CORNEAL PATHOLOGY DYSTROPHY DEGENERATION

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CORNEAL PATHOLOGY DYSTROPHY DEGENERATION Powered By Docstoc
					                                                          Michael DePaolis, OD, FAAO
                                                            Visionary Eye Associates
                                                      University of Rochester Medical Center
 CONTEMPORARY USES OF BANDAGE CONTACT
  LENSES IN PRIMARY OPTOMETRIC PRACTICE              FINANCIAL DISCLOSURE STATEMENT
                                           CLINICAL INVESTIGATOR
                                          Alcon
           Vision Institute of Canada     Allergan
            Annual Fall Conference        AMO
                                          Bausch & Lomb
       October 23, 2009 4:20 – 6:00pm     Ciba Vision
                                          Cooper Vision
                                          Paragon Vision Sciences
          Paul Karpecki, OD, FAAO         SynergEyes
                                          VIistakon
         Michael DePaolis, OD, FAAO
                                          Optometric Editor, PRIMARY CARE OPTOMETRY NEWS

              mgadep@aol.com              Independent Board Member, TLC Vision




                                                     CORNEAL PATHOLOGY
THERAPEUTIC BANDAGE CONTACT LENSES                DYSTROPHY & DEGENERATION
   QUESTIONS FOR CONSIDERATION                CHARACTERISTICS OF CORNEAL DYSTROPHIES
                                               EARLY ONSET (BY 3rd DECADE)
WHAT IS THE RATIONALE FOR PRESCRIBING          HEREDITARY / APPROX 50% AUTOSOMAL DOMINANT
BANDAGE LENSES?                                CENTRAL CORNEAL LOCATION
                                               BILATERAL / SYMMETRIC
                                               NO ASSOCIATED SYSTEMIC DISEASE
WHAT ARE THE CONTEMPORARY CLINICAL
INDICATIONS?
                                              CHARACTERISTICS OF CORNEAL DEGENERATIONS
                                               LATE ONSET
WHAT ADJUNCT THERAPY IS NECESSARY?             NO HEREDITARY PATTERNS
                                               PERIPHERAL OR CENTRAL CORNEA
HOW EFFECTIVE ARE SILICONE HYDROGEL            UNILATERAL / ASYMMETRIC
LENSES AS BANDAGE LENSES?                      ASSOCIATED SYSTEMIC VASCULAR DISEASE
          CORNEAL PATHOLOGY                        CORNEAL PATHOLOGY
       DYSTROPHY & DEGENERATION                 DYSTROPHY & DEGENERATION
EPITHELIAL BASEMENT MEMBRANE DYSTROPHY   MEESMAN’S (EPITHELIAL) DYSTROPHY


40% PREVALENCE                            AUTOSOMAL DOMINANT
75% BILATERAL                             EARLY ONSET
10% RCE                                   EPITHELIAL VESICLES
LATE ONSET                               -> RCE’s


TREATMENT                                TREATMENT
 LUBRICATE &                              LUBRICATE &
HYPEROSMOTICS                            HYPEROSMOTICS
 BANDAGE LENS                             BANDAGE LENS
 DEBRIDEMENT,                             PTK
STROMAL PUNCTURE, or PTK




          CORNEAL PATHOLOGY                        CORNEAL PATHOLOGY
       DYSTROPHY & DEGENERATION                 DYSTROPHY & DEGENERATION
REIS-BUCKLERS (BOWMAN’S) DYSTROPHY       LATTICE (STROMAL) DYSTROPHY

 AUTOSOMAL DOMINANT                       AUTOSOMAL DOMINANT
 EARLY ONSET                              EARLY ONSET
 HONEYCOMB OR                             LATTICE AMYLOID OPACITIES
FISHNET OPACITIES                         BM DISRUPTION -> RCE’s &
 BM SCAR -> RCE’s                        POOR VA

TREATMENT                                TREATMENT
 LUBRICATE &                              LUBRICATE &
HYPEROSMOTICS                            HYPEROSMOTICS
 BANDAGE LENS or                          BANDAGE LENS or
RGP’s                                    RGP’s
 PTK -> PKP                               PTK -> PKP
          CORNEAL PATHOLOGY                               CORNEAL PATHOLOGY
       DYSTROPHY & DEGENERATION                        DYSTROPHY & DEGENERATION
GRANULAR (STROMAL) DYSTROPHY                    MACULAR (STROMAL) DYSTROPHY

 AUTOSOMAL DOMINANT                              AUTOSOMAL RECESSIVE
 EARLY ONSET                                     EARLY ONSET
 CORNFLAKE HYALIN                                GROUND GLASS
OPACITIES                                       MPS OPACITIES
 BM DISRUPTION ->                                BM DISRUPTION ->
RCE’s & POOR VA                                 RCE’s & POOR VA

TREATMENT                                       TREATMENT
 LUBRICATE &                                     LUBRICATE &
HYPEROSMOTICS                                   HYPEROSMOTICS
 BANDAGE LENS or RGP’s                           BANDAGE LENS or RGP’s
 PTK -> PKP                                      PTK -> PKP




                                                             CORNEAL PATHOLOGY
          CORNEAL PATHOLOGY                               DYSTROPHY & DEGENERATION
       DYSTROPHY & DEGENERATION
CENTRAL CRYSTALLINE (STROMAL) DYSTROPHY         FUCH’S (ENDOTHELIAL) DYSTROPHY

 AUTOSOMAL DOMINANT / BILATERAL / EARLY ONSET    BILATERAL / LATE ONSET
 NEEDLE SHAPED CHOLESTERAL CRYSTALS              GUTTATA -> STROMAL & EPITH EDEMA -> RCE’s & POOR VA
 SLIGHT REDUCED VA

TREATMENT                                       TREATMENT
 MONITOR                                         LUBRICATE &
 (CHOLEST / TRIGLYCERIDES)                      HYPEROSMOTICS

 PKP RARE                                        BANDAGE LENS

                                                 PKP
            CORNEAL PATHOLOGY                                    CORNEAL PATHOLOGY
         DYSTROPHY & DEGENERATION                             DYSTROPHY & DEGENERATION
POSTERIOR POLYMORPHOUS (ENDOTHELIAL) DYSTROPHY       SALZMANN’S NODULAR DEGENERATION

BILATERAL / EARLY ONSET                              ASYMMETRIC / POST INFLAMMATION
SWISS CHEESE VESICLES -> STROMAL & EPITH EDEMA       ELEVATED HYALINE NODULES -> RCE’s & IRREG ASTIG ->POOR VA
SLIGHT REDUCED VA
                                                     TREATMENT
TREATMENT                                             LUBRICATE &
 MONITOR                                             HYPEROSMOTICS
(GLAUCOMA &
KERATOCONUS)                                         STEROID gtt

 LUBRICATE &                                         BANDAGE LENS or RGP’s
HYPEROSMOTICS
                                                     KERATECTOMY or PTK
PKP




            CORNEAL PATHOLOGY                                    CORNEAL PATHOLOGY
         DYSTROPHY & DEGENERATION                             DYSTROPHY & DEGENERATION

BAND KERATOPATHY
                                                     EXCIMER PTK INDICATIONS
ASYMMETRIC / ANTERIOR CORNEA
SWISS CHEESE CALCIUM DEPOSITION -> RCE’s & POOR VA   Sher, etal Arch Ophth 109(4):1991

TREATMENT                                            N = 33 EYES
 LUBRICATE &
                                                     OPACITY & IRREGULAR ASTIGMATISM
HYPEROSMOTICS

EDTA TREATMENT                                        IMPROVED SCARRING
                                                      NO SIGNIFICANT ASTIGMATISM CHANGE
PTK                                                   ~ 50% IMPROVED VISUAL ACUITY
                                                      ~ 50% HYPEROPIC SHIFT
              CORNEAL PATHOLOGY
                                                                      CORNEAL PATHOLOGY
           DYSTROPHY & DEGENERATION
                                                                   DYSTROPHY & DEGENERATION

EXCIMER PTK INDICATIONS
                                                        EXCIMER PTK INDICATIONS
Park, etal Am Acad Ophth Mtg 1992
                                                        Aquavella, DePaolis, Ryan Am Acad Ophth Mtg 1991
N = 41 EYES
OPACITY & IRREGULAR ASTIGMATISM                         N = 10 EYES
                                                        RGP CONTACT LENSES AS PREDICTOR OF PTK SUCCESS
77% VISUAL ACUITY >/= PREOPERATIVE LEVEL
87% CLARITY >/= PREOPERATIVE LEVEL                      RGP CL VA 4+ SNELLEN LINES > SPECTACLE VA
93% COMFORT >/= PREOPERATIVE LEVEL                       86% BENEFICIAL OUTCOME
                                                        RGP CL VA < 1 SNELLEN LINE CHANGE FROM SPECTACLE VA
GOOD -> SALZMANN / REIS BUCKLER / LATTICE                33% BENEFICIAL OUTCOME
POOR -> HSV SCAR / BAND KERATOPATHY / TRAUMA SCAR




              CORNEAL PATHOLOGY
                                                                      CORNEAL PATHOLOGY
           DYSTROPHY & DEGENERATION
                                                                   DYSTROPHY & DEGENERATION

EXCIMER PTK INDICATIONS
                                                        EXCIMER PTK CONTRAINDICATIONS
ANTERIOR CORNEAL PATHOLOGIES (ANTERIOR 1/3 OR CORNEA)
SUPERFICIAL SCARS, SUPERFICIAL DYSTROPHIES               UNCONTROLLED OCULAR DISEASE
RECURRENT CORNEAL EROSION, & ELEVATED LESIONS
                                                         OCULAR SURFACE DISEASE, IRITIS, UVEITIS, & HERPES

                                                         PATHOLOGY OF POSTERIOR 2/3 OF CORNEA
                 CORNEAL PATHOLOGY
              DYSTROPHY & DEGENERATION            THERAPEUTIC BANDAGE CONTACT LENSES
                                                       RATIONALE FOR PRESCRIBING
EXCIMER PTK

PROCEDURAL CONSIDERATIONS                        HISTORICAL PERSPECTIVES
 TRANSEPITHELIAL ABLATIONS with MASKING AGENTS
 SMALL -> LARGE DIAMETER ABLATIONS
                                                  Celsus -> Honey soaked linen
 PLANO ABLATION PROFILES
 LESS IS BETTER
                                                  Ridley -> Glass scleral shell
POTENTIAL COMPLICATIONS
  DELAYED EPITHELIAL HEALING                      Kaufman & Gasset -> Hydrophilic lenses
 CORNEAL INFECTION
 PERSISTENT CORNEAL HAZE
                                                  Aquavella -> Expanded options
 INDUCED REFRACTIVE ERROR
 LOSS OF BCVA




   THERAPEUTIC BANDAGE CONTACT LENSES              THERAPEUTIC BANDAGE CONTACT LENSES
          MATERIAL PROPERTIES                           RATIONALE FOR PRESCRIBING
                                                  Pain relief
HYDROPHILIC BANDAGE CLINICAL EFFICACY DUE TO

                                                  Protection
  Oxygen
  permeability
                                                  Wound splinting

  Design flexibility
                                                  Surface wetting

  Dimensional
                                                  Vision
  stability

                                                  Drug delivery
  Optical clarity
    THERAPEUTIC BANDAGE CONTACT LENSES                    THERAPEUTIC BANDAGE CONTACT LENSES
               DRUG DELIVERY                                WHEN IS AN ANTIBIOTIC NECESSARY ?
 DOES DRUG DELIVERY MAKE SENSE ?
                                                          Always Use Prophylactic Antibiotics
    Lesher & Gunderson. Opt & Vis Sci 70(12) : 1993.
 Sustained release rates
                                                        Dohlman, etal. Arch Ophth 90:367, 1973.
 Ciprofloxacin -> Etafilcon
 Prednisolone phosphate -> Polymacon                      Antibiotics Do Not Significantly Alter Flora
 Cromolyn Sodium -> Polymacon
                                                        Binder & Worthen. Arch Ophth 94:2109, 1976.
   Taravella, Stepp, Young CLAO 24(3):1998.
 Assessed AC [Drug] in 21 cataract patients
 Group 1: Tobradex q15min x 3                             Antibiotics Should Be Used Judiciously
 Group 2: Tobradex soaked collagen shield               Nesburn. Ophthal 86:1130, 1979.
 Anterior chamber levels of drug same for both groups
 Anterior chamber levels were < MIC for both groups
                                                          Rx antibiotics for ‘at risk’ & postoperative eyes
    Drug impregnated contact lenses ?




    THERAPEUTIC BANDAGE CONTACT LENSES                    THERAPEUTIC BANDAGE CONTACT LENSES
      WHEN IS AN ANTIBIOTIC NECESSARY ?                           CLINICAL INDICATIONS

Detorakis, etal J Refr Surg 14(6):1998.                   Bullous keratopathy
                                                          Corneal abrasion
60 Bandage lenses from
                                                          Persistent & recurrent corneal erosions
PRK / PTK / LASIK patients
                                                          Keratoconus adjunct
   18% contaminated with                                  Thygeson’s keratitis
Staphylococcus epidermidis                                Corneal trauma
                                                          Penetrating keratoplasty
    Contamination more common
                                                          Excimer laser PRK or LASIK
In females

   Contamination not specific to one procedure
    THERAPEUTIC BANDAGE CONTACT LENSES
            CLINICAL INDICATIONS                                  THERAPEUTIC BANDAGE CONTACT LENSES
                                                                          CLINICAL INDICATIONS
 Bullous keratopathy
                                                               Luchs, etal Ophth 104(5):1997
    Reduces pain
                                                                  N = 918 Bullous Keratopathy Patients
    Reduces edema &                                               4.7% developed ulcerative keratitis
    improves vision                                               Streptococcus pneumoniae most common
                                                                  Prophylactic antibiotic conferred no
    Adjunct hyperosmotics ?                                       protective
    Miller CLS 21(9):2006.
                                                               Risk Factors For Infectious Keratitis?
    Additional considerations:                                    Steroid use
         DSAEK                                                    Bandage lens use
         Penetrating keratoplasty                                 Increased bullae




                                                                       THERAPEUTIC BANDAGE CONTACT LENSES
    THERAPEUTIC BANDAGE CONTACT LENSES                                         CLINICAL INDICATIONS
            CLINICAL INDICATIONS
                                                               Clinical Case – 56 yom
Lim & Vogt Eye & Cont Lens 32(5):2006
                                                               Ocular History
   N = 24 Bullous Keratopathy Patients
with painful eye                                                  Keratoconus OU x 35 yrs
                                                                  Bilateral PKP x 30 yrs
                                                                  Bilateral RK x 25 yrs
   1 Month each with Sauflon 85,                                  Bilateral IOL x 5 yrs
Night & Day, and PureVision                                       Bilateral Graft Failure

                                                                  BCVA (SCL + Rx)
                                                                  OD 20/200
  All three lenses fit similarly                                  OS 20/150
  Comfort: PureVision 3.9 Night & Day 3.8 Sauflon 2.8
  Pain reduction: PureVision 3.8 Night & Day 3.7 Sauflon 2.2
        THERAPEUTIC BANDAGE CONTACT LENSES                                THERAPEUTIC BANDAGE CONTACT LENSES
                CLINICAL INDICATIONS                                              CLINICAL INDICATIONS
Clinical case – 56 yom                                                 Corneal abrasion

   8 weeks s/p DSAEK OS
                                                                         Reduces pain
   BCVA 20/30
                                                                         Accelerates
   PureVision   86 140 -050                                              healing ?

                                                                         Adjunct
                                                                         prophylactic
                                                                         antibiotics




    THERAPEUTIC BANDAGE CONTACT LENSES                                     THERAPEUTIC BANDAGE CONTACT LENSES
            CLINICAL INDICATIONS                                                   CLINICAL INDICATIONS
                                                                       Persistent epithelial defect / recurrent corneal erosion
Donnenfeld, etal Ophth 102(6):1995.
                                                                         Reduces pain
N = 47 Eyes with corneal abrasion randomized to receive
   Patch                                                                 Accelerate
   Bandage lens                                                          healing ?
   Bandage lens & nsaid gtt
                                                                         Adjunct
  No significant difference in healing time between treatment groups     prophylactic
                                                                         antibiotics
  Bandage lens groups returned to normal activities more quickly
                                                                         Additional considertions:
  Significant decreased pain in bandage lens & nsaid group               Is it trauma or dystrophy induced?
                                                                         Is doxycycline, tarsorraphy, or amniotic membrane indicated ?
                                                                         Is stromal puncture, diamond burr debridement, or ptk indicated ?
        THERAPEUTIC BANDAGE CONTACT LENSES                                  THERAPEUTIC BANDAGE CONTACT LENSES
                CLINICAL INDICATIONS
                                                                                    CLINICAL INDICATIONS
PERSISTENT EPITHELIAL DEFECT
Simsek, etal Cornea 15(6):1996.                                          WHAT ABOUT STROMAL PUNCTURE, DEBRIDEMENT, OR PTK ?
N = 30 eyes in 15 rabbits
6mm central corneal epithelial trephination                              Reidy JJ, Paulus MP, Gona S Cornea 19(6):2000.
Collagen shield vs bandage lens vs control
                                                                         N = 104 Patients with history of recurrent corneal erosion
Epithelial closure evaluated at 24-48 hours
   Collagen & bandage lenses performed similarly                         36% male & 64% female
   Wound healing slower in the control eye                               45% History of trauma
                                                                         29% History of ABMD
RECURRENT CORNEAL EROSION                                                17% History of trauma & ABMD
Dursun, etal AJO 132(1):2001
  Metalloproteinase-9 inhibitor
  Doxycycline                                                               Conservative tx for 50% patients -> 6% recurrence
  Corticosteroids                                                           Stromal micropuncture in 36% patients -> 40% recurrence
  Effective in treating recurrent corneal erosions                          Epithelial debridement in 10% patients -> 18% recurrence
                                                                            Superficial keratectomy in 4% patients -> 25% recurrence
Doxycycline 50mg po qd x 1mth & 20mg qd x 1 mth
Alrex 1gtt tid & Muro ung qhs




   THERAPEUTIC BANDAGE CONTACT LENSES                                       THERAPEUTIC BANDAGE CONTACT LENSES
           CLINICAL INDICATIONS                                                     CLINICAL INDICATIONS

Keratoconus with apical erosion
                                                                        Keratoconus apical corneal abrasions
Weissman, etal Opt & Vis Sci 71(11):1994.
Contact lens corneal abrasion incidence                                  Reduces pain
784 Patient visits over 2 month period                                   Improves contact lens tolerance
                                                                         Faciliates re-epithelialization
Abrasions occurred in
 7.4% Keratoconus patients                                               Temporary application (~4 weeks)
 1.4% Non-keratoconus patients                                           Bandage lens as piggyback carrier
                                                                         Daily disposable or silicone hydrogel
Lema, etal Cornea 2008.                                                  Antibiotic ung qhs
 Compared controls, keratoconus w/o contact lens wear, & keratoconus
with contact lens wear                                                  Additional considerations:
 Keratoconus with contact lens wear had significantly increased IL-6,    Piggyback, SynergEyes, or scleral lens ?
TNF alpha, ICAM-1, & VCAM-1 in the tear film                             Is ptk indicated ?
                                                          THERAPEUTIC BANDAGE CONTACT LENSES
   THERAPEUTIC BANDAGE CONTACT LENSES
                                                                  CLINICAL INDICATIONS
           CLINICAL INDICATIONS
Thygeson’s keratitis                                   Keratoconjunctivitis sicca

   Reduces discomfort
                                                          Less pain, improved surface
                                                       protection, & improved vision
   Improves vision ?
                                                          Maximal dry eye management
   Unilateral vs bilateral
                                                       essential prior to bandage lens
   application
                                                         Punctal occlusion critical
   Worn daily
                                                         Silicone hydrogel vs daily disposable
Additional considerations:
  Steroids or ptk ? Goldstein, etal CLAO 28(4):2002.
                                                         Do the benefits outweigh the risks ?
  Restasis ?




   THERAPEUTIC BANDAGE CONTACT LENSES                    THERAPEUTIC BANDAGE CONTACT LENSES
           CLINICAL INDICATIONS                                  CLINICAL INDICATIONS
                                                        Penetrating keratoplasty
CORNEAL PERFORATION
                                                           Reduces discomfort
  SMALL SIZE
WITH CLEAN MARGINS                                         Facilitates epithelial
                                                           healing
  TEMPORARY
APPLICATION                                                Adjunct antibiotics
                                                           & steroids
   ADJUNCT ANTIBIOTICS
                                                        Additional considerations:
                                                          For how long is bandage worn ?

   IS CYANOACRYLATE INDICATED?
   THERAPEUTIC BANDAGE CONTACT LENSES                       THERAPEUTIC BANDAGE CONTACT LENSES
           CLINICAL INDICATIONS                                     DISPOSABLE OPTIONS
  Dohlman K-Pro synthetic cornea
                                                         Arora, etal CLAO 26(3) : 2000.
     Reduces discomfort
                                                           Disposable lens performance
                                                           N = 28 patients post PKP surgery
     Mitigates against epithelial migration
                                                           Ciba Focus lens
     Adjunct antibiotics & steroids
            Vancomycin 20 mg/ml bid                        Rationale: Epithelial defect, wound leak, graft edema,
                                                           keratoconjunctivitis sicca, & to preserve epithelial integrity
            Quixin bid
            Pred Forte bid
                                                           71% overall success
  Additional considerations:
    For how long is bandage worn ?                         Complications: Stromal graft edema
    Kontur 55% H2O large diameter or Silicone hydrogel




                                                            THERAPEUTIC BANDAGE CONTACT LENSES
   THERAPEUTIC BANDAGE CONTACT LENSES                               CLINICAL INDICATIONS
           DISPOSABLE OPTIONS

Hoefling-Lima, etal CLAO J 28:2002.                      Perioperative PRK, PTK, Epi-LASIK, & LASEK

40 yof with bilateral PKP for                               Reduces pain
Sjogren’s corneal melt
                                                            Accelerates healing ?
Post PKP persistent
Epithelial defect                                           Adjunct NSAID, antibiotic,
                                                            & steroid gtt
Bilateral bandage lens
                                                            Oral analgesics
Bilateral candida albicans
Infection                                                Additional considerations:
                                                           Limit wear time to 4 days
  THERAPEUTIC BANDAGE CONTACT LENSES                           THERAPEUTIC BANDAGE CONTACT LENSES
                                                                       CLINICAL INDICATIONS
          CLINICAL INDICATIONS
                                                        PERIOPERATIVE LASEK
Perioperative PRK
                                                        Perez-Gomez, etal Siliconehydrogels.org: 2005
                                                        N = 18 LASEK patients
Engle, etal J Cat Ref Surg 31(4):2005
                                                        PureVision vs Night & Day
                                                        Same p/o meds & 3 day evaluation
N = 100 PRK Patients
                                                        No significant difference in …
Acuvue 2 vs Night & Day
                                                           Conjunctival or limbal injection or subjective symptoms
Same postoperative medications
                                                           Complete closure in 89% PureVision & 82% Night & Day eyes
Monitored epithelial defect closure & discomfort
                                                        Gil-Cazorla, etal J Ref Surg 24(2): 2008
Night & Day …..
                                                        N = 32 LASEK eyes
   Smaller epithelial defect
                                                        PureVision vs Equis 60 as HBL for 5 days
   Less discomfort
                                                           No difference in comfort, limbal hyperemia, or debri
   Less tetracaine use … for postoperative days 1 & 2
                                                           Improved epithelial status at day 5 for PureVision




       THERAPEUTIC BANDAGE CONTACT LENSES
                                                           THERAPEUTIC BANDAGE CONTACT LENSES
               CLINICAL INDICATIONS                                CLINICAL INDICATIONS
Perioperative LASIK                                     Perioperative LASIK

   Epithelial defect
                                                        Ahmed I, Breslin CW        J Cat & Ref Surg 27(12):2001.

   Flap striae ?
                                                        Bilateral LASIK
                                                        Post-LASIK comfort evaluation
   Adjunct antibiotic & steroid gtt
                                                        40 Patients – bandage contact lens vs no contact lens
                                                        26 Patients – bandage contact lens vs tetracaine
   Is it indicated beyond 2 days ?
                                                        54 Patients – tetracaine vs voltaren

Walker, Wilson Cornea 19(2):2000.
                                                        Patient preferences
Bandage lens for post-op day 1
                                                          30% Bandage contact lens vs 58% no contact lenses
N= 906 LASIK eyes
                                                          15% Bandage contact lens vs 85% tetracaine
3 eyes (0.33%) developed epithelial ingrowth
                                                          24% Tetracaine vs 39% voltaren
    THERAPEUTIC BANDAGE CONTACT LENSES                                                 THERAPEUTIC BANDAGE CONTACT LENSES
            CLINICAL INDICATIONS                                                          QUESTIONS FOR CONSIDERATION
                                                                                   How effective are silicone hydrogels as therapeutic bandages ?
4TH GENERATION FLUOROQUINOLONE RESISTANCE
                                                                               Lindahl, DePaolis, Aquavella CLAO 17(4) : 1991.
Moshifar, etal Cat & Ref Surg 32(3):2006
  Case Reports: Bacterial keratitis                                            Disposable bandage lens performance (n = 39 patients)
postoperative PRK and LASIK                                                       Acuvue or SeeQuence lenses worn from 1 – 56 days (mean = 8.75 )
                                                                                  35/39 (90%) improved symptoms
  Pseudomonas aeruginosa                                                          34/39 (87%) improved objectively
post-PRK despite moxifloxacin prophylaxis
                                                                                  Tear gtt, antibiotic gtt, & steroid gtt where appropriate
  MRSA keratitis post-LASIK
despite gatifloxacin prophylaxis                                               Successes
                                                                                  Epithelial defects
   Successfully treated                                                           Bullous keratopathy
with fortified aminoglycosides
                                                                                  Post-op pain
If suspected MRSA - > fortified vancomycin (20-50 mg/ml)                       Failures
                                                                                  Dry eye




   THERAPEUTIC BANDAGE CONTACT LENSES                                                  THERAPEUTIC BANDAGE CONTACT LENSES
           DISPOSABLE OPTIONS                                                                    COMPLICATIONS
Gupta, etal CLAO 24(2) : 1999.                                                 Dohlman, Boruchoff, & Mobilia. Arch Ophth 90(11) :1973.
                                                                               Tradtional lens options (n = 273 eyes)
Disposable bandage lens performance (n = 45 patients)
Acuvue lens with 3 month follow-up                                                Severe keratitis = 1.4%
Bandages Rx for epithelial healing, structural support, and symptom relief        Infiltrative keratitis = 4.0%
   75% overall success                                                            Neovascularization = 2.9%
   Successes: epithelial defect, surgical adunct                                  Lens spoilage = 6.8%
   Reasons for discontinuation: dry eye, deposits, lens loss, &                   Lens loss = 12.5%
   neovascularization                                                             Lens rejection = 13.7%

Bouchard, Trimble CLAO 22(2) : 106, 1996.
Disposable bandage lens performance (n = 38 patients)
Acuvue lens with treatment ranging from 7 days to 12 months                    Tanner & DePaolis. Clin Eye VIs Care 4(4) : 1992.
                                                                               Disposable lens options (n = 68 eyes)
Bandage Rx for mechanical protection, wound healing, and symptom relief
   71% overall success                                                            Severe keratitis = 3.4%
   Reasons for discontinuation: lens loss, discomfort, tight lens, & corneal      Contact lens acute red eye = 1.7%
   ulcer                                                                          Lens spoilage = 3.4%
                                                                                  Lens loss = 19.0%
                                                                                  Lens rejection = 8.6%
         THERAPEUTIC BANDAGE CONTACT LENSES                              THERAPEUTIC BANDAGE CONTACT LENSES
                   COMPLICATIONS                                                 DISPOSABLE OPTIONS
 Clinical Case – AS 17 yom
                                                                      Historical advantages of disposable bandage contact lenses
 Ocular history: ‘Cat scratch lacertion 2 weeks                          Minimize lens spoilage concerns
 prior. Soflens 38 bandage lens OD. Ciloxan OD qid.                      Minimize lens hygiene concerns
 No c/o.                                                                 More cost effective alternative
 VA OD cc 20/100 & OS s20/20.
                                                                      Limitations of disposable bandage lenses
 Biomicroscopy – OD bandage lens clean & well
                                                                         Limited lens parameters
 positioned. Lids flat, conjunctiva clear, isolated                      Thin, low modulus designs
 corneal ‘macrovacuoles’ OD, ac with occasional                          Limited physiologic response
 cell, ac d&q, iris normal, lens clear.
                                                                      Potential advantages of silicone disposable bandage lenses
 Plan:                                                                  Increased oxygen transmission -> improved metabolism
 1. discontinue bandage lens OD                                         Protein deposti resistance -> less spoilage related complications
 2. initate suture removal.                                             Increased mobility -> better tear exchange
 3. Vigamox OD q2h                                                      Increased modulus -> better retention & vision (?)
 4. Refresh liquigel OD qprn
                                                                        FDA approved: PureVision, Night & Day, Oasys




                                                                              THERAPEUTIC BANDAGE CONTACT LENSES
    THERAPEUTIC BANDAGE CONTACT LENSES                                                DISPOSABLE OPTIONS
            DISPOSABLE OPTIONS                                        Montero, Mely, & Sparholt CLAO 29(1S):2003.
                                                                      NIGHT & DAY
Lin, Tan, & Chan CLAO 27(4):2001                                      N = 41 eyes (20 acute & 21 chronic cases)
PUREVISION                                                            Average wear time 17 days (acute) & 35 days (chronic)
N = 54 eyes (post-op = 36 & medical = 18)                                78% experienced resolution of pain
Average wear time = 1.1 months                                           74% experienced resolution of corneal signs
  96% improved corneal healing                                           63% experienced improved vision
  96% improved pain relief                                               9.9% had a complication
 1 case of culture (-) infiltration
                                                                      Kampolat, etal Cornea 22(8):2003.
                                                                      NIGHT & DAY
Arora, etal Cont Lens & Ant Eye 27(1):2004                            N = 50 eyes with mean wear time of 2.4 months
PureVision                                                            Variety of medical & surgical cases
N = 30 eyes with wear time of 3 – 90 days                                Mean gain in visual acuity 1.8 +/- 2.8 logMAR units
Used for epithelial defects, perforations, and corneal burns             No significant complications
 Therapeutic success in 87% of eyes                                      “Less frequent handling may be better for patients with epithelial trauma”
 Complications included dry eye, lens loss, tight lens, & infection
                                                                                    THERAPEUTIC BANDAGE CONTACT LENSES
    THERAPEUTIC BANDAGE CONTACT LENSES
                                                                                            DISPOSABLE OPTIONS
            DISPOSABLE OPTIONS
Clinical case – 51 yom                                                          51 yom - 5 day f/u examination


Ocular history: c/o painful, red, photophobic, and blurry right eye of 2 days   CC: ‘woke up @ 3am with intense pain OD’ Compliant with medications.
duration. No trauma. No recent URI. Lubricating gtt of limited benefit. Has
had 2 prior episodes over past year.                                            VA cc OD 20/25. Biomicroscopy – persistent RCE OD. ABMD OU.

Systemic history: hypertension & gerd. Metoprolol, hctz, nexium. NKDA.          Plan: PureVision OD, Vigamox OD qid, f/u 1 week.

VA cc: OD 20/20- & OS 20/20                                                     51 yom – 9 day f/u examination

Biomicroscopy: ABMD OU &                                                        CC: ‘bandage lens great for 3 days, now uncomfortable’ Vigamox OD qid.
recurrent corneal erosion OD.
                                                                                VA cc OD 20/25-. Biomicroscopy – ABMD OU. Tight lens OD.
Plan: Systane ou qid,
Muro (5%) ung ou qhs, f/u 1 week.




                                                                                    THERAPEUTIC BANDAGE CONTACT LENSES
    THERAPEUTIC BANDAGE CONTACT LENSES
                                                                                            DISPOSABLE OPTIONS
            DISPOSABLE OPTIONS                                                  Clinical case - 56 yof

51 yom – 9 day f/u examination                                                  Ocular history: ‘c/o blurred vision with eyeglasses. Has corneal dystrophy
                                                                                ou. Brother has corneal dystrophy with bilateral PKP and bilateral graft
Treatment options:                                                              rejection … I want to avoid surgery. Muro gtt ou prn – limited relief.
 Doxycycline
 Stromal micropuncture                                                          VA cc OD 20/100 & OS 20/80.
 Diamond burr debridement
 Excimer ptk                                                                    Biomicroscopy – Grade 1 ABMD ou &
                                                                                grade 1+ Fuch’s endothelial dystrophy.
Plan:
 Rx PureVision bandage lens qhs with removal qam                                Impression: ABMD ou, Fuch’s corneal
 Blink gtt ou qid                                                               dystrophy ou.

                                                                                Plan:
Treatment successful with discontinuation of bandage lens @ 4 months.           1.PureVision 87 145
                                                                                       -300 -125 x 68 = 20/30
No recurrences > 1 year. Uses Refresh liquigel OU qhs & Blink gtt OU qid.              -350 -150 x 107 = 20/25
                                                                                2.     AoSept clear care qhs / replace q 1 month     3. Muro ung ou qhs.
    THERAPEUTIC BANDAGE CONTACT LENSES
                                                                                         THERAPEUTIC BANDAGE CONTACT LENSES
            DISPOSABLE OPTIONS
                                                                                               CLINICAL CONSIDERATIONS
56 yof – 2 year f/u visit

Ocular history: No c/o. ‘vision in right eye a little blurry.’ Wearing soft lenses   Is IOP measurement through a bandage contact lens accurate ?
ou qd x 12+ hours. Clear care qhs. Replace q 1 mth. Muro ung ou qhs.
                                                                                     Scibilia, Ehlers, Donshik CLAO 22(4):1996.
VA cc OD 20/60 & OS 20/30.
                                                                                     10 normal & 10 abnormal eyes
Biomicroscopy – Grade 1 ABMD ou &                                                    Used tono-pen, goldmann, & pneumotonometry
grade 3 Fuch’s endothelial dystrophy.                                                Measurements taken over Acuvue, B&L O4, & Permalens
                                                                                        All three tonometers measured accurately over all three bandage contact
Impression: ABMD ou, Fuch’s corneal                                                     lenses for normal and abnormal eyes
dystrophy ou.
                                                                                     Allen, RJ, etal ARVO 2004.
Plan:
1.DSAEK consult.                                                                     20 normal eyes
2.Continue with scl ou qd.                                                           Goldmann tonometry with and without PureVision bandage lens
                                                                                        No difference in IOP’s with or without bandage lens




     THERAPEUTIC BANDAGE CONTACT LENSES
        QUESTIONS FOR CONSIDERATION
     WHAT IS THE RATIONALE FOR PRESCRIBING BANDAGE
     LENSES?

     WHAT ARE THE CONTEMPORARY CLINICAL INDICATIONS?

     WHAT ADJUNCT THERAPY IS NECESSARY?

     HOW EFFECTIVE ARE SILICONE HYDROGEL LENSES AS
     BANDAGE LENSES?

     THANK YOU FOR ATTENDING THE VISION INSTITUTE’S 2009
                     ANNUAL CONFERENCE
           Michael DePaolis, OD, FAAO mgadep@aol.com