The Use of the Esclera Scleral Contact Lens in the Treatment of Moderate to Severe Dry Eye Disease

Customized Scleral Lenses: An Alternative Tool for Severe Dry Eye Disease-A Case Series

Purpose: Dry eye disease (DED) is a multifactorial condition significantly impacting patients' quality of life (QoL). This study aims to present a case series highlighting the effectiveness of customized scleral lenses in managing severe DED and improving patient outcomes. Methods: This case series includes three patients with severe DED refractory to conventional treatments. Customized scleral lenses were fitted for each patient, and clinical outcomes were evaluated over a period of two months. Assessments included best-corrected visual acuity (BCVA), slit-lamp examination findings, and corneal National Eye Institute (NEI) scores. Results: All three patients demonstrated significant improvements in BCVA, reductions in ocular symptoms, and enhanced ocular surface health. Patient 1, with secondary Sjögren's syndrome and suspected mucous membrane pemphigoid, showed resolution of conjunctival hyperemia and epithelial defects. Patient 2, with graft versus host disease, exhibited resolution of punctate keratitis and the absence of thread mucus. Patient 3, post-oncologic surgery, achieved complete resolution of keratoconjunctivitis sicca and the restoration of vision. Conclusions: Customized scleral lenses are a useful therapeutic option for severe DED, providing significant symptomatic relief and enhancing patients' quality of life. Their use should be considered in refractory cases to optimize ocular surface health and visual outcomes.

Scleral Lenses for Managing Dry Eye Disease in the Absence of Corneal Irregularities: What Is the Current Evidence?

Scleral lenses (SLs) are large-diameter rigid contact lenses that are a mainstay treatment for eyes with corneal irregularities. In recent years, there has been increased interest in the role of managing dry eye disease (DED) with SLs, as many patients with DED have reported symptomatic relief with SL wear. The role of SLs for DED management when there are associated corneal irregularities is supported by individual case reports and studies. This has prompted practitioners to begin advocating using SLs in DED cases, even in the absence of associated corneal irregularities and other ocular surface diseases (OSDs). There have also been discussions on potentially placing SLs earlier in the treatment hierarchy of DED, where it currently sits at a more advanced level of intervention (Step 3) in the TFOS DEWS II Report. This review will present the currently available, albeit sparse, evidence that supports and suggests this practice, as well as ancillary evidence supporting the purported benefits of SL wear in DED. The advantages of SL wear, such as corneal healing, absence of tear evaporation and contact lens dehydration, and improved visual acuity with associated increased wear comfort, and how this will benefit DED patients will be explored. Conversely, the challenges associated with fitting SLs in DED patients, including increased midday fogging, poor wettability, and subjective patient satisfaction, will also be presented, as well as a discussion on the key considerations for SL fitting in this population. Overall, while more research is needed to support the use of SLs in DED patients without associated corneal irregularities and other forms of OSD, the use of these lenses may prove to have a potentially wider role given their reported ancillary benefits in these populations.

Systematic review of ocular surface treatments in the setting of thyroid eye disease

Introduction

Approximately 85% of patients with thyroid eye disease experience ocular surface symptoms. Although corneal exposure plays a role in inducing inflammatory changes to the ocular surface, multiple studies reveal more complexity to the abnormal tear film composition and parameters in thyroid eye disease patients including those who do not have proptosis or increased corneal exposure. Currently, a majority of cases of thyroid associated dry eye symptoms are given treatments intended for ocular surface disease arising from different etiologies.

Methods

Medline via Ovid, Cochrane CENTRAL, PubMed, and Google Scholar were systematically searched for articles evaluating the efficacy of treatments for dry eye symptoms in patients with thyroid eye disease. Articles were from all geographic regions and dates ranged from inception until October 2023.

Results

Seven papers ultimately met inclusion criteria and were included in this review. These papers revealed that multiple topical and non-topical treatment modalities address dry eye symptoms in thyroid eye disease and improve subjective and objective ocular surface parameters. However, due to the few studies that exist and due to disparities in sample size and study design, no overwhelming best practices were identified that could influence clinical practice.

Conclusion

This systematic review identifies the current treatments that exist and highlights the clear unmet need for a large population suffering with dry eye symptoms. Ideally, further well-designed investigations into this area would target topical, non-invasive modalities to develop first line options for thyroid eye disease patients.

Mapping the research on Sjögren's syndrome-related dry eye disease: a bibliometric network analysis of the past 20 years

PURPOSE

Our study aimed to make a bibliometric analysis on Sjögren's syndrome-related dry eye disease (SS-DED), explore its potential research hotspots, and provide critical information for future research interest and undeveloped topics in this field, which can benefit clinicians and researchers.

METHODS

We extracted all publications relating to SS-DED from 2003 to 2022 from the Web of Science Core Collection database. Original articles and reviews in English were included. The contributions of different countries, institutions, journals, and authors were compared, and the research hotspots were visualized for network analysis through GraphPad Prism, CiteSpace, and VOSviewer.

RESULTS

We enrolled a total of 987 publications. The United States contributed the most publications (281, 28.5%), followed by China (157, 15.9%) and Japan (80, 8.11%). Publications from the United States were cited more frequently (13,060 citations), with the highest H-index of 57. China ranked second in the total number of publications, the papers were not cited frequently (3790 citations), and the H-index ranked second (H-index = 31). PLoS One (32, 3.24%) published the most papers, and the University of California system had the highest number of publications (45, 4.56%). Bootsma H from the Netherlands published the most papers. The trend of research hotspots evolved mainly from the basic manifestation to pathogenesis and treatment of SS-DED and paid more attention to distinguishing SS-DED from that dry eye disease without SS.

CONCLUSIONS

Based on the bibliometric, co-citation, and network analyses in this study, we obtained the annual publications and citations, the growth trends of publications, the productivity of countries, organizations, journals, and authors, high-quality publications, and the emerging hotspots of SS-DED, which may open new doors for promising research directions.

Smart Contact Lens Systems for Ocular Drug Delivery and Therapy

Ocular drug delivery and therapy systems have been extensively investigated with various methods including direct injections, eye drops and contact lenses. Nowadays, smart contact lens systems are attracting a lot of attention for ocular drug delivery and therapy due to their minimally invasive or non-invasive characteristics, highly enhanced drug permeation, high bioavailability, and on-demand drug delivery. Furthermore, smart contact lens systems can be used for direct light delivery into the eyes for biophotonic therapy replacing the use of drugs. Here, we review smart contact lens systems which can be classified into two groups of drug-eluting contact lens and ocular device contact lens. More specifically, this review covers smart contact lens systems with nanocomposite-laden systems, polymeric film-incorporated systems, micro and nanostructure systems, iontophoretic systems, electrochemical systems, and phototherapy systems for ocular drug delivery and therapy. After that, we discuss the future opportunities, challenges and perspectives of smart contact lens systems for ocular drug delivery and therapy.

Assessment of meibomian gland drop-out and visibility through a new quantitative method in scleral lens wearers: A one-year follow-up study

OBJECTIVES

To validate a previously developed algorithm based on the visibility of meibomian gland images obtained with Cobra fundus camera and to assess the changes in meibomian glands in scleral lens wearers over one year of lens wear.

METHODS

Infrared meibography was obtained from the upper eyelid using the Cobra fundus camera in forty-three volunteers (34.2 ± 10.1 years). Meibographies were classified into 3 groups: Group 1 = good subjective gland visibility and gland drop-out < 1/3 of the total area; Group 2 = low visibility and gland drop-out < 1/3; and Group 3 = low visibility and gland drop-out > 1/3. Meibomian gland visibility metrics were then calculated using the developed algorithm from the pixel intensity values of meibographies. Repeatability of new metrics and their correlations with gland drop-out were assessed. Meibographies and ocular symptoms were also assessed after 1 year of scleral lens wear in 29 subjects.

RESULTS

Gland drop-out percentage was not statistically different between groups 1 and 2 (p = 0.464). Nevertheless, group 1 showed higher grey pixel intensity values than the other groups. Statistically significant correlations were found between gland visibility metrics and gland drop-out percentage. Repeatability was acceptable for all metrics, coefficient of variation achieving values between 0.52 and 3.18. While ocular symptoms decreased with scleral lens wear (p < 0.001), no statistically significant differences were found in gland drop-out percentage (p = 0.157) and gland visibility metrics (p > 0.217).

CONCLUSIONS

The proposed method can assess meibomian gland visibility in an objective and repeatable way. Scleral lens wear appears to not adversely affect meibomian gland drop-out and visibility while might improve dry eye symptoms after one year of lens wear. These preliminary results should be confirmed with a control group.

Therapeutic Hyper-CL soft contact lens in Sjögren's syndrome

Purpose

Observations

Conclusions and importance

Corneal Confocal Analysis after Scleral Lens Wear in Keratoconus Patients: A Pilot Study

SIGNIFICANCE

Scleral lenses rely on the scleroconjunctival region without bearing the cornea, which could improve the symptoms and modify the corneal nerve plexus morphology.

PURPOSE

This study aimed to evaluate symptoms and changes in corneal nerve plexus morphology and density of Langerhans cells in keratoconus patients with and without intrastromal corneal ring before and after scleral lens wear.

METHODS

Sixteen scleral lens wearers with keratoconus were recruited for this short-term experimental pilot study. Subjects were divided into two groups: keratoconus group and intrastromal corneal ring segment group. All subjects were examined in two visits: baseline (before scleral lens wear) and after 6 months of scleral lens wear, after lens removal. The Schirmer I test, the Ocular Surface Disease Index, tear breakup time, and in vivo confocal microscopy were evaluated.

RESULTS

The mean age was 42.33 ± 11.27 years. A significant decrease in tear breakup time was found in the total group ( P = .01, Wilcoxon) compared with baseline. Ocular Surface Disease Index score had decreased after 6 months of scleral lens wear in the keratoconus with intrastromal corneal ring segment subgroup ( P = .03, Wilcoxon) and in the total group ( P = .001, Wilcoxon). No statistical changes in nerve density, tortuosity, and ramification were found for either the total group or the subgroup. However, the mean nerve length was higher in all groups, especially in the keratoconus subgroup ( P = .03, Wilcoxon) after 6 months of scleral lens wear. Regarding optical density, the total group showed a significant increase after 6 months of wearing ( P = .02, Wilcoxon). Finally, Langerhans cell density was not statistically different in any group.

CONCLUSIONS

These results suggest that scleral lens wearing improves the symptoms and increased the mean length nerves after 6 months of wear use in keratoconus patients.

Lacrimal Gland Insufficiency in Aqueous Deficiency Dry Eye Disease: Recent Advances in Pathogenesis, Diagnosis, and Treatment

BACKGROUND

Aqueous deficiency dry eye disease is a chronic and potentially sight-threatening condition, that occurs due to the dysfunction of the lacrimal glands. The aim of this review was to describe the various recent developments in the understanding, diagnosis and treatment of lacrimal gland insufficiency in aqueous deficiency dry eye disease.

METHODS

A MEDLINE database search using PubMed was performed using the keywords: "dry eye disease/syndrome", "aqueous deficient/deficiency dry eye disease", "lacrimal gland" and "Sjogren's syndrome". After scanning through 750 relevant abstracts, 73 eligible articles published in the English language from 2016 to 2021 were included in the review.

RESULTS

Histopathological and ultrastructural studies have revealed new insights into the pathogenesis of cicatrising conjunctivitis-induced aqueous deficiency, where the lacrimal gland acini remain uninvolved and retain their secretory property, while significant ultrastructural changes in the gland have been observed. Recent advances in diagnosis include the techniques of direct clinical assessment of the lacrimal gland morphology and secretion, tear film osmolarity, tear film lysozyme and lactoferrin levels, tear film interferometry and lacrimal gland confocal microscopy. Developments in the treatment of aqueous deficiency dry eye disease, apart from the nanoparticle-based tear substitutes, include secretagogues like diquafosol tetrasodium and rebamipide, anti-inflammatory topical agents like nanomicellar form of cyclosporine and lifitegrast, scleral contact lenses, neurostimulation, and acupuncture for increasing the amount of tear production, minor salivary gland transplantation, faecal microbial transplantation, lacrimal gland regeneration and mesenchymal stem cell therapy.

CONCLUSIONS

Significant advances in the understanding, diagnosis and management of lacrimal gland insufficiency and its role in aqueous deficiency dry eye disease have taken place within the second half of the last decade. Of which, translational breakthroughs in terms of newer drug formulations and regenerative medicine are most promising.

Scleral Lens Thickness and Corneal Edema Under Closed Eye Conditions

OBJECTIVES

To examine the relationship between central lens thickness and central corneal edema during short-term closed eye scleral lens wear.

METHODS

Nine participants (mean age 30 years) with normal corneas wore scleral lenses (Dk 141) under closed eye conditions on separate days with nominal center thicknesses of 150, 300, 600, and 1,200 μm. Epithelial, stromal, and total corneal edema were measured using high-resolution optical coherence tomography immediately after lens application and after 90 min of wear, before lens removal. Data were corrected for variations in initial fluid reservoir thickness and compared with predictions from theoretical modeling of overnight scleral lens wear.

RESULTS

Scleral lens-induced central corneal edema was primarily stromal in nature. The mean±standard error of corrected total corneal edema was 4.31%±0.32%, 4.55%±0.42%, 4.92%±0.50%, and 4.83%±0.22% for the 150-, 300-, 600-, and 1,200-μm lenses, respectively. No significant differences in the corrected total corneal edema were observed across all thickness groups (P=0.20). Theoretical modeling of overnight scleral lens wear seemed to overestimate the relative increase in central corneal edema as a function of decreasing lens Dk/t for values lower than 25.

CONCLUSION

The magnitude of scleral lens-induced central corneal edema during short-term closed eye lens wear did not vary significantly with increasing central lens thickness. Theoretical modeling of overnight closed eye scleral lens wear seems to overestimate the effect of increasing lens thickness.

OSDI Outcomes Based on Patient Demographic and Wear Patterns in Prosthetic Replacement of the Ocular Surface Ecosystem

PURPOSE

To evaluate the impact of prosthetic replacement of the ocular surface ecosystem (BostonSight PROSE) treatment on symptom outcomes based on the Ocular Surface Disease Index (OSDI).

PATIENTS AND METHODS

This was a single-center, retrospective analysis of consecutive patients who initiated PROSE treatment between September 2017 and December 2019 by the same clinician. The primary outcome measure was to compare OSDI survey scores at baseline prior to PROSE treatment and at follow-up, after PROSE treatment. Indication for treatment, sex, age, device diameter, average wear time, preexisting mental illness, duration of PROSE wear, and status of PROSE wear at follow-up were also studied.

RESULTS

A total of 134 patients underwent PROSE treatment and completed a baseline OSDI survey during the study period. Forty-three patients completed a follow-up OSDI survey and were included in the study analysis. The most common treatment indications were keratoconjunctivitis sicca (n=27) and corneal ectasia (n=16). Baseline average OSDI score was 56.9±23.7 for the 43 subjects who completed a subsequent OSDI survey. The last documented average follow-up OSDI for those 43 subjects was 23.8±15.6, median (IQR) of 22.9 (10.4 to 32.3), and a statistically significant 54.7±27.6% average improvement from baseline (p<0.01). All patients, except for two, showed improvement in OSDI score. Statistically significant improvement occurred regardless of underlying diagnosis with no statistically significant difference based on age, sex, mental illness, or device diameter and no statistical correlation with average wear time, or duration of PROSE wear.

CONCLUSION

PROSE treatment improves visual function and symptom relief as demonstrated by the OSDI survey. Sex, age, preexisting mental illness, device diameter, average wear time, and duration of wear had no statistically significant impact on OSDI outcomes.

Acute and Chronic Management of Ocular Disease in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis in the USA

Stevens Johnson syndrome and toxic epidermal necrolysis are on a spectrum of a severe, immune-mediated, mucocutaneous disease. Ocular involvement occurs in the vast majority of cases and severe involvement can lead to corneal blindness. Treatment in the acute phase is imperative in mitigating the severity of chronic disease. Advances in acute treatment such as amniotic membrane transplantation have shown to significantly reduce the severity of chronic disease. However, AMT is not a panacea and severe chronic ocular disease can and does still occur even with aggressive acute treatment. Management of chronic disease is equally critical as timely intervention can prevent worsening of disease and preserve vision. This mini-review describes the acute and chronic findings in SJS/TEN and discusses medical and surgical management strategies.

Clinical Aspects of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis With Severe Ocular Complications in Brazil

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute and potentially fatal inflammatory vesiculobullous reactions that affect the skin and mucous membranes, and which are most often triggered by particular medications and infections. In Brazil, the drugs most frequently associated with TEN and SJS include cold medicine such as dipyrone and NSAIDs, followed by carbamazepine, phenobarbital, penicillin, and allopurinol. Genetic variations have been found to increase the risk of SJS/TEN in response to triggering factors such as medications. The most closely associated genes found in Brazilian cold-medicine-related SJS/TEN patients with severe ocular complications are HLA-A^*66:01 in those of mixed African and European ancestry and HLA-B^*44:03 and HLA-C^*12:03 in those of solely European ancestry. Our classification system for grading ocular surface complication severity in SJS/TEN patients revealed the most severe complications to be limbal stem cell deficiency and dry eye. Changes to the conjunctival flora have also been observed in SJS/TEN patients. Our group identified bacterial colonization in 95% of the eyes (55.5% of which were gram-positive cocci, 25.5% of which were gram-negative bacilli, and 19% of which were gram-positive bacilli). Several new treatment options in the acute and chronic ocular management of the SJS/TEN patients have been described. This article highlights some Brazilian institutions' contributions to ocular surface care in both the acute phase (including the use of amniotic membrane transplantation) and the chronic phase (such as eyelid margin and fornix reconstruction, minor salivary gland transplantation, amniotic membrane and limbal transplantation, scleral contact lenses, anti-angiogenic eyedrops for corneal neovascularization, ex-vivo cultivated limbal epithelium transplantation, conjunctival-limbal autografting, oral mucosa transplantation, and keratoprosthesis).

Assessment of a Novel Lens Surface Treatment for Scleral Lens Wearers With Dry Eye

OBJECTIVES

To compare lens comfort and dry eye (DE) symptoms of DE scleral lens (SL) wearers fit with polyethylene glycol (PEG)-based surface-treated and untreated SLs. Dry eye signs, comfortable SL wearing time (WT), vision quality, and lens-related ocular surface changes were also assessed.

METHODS

Twenty-one SL wearers with DE and SL discomfort were enrolled in a double-masked crossover study. Participants were randomized to wear their untreated or PEG (Tangible Hydra-PEG, Tangible Science; Redwood, CA) surface-treated SL of the same parameters first for 30 days. Lens comfort, DE symptoms, and ocular surface assessments were measured at baseline, after the first test period, and after the crossover. Comfortable lens WT and frequency of foggy vision were recorded. Comparisons were assessed using paired t tests or Wilcoxon signed-rank tests.

RESULTS

Polyethylene glycol-treated SL wear resulted in significantly improved: lens comfort (P=0.003), DE symptoms (P=0.004), corneal sodium fluorescein staining (P=0.01), temporal conjunctival lissamine green staining (P=0.01), lid wiper epitheliopathy (P=0.002), conjunctival papillae (P=0.003), frequency of foggy vision (P=0.002), tear break-up time (TBUT) (P=0.01), and comfortable lens WT (P=0.002) compared with untreated wear. There were no significant changes between treated and untreated lens wear for TBUT over the SL (P=0.14) and nasal conjunctival lissamine green staining (P=0.06).

CONCLUSIONS

Polyethylene glycol surface-treated SLs provided improved comfort, reduced DE symptoms, and reduced ocular surface compromise compared with untreated SLs for participants with DE.

Fluid Reservoir Thickness and Corneal Edema during Open-eye Scleral Lens Wear

SIGNIFICANCE

There is debate concerning corneal oxygenation during scleral lens wear due to the potential additive hypoxic effect of a lens plus a fluid reservoir. This study investigated the agreement between theoretical models and empirical measurements of scleral lens-induced corneal edema with respect to central fluid reservoir thickness.

PURPOSE

The purpose of this study was to examine the effect of altering the fluid reservoir thickness on central corneal edema during short-term open-eye scleral lens wear and to compare these empirical measurements with predictive theoretical models.

METHODS

Ten participants (age, 30 ± 4 years) with normal corneas wore highly oxygen-permeable scleral lenses (141 Dk ×10 cm O2 (cm)/[(s) (cm) (mmHg)]) on separate days with either a low (mean, 144; 95% confidence interval [CI], 127 to 160 μm), medium (mean, 487; 95% CI, 443 to 532 μm), or high (mean, 726; 95% CI, 687 to 766 μm) initial fluid reservoir thickness. Epithelial, stromal, and total corneal edema were measured using high-resolution optical coherence tomography after 90 minutes of wear, before lens removal. Data were calculated or extracted from published theoretical models of scleral lens-induced corneal edema for comparison.

RESULTS

Scleral lens-induced central corneal edema was stromal in nature and increased with increasing fluid reservoir thickness; mean total corneal edema was 0.69% (95% CI, 0.34 to 1.04%), 1.81% (95% CI, 1.22 to 2.40%), and 2.11% (95% CI, 1.58 to 2.65%) for the low, medium, and high thickness groups, respectively. No significant difference in corneal edema was observed between the medium and high fluid reservoir thickness groups (P = .37). "Resistance in series" oxygen modeling overestimated the corneal edema observed for fluid reservoir thickness values greater than 400 μm.

CONCLUSIONS

Scleral lens-induced central corneal edema increases with increasing reservoir thickness, but plateaus at a thickness of around 600 μm, in agreement with recent theoretical modeling that incorporates factors related to corneal metabolism.

CLEAR - Medical use of contact lenses

The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.

Evaluation of corneal topography, tear film function and conjunctival impression cytology after long-term scleral contact lens wear in keratoconus patients

Purpose: To investigate the impact of long-term scleral contact lens (ScCL) wear on corneal curvature, corneal thickness, tear film function, and ocular surface in patients with keratoconus.Methods: Sixteen keratoconus patients wearing ScCLs for 6 months were enrolled in the study. Corneal topography, tear osmolarity test, Schirmer 1 test, tear film break-up time (TBUT) test, and impression cytology analysis were assessed at baseline and follow-up examinations.Results: There were no significant differences in visual acuity, keratometric and pachymetric values after 6 months of ScCL wear compared to baseline (p>0.05 for all). Tear osmolarity, Schirmer 1 test, and TBUT test results showed no significant change during follow-up (p>0.05 for all). Median goblet cell density and grade of squamous metaplasia did not differ significantly at 1-month. However, there was a gradual deterioration in goblet cell density and Nelson grade until the third-month visit compared to baseline (p for goblet cell, p=0.003; p for Nelson grade, p=0.003). These impaired cytological features observed at 3-month visit persisted at 6-month visit (p for goblet cell, p=0.008; p for Nelson grade, p<0.001).Conclusion: Six months of ScCL wear did not induce any changes in corneal curvature and thickness and also did not affect tear function tests in keratoconic eyes. The only significant changes observed were a decrease in goblet cell density and metaplastic changes in conjunctival epithelium in impression cytology analysis. Further investigations may be needed to better understand the cause of impairment in cytological features of ocular surface and its clinical implications.

Müller Muscle-conjunctival Resection with or without Tarsectomy and Combined with Bandage Contact Lens Use in Ptosis Patients with Corneal Graft

PURPOSE

To examine the efficacy of ptosis correction with a Müller muscle-conjunctival resection with or without tarsectomy (MMCR±T), combined with bandage contact lens (BCL) use, in corneal graft patients.

METHODS

Seven patients with corneal grafts who underwent MMCR±T for treatment of ptosis were evaluated retrospectively. A BCL was applied to the grafts at the end of the surgery. The collected data included preoperative and postoperative visual acuity, marginal reflex distance 1 (MRD-1), presence of Hering's dependency by the phenylephrine test, symmetry outcomes, and complications after MMCR±T.

RESULTS

The average duration between the penetrating keratoplasty and MMCR±T was 14 months, with a follow-up time of 10.4 months after MMCR±T. Hering's dependency was observed in four (57.2%) patients before MMCR±T, and MRD-1 was increased in all patients based on preoperative phenylephrine tests. The mean preoperative MRD-1 was -0.14 ± 0.55 mm, and the mean postoperative MRD-1 was 2.35 ± 0.89 mm (p < 0.0001). Symmetry outcomes of perfect (<0.5 mm), good (0.5-1 mm), and fair (≥1 mm) were noted after MMCR±T in three, three, and one patients, respectively. During the follow-up, no obvious corneal epitheliopathy, keratitis, or corneal graft rejection/failure were noted in any cases. BCL use was well tolerated by all patients.

CONCLUSIONS

Most patients achieved good surgical outcomes with the application of the BCL to protect the graft and with the use of the phenylephrine test and Hering's dependency to predict the final eyelid position and symmetry. MMCR±T combined with BCL may therefore represent an alternative approach for correction of ptosis in patients with corneal graft.

Therapeutic Contact Lenses in the Treatment of Corneal and Ocular Surface Diseases-A Review

Therapeutic contact lenses (TCLs) are often used in the management of a wide variety of corneal and ocular surface diseases (OSDs). Indications of TCL include pain relief, enhancing corneal healing, corneal sealing, corneal protection, and drug delivery. For painful corneal diseases such as bullous keratopathy, epidermolysis bullosa, and epithelial abrasions/erosions, bandage contact lenses (BCLs) provide symptomatic relief. Postoperatively in photorefractive keratectomy or laser epithelial keratomileusis, BCLs also alleviate pain. In severe OSDs such as severe dry eye, Stevens-Johnson syndrome/toxic epidermal necrolysis, gas-permeable scleral contact lenses are often used to enhance corneal healing. BCLs are used post-keratoplasty, post-trabeculectomy, and post-amniotic membrane transplantation to enhance healing. BCLs, with or without glue adhesives, are used to seal small corneal perforations and sometimes also used as bridging treatment before penetrating keratoplasty in larger corneal perforations. In patients with eyelid conditions such as trichiasis, ptosis, and tarsal scarring, BCLs are also effective in forming a mechanical barrier to protect the cornea. A relatively new use for TCLs is in ocular drug delivery where TCLs are used to maintain therapeutic concentrations of medication on the ocular surface. Contraindications of the use of TCLs include infective keratitis, corneal anesthesia, and significant exposure keratopathy with inadequate eyelid position or movement. Complications of TCL include infective keratitis, corneal hypoxia and associated complications, corneal allergies and inflammation, and poor lens fit. Overall, TCLs are effective in the treatment of corneal and OSDs but contraindications and complications must be considered.

Efficacy of Bandage Contact Lenses versus Eye Patching in Early Postoperative Period of Müller's Muscle-Conjunctival Resection

PURPOSE

Patients with blepharoptosis who are treated with Müller's muscle-conjunctival resection (MMCR) may experience postoperative pain and discomfort related to the suture material on the palpebral conjunctiva. This study aims to compare the postoperative subjective complaints, such as pain and discomfort, with a visual analog scale (VAS), and objectively evaluate the cornea with a tear break-up time (TBUT) test and fluorescein staining following MMCR that was managed by either a bandage contact lens (BCL) or eye patching.

METHODS

Forty patients who had undergone a unilateral MMCR were randomized into 2 groups. Group 1 (n = 20) received a BCL, and group 2 (n = 20) received an eye patch following the MMCR. Patients were evaluated postoperatively at 1 and 7 days in this prospective study. The postoperative pain was measured using a VAS, and the requirement for anti-inflammatory medication was analyzed. A slit-lamp examination was performed to evaluate the cornea with a TBUT test and fluorescein staining by objectively using the National Eye Institute (NEI) classification.

RESULTS

BCL treatment decreased the VAS score, the need for anti-inflammatory medications, and fluorescein staining using the NEI score and increased the TBUT score significantly compared with the eye patch treatment (p < 0.001).

CONCLUSIONS

Our findings suggest that the use of a BCL may be beneficial in terms of reducing early postoperative pain and eye stinging, protecting the cornea, and retaining the ability to perform daily activities following a MMCR.

Outcomes of Scleral Contact Lens Use in Veteran Population

OBJECTIVES

To document outcomes associated with use of scleral contact lenses (SL) in the veteran population and analyze the medical and demographic factors that affect these outcomes, specifically those involved in contact lens discontinuation.

METHODS

A retrospective study of consecutive patients first fitted with Jupiter Scleral lenses at the Michael E. DeBakey Veterans Affairs Medical Center between 2010 and 2018. The primary outcome was continuation of SL use at 1 year. Demographic factors and variables such as presence of comorbid diseases, improvement in visual acuity, and daily lens wear time were compared. Logistic regression analysis was used to determine which factors were associated with SL discontinuation.

RESULTS

One hundred twenty patients with a mean age of 56.7±15.1 years were fitted with SL during the study period. The most common diagnosis was corneal ectasia (55.8%). Sixty-six (55.0%) patients had difficulty with wear, the most common being ocular irritation (20.0%) and mid-day fogging or bubbles (15.8%). Forty-one patients (34.2%) discontinued SL use with a median time from fitting to discontinuation of 5.2 months. The most common reason for SL discontinuation was difficulty with insertion and removal (53.7%). Comorbid neurologic disease had a statistically significant association with discontinuation (odds ratio 4.6, 95% confidence interval 1.3-17, P=0.022). There were statistically significant differences in mean visual acuity improvement (P=0.003) and daily wear time (P<0.001) but not age (P=0.70) between patients who continued and discontinued lens use.

CONCLUSIONS

Scleral contact lenses are effective for treating a wide variety of ocular diseases and have positive outcomes in veterans. This study aids in understanding patient factors that affect outcomes of SL use in veterans. Further prospective studies are needed to make formal recommendations regarding candidate selection.

Primary Sjögren's syndrome and the eye

Primary Sjögren syndrome is an autoimmune disease that mainly affects exocrine glands such as the salivary and lacrimal glands. In addition, systemic involvement is common. Primary Sjögren syndrome is of particular interest to ophthalmologists as it constitutes an important differential diagnosis in conditions with dry eye disease. In addition, ocular tests for more precisely diagnosing and monitoring primary Sjögren syndrome have become increasingly important, and new therapeutics for local and systemic treatment evolve as a result of increased understanding of immunological mechanisms and molecular pathways in the pathogenesis of primary Sjögren syndrome. We provide an update of interest to ophthalmologists regarding pathogenesis, diagnosis, investigative procedures, and treatment options.

Presbyopia and the aging eye: Existing refractive approaches and their potential impact on dry eye signs and symptoms

Every part of the human body is subject to aging, including the eye. An increased prevalence of dry eye disease with age is widely acknowledged. Aging threatens ocular surface homeostasis, altering the normal functioning of the lacrimal functional unit and potentially leading to signs and symptoms of dry eye. Additional age-related processes take place within the crystalline lens, leading to presbyopia and cataractogenesis. Correction strategies for presbyopia and cataracts may directly or indirectly challenge the ocular surface. Contact lenses disturb the normal structure of the tear film and can interact negatively with the ocular surface, further deteriorating an already unbalanced tear film in presbyopes, however, newer contact lens designs can overcome some of these issues. Moreover, cataract and corneal refractive surgeries sever corneal nerves and disrupt the corneal epithelium and ocular surface, which can influence surgical outcomes and aggravate dryness symptoms in older age groups. This review summarises the current understanding of how the invasive nature of contact lens wear and cataract and refractive surgery influence signs and symptoms of ocular dryness in an aging population.

Miniscleral lenses in the treatment of patients with dry eye syndrome (first own experience)

Background. Scleral lenses, due to their benefits, hold a specific position among all types of contact lenses. Some years ago, they began to be used successfully not only for the correction of complex types of refractive errors, when other types of correction failed to achieve satisfactory visual function and visual rehabilitation of patients, but also as a therapeutic system in the management of ocular surface disease. Purpose. To evaluate the efficacy of rigid gas permeable miniscleral contact lenses as a therapeutic system in the management of patients with dry eye syndrome by filling the space under the lens with a non-preserved sodium hyaluronate solution. Materials and methods. In the study, 7 patients (11 eyes) with keratectasias after corneal surgery and concomitant dry eye syndrome were included. In the treatment and rehabilitation of these patients, miniscleral contact lenses were used during daytime with additional filling of the space under the lens with a non-preserved sodium hyaluronate solution. Results. As a criterion of the effectiveness of miniscleral contact lens use for therapeutic purposes, along with a significant increase in visual function in patients with complex corneal pathology, the elimination of discomfort due to restoration of the corneal epithelium integrity and improvement of their quality of life is considered.

Prosthetic Replacement of the Ocular Surface Ecosystem Treatment for Ocular Surface Disease in Pediatric Patients With Stevens-Johnson Syndrome

PURPOSE

To report the outcomes of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in pediatric patients with chronic ocular surface disease associated with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

DESIGN

Retrospective, interventional case series.

METHODS

Patients aged 18 years or younger seen in consultation for PROSE treatment at a single center between January 1992 and December 2016 with a history of SJS/TEN were reviewed. Demographics, etiology of SJS/TEN, age at treatment milestones, best-corrected visual acuity (BCVA) at treatment milestones, and treatment failures were recorded. BCVA at the initial presentation visit was compared to BCVA at the time of PROSE device dispense and at the last recorded visit.

RESULTS

Twenty-seven female and 22 male patients were reviewed. Reported etiology was antibiotic (n = 19), antiepileptic (n = 9), antipyretic (n = 9), other (n = 3), and unknown (n = 9). The mean age was 6.4 years at disease onset and 9.3 years at time of initial presentation. The mean duration of follow-up was 5.45 years. The median BCVA at the initial presentation was 0.6 logMAR (20/80 Snellen), and was significantly improved to 0.18 logMAR (20/30 Snellen) at the time a PROSE device was dispensed (P < .0001). The median BCVA at the last recorded visit was significantly improved to 0.18 logMAR (20/30 Snellen, P = .0004). There were 15 patients who failed PROSE treatment (30.6%).

CONCLUSIONS

PROSE treatment is feasible in over two thirds of pediatric patients with chronic ocular surface disease related to SJS/TEN and results in significant improvement in vision that is durable over a period of many years.

How to treat Sjögren's syndrome

SS is a chronic, autoimmune disease of unknown aetiology for which there is no known curative treatment. Although dryness of the eyes and mouth are the classically described features, patients often experience drying of other mucosal surfaces and systemic manifestations, including fatigue and arthralgia. There is an association with other autoimmune diseases, especially thyroid disease, coeliac disease and primary biliary cholangitis. Systemic features may affect up to 70% and include inflammatory arthritis, skin involvement, haematological abnormalities, neuropathies, interstitial lung disease and a 5-10% lifetime risk of B cell lymphoma. Treatment should aim to empower patients to manage their condition; conserve, replace and stimulate secretions; prevent damage; and suppress underlying systemic disease activity.

Acanthamoeba keratitis in patients wearing scleral contact lenses

PURPOSE

To report a series of cases of Acanthamoeba keratitis (AK) in scleral lens wearers with keratoconus to determine whether this type of contact lens presents a greater risk for development of infection.

METHODS

This study reports three patients who wore scleral contact lenses to correct keratoconus and developed AK. The diagnoses of AK were established based on cultures of the cornea, scleral contact lenses, and contact lens paraphernalia. This study investigated the risk factors for infections.

RESULTS

The possible risks for AK in scleral contact lens wearers are hypoxic changes in the corneal epithelium because of the large diameter and minimal tear exchange, use of large amounts of saline solution necessary for scleral lens fitting, storing the scleral lens overnight in saline solution rather than contact lens multipurpose solutions, not rubbing the contact lens during cleaning, and the space between the cornea and the back surface of the scleral lens that might serve as a fluid reservoir and environment for Acanthamoeba multiplication. Two patients responded well to medical treatment of AK; one is still being treated.

CONCLUSIONS

The recommendations for use and care of scleral contact lenses should be emphasized, especially regarding use of sterile saline (preferably single use), attention to rubbing the lens during cleaning, cleaning of the plunger, and overnight storage in fresh contact lens multipurpose solutions without topping off the lens solution in the case.

An analysis of anterior scleral shape and its role in the design and fitting of scleral contact lenses

PURPOSE

The purpose of this study was to evaluate the shape of the anterior sclera by measuring the sagittal height and corneoscleral transition angles in the four cardinal and four oblique segments of the eye.

MATERIALS AND METHODS

In this study, 78 normal eyes of 39 subjects were evaluated. The sagittal height, corneoscleral angle and scleral angle were measured at three chord lengths (10.0mm, 12.8mm and 15.0mm) in all eight segments of the anterior eye using optical coherence tomography (Zeiss Visante AS-OCT). Scleral toricity was calculated for each eye, defined as the greatest sagittal height difference found between two perpendicular meridians.

RESULTS

At a 12.8mm chord length, the shape of the anterior eye was found to be nearly rotationally symmetric, and at a chord of 15.0mm the shape became more asymmetric. The average sagittal heights of the eight segments at a 12.8mm chord ranged from 2890μm to 2940μm; at a 15.0mm chord they ranged from 3680μm to 3790μm. The average scleral angles at a 15.0mm chord ranged from 35.17° to 38.82°. Significant differences between opposing segments were found in the sagittal height and scleral angle measurements at a chord of 15.0mm (sagittal height p≤0.0021; scleral angle p≤0.0105). The nasal measurements revealed flatter scleral angles and concave corneoscleral transitions, whereas temporal scleral angles were steeper, with tangential or convex corneoscleral transitions.

CONCLUSION

These findings are important to consider when designing and fitting contact lenses that rest beyond the boundaries of the limbus, such as scleral lenses.

Update in Current Diagnostics and Therapeutics of Dry Eye Disease

Dry eye disease (DED) represents a heterogeneous group of conditions with tear film insufficiency and signs and/or symptoms of ocular surface irritation. The clinical manifestations of DED can be highly variable; hence the diagnosis is often based on a combination of symptoms, signs, and clinical tests, given that any one of these alone would miss a significant number of patients. Similarly, the treatment must often be tailored to each patient by targeting the specific mechanisms involved in his or her disease. The purpose of this review is to summarize recent advances that have allowed us to better recognize, categorize, and treat patients with DED. The most notable new diagnostic tests in DED are tear film osmolarity, inflammatory biomarkers, and meibomian gland imaging. Therapeutically, anti-inflammatory therapy, meibomian gland heating and expression, and scleral contact lenses are some of the latest options available for treating DED.

Comparison of the influence of corneo-scleral and scleral lenses on ocular surface and tear film metrics in a presbyopic population

PURPOSE

To assess and compare the effect of the corneo-scleral lenses (C-ScL) and scleral lenses (ScL) on tear film parameters and central corneal thickness (CCT) in healthy presbyopic subjects.

METHODS

Thirty subjects wore two contact lenses (CLs), randomly assigned, of neutral power, but of different diameters, 12.7mm (C-ScL) and 18mm (ScL) and being equal in the others parameters: material (HS100) and centre thickness (0.29mm). At baseline, 20min after insertion and at 8h, the tear meniscus area (TMA) and CCT was measured (with optical coherence tomography) as well as tear osmolarity.

RESULTS

TMA revealed statistical differences for both lenses at 20min (p<0.001), and also at 8h (p=0.003), being greater for the C-ScL. CCT showed statistical differences for both lenses at 20min (p=0.002), and also at 8h (p=0.001), being lower for the C-ScL. Osmolarity did not reveal statistical differences at 20min (p=0.29), while it was statistically different at 8h (p=0.03), being lower for the C-ScL.

CONCLUSIONS

C-ScL lead to a lesser reduction in the TMA and a lower induced hypoxic stress than the ScL. Osmolarity levels remained within normal values across the day with no clinical difference between lenses. Both designs can represent a good optical platform for correcting presbyopia as well as protecting the ocular surface by vaulting the cornea.

A clinical utility assessment of the automatic measurement method of the quality of Meibomian glands

Background

Meibomian gland dysfunction (MGD) is one of the most common diseases observed in clinics and is the leading cause of evaporative dry eye. Today, diagnostics of MGD is not fully automatic yet and is based on a qualitative assessment made by an ophthalmologist. Therefore, an automatic analysis method was developed to assess MGD quantiatively.

Materials

The analysis made use of 228 images of 57 patients recorded by OCULUS Keratograph^® 5 M with a resolution of 1024 × 1360 pixels concern 30 eyes of healthy individuals (14 women and 16 men) and 27 eyes of sick patients (10 women and 17 men). The diagnosis of dry eye was made according to the consensus of DED in China (2013).

Methods

The presented method of analysis is a new, developed method enabling an automatic, reproducible and quantitative assessment of Meibomian glands. The analysis relates to employing the methods of analysis and image processing. The analysis was conducted in the Matlab environment Version 7.11.0.584, R2010b, Java VM Version: Java 1.6.0_17-b04 with Sun Microsystems Inc. with toolboxes: Statistical, Signal Processing and Image Processing.

Results

The presented, new method of analysis of Meibomian glands is fully automatic, does not require operator’s intervention, allows obtaining reproducible results and enables a quantitative assessment of Meibomian glands. Compared to the other known methods, particularly with the method described in literature it allows obtaining better sensitivity (98%) and specificity (100%) results by 2%.

Conjunctival impression cytology evaluation of patients with dry eye disease using scleral contact lenses

PURPOSE

To evaluate conjunctival impression cytology and HLADR expression changes after wearing scleral contact lenses (ScCLs) for moderate to severe dry eye disease (DED).

DESIGN

Prospective interventional case series.

METHODS

Forty-one eyes from 25 patients with moderate to severe DED were evaluated for Esclera ScCL treatment. Best-corrected visual acuity (BCVA) and slit-lamp findings were assessed. Impression cytology specimens were obtained from DED patients at the baseline and after wearing ScCLs for 12 months. The impression cytology specimens were analyzed using morphological results score, and HLA-DR positive cells were detected and quantified. The values were compared to assess the IC changes after wearing ScCLs.

RESULTS

Forty-one eyes from 25 patients were fitted with ScCLs to manage DED. The underlying diseases were Stevens-Johnson syndrome (22 eyes), Sjogren's syndrome (11 eyes), graft-versus-host disease (2 eyes), dry eye after keratomileusis (2 eyes) and undifferentiated ocular surface disease (4 eyes). The HE-PAS impression cytology score did not differ significantly before and after wearing ScCLs for 12 months in DED patients (p>0.05). The percentage of eyes expressing the HLA-DR antigen in the temporal conjunctiva after wearing ScCL for 12 months significantly increased in patients with Sjogren's syndrome (11.11% to 66.66%; p=0.0498). In groups with Stevens Johnson syndrome and other ocular surface disorders, we did not observe statistically significant differences (p>0.05).

CONCLUSIONS

The ScCLs did not change the parameters used to evaluate inflammatory processes, which were measured using conjunctival impression cytology and HLA-DR expression, except in Sjogren syndrome, in which there was an unexpected increase in HLA expression.

A quantitative method for assessing the quality of meibomian glands

INTRODUCTION

Meibomian gland dysfunction is a common cause of dry eye syndrome which can also lead to eyelid inflammation. Today, diagnostics of meibomian glands is not fully automatic yet and is based on a qualitative assessment made by an ophthalmologist. Therefore, this article proposes a new automatic analysis method which provides a quantitative assessment of meibomian gland dysfunction.

METHOD

The new algorithm involves a sequence of operations: image acquisition (acquisition of data from OCULUS Keratograph® 5M); image pre-processing (image conversion to gray levels, median filtering, removal of uneven lighting, normalization); main image processing (binarization, morphological opening, labeling, Gaussian filtering, skeletonization, distance transform, watersheds). The algorithm was implemented in Matlab with Image Processing Toolbox (Matlab: Version 7.11.0.584, R2010b) on a PC running Windows 7 Professional, 64-bit with the Intel Core i7-4960X CPU @ 3.60GHz.

RESULTS AND CONCLUSIONS

The algorithm described in this article has the following features: it is fully automatic, provides fully reproducible results - sensitivity of 99.3% and specificity of 97.5% in the diagnosis of meibomian glands, and is insensitive to parameter changes. The time of image analysis for a single subject does not exceed 0.5s. Currently, the presented algorithm is tested in the Railway Hospital in Katowice, Poland.