Chronic Graft-Versus-Host Disease
ocular dryness & corneal staining
Lynette Johns OD FAAO FSLS FBLCA
Scleral lenses are extraordinary tools in managing ocular surface disease. They provide a unique rigid surface that creates a barrier to the environment while also creating a liquid reservoir that submerges the cornea in constant lubrication or hydration. Utilization of scleral lenses for ocular surface disease is not a new concept. In a paper by Ridley et al in 1963, 5% of 3,000 PMMA scleral lens fits were used to manage ocular surface disease.1 We also know that scleral lenses can be utilized in resurfacing longstanding persistent epithelial defects.2,3 However, on a smaller scale, there can be a significant reduction in corneal staining that happens quite rapidly.
A 47-year-old white male complained of extreme dryness, OS greater than OD and worse at night, and intense light sensitivity. He also complained of blur and redness. The severity of his visual blur was associated with the ocular dryness symptoms. He had a history of non-Hodgkin’s Lymphoma and was treated with a stem cell transplant five years prior. Ocular symptoms began six months after the transplant and have continued to worsen ever since. He was diagnosed with chronic graft-versus-host disease (GVHD) by his cornea specialist.
Figure 1: corneal staining OD (top) and OS.
Past ocular treatments included a course of topical corticosteroid and topicalcyclosporine. Oral doxycycline had been prescribed for approximately 2 months, but it was discontinued because the patient reported no improvement. Nighttime ocular ointments were attempted but were not desirable because of the associated blur. Punctal plugs of all four puncta provided minimal relief, and the patient had cauterization of superior and inferior puncta OU. Best spectacle corrected acuity was 20/25+2 OD and 20/40 OS. Figure 1 shows the presentation of both corneas.
Scleral Lens Fit
We initiated scleral lens fitting. The right eye was fit with a 20.0 mm lens that had a sagittal depth of 4.4 mm across a 15.0 mm chord, an approximate haptic radius of 14.5, base curve 7.9 and power -1.00 that provided 20/20 vision. The left eye was also fit with a 20.0 mm diameter lens. The sagittal depth was 4.5 mm across a 15.0 mm chord with an approximate haptic radius of 14.5, base curve 7.9 and power -1.25 that provided 20/25- acuity. There was no corneal or conjunctival staining (Figure 2) after 5 hours of continuous wear with preservative-free saline solution filling the lens.
Figure 2: absence of corneal staining OD (top) and OS. after 5 hours of lens wear.
Discussion & Closing Remarks
While there is a lot to learn about the underlying mechanism of how scleral lenses support the ocular surface and reduce corneal staining, the objective evidence of the benefit is clear. Subjectively, patients also report an immediate attenuation of pain symptoms upon application of the lenses. Caution must be taken when fitting patients who have ocular surface disease. These patients often have complex ocular and medical histories. Appropriate referral and medical co-management should be exercised to benefit such patients, especially if the scleral fitter has limitations in his or her scope of practice. Patients who are fit with scleral lenses to treat ocular surface disease must be monitored closely and routinely to maintain and ensure the best outcome. If corneal staining appears beneath a scleral lens that was not present prior to initiating the fitting, we should carefully evaluate the corneal clearance as well as solutions used to fill the lens.
1. Ridley F. Scleral Contact Lenses. Their Clinical Significance. Arch Ophthalmol. 1963 Dec;70:740-5
2. Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol. 2000 Jul;130(1):33-41
3. Lim P, Ridges R, Jacobs DS, Rosenthal P. Treatment of persistent corneal epithelial defect with overnight wear of a prosthetic device for the ocular surface. Am J Ophthalmol. 2013 Dec;156(6):1095-101
Lynette Johns is an adjunct assistant professor and clinical attending in contact lenses at the New England College of Optometry.
She was formerly the senior optometrist at the Boston Foundation for Sight where she exclusively fit scleral lenses and managed complex corneal disease.
She is a fellow of the American Academy of Optometry and Scleral Lens Education Society as well as a fellow of the BCLA. She is a clinical and educational consultant to the GP and specialty soft lens division of Bausch + Lomb.