lens. Silicone rubber lenses are difficult tection of the ocular surface from eyelashes,
below) the silicone hydrogels are used for to fit. The total diameter must closely corre- keratin, exposure, and glue. In the presence
mechanical protection (short term) and for spond to the corneal diameter and, of a severe dry eye silicone rubber lenses

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Table 5 Therapeutic contact lens selection: examples

CHOICE FIRST LAST


Pain relief Hydrogel Silicone Hydrogel Scleral Limbal RGP

Courtesy of Illustration Dept.,


Epithelial healing Silicone Hydrogel Hydrogel Scleral Limbal RGP
Perforation Silicone Hydrogel Hydrogel Scleral Limbal RGP

Moorfields Hospital
Sensitive eye Hydrogel Silicone Hydrogel Scleral Limbal RGP
Ease of fit Hydrogel Silicone Hydrogel Limbal
RGP Scleral
Figure 6
SEVERITY MILD SEVERE Scleral lens for cicatrising conjunctivits
Exposure Hydrogel Silicone Hydrogel Limbal
RGP Scleral Collagen shields
Dry eye Hydrogel Silicone Hydrogel Limbal
RGP Scleral Collagen shields may be used to promote
Corneal re-epithelialisation. They mould to the
protection Hydrogel Silicone Hydrogel Limbal shape of the cornea and dissolve over time
RGP Scleral so they have been advocated for managing
Irregular epithelial defects. However, they are
astigmatism Hydrogel Silicone Hydrogel Limbal uncomfortable, give poor vision, the cornea
RGP Scleral cannot be examined through the shield, the
dissolution rate is variable and unpre-
dictable, and finally they are difficult to
improved the ocular environment to assist Lim from Jack Allen (diameter 14.00 mm) remove. They are no longer available in the
wound healing of a corneal perforation and both available in a wide range of parame- UK and were never widely adopted.18
to promote re-epithelialisation of a persistent ters, with bespoke lenses available. The
epithelial defect. The lens was also used to goal is to achieve a fit with alignment to Clinical indications
provide pain relief for ocular surface disease. slight pooling centrally, with broad edge
clearance to enable rapid tear exchange. The objectives for therapeutic lens fitting
Limbal diameter RGP lenses are:
applications and properties Scleral lenses Pain relief: exposed or compressed
corneal nerve endings e.g. bullous
A rigid gas permeable lens that covers the Properties and applications (Figure 6) keratopathy, recurrent corneal erosion
cornea has the advantage of offering com- With a typical diameter of 23mm, rigid gas syndrome (RES) and band keratopathy
plete corneal protection, maintaining a permeable scleral lenses offer protection of (causing pain on blinking on palpebral
corneal tear reservoir, and can be used with both the cornea and the bulbar conjuncti- conjunctiva).
topical medication. Also lenses with a high va.15,16,17 If the lens is fitted to give corneal The promotion of epithelial healing:
oxygen transmissibility are available (e.g. and limbal clearance the lens will maintain persistent epithelial defect (PED) and
Boston XO, Paragon 100 and Optimum a tear reservoir while protecting the cornea RES
Extreme) which flex less than silicone rub- from the shearing forces of the eyelids. The maintenance of ocular hydration:
ber, so are less likely to bind. The fitting Thus Sjögrens, cicatrising conjunctivitis and severe dry eye, corneal exposure
techniques and methods of insertion and corneal exposure are typical indications. The mechanical protection of the
removal of RGP lenses are familiar to most The lens may be used when there are no ocular surface: e.g. from trichiasis,
experienced contact lens practitioners (in tears. The lens is stable, almost regardless entropion and conjunctival keratin
comparison to scleral or silicone rubber of the ocular anatomy, and their large size Apposition of wound edges: e.g. in
lenses). The lenses can be used in severe dry means that some patients find them rela- corneal perforation, leaking
eye, corneal exposure, trichiasis, and; in tively easier to handle than alternative lens trabeculectomy blebs and after suture
these cases they assist with wound healing types. However, some patients find them removal
and may even offer pain relief.14 difficult to handle. Also, they are relatively Maintain fornices: e.g. following
expensive and have complex fitting and conjunctival biopsy or sugery and
Fitting therapeutic limbal manufacture requirements, although this chemical burn, and to prevent symble-
RGP lenses has become simpler since the introduction pharon resulting from acid or alkali
of pre-formed gas permeable lens designs. burns to the bulbar or palpebral con-
Currently two choices are available, either Other indications include maintenance of junctiva
to use a fitting set or by designing a fornices, ptosis prop, promotion of epithe- Ptosis prop
bespoke lens for each patient. Suitable lial healing in the presence of a severe dry Drug delivery
lenses are the Limbal lens from Moorfields eye, and rarely pain relief, neurotrophic ker- When more than one objective is indicat-
Eye Hospital (diameter 12.5mm) and the S- atitis and persistent epithelial defects. ed (e.g. pain relief and wound healing in

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recurrent erosion syndrome) it can be useful Table 6 Topical medication and contact lenses
to establish a primary goal.
Hydrogel * Silicone Silicone Rigid: Rigid:
Pain relief hydrogel* rubber corneal scleral
Fluorescein     
One of the most common indications for Ointments  ?   
therapeutic lenses is for the symptomatic (V.A.) (V.A.) (V.A.) (V.A.)
relief from ocular pain.2,3,8,19,20,21,22 The Oil base drops     
cause of ocular pain includes exposed or Preserved Rx Short term Short term   
compressed nerve endings in recurrent Un-preserved Rx     
corneal erosion, Thygeson's disease, and
bullous keratopathy, tension from the eyelid *Benzalkonium chloride binds to hydrogel lenses
on mucous-epithelial tags in filamentary On cases with severe dry eye, ointments are being used with silicone hydrogel lenses
keratitis and superior limbic keratitis. The although the effect on the lens is unpredictable.
pain relief mechanism is similar in each of
these cases as the lens protects the cornea
from the shearing force of the eyelid during any soft lens in marked entropion. In the epithelialisation takes place with silicone
blink. Conversely in band keratopathy it is case of a descemetocele the role of the lens rubber lenses when the lens makes no con-
the eyelid that is protected from the rough is to support the thin cornea to prevent per- tact with the cornea in the area of the
surface of the cornea. In most cases a lens foration and the considerations are similar epithelial defect, and the role of the epithe-
that is smooth (i.e. low coefficient of resist- to the management in apposition of wound lial basement membrane needs to be con-
ance) and soft (low modulus of elasticity) edges. A lens used for mechanical protec- sidered.
with minimal movement will provide maxi- tion may also provide secondary pain relief As the contact lens is being used to pro-
mal pain relief. A thin hydrogel lens or sec- and the promotion of epithelial healing. mote corneal wound healing, the key ele-
ond generation silicone hydrogel best meets Neurotrophic keratopathy secondary to ments required to maximise wound-healing
these requirements. In a severe dry eye the diabetes, herpes zoster or nerve palsies, need to be considered when selecting a
tears no longer lubricate and protect the presents an especially challenging role for lens. The mitosis rate of corneal epithelial
cornea from the movement of the tarsal therapeutic lenses. A persistent epithelial cells may be influenced by the change of
conjunctiva during blink. In this case pain defect results from the epithelial fragility in environment caused by the lens. So the suc-
relief is achieved by maintaining ocular these eyes thus protection from the shear- cess of the therapeutic lens may depend on
hydration and the selection of lenses is dis- ing force of the eyelid is required. Although an adequate oxygen supply and ocular
cussed later. the management is typically a hydrogel or hydration. Thus, subject to lens fit and toler-
silicone hydrogel lens, success is limited. If ance, a silicone hydrogel (see discussion ear-
Mechanical protection of this is not successful it may be due to the lier) should be the lens of first choice. All
ocular surface contact lens/ corneal contact, thus an alter- topical medication should be un-preserved
native contact lens management option is a to prevent any toxic effect impeding re-
A lens can protect the cornea or the tarsal sealed RGP scleral lenses fitted to avoid any epithelialisation. The underlying cause of
conjunctiva,2,3,13,7,8 for example miss- corneal contact. the persistent epithelial defect needs to be
directed eyelashes, trichiasis and entropion, addressed especially if there is corneal expo-
conjunctival and corneal keratin, concre- Promotion of epithelial sure or a severe dry eye (see maintenance of
tions, exposed ocular and palpebral sutures healing corneal hydration).
and corneal exposure - which will be dis-
cussed under the maintenance of ocular In both recurrent corneal erosions23,24 (RCE) Maintenance of corneal
hydration. and for persistent epithelial defects (indo- hydration
The lens must be stable and robust lent ulcers) 4,25 the objective is to promote
enough to provide protection to the ocular corneal re-epithelialisation. The more com- Corneal desiccation may be secondary to
surfaces and not be degraded by the source mon indication is for recurrent corneal ero- either ocular exposure or a dry eye.
of ocular trauma. Thus lens selection sions (RCE) secondary to anterior stromal Exposure can be caused by eyelid abnormal-
depends on the severity of the condition, dystrophies (e.g. Map-Dot-Fingerprint) or ities such as entropion, ectropion, lid retrac-
with scleral lenses used for the most severe trauma (pain relief is also an objective). It is tion, eyelid trauma, or secondary to
cases, progressing through limbal diameter presumed that a contact lens offers protec- proptosis. A severe dry eye may be due to
RGP, silicone hydrogels and finally hydrogels tion of the unstable epithelium from the Sjögren's syndrome, connective tissue disor-
for short-term management of mild cases. If shearing action of the eyelids. In addition ders such as rheumatoid arthritis and SLE, or
a soft lens is considered then a thick lens Leibowitz4 has described how fibrin laid any cause of cicatrising conjunctivitis such
with a low water content may be more down on the lens may provide a scaffold for as ocular pemphigoid and Steven Johnson's
resilient, or silicone hydrogels with a high new epithelium to grow along the lens sur- syndrome. The management depends on
modulus, such as Purevision or Night & Day. face and then surface the cornea. However the severity of the dry eye or exposure.
Note that eyelashes will usually get under this cannot be the sole mechanism as re- Corneal signs range from mild keratopathy

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to dellen with vascularisation and even with a centre thickness 0.12mm may be suf- possible. This has had limited commercial
corneal perforation in severe cases. Scleral ficient; otherwise larger lenses up to 22mm success possibly because of variable delivery
lenses can maintain a tear reservoir over the in diameter are available.9 of the medications, an increased risk sec-
exposed bulbar conjunctiva and If the eye is dry, e.g. a corneal melt in ondary to the contact lens, and expense.
cornea,15,17 for severe cases only requiring rheumatoid arthritis or Sjögrens syndrome,
corneal protection a limbal rigid gas perme- it is more important to maintain the ocular Summary
able (RGP)14 is used replacing silicone rub- hydration. For acute management of these
ber lenses13 with low water content cases Wohlk silicone rubber lenses were All types of contact lenses may need to be
hydrogel or silicone hydrogel (see table) for previously advocated3 but since these are considered when managing therapeutic
milder cases. Note that on a severe dry eye no longer produced, low water content sili- contact lens patients. The potential thera-
a hydrogel lens can exacerbate the condi- cone hydrogel lenses together with copious peutic role of contact lenses over the past
tion by competing with the cornea for the ocular lubricants and ointment at night few years has expanded due to the advent
topical lubrication or tears, and in some have been adopted successfully by the of new lens materials and designs.
cases the lens dehydrates to become a xero- author. Disposable thin mid-water content lenses
gel on the eye. All lens types may require A large penetrating injury may need to be have simplified the fitting of hydrogel lens-
additional ocular lubricants, without preser- sutured, or a small hole could be glued. es. Biotechnological advances in hydrogel
vatives, since the inadequate dilution by the After applying glue a bandage lens may be polymers have produced lenses that are less
tears readily produces a toxic epitheliopathy required to protect the glue and provide influenced by adverse ocular environments.
(see table 6). pain relief from the glue's rough surface. The use of the latest generation of silicone
hydrogel lenses will hopefully combine a
Apposition of wound edges Maintenance of fornices reduction in contact lens related hypoxic
complications with the benefit of traditional
Whether secondary to trauma or surgery, if Scleral rings of different sizes are available hydrogels, low modulus of elasticity. First
the ocular wound is small a hydrogel lens to maintain the fornices when there is a risk generation silicone hydrogels and limbal
can be used as a splint to support the of symblepharon. This is usually post con- diameter RGP lenses may now be used
cornea during healing.26 Typical surgical junctival or eyelid surgery i.e. removal of instead of scleral or silicone rubber lenses to
causes include graft dehiscence, leaking tra- conjunctival tumour, acute chemical con- simplify the management in some cases
beculectomy, gaping wound post cataract junctival ulceration and fornix reconstruc- requiring corneal protection or the mainte-
surgery, either pre or post suture removal, tion. The largest ring that will fit into the nance of corneal hydration.
accidental penetration during radial kerato- fornices and avoid corneal contact should The benefit of the lenses available must
tomy or any case when the cornea or sclera be inserted. If all the rings are too large the be compared to the risks for each condition
is Sidal positive. Using a contact lens may biggest diameter hydrogel lens that will fit and should be placed in the context of the
avoid the use of sutures with the associated into the fornices may be tried. Scleral rings medical and surgical alternatives.
corneal irregular astigmatism and scarring. are not advocated in the active stages of
The objectives are to maintain apposition cicatrising conjunctivitis as they can be References
of the wound edges, to seal the aqueous engulfed by the symblepharon.
leak and to protect the cornea from the eye- 1. Sabell AG (1997) The history of con -
lid forces during blink to enable wound Ptosis props tact lenses : In: Phillips AJ, Speedwell L
healing to take place. A soft lens is usually (Eds) Contact Lenses, Butterworth
required. Historically thick low water con- If the eyelid occludes the visual axis, a ptosis Heinemann: 1-17.
tent hydrogel lenses have been proposed to prop may be required. A modified scleral 2. McDermott ML, Chandler JW (1989)
encourage corneal oedema and seal the lens may be successful depending on the Therapeutic Uses of Contact Lenses. Surv
wound, but the hypoxia may impede force closing the eyelid. Indications include Ophthalmol33: 381-394.
wound healing and epithelial cell reproduc- ocular myopathy, myasthenia gravis, eyelid 3. Smiddy WE et al. (1990) Therapeutic con-
tion27 thus the use of a lens with a high trauma and neurological problems (e.g.third tact lenses. Ophthalmology97: 291-5.
oxygen transmission should be advocated. If nerve palsy). The simplest solution is to use 4. Leibowitz HM, Rosenthal PR (1971)
the wound is corneal a silicone hydrogel a thick lens, but cutting a full thickness slot Hydrophilic contact lenses in corneal dis-
would therefore be the lens of first choice, (Trodd type) or partial shelf for the eyelid to ease. I. Superficial sterile indolent ulcers.
as long as the fit is satisfactory. If a lens is rest on may be necessary. The best solution Arch Ophthalmol85:163-5.
used to seal a corneal wound to assist the may be to utilise a spectacle ptosis prop 5. Liesegang TJ. (1997) Contact lens-related
reformation of a flat anterior chamber then with a scleral lens used to prevent expo- microbial keratitis: Part I: Epidemiology.
a lens with a low modulus of elasticity may sure.16 Cornea. 16(2):125-31.
be preferred as the fit can remain adequate 6. Holden BA, Sweeney DF, Sanderson G
as the anterior chamber reforms. For leaking Drug delivery (1984) The minimum precorneal oxygen
trabeculectomies or other scleral wounds a tension to avoid corneal oedema. Invest.
large diameter lens is required, depending A hydrogel lens may be hydrated in topical Ophthalmol. Vis. Sci. 25: 476-80.
on the distance from the limbus a medication. When the lens is placed on the 7. Aquavella JV (1974) Therapeutic Uses of
9.50:plano: 16.50, 75% water content lens, cornea an increase exposure to the drug is Hydrophilic Lenses Inv. Ophthal 484-6.

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8. Gasset AR, Kaufman HE (1970) tions of a limbal diameter rigid gas perme- 21. Mondino BJ, Zaidman GW, Salamon SW
Therapeutic uses of hydrophilic contact able lens, [ARVO abstract]. Invest (1982) Use of pressure patching and soft
lenses. Am. J. of Ophthalmology69: Ophthalmol Vis Sci. 41,4 B382. contact lens in superior limbic keratocon-
252-9. 15. Tan DTH, Pullum KW, Buckley RJ (1995): junctivitis. Arch Ophthalmol.100: 1932-
9. Blok MDW et al (1990) Use of megasoft Medical applications of scleral lenses: 1 A 4.
bandage lens for treatment of complica- retrospective analysis of 343 cases. Cornea 22. Forstot SL, Binder PS (1979) Treatment
tions after trabeculectomy. Am J of 14(2): 121-9. of Thygeson's superficial punctate ker-
Ophthalmol 110: 264-268. 16. Pullum KW & Buckley RJ (1997) A study atopathy with soft contact lenses. Am J. of
10. Lim L, Tan DT, Chan WK (2001) of 530 patients referred for rigid gas perme- Ophthalm.88: 186-9.
Therapeutic use of Bausch & Lomb able scleral contact lens assessment. 23. Hykin PG, Foss AE, Pavesio C, Dart JKG
PureVision contact lenses. CLAO J. 27(4): Cornea 16: 612-22. (1994): The natural history and manage-
179-85. 17. Tappin MJ, Pullum KW, Buckley RJ ment of recurrent corneal erosion: A
11. Pritchard N Jones L Dumbleton K Fonn (2001) Scleral contact lenses for overnight prospective randomised trial. Eye 8:35-40.
D (2000) Epithelial inclusions in association wear in the management of ocular surface 24. R Williams, RJ Buckley (1985)
with mucin ball development in high-oxy- disorders. Eye 15(Pt 2):168-72. Pathogenesis and treatment of recurrent
gen permeability hydrogel lenses. Optom 18. Rubenstein MP: Collagen contact lenses erosion British Journal of
Vis Sci. 77(2): 68-72. – a review. Contact Lens Journal 17(4): Ophthalmology 69: 435-7.
12. La Hood D, Sweeney DF, Holden BA 115-8. 25. Gasset AR, Kaufman HE (1973)
(1988) Overnight corneal oedema with 19. Leibowitz HM (1972) Hydrophilic con- Hydrophilic lens therapy of superficial sterile
hydrogel, rigid gas permeable and silicone tact lenses in corneal disease. IV Penetrating corneal ulcers Ann of Ophthalmol 139-42.
elastomer contact lenses. Int. Contact corneal wounds. Arch Ophthalmol. 88: 26. Leibowitz HM, Rosenthal P (1970)
Lens Clinic 15: 149-54. 602-6. Hydrophilic contact lenses in corneal disease
13. Woodward EG (1984) Therapeutic 20. Gasset AR, Uotila MH (1973): Fitting II. Bullous keratopathy Arch. J.
Silicone rubber lenses. Journal of BCLA 7: softcon hydrophilic lenses in normal and dis- Ophthalmol.2: 142-4.
39-40. eased eyes. Survey of Ophthalmol . 18: 27. Holden BA, Mertz GW, McNAlly JJ (1983)
14. Ehrlich DP (1999) Therapeutic applica- 128-36. Corneal swelling response to contact lenses

Module questions Course code: c-4087


Please note, there is only one correct answer. Enter online or by form provided.
1. Which of the following mechanisms 4. In selecting a lens for an eye with a 8. The first choice for correcting a ptosis is
are NOT thought to contribute corneal laceration and flat anterior cham- a:
towards the therapeutic action ber which of the following has NOT been a. Hydrogel lens
of a lens? proposed? b. Silicone hydrogel lens
a. Acting as a barrier from the motion of the a. a thin lens c. Limbal diameter RGP lens
eyelids b. a lens which causes corneal hypoxia d. Scleral lens
b. The promotion of pervaporation through a c. a thick lens
hydrogel lens d. A lens which causes pervaporation 9. The first choice therapeutic lens for
c. The retention of a stable peri-ocular tear film superior limbic keratitis is a:
d. The retention of a matrix of fibrin 5. A scleral lens is NOT used for one of the a. 20.0 mm hydrogel lens
following b. 14.0 mm silicone hydrogel
a. Dry eye c. 12.5 mm diameter RGP
2. The ideal therapeutic lens for recurrent b. Pain relief d. 23.0 mm diameter scleral lens
erosion syndrome has which of the c. To prevent symblepharon from ocular
following properties? pemphigoid 10. The first choice contact lens for filiamen-
a. High oxygen permeability, high modulus of d. Persistent epithelial defects tary keratitis is currently
elasticity, high coefficient of resistance. a. Hydrogel lens
b. High oxygen permeability, high modulus of 6. If a lens is required to help reform b. Silicone hydrogel lens
elasticity, low coefficient of resistance. a collapsed anterior chamber, which c. Limbal diameter RGP lens
c. Low oxygen permeability, Low modulus of of the following is the lens of first d. Scleral lens
elasticity, low coefficient of resistance. choice?
d. High oxygen permeability, Low modulus of a. A limbal diameter RGP with a high Dk 11. In trichiasis the following lens is LEAST
elasticity, low coefficient of resistance. b. A limbal diameter RGP with a low Dk likely to be selected
c. A silicone hydrogel with a low modulus of a. Hydrogel lens
elasticity b. Silicone hydrogel lens
3. In selecting a therapeutic lens for a per- d. A hydrogel with a high modulus of elasticity c. Limbal diameter RGP lens
sistent epithelial defect (subject to d. Scleral lens
obtaining a satisfactory fit) which of the 7. Which lens type is most likely to offer
following is true? protection from severe entropian? 12. A lens with a diameter of 12 mm to
a. Silicone hydrogel lenses should be the first a. Hydrogel lens 14mm is NOT typically selected for cases
choice b. Silicone hydrogel lens a. With restricted fornices
b. Hydrogel lenses should be the first choice c. Limbal diameter RGP lens b. With a leaking trabeculectomy
c. Rigid gas permeable lenses are not used d. Scleral lens c. Requiring maintenance of corneal hydration
d. Scleral lenses are not used d. Requiring corneal protection

An answer return form is included in this issue. It should be completed and returned to: CET initiatives (c-4087), OT, McMillan Scott, 9 Savoy Street London WC2E 7HR
by 16 August, 2006. Under no circumstances will forms received after this date be marked – the answers to the module will have been published in
our 18 August, 2006 issue.

30 | July 14 | 2006 OT
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Module questions Course code: c-4087

Please note, there is only one correct answer. Enter online or by form provided.

In the summer a production error led to the incorrect date being assigned to the published answers
to the Pay As You Learn article by Dan Ehrlich, ‘Therapeutic contact lenses’ (published in our July 14
2006 edition). Readers who were misinformed following the publication of this CET article - which was
module 5, part 1 - or who failed can now ‘re-sit’ in effort to gain credits from the eight page item with
the new questions (below)
1. The retention of a fibrin matrix by a contact lens is believed to: 7. The largest reported diameter of a hydrogel
a. Reduce neutrophil infiltrate from the tears. therapeutic lens is:
b. Promote pervaporation through a hydrogel lens. a. 22.0 mm.
c. Retain a stable peri-ocular tear film. b. 16.5 mm.
d. Assist corneal re-epithilialisation. c. 15.5 mm
d. 14.0 mm
2. The ideal hydrogel lens used to provide continuous protection
of the cornea from trichiasis has the following properties?
a. High oxygen permeability, high modulus of elasticity, high coefficient 8. Silicone rubber contact lenses have a oxygen permeability
of resistance. (units x 10(-9) (cm x ml O2)/(sec x ml x mmHg) of:
b. High oxygen permeability, high modulus of elasticity, low coefficient a. 50- 100
of resistance. b. 100- 200
c. Low oxygen permeability, Low modulus of elasticity, low coefficient c. 200 – 400
of resistance. d. 400 - 600
d. High oxygen permeability, Low modulus of elasticity, low coefficient
of resistance.

9. Which of the following is FALSE about neurotrophic keratitis?


3. Therapeutic lens wearers have a reported risk of microbial
a. Can be associated with diabetes
keratitis of approximately:
b. Can be associated with nerve palsies
a. 2/10,000 per year.
c. Can be associated with herpetic eye disease
b. 5/10,000 per year.
d. Persistent epithelial defects secondary to neutrophic keratitis are
c. 50/10,000 per year.
typically managed with scleral lenses.
d. 20/10,000 per year.

4. In selecting a therapeutic lens for a painful eye with an


10. Which of the following statements is FALSE?
irregular vascularised cornea secondary to bullous keratopathy,
a. Corneal desiccation is typically caused by ocular exposure
which is the optimal lens choice?
and dry eye.
a. Proclear monthly biocomptables (Coopervision).
b. Corneal exposure may be caused by entropian and ectropian.
b. Night & Day (CIBA vision)
c. A severe dry eye may result from ocular cicatricial pemphigoid.
c. Limbal diameter RGP lens (Moorfields Eye Hospital)
d. Corneal dessication is typically caused by ptosis
d. RGP Scleral lens (Innovative Sclerals)

5. A patient presents with pain in their only eye, secondary to


recurrent erosion. The patient complains of worse pain in the 11. Which of the following statements is TRUE?
early hours of the morning. They have 6/5 vision with their a. If a hydrogel therapeutic lens is required for an irregular surface an
spectacles (-6.00/-2.75x40). Which therapeutic lens is reduced thickness is required
theoretically the current lens of first choice for this patient? b. If a hydrogel lens is used for an eye with a severe dry eye select a
a. Night & Day, CIBA vision lens with low “bound” water.
b. Acuvue Oasys c. If there are restricted fornices a lens with a diameter of 23.0 mm.
c. PureVision, Bausch & Lomb should be selected.
d. Proclear, Coopervision d. If a hydrogel lens gives inadequate corneal coverage the BOZR
should be flattened.
6. A patient presents with a corneal graft that is seidal positive.
The first choice therapeutic lens is (subject to obtaining a satis-
factory fit): 12. Which of the following statements is TRUE?
a. Hydrogel lens a. Thick RGP corneal lenses are used to correct ptosis.
b. Silicone Hydrogel lens b. Thick RGP scleral lenses are used to correct ptosis
c. Limbal diameter RGP lens c. Large diameter RGP corneal lenses are used to correct ptosis.
d. Scleral lens d. Large diameter RGP scleral lenses are used to correct ptosis.

An answer return form is included in this issue.


It should be completed and returned to:
CET initiatives (c-4087), OT,
by December 13, 2006. Under no circumstances will forms received after this date be marked –
the answers to the module will have been published in our December 15, 2006 issue.

34 | November 17 | 2006 | OT