Fernando Ballesteros MSc, OD teaches at the Optometric Investigations Institute, La Salle University, in Bogotá-Colombia. He has also worked in private practice since 1980.
Therapeutic bandage contact lenses for the promotion of wound- healing and reduction of discomfort from corneal injuries/damage have been in use for some time. This case report demonstrates the use and effectiveness of a silicone hydrogel scleral contact lens as a bandage contact lens for a compromised bulbar conjunctiva.
A 57-year-old patient presented for an annual regular eye exam. Upon examination, a vascularized and keratinized nasal pterygium was diagnosed in the right eye and the patient was advised of the need for pterygium excision surgery. A conjunctival Z-plasty procedure was conducted, with no intra-operative complications. This surgical technique involved avulsing, peeling and excising the pterygium. Once the pterygium was removed, a free conjunctival graft from a donor site (superotemporal bulbar quadrant) was used to cover the bare sclera. The conjunctival tissue removed (pterygium) was sent for histology testing.
The following medications were prescribed:
- Refresh® Optive™ (Carboxymethycellulose 0.5% + Glycerin 0.9%, Allergan, USA) every two hours
- Tobradex (Tobramycin 0.3% , Dexamethasone 0.1%, ALCON, USA) three times a day
- Mitomycin-C every four hours for six days
The patient was seen at subsequent follow up visits:
Day 5 – Patient reported some discomfort, as expected. Ocular findings were normal.
Day 9 – Patient reported acute itching with each instillation of Mitomycin-C. Mild corneal keratitis was found. Patient was advised to continue with medications.
Day 13 – Re-absorption of the conjunctival graft and scleral thinning was noted. Patient was advised that a second surgery was required, which was performed the next day using the same technique without any complications.
Day 16 – The sutures appeared to be in good condition. There was mild scleral thinning at the 4 o´clock perilimbal area.
The pathology report indicated the presence of conjunctival intraepithelial neoplasia. Mitomycin-C usage was continued to control replication of neoplasia.
Eight days after the second surgery, the conjunctival graft was re-absorbed, leaving the sclera exposed and thinned with the possibility of ocular perforation. This condition did not improve despite the application of the new conjunctival graft (Figure 1).
A scleral silicone hydrogel contact lens was used as a therapeutic bandage lens for the compromised conjunctiva. The contact lens (Keratos SurgeryLens) (Table 1) was fitted to be worn for extended wear, with the use of two lubricants (hydroxypropyl methylcellulose, Tears Naturale, Alcon, USA) and loteprednol etabonate 0.2% (Poen, Argentina).
Table 1. Material Characteristics
|Oxygen permeability at 35°C (ISO)X10-11 (cm2/sec)[mlO2/(mlxmmHg)]||60|
|Oxygen transmissibility at 35°C (ISO) 0.08ctX10-9 (cm2/sec)[mlO2/(mlxmmHg)]||75|
Three days after fitting the contact lens, the scleral defect had enlarged. An oculoplasty was performed to aid the wound healing process. A conjunctival graft was transplanted from the left to the right eye. Topical ocular medication, Vigadexa (moxifloxacine 0.5% and dexamethasone 0.1%, Novartis AG) and another lubricant (sodium hyaluronate 4mg, Lagricel, Sophia, Mexico) were prescribed for both eyes, to be instilled hourly four times a day.
Two days after the conjunctival graft surgery, the scleral silicone hydrogel contact lens was refitted to the right eye in conjunction with the use of Vigadexa three times per day and lubricants (hydroxypropyl methycellulose, Genteal, ALCON, USA) every half hour (Figures 2 and 3). Full coverage of the conjunctival Z-plasty area was achieved by the scleral lathe cut, tricurve silicone hydrogel contact lens. A systemic antibiotic (doxycycline) was prescribed the following day.
On examination the next day it was noted that the wound healing process had commenced. The patient continued with the course of prescribed treatment. A systemic non-steroideal anti-inflammatory, diclofenac was prescribed three times per day for ocular pain control, and autologus serum was added to the therapy. Two days after the initiation of this new treatment scheme, the patient reported improvement in ocular symptoms.
Seven days after the fitting of the corneo-scleral contact lens, the wound healing process became more obvious. Scleral thinning was no longer visible; the overlying conjunctiva appeared to be re-epithelializing. Extended wear of the scleral contact lens was continued in conjunction with instillation of vigadexa three times per day and Tears Natural® for the next three weeks. All other medications were discontinued.
Extended wear of the bandage contact lens (Figure 4) was discontinued after one month. Antibiotic treatments and lubricants were to be used for one more week until the next scheduled ophthalmological appointment.
In this particular case, a scleral silicone hydrogel contact lens was fitted as a therapeutic device for the nasal bulbar conjunctiva. The application of this contact lens design protected the exposed sclera, and at the same time appeared to promote wound healing. The contact lens offered protection to the conjunctival graft by isolating the affected area from potential friction forces of the upper eyelid and helped to mitigate the ocular pain.
The utilization of this bandage contact lens allowed the use of topical medication as an adjunctive therapy. The contact lens may have behaved as a reservoir of the topical medications, serving as a drug delivery vehicle and increasing the amount of time the medication was in contact with the ocular surface.
The availability of materials with high oxygen permeability offer practitioners increased flexibility to tailor different designs for specific pathological conditions or postoperative ocular surface complications. Due to the short-term use of the bandage lens, hypoxic complications were not expected. However, the risk of corneal infection could not be neglected, and hence close follow up should be mandatory.
This case highlights the fundamental role that contact lens design may play in the overall management of complications after a conjunctival Z-plasty procedure.