contact lens
Bandage Contact Lenses to the Rescue
Soft contact lenses greatly increase our success in
treating corneal abrasions.
BY
RICHARD HOM, O.D., F.A.A.O.
It's Monday morning and
three cases of corneal abrasion or corneal pathology present to your office. Or
you're co-managing refractive surgery and a patient returns one day
postoperatively with PRK (photorefractive keratectomy) rather than LASIK
(laser-assisted in situ keratomileusis). What do you do?
Dealing with abrasions
The
above scenarios aren't uncommon nor are they unexpected for today's optometrist.
In fact, we are uniquely positioned and capable to manage these kinds of eye
problems. For most doctors, corneal abrasions are straightforward. Whatever
management we may use, the goals are the same: encourage epithelial growth and
migration, relieve pain and preserve best-corrected visual acuity. Any
epithelial defect caused by mechanical trauma, or innate tissue defect can be an
abrasion. Because abrasions don't happen in a sterile environment, the prospect
for microbial keratitis or even ulceration is always present and constitutes one
of the challenges associated with the management of this eye problem.
Other challenges include significant photophobia,
sharp eye pain and blepharo-spasm. In addition, these patients are anxious
because they don't see well. Doctors know that this condition is self-limiting
and frequently doesn't require any medical treatment, with resolution occurring
in 24 to 48 hours.
But abrasion patients don't always experience
pain in the same way. Some are stoic and have minimal complaints. Others are
extremely unhappy. Therefore, treating pain can be as important as resolving the
epithelial defect in abrasion management. Bandage soft contact lenses (BSCL)
address all the concerns inherent in corneal abrasions.
Introducing the BSCL
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BSCLs
at Your Disposal |
PureVision, Bausch & Lomb
Focus Night & Day, CIBA Vision
ProClear, Coopervision
Acuvue Advance, J & J
Bandage Lens, Optik K & R
CLPL Simplon Therapeutic, UltraVision |
For years, the first choice of treatment for
corneal abrasions was the pressure patch (PP). When appropriately applied, the
PP prevented excessive eye movement, accidental aggravation or another injury to
the eye. It also kept the eye closed. It was theorized also that the eye was
continually bathed in antibiotic solution or ointment to minimize the chance of
microbial keratitis. Although helpful, the PP didn't seem to provide pain
relief, with patients often needing narcotic analgesics.
Two events changed abrasion management. The first
was a series of reports that the PP did not improve corneal healing over eyes
without the PP. The second was the introduction of the therapeutic or bandage
soft contact lens (BSCL) in the mid 1970s.
With the PP seemingly irrelevant in healing the
cornea, practitioners re-examined its relative inability to reduce pain
substantially and prevent repeat injury. The BSCL met these two criteria and
even one-upped the opaque PP, allowing the patient to see out of the injured eye
instead of obscuring vision.
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Fitting Pearls |
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Other tips I've picked-up on using BSCLs to treat
corneal abrasions include the following:
► "I tend
to use silicone hydrogels with the lowest BC [base
curve] ... to minimize lens movement on the eye for
traumatic corneal abrasions or lacerations up to 3mm to
4mm average diameters," says Dr. Jan Boehringer, an
optometrist in Indiana.
►
Dr. Gary Fisher, of Marion, Iowa, suggests using a BSCL
when the corneal abrasion is at least 4mm x 4mm.
►
North Kingstown, Rhode Island's Dr. Paul Zerbinopoulos
also recommends adding an antibiotic and ocular
lubricant over the lens for best possible results.
►
I will add that fear of accidental lens dislodgement and
loss is palpable, but this need not be an overriding
objection to BSCL use. With the appropriate training
this should not be a concern.
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Since its inception, the BSCL seemed like the
perfect solution for the abrasion. Initial patient acceptance was very high
because pain relief was almost immediate and was dramatic. But the early BSCLs
had problems. Their low water content (normally in the FDA Group 1 Lens Class),
may have simplified handling, but it also interfered with normal corneal
physiology because they were too thick or got dirty too quickly. And the lenses
were expensive, sometimes costing $50 each.
However, these early lenses worked. In one of my
first cases in the late 1970s, a young woman who injured her eye when she
reached for a large can of tomato sauce on a high shelf was referred to my
office. The can fell against her eye, causing an 8mm penetrating wound.
Postoperatively, she experienced intolerable ocular pain and was refused
analgesics because of her past history of difficulty in metabolizing them. I
tried a FDA-labeled Group 1 BSCL and it immediately relieved her pain. I was
impressed! But what troubled me was the relatively poor physiologic performance
of these lenses. In this case, the cornea swelled sufficiently for me to see
endothelial folds.
Just a couple of years after the Group 1 lenses
were introduced, Group 4 55% water content soft contact lenses arrived and
helped somewhat. Comfort was unquestionably better. One of the first Group 4
lenses I used, the Hydrocurve II (CIBA Vision), seemed to work well when worn up
to 48 hours continuously, but tended to dehydrate faster than the low-water
content, Group 1 lenses. Thus, they ultimately caused even more discomfort than
the Group 1 lens. However, their larger size did help in covering more of the
corneas and seemed to move less on an eye without excessive topographical
irregularity.
BSCLs in everyday practice
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Case 1: A
fingernail caused this abrasion.
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Now we'll examine how BSCLs can help with the
abrasion problems that can walk into your office any day. The following three
examples are real-life cases I've had.
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CASE 1. A
35-year-old woman accidentally scratched her own eye with her fingernail as she
slept. She presented to the emergency room the next morning with pain she rated
as 10 out of 10 (in other words, debilitating), photophobia and 20/200 vision in
the affected eye. The abrasion was 6mm x 5mm (horizontal x vertical) and
centered on the visual axis. If I had seen this patient 20 years earlier, I
would have immediately instilled copious amounts of antibiotic ointment and
applied a PP. My emergency room coverage over the years made me quite skilled at
this.
I started the patient on erythromycin ophthalmic
ointment five to six times a day to minimize lid interaction on the cornea and
antibiosis. I then added cyclopentolate 1% four times a day, to control the
pain. While pain decreased after one hour, it was never eliminated until I added
hydrocodone (Vicodin, Abbot), one tablet, every six hours.
The abrasion resolved without the use of the BSCL,
but there were significant pain issues that required prescription analgesia.
With this classical management technique, successful and complete resolution of
the abrasion is possible with relevant antibiosis and appropriate oral
analgesia. But the patient still experiences pain and discomfort.
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Case 2:
Central corneal abrasion upon presentation.
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■ CASE 2.
A 50-ish woman felt something in her eye while cleaning and vacuuming her house.
She irrigated her eye extensively and thought that she had removed the foreign
body. Three days later, she experienced intense (9/10 or 10/10) eye pain,
photophobia and 20/100 vision. The photograph below shows oblong, 6mm high x 5mm
wide corneal abrasion, vertically oriented. In this case, the mechanism of the
abrasion was different from that of the patient in our first case, although
similar in that an initial foreign body caused the injury and its
unsophisticated removal probably caused the abrasion. I inserted a Group 4 lens
with a 8.9mm base curve and 15mm diameter. The patient felt better immediately.
What made this
especially unique is her historical use of a fentanyl transdermal patch (Duragesic,
Johnson & Johnson) for unremitting back pain. With this kind of systemic
analgesia, any additional analgesia for the relief of eye pain would have been
minimal.
The tip from this case is the concomitant use of
antibiotics with a BSCL in place. Doctors have dipped the lens in antibiotic
solution or applied it topically over the lens while in situ or before lens
placement. We don't know for certain whether one method of antibiotic support
for a lens in situ is better than the other. What we do know is that the
antibiotic delivery vehicle can destabilize the lens fit. Despite the
destabilization, some form of antibiotic support is necessary. In my opinion, I
think the use of topical ophthalmic solution may be better than ointment.
When the patient applied the erythromycin
ointment, the lens immediately moved excessively on blink. I believe that the
ointment increased, rather than minimized, the friction between the lens and the
lid. In the end, this patient healed nicely with a return to 20/25 vision and a
very small scar.
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Case 3:
Corneal laceration with bandage lens situ.
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CASE 3. This one
is seemingly complicated. It illustrates the principles of corneal wound care.
The patient was a 42-year-old male who was assaulted and experienced a ruptured
globe including multiple fractures of the face, nose and orbit. At day one
post-op he received numerous corneal sutures to close a corneal laceration
wound. The next day, he appeared for follow-up with a loosely applied patch over
the eye. He had loosened the patch throughout the night in order to instill
topical medications.
With a history of an
open wound, endophthalmitis became the most significant potential post-operative
complication. I knew that if I were to use a BSCL on this patient, it must not
increase or enhance the prospect for endophthalmitis. I ended up using a
large-diameter, Group 4 hydrogel lens. This lens, though, moved off-center on
each blink when out of the bottle. The photo above (top) shows the lens not only
has a bubble underneath, but is also de-centered. Repeated lens dislodgement
occurred until the fifth reinsertion finally was stable on the eye.
Expanded applications
In these three cases, the traditional crop of
bandage lenses seemed adequate for continuous wear of up to seven days. To
expand the repertoire of conditions for BSCL use to include recurrent corneal
erosion, bullous keratopathy and severe corneal autoimmune conditions, a better
performing lens was necessary. The ideal BSCL should have excellent or superior
oxygen transmissibility, be easy to handle and stable on the eye. The silicone
hydrogel (SiHy) lens seems to be the answer for many of the current clinical and
performance concerns.
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Case 3:
Initial presentation status post-op with corneal sutures
in place. |
Low in water content, these lenses handle much
like the traditional Group 1 lens. However, they exceed the oxygen
transmissibility of current high-Dk, hydrogel lenses.
In fact, I've heard many leading O.D.s say that
the silicone hydrogel lens is their first choice BSCL. Dr. Angelo De Vivo, a
Mentor, Ohio optometrist with broad experience in refractive surgery
co-management and corneal disease, gives high praise to the material as a BSCL.
"Today, the SiHy [BSCL] is my first choice over traditional patching," he says.
"I use these [BSCLs] for keratitis, corneal abrasions and PRK postoperative
management, as well as RCE [recurrent corneal erosion]."
Ease their pain
Corneal abrasion management is no longer just
about managing wound closure. It is also about pain management. With the
appropriate armamentarium of BSCLs, oral analgesics, topical and oral
antibiotics, excellent results are possible. Whether you use the traditional
hydrogel or the newer silicone hydrogel materials, the BSCL will provide
satisfactory results if fit for complete corneal coverage and centered with
minimal movement.
So, when you see that next 4mm x 4mm corneal
abrasion, grabbing the BSCL rather than that oral narcotic and PP may be your
best plan of action.
Dr. Hom is Coordinator, Primary Care
Optometry, San Mateo Medical Center. Reach him through his web site at
http://www.geocities.com/rchom/
Optometric Management, Issue: November 2006