GP lens eye Rounds

OCULAR SURFACE DISEASE: Patient Candidacy

Julie Song OD, FAAO, FSLS

The primary categories of patients who can be successful with scleral lens wear include patients with ocular surface disease whose clinical signs and symptoms persist beyond primary and secondary dry eye treatments, as well as patients who suffer from neurotrophic conditions with signs of ocular surface disease.¹ For patients who are suffering from ocular surface disease and who have already tried a variety of ocular lubricants, lid hygiene treatments, punctal occlusion, and topical prescription medications in an attempt to alleviate their clinical signs and symptoms, therapeutic scleral lenses can be a tertiary level treatment.² Scleral lenses can specifically improve corneal punctate staining and filaments from filamentary keratitis in these types of patients.

For patients who have symptoms of neuropathic pain or keratoneuralgia, scleral lenses can disrupt the pain cycle for patients who develop a hypersensitivity of the ocular somatosensory nerves following corneal nerve disruption and who have exaggerated scleral and conjunctival pain from secondary hyperalgesia.^{1, 3-5} Scleral lenses, therefore, have the potential benefit of helping patients who have ‘stain without pain’, as well as pain without stain, hereby encompassing a large percentage of the patients who suffer from different etiologies and manifestations of ocular surface disease.

That being said, there are several contraindications for scleral lenses that can arise in patients with severe ocular surface disease. These patients include those who are immunocompromised, diabetic, and/or have non-healing epithelial defects as complications can potentially arise related to scleral lens wear.¹ However, for patients with severe ocular surface disease, they are rarely utilizing scleral lens wear independently without additional treatment modalities to manage their ocular surface disease. There have been studies performed potentially recommending the use of prophylactic antibiotics with patients who may have complications, but the evidence is not conclusive.⁶ That being said, there are generally no age restrictions for scleral lens wear and for patients who struggle with application and removal, there are additional tools on the market that can be utilized to aid patients who have limitations.¹

Sources

1. Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auckl). 2018;10:65-74. Published 2018 Jul 11.
2. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.
3. Levitt AE, Galor A, Weiss JS, et al. Chronic dry eye symptoms after LASIK: parallels and lessons to be learned from other persistent post-operative pain disorders. Mol Pain. 2015;11:21. Published 2015 Apr 21.
4. Galor A, Zlotcavitch L, Walter SD, et al. Dry eye symptom severity and persistence are associated with symptoms of neuropathic pain. Br J Ophthalmol. 2015;99(5):665-668.
5. Rosenthal P, Baran I, Jacobs DS. Corneal pain without stain: is it real? Ocul Surf. 2009;7(1):28-40.
6. Foulks GN, Forstot SL, Donshik PC, et al. Clinical guidelines for management of dry eye associated with Sjögren disease. Ocul Surf. 2015;13(2):118-132.