Neovascularization & Ghosting in Scleral Lens Wear
Lynette Johns OD FAAO FSLS
Neovascularization is a well-known risk with contact lenses. The following case demonstrates how a scleral ocular surface prosthetic device provided a therapeutic environment that reduced perfusion in a vascularized cornea. This effect continued over the course of 4 years.
A 38-year-old female suffered from toxic epidermal necrolysis syndrome (TENs) secondary to Lamictal in October 2006. While in the burn unit, she developed bilateral Candida keratitis. The right eye ulcerated and spontaneously perforated in March 2007. The perforation was treated with tissue glue. She arrived at the Boston Foundation for Sight office for prosthetic replacement of the ocular surface ecosystem (PROSE) treatment where we began to fit both eyes with scleral lenses designed as prosthetic devices in May 2007. Entering acuity was 20/200 OD through a bandage soft contact lens and 20/50+1 OS uncorrected.
The patient was extremely photophobic during the examination. Schirmer’s scores were 0 mm in each eye. The lid margins were keratinized with trichiasis and distichiasis OD>OS. The tissue glue in the right eye had since fallen off and the cornea was intact. The right eye had inferior deep stromal and superficial vessels that extended into the visual axis with fibrosis leading to the area that had perforated. The conjunctiva was moderately hyperemic. We proceeded with her bilateral treatment, aiming to replace the ocular surface function by lubricating the corneas as well as to provide visual rehabilitation.
Figure 1 (above) demonstrates the right eye presentation during the fitting process while wearing a device. She achieved 20/30-2 with the right device and 20/25+1 with the left. She returned 5 months later for a follow-up evaluation, and Figure 2 (beneath) shows the marked attenuation of the neovascularization perfusion. The scarring had remained. Visual acuity was 20/30-2 OD and 20/20 OS with the devices.
She returned after 4 years for a re-evaluation of her devices in July 2011. Figure 3 (beneath) demonstrates that the vessels maintained the ghosted appearance as they had 4 years earlier. She continued wearing the devices daily during all waking hours. Vision was 20/30+1 OD and 20/20-2 OS. We advised annual device follow-up evaluations to ensure her safety and to reduce risk of complications.
Neovascularization is still a risk for scleral device wear especially in compromised corneas. We often weigh the benefits of proceeding with treatments against the risks. It is crucial to document any form of neovascularization at the entrance examination. Co-managing physicians may advise a patient to discontinue device wear if they observe neovascularization. Careful documentation of the cornea prior to device fitting as well as a documented discussion of risks and benefits may ensure safe and effective treatment of your patients. Vigilant documentation may provide evidence against discontinuation of treatment.
Dr. Lynette Johns has been the senior optometrist at the Boston Foundation for Sight since 2005.
She is a graduate of the New England College of Optometry where she completed a residency in cornea and contact lenses. She is adjunct clinical faculty at the New England College of Optometry.
Dr. Johns is a fellow of the American Academy of Optometry and a fellow of the Scleral Lens Education Society.