contact lenses are an essential therapeutic tool in any optometric practice.
These tips will help you become more familiar with them.
By: LOUISE A. SCLAFANI, O.D.
optometrists don't feel comfortable offering a bandage contact lens (BCL) to a patient
because they lack experience and fear that they may worsen the condition. After
I saw the amazing response from my first few patients, I was convinced that bandage
contact lenses are a good first line therapy, and not just a late phase therapy
after failure to improve.
BCLs are a common, effective way to treat epithelial defects.
A bandage lens offers protection from mechanical stress caused by the lids upon
normal blinking. The resulting friction can easily tear the ragged edge of a defect
and cause an increase in the surface area of the abrasion as well as inflammation.
A BCL protects the eye and aids in wound healing. It may also reduce the inflammatory
BCLs can be useful for patients who are afflicted with corneal
edema because these lenses can draw fluid out of the cornea and protect from potential
defects that result from the erupting microcysts.1 You can also use a
BCL to create a more regular refracting surface by masking surface irregularities.
This will help you determine a patient's potential vision and offer some reassurance
to the patient as they heal. Prophylactically, these lenses may help prevent damage
to compromised corneas that are at risk, such as those with exposure. Many BCLs
absorb topical therapeutics, making them an option for medication delivery.
And, some studies indicate that patients prefer bandage contact
lenses to pressure patching. While the re-epithelialization time is the same, psychometric
analysis shows patients preferred the comfort of the BCL, antibiotic, NSAID combination
and ability to resume normal activities.2
CONSIDERING THE OPTIONS
When discussing BCLs with patients, make them aware of the potential
risks and benefits. Risks include infection, which can be prevented with antibiotic
therapy. It's imperative that the patient be available for a one-day follow-up visit
after you apply the lens and commit to regular follow-up. Some patients may express
concern about handling. Advise them that they will never need to handle the lens.
Once the BCL is in place, they should not touch it and if it falls out, they should
discard it. Relieving them of any responsibility makes them more amenable to the
therapy. There are some patients who are reluctant because they are already in pain
and they fear the lens will increase the discomfort. However, once I put the lens
in, many patients have an immediate reduction in pain. And, it's well known that
a patient free of pain heals faster.
|Use a narrow slit beam to measure
the height and width of the defect
to monitor progress.
When examining a patient with an epithelial defect, you'll
need to record some key factors to determine the efficacy of your treatment. Ask
the patient to subjectively grade symptoms of photophobia, redness, foreign body
sensation and pain. Keep in mind that visual acuity may be influenced by high-viscosity
medications such as ointments, mucin, or deposits on the BCL. Document the size
and location of the defect on the cornea with diagrams: central abrasions are more
sight-threatening and need to be monitored more closely. Record horizontal and vertical
dimensions using the slit lamp scale "PICTURE" feature or a percentage of the cornea.
This offers an objective means by which you can monitor the patient's progress.
Note the depth if possible. Also, be sure to check for any evidence of an anterior
chamber reaction that can easily occur due to the inflammatory cascade. Use a cycloplegic
agent twice daily to manage pain and po-tential iritis. Instill prior to inserting
the BCL and prescribe for home use.
THE RIGHT LENS
After you determine that a patient is a good candidate for a BCL
and obtain his or her consent, you'll need to decide which one to use. Many doctors
use other lenses off-label and achieve good results. The advent of disposable lenses
has truly made the use of BCLs more common and efficacious. These lenses are economical
and readily available to both the practitioner and the patient, allowing for less
restriction in prescribing methods. The ideal lens should offer a smooth surface
with minimal edge thickness and good wettability for reduced lens awareness. Shoot
for maximum oxygen permeability to prevent edema, reduce inflammation, and the ability
to keep the lens on the eye for many days. When dehydration is needed, such as in
bullous keratopathy, a lens with higher water content is desirable. In patients
with severe dry eye, a lower water content lens is best. I often use CIBA Vision's
Focus Night & Day since it meets most of the above criteria and is approved
for therapeutic use. I have also used Johnson & Johnson's Acuvue Advance and
Coopervision ProClear when patients require a larger diameter or tighter fit. Bausch
& Lomb Pure-vision also fits the above agenda and is a good choice. Although
we may be inclined to dispense lenses from our disposable trials, I purchase boxes
specifically for bandage purposes. This allows me to keep track of how often I use
BCLs and to bill the patient appropriately.
The goal in fitting a BCL is to have a lens that fully covers
the epithelial defect, has minimal movement, minimal interaction with any conjunctival
abnormalities and maximum comfort for the patient. Although anesthetics make the
examination of these patients much easier, I prefer to wait until the effects are
diminished so that I can determine if the lens offers relief.
Begin by opening the lens package and removing half of the solution.
I place about five drops of a broad-spectrum antibiotic and an optional five drops
of a non-preserved anti-inflammatory and allow the lens to soak for five minutes.
I then insert the lens in the normal manner. Some advocate the use of a swab, but
there is high risk for cotton filaments to become embedded under the lens, which
can lead to more problems. Allow the lens to settle and after ten minutes, if the
lens fits well, you can discharge the patient. Minimal to no movement is preferable
so I advocate the highest possible oxygen permeability. Prescribe the patient a
broad-spectrum antibiotic such as Zymar (gatifloxacin 0.3%, Allergan) or Viga-mox
(moxifloxacin 0.5%, Alcon) to instill every four hours. This will prevent corneal
infection due to exposure. Because resistance to therapy is increasing, judicious
yet therapeutic doses are required. Studies have shown using Acular (ketorolac tromethamine
0.5%, Allergan) q.i.d. during the first 48 hours can decrease pain by 40%. However,
use beyond the 48-hour period may cause a 20% increase in healing time. I advocate
using samples of the non-preserved formulation in single use vials so that the patient
has a limited amount to use. I also recommend lubricating drops that contain hyaluronic
acid (HA). There is some evidence in animal models that it may accelerate wound
repair. HA plays a role in tissue reconstruction following injury.3 AMO
Blink and Ciba Aquify are options that include HA.
|To remove a BCL, It's best to
use swabs to float the lens and
slide it out.
You must follow-up with these patients the next day. If the situation
is improving, and the patient is not high-risk, you can schedule subsequent visits
less frequently, such as every two to three days. Patients who are at risk include
immunocompromised patients, autoimmune patients, diabetics, monocular patients,
children, contact lens wearers, those with a history of HSV, or any patient you
feel is at risk for infection or perforation. BCLs are not contraindicated for these
patients, but your management needs to be more prudent.
BCLs do not absorb sodium fluorescein, so it's much easier to evaluate the abrasion.
Pay attention to adjacent tissue for indications of infection or infiltration. It
is not uncommon to see a 25%-50% reduction in the size of the abrasion in a 24-hour
period. It is imperative not to remove the lens to evaluate. Removing the lens will
disrupt the mitosis and migration of epithelial cells and result in poor adhesion
of the hemi-desmosomes to the basement membrane.
The lens should stay on the eye as long as the situation continues
to improve. Once full resolution is achieved, keep the lens on for another week
and taper or discontinue all the medications except the lubrication. There are several
stages to healing and the late phases continue long after the wound closes. I usually
float the lens with a multi-purpose solution, slide it with cotton swabs to the
conjunctiva and then "chopstick" it out. Do not pinch the lens since this mechanical
pressure can result in another break.
There are some complications that can occur from bandage contact
lens use. The most common is loss of the lens after the patient leaves the office.
This is not a problem as long as the patient does not try to manipulate the lens
back into the eye. There is also the potential for a super infection if the patient
is not compliant with drops and the microorganism is present. Too tight a fit, or
absorption of the drug into the lens or conjunctival chemosis may cause corneal
edema, which can manifest as vertical stress lines in the deep layers. Visual acuity
is effected so remove the lens and refit if necessary.
There are some situations in which a BCL is not an option due
to hygiene, socio-economic issues, high-risk patients, non-consent, or just failure
of the lens to stay on the eye. Pressure patching was once standard therapy and
many emergency rooms still utilize this technique. It is important to truly apply
enough pressure to the eye with gauze padding to prevent movement of the eye. The
disadvantages to this treatment include an inability to re-instill medications and
potential corneal edema. A collagen shield acts much like a BCL and the collagen
aids in healing as the shield melts onto the cornea. The disadvantage is that the
shield is opaque and therefore visually bothersome.
When BCLs, collagen shields and pressure patching fail, a tarsorrhaphy
can be performed. This is a surgical procedure that partially or completely closes
the palpebral fissure by suturing the superior and inferior lids at the lateral
aspect. This method allows for administration of therapeutic drops or ointment and
easy evaluation of the cornea. The risks include lid lacerations due to the suture
"cheese-wiring" through the tissue. Plastic clips are knotted on the ends of the
sutures to prevent this complication.
If the situation continues to worsen and there is risk for
corneal perforation, more extreme measures may be employed. Ophthalmology has longed
used cyanoacrylate compounds off-label to glue corneal tissue. Liquid Bandage (J&J)
has been investigated as a possible sealant following clear corneal incisions and
may be a future option for other corneal defects.4 Another option is
a surgical procedure in which a conjunctival flap serves to cover the wound. An
incision is made on one side of the limbus to release the conjunctiva from Tenon's
capsule. The tissue is then stretched over the corneal wound and sutured onto the
opposite limbus. For chronic conditions, such as lagophthalmus, a lid splint can
be helpful. This is an unobtrusive, non-pressure patch that prevents elevation of
the lid. It has an adhesive on one side with enough rigidity on the other to hold
the eyelid in the closed position.
|This patient's BCL fell out,
resulting in an RCE.
Once the defect has resolved, educate the patient about the potential
for recurrent corneal erosion (RCE) syndrome. After injury, fibronectin coats the
surface of migrating cells that will form adhesions to the underlying tissue. The
normal healing process takes six to eight weeks.
with RCE have an increased concentration of metallo-proteinase enzymes (MMP) that
may dissolve the basement membrane and fibrils, which leads to subsequent traumatic
erosions due to thickened basement membrane with poor hemi-desmosomal attachments.5
Approximately 50% of RCE are due to a history of traumatic injuries that were not
completely healed. Oral doxycycline has been shown to reduce MMP by 70% if administered
for two months, using 50mg twice daily. Topical steroids, such as Pred Forte (prednisolone
acetate 1%, Allergan), Fluorometholone acetate (Flarex, Alcon; Eflone, Novartis)
or Lotemax (loteprednol etabonate 0.5%, Bausch & Lomb) are also effective if
given t.i.d. for two to three weeks. Hyperosmotic agents and hot compresses can
also help draw fluid from the cornea and allow for the formation of tighter junctions.
These should be applied daily for three to six months to get the full benefit. Lubricants
and/or punctal occlusion can assist in tear retention, which is also important to
I use BCLs in my practice at least once a week. They assist in
wound healing with minimal effect on visual acuity, provide comfort in painful situations
and assist in preventing RCE. If you've been fearful of BCLs in the past, consider
their benefits over alternative treatments and use these tips as your guide. OM
1. Baldone JA, Kaufman HE. Soft contact lenses and clinical disease.
Am J Ophthalmol. 1983;95:851.
2. Donnenfeld ED, Selkin BA, Moadel K, et al. Controlled evaluation
of bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating
traumatic corneal abrasions. Ophthalmol. 1995 Jun;106(6):979-84.
3. Haider AS, et al. In vitro model of "wound healing" analyzed
by laser scanning cytometry: accelerated healing of epithelial cell monolayers in
the presence of hyaluronate. Cytom. 2003;53:1-8.
4. Ritterband DC. Liquid bandage successfully seals clear corneal
incisions. Rev Ophthalmol. 2005 Sept;9:56-58.
5. Dursan D, Kim M, Solomon A, Plugfelder C. treatment of recalcitrant
recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline
and corticosteroids. Am J Ophthalmol. 2001 July;132:8-13.
This Strategic Skill Builders Continuing
Education article is made possible by a grant from CIBA Vision. The content is
independently produced by Optometric Management. Please submit your answer card
by May 1, 2006.
|BANDAGE CONTACT LENSES INDICATIONS
Acute Conditions Traumatic
foreign body removal
Shield ulcer from
Surgical Result Epithelial
defects due to retinal surgery
Extrusion of intra-stromal
wetting due to filtering blebs
Chronic Conditions Severe
from Bells Palsy
resulting in poor wetting
Corneal Disease Thygeson's
Superficial Punctate Keratopathy
Piggyback for keratoconus,
Relief of epithelial
breakdown for KCN or CRT
USED TO TREAT ABRASIONS
Pain Relief Acular
PF (ketorolac tromethamine, Allergan)
Voltaren (diclofenac sodium, Novartis)
Ocufen (flurbiprofen sodium, Allergan)
Co-administer Motrin 400-600 mg
Acetaminophen 500-1000 mg
Infection Prophylaxis Zymar
(gatifloxacin 0.3%, Allergan)
Vigamox (moxifloxacin 0.5%,Alcon)
Polytrim (polmyxin B, Allergan)
Reduce Recurrence Doxycycline 50
Hyperosmotics (Muro 128)
Optometric Management, Issue: November 2005