The impact of conjunctivochalasis on dry eye symptoms and signs.

PURPOSE: The purpose of this project was to study the relationship between conjunctivochalasis (Cch) and ocular signs and symptoms of dry eye. METHODS: Ninety-six patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration hospital over 12 months. Symptoms (via the dry eye questionnaire 5 [DEQ5]) and signs of dry eye were assessed along with quality of life implications. Statistical analyses comparing the above metrics among the three groups included χ(2), analysis of variance, and linear regression tests. RESULTS: Participants were classified into three groups: nasal conjunctivochalasis (NCch; n = 31); nonnasal conjunctivochalasis (non-NCch; n = 41); and no conjunctivochalasis (no-Cch; n = 24). Patients with NCch had more dry eye symptoms than those with non-NCch (DEQ5: NCch = 13.8 ± 5.0, non-NCch = 10.2 ± 5.0, no-Cch = 11.6 ± 5.8; P = 0.014), and more ocular pain than those with Non-NCch and no-Cch (numerical rating scale [NRS]: NCch = 4.5 ± 3.0, non-NCch = 2.3 ± 2.8, no-Cch = 3.3 ± 2.6; P = 0.008). They also had worse dry eye signs compared to those with no-Cch measured by Schirmer score with anesthesia (NCch = 14.5 ± 6.9, non-NCch = 16.8 ± 8.2, no-Cch = 19.9 ± 6.4; P = 0.039); meibomian gland dropout (NCch 1.8 ± 0.9, non-NCch = 1.4 ± 1.0, no-Cch = 1.0 ± 1.0; P = 0.020); and eyelid vascularity (NCch = 0.84 ± 0.8, non-NCch = 0.74 ± 0.7, no-Cch = 0.33 ± 0.6; P = 0.019). Moreover, those with NCch more frequently reported that dry eye symptoms moderately to severely impacted their quality of life (NCch = 87%, non-NCch = 51%, no-Cch = 58%; P = 0.005). CONCLUSIONS: The presence of NCch associates with dry eye symptoms, abnormal tear parameters, and impacts quality of life compared with non-NCch and no-Cch. Based on these data, it is important for clinicians to look for Cch in patients with symptoms of dry eye.

Visual performance and the ocular surface in traumatic brain injury.

The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.

Scleral contact lens management of bilateral exposure and neurotrophic keratopathy.

We report an interesting case of therapeutic scleral lens management of bilateral exposure and neurotrophic keratopathy resulting from bilateral cranial nerve (CN) palsies including V, VI and VII, which caused lagophthalmos and anaesthetic corneas. Subsequent development of severe exposure keratitis with vascularisation and keratinisation of the inferior cornea was previously treated with intensive ocular lubrication, botulinum toxin injections to the upper eyelid levator muscle, temporary tarsorrhophies, bilateral amniotic membrane grafts, punctal plugs, lid taping, gold eyelid weights and soft bandage contact lenses. Corneal integrity was re-established but visual acuity remained significantly compromised by corneal vascularisation, scarring and keratin deposits. Visions on presentation to the contact lens department were R 1.90 logMAR, L 1.86 logMAR. Therapeutic, high Dk, non-fenestrated, saline filled, scleral lenses were fitted. Daily wear of these lenses have protected and hydrated the cornea, enabling corneal surface recovery whilst retaining visual and social function. The visual acuities 6 months post-scleral fitting with lenses in situ are R 0.90 logMAR and L logMAR 0.70.

External lid loading for the temporary treatment of paresis of the M. orbicularis oculi: a case report.

This clinical note re-introduces external lid loading with the help of a lead weight for the temporary treatment of lagophthalmos. Although simple and effective, the technique is rarely used. Instead of wearing a monoculus, the patient uses an individually tailored lead weight (0.8-mm thickness, 1.0-2.0g) stuck on the lid to enable its closure. Spontaneous ptosis indicates a too-heavy weight. With the musculus (M.) levator palpebrae intact, lid lifting is possible. The effect is gravity dependent; therefore, the patient has to wear the monoculus at night. To minimize the risk for lead intoxication, the surface of the weight is varnished. In the case of persistent M. orbicularis oculi paresis, internal lid loading can follow. Since 1997, a total of 152 lagophthalmos cases have been treated. All patients could close the lid immediately. Almost half the patients had to readjust the weight several times per day because of hooded eyelids. Compliance was high, and partial or complete restoration of M. orbicularis oculi function occurred in 60% of cases. In some subjects, restoration of the M. orbicularis oculi was faster than for the M. orbicularis orbis. External lid loading for the temporary treatment of lagophthalmos is simple and effective. Compared with a monoculus, vision is unimpaired and the aesthetic is more appropriate for most patients. Faster restoration of the M. orbicularis oculi hints at a potentially facilitatory effect of the weight.

Lente de contato escleral na reabilitação ocular de pacientes com síndrome de Stevens-Johnson / Scleral contact lens for ocular rehabilitation in patients with Stevens-Johnson syndrome

OBJETIVO: Avaliar a eficácia do uso das lentes de contato esclerais no manejo das sequelas oculares de pacientes portadores de síndrome de Stevens-Johnson. MÉTODOS: Foram avaliados, retrospectivamente, pacientes com sequelas oculares da síndrome de Stevens-Johnson que iniciaram o uso de lente de contato escleral. Os pacientes foram submetidos a avaliação subjetiva dos sintomas através de um questionário; exame oftalmológico (medida da acuidade visual, biomicroscopia, coloração da superfície ocular com colírio de fluoresceína, teste de Schirmer). RESULTADOS: Dez olhos de 7 pacientes foram analisados. A acuidade visual dos pacientes variou de movimentos de mão a 20/25. Todos os pacientes apresentavam algum grau de opacidade corneal e simbléfaro leve. A lente de contato escleral foi adaptada com sucesso em 90 por cento dos olhos. Em todos estes casos os pacientes referiram melhora dos sintomas e da visão. Com relação aos achados biomicroscópicos observou-se melhora da hiperemia conjuntival e da ceratite, e diminuição da secreção mucosa em 90 por cento dos olhos. CONCLUSÕES: Foi possível uma adaptação bem sucedida da lente de contato escleral em grande parte dos pacientes, com melhora dos sintomas e da acuidade visual provavelmente consequentes à melhora da regularização da superfície ocular. As lentes de contato esclerais representam uma importante e acessível alternativa para a redução da limitação ocasionada pelos danos sequelares da síndrome de Stevens-Johnson.

PURPOSE: To evaluate the efficacy of scleral contact lenses use on the management of ocular sequelae from Stevens-Johnson syndrome patients. METHODS: In a retrospective study, patients who suffered sequelae of Stevens-Johnson syndrome and started the use of scleral contact lenses were followed. Patients were submitted to an evaluation of symptoms through a questionnaire; ophthalmologic exam (visual acuity measurement, biomicroscopy, ocular surface staining with fluorescein drops, Schirmer test). RESULTS: Ten eyes of seven patients were analyzed. Visual acuity varied from hand movements to 20/25. All patients presented some degree of corneal opacity and slight symblepharon. In patients whose adaptation to scleral contact lenses was successful (90 percent), they all refered improvement of symptoms and sight. As for the biomicroscopic findings it was observed an improvement of conjunctival hyperemia and keratitis and a reduction of the mucous secretion in 90 percent the cases. CONCLUSIONS: A successful adaptation to scleral contact lenses was feasible on most patients, with relief of symptoms and better visual acuity, probably due to regularization of the surface. Scleral contact lenses represent an important and accessible alternative to reduce the limitations inferred by the damages from Stevens-Johnson syndrome.

Relationship between corneal topographic indices and scleral lens base curve.

OBJECTIVES: To determine whether parameters of anterior corneal contour as identified by topographic analysis (steep and flat simulated keratometry, reference sphere) predict the base curve of Jupiter scleral lenses in patients with dry eye syndrome and keratoconus. METHODS: We identified 33 eyes with dry eye syndrome and 21 eyes with keratoconus that were fit with Jupiter scleral lenses of standard design between June 2006 and July 2009. Steep and flat simulated keratometry powers and shape factor from axial topographic maps, reference sphere from elevation maps, and base curve of the scleral lens prescribed for each eye were recorded. Correlations between topographic indices and base curve were evaluated by using the Pearson correlation coefficient, and significances were completed by using generalized estimating equation models. RESULTS: In dry eye syndrome, the base curve of the final scleral lens prescribed correlated with the steep keratometric power (r = 0.70, P = 0.05, n = 33), the flat keratometric power (r = 0.71, P<0.001, n = 33), and the reference sphere (r = 0.73, P = 0.002, n = 33). In eyes with keratoconus, base curve also correlated with the steep keratometric power (r = 0.72, P<0.001, n = 19), the flat keratometric power (r = 0.70, P<0.001, n = 19), and the reference sphere (r = 0.68, P<0.001, n = 21). There were no correlations between base curve and shape factor. CONCLUSIONS: In eyes with normal and abnormal ocular contour, base curve of scleral lenses correlates with reference sphere and steep and flat keratometric powers, but the predictive relationship is weak (r ∼0.50). Diagnostic fitting may be the most efficient method of fitting scleral lenses at present.

Effect of contact lens wear and a near task on tear film break-up.

PURPOSE: To study the effect of extrinsic controls on blinking by examining blink parameters and tear stability among adapted soft contact lens (CL) wearers performing tasks that require varying amounts of visual concentration. METHODS: The Demographic Questionnaire, Contact Lens Dry Eye Questionnaire, and Current Symptoms Questionnaire were completed by 15 adapted soft CL wearers (nine females). Three 55 s simultaneous measurements of tear film stability via retroillumination and blinking were obtained with a slit-lamp biomicroscope and 200 Hz video camera while subjects listened to music and played a video game with and without their habitual CLs. Interblink interval (IBI) and blink amplitude (BA) were calculated. The area of break-up (AB) was calculated for the retroillumination image before each blink. The Current Symptoms Questionnaire was completed four times throughout testing. RESULTS: With the game compared to music, IBI was significantly longer and BA significantly decreased without CLs (p < or = 0.001). With CLs, the IBI did not significantly change between tasks but the BA significantly decreased (p = 0.100). The AB significantly increased with CL and the game (paired t-test, p < or = 0.001). The BA was significantly correlated with self-reported severity of dry eye for all testing scenarios (Spearman r > or = 0.5579, p < 0.0001) and several symptom measures (Spearman r > or = 0.6262, p < 0.0001). The AB was significantly correlated with symptom measures including bothersome discomfort for the game with and without CLs (Spearman r > or = 0.5064, p < 0.0001). CONCLUSIONS: During tasks requiring concentration, the IBI increased (blink rate decreased) and many blinks were incomplete without CLs. With CLs, tear film instability increased. Blinking frequency also increased, but it remained high when subjects played the game, and symptoms of ocular irritation increased. This suggests that wearing soft CLs, even when fully adapted, provides enough extrinsic ocular surface stimulation to override internal controls and affect blink parameters.

Passive cigarette smoke exposure and soft contact lens wear.

PURPOSE: To prospectively investigate the effects of passive cigarette smoke exposure on the ocular surface and tear film in soft contact lens (SCL) wearers. METHODS: Twelve right eyes of 12 SCL wearers without any ocular or systemic diseases and 10 right eyes of 10 subjects who never wore CLs were examined before and 2 h after 5 min of passive cigarette smoke exposure in a controlled smoke chamber. Tear evaporation rate measurement, tear film break-up time (TBUT) examination, ocular surface fluorescein, rose bengal stainings, and Schirmer I test were performed at each visit. RESULTS: The mean tear evaporation rates, TBUTs, and vital staining scores were significantly worse in CL wearers compared with healthy control subjects. TBUTs showed significant worsening after passive smoke exposure in both groups. The mean tear evaporation rate and vital staining scores showed a significant increase with brief passive smoke exposure in subjects not wearing CLs but not in CL wearers. CONCLUSION: Even brief passive exposure to cigarette smoke is associated with adverse effects on the ocular surface as evidenced by an increase in tear instability and damage to the ocular surface epithelia in SCL wearers and non-CL wearers.

[Scleral contact lens for ocular rehabilitation in patients with Stevens-Johnson syndrome]. / Lente de contato escleral na reabilitação ocular de pacientes com síndrome de Stevens-Johnson.

PURPOSE: To evaluate the efficacy of scleral contact lenses use on the management of ocular sequelae from Stevens-Johnson syndrome patients. METHODS: In a retrospective study, patients who suffered sequelae of Stevens-Johnson syndrome and started the use of scleral contact lenses were followed. Patients were submitted to an evaluation of symptoms through a questionnaire; ophthalmologic exam (visual acuity measurement, biomicroscopy, ocular surface staining with fluorescein drops, Schirmer test). RESULTS: Ten eyes of seven patients were analyzed. Visual acuity varied from hand movements to 20/25. All patients presented some degree of corneal opacity and slight symblepharon. In patients whose adaptation to scleral contact lenses was successful (90%), they all refered improvement of symptoms and sight. As for the biomicroscopic findings it was observed an improvement of conjunctival hyperemia and keratitis and a reduction of the mucous secretion in 90% the cases. CONCLUSIONS: A successful adaptation to scleral contact lenses was feasible on most patients, with relief of symptoms and better visual acuity, probably due to regularization of the surface. Scleral contact lenses represent an important and accessible alternative to reduce the limitations inferred by the damages from Stevens-Johnson syndrome.

Struggle with hydrogel CL wear increases with age in young adults.

PURPOSE: To report the symptoms and experiences associated with habitual hydrogel (Hyd) and silicone hydrogel (SiHy) contact lenses (CLs) among young adults and measure their association with age. METHODS: Questionnaire responses from 699 Hyd and 183 SiHy wearers were analyzed to test the association of age with features indicating struggle with CL wear. Prevalence by age was compared between groups with Pearson's chi-square and within groups with Spearman's correlation coefficient. RESULTS: Hyd and SiHy groups were similar for sex and age distribution. Diagnosis of dry eye increased with age in the Hyd wearers from 10.6% to 21.1% (18-24 vs. 30-35 years), but was approximately 19% in the SiHy wearers across age. Adverse environments caused more discomfort with Hyd than SiHy lenses and Hyd wearers' discomfort increased with age (smoky (p=0.0001), dry air environments (p=0.002), after napping or sleeping (p=0.004). More Hyd wearers considered discontinuation of CL wear with age, from 4.6% to 14.2% (18-24 vs. 30-35 years, p<0.04), but the proportion remained steady at 9% across age for SiHy wearers (p=0.46). CONCLUSIONS: From 18 to 35 years, hydrogel CL wearers reported increasing struggle with CL wear and more negative ratings compared to SiHy wearers. Older hydrogel CL wearers were also more likely to consider discontinuing CL wear compared with younger hydrogel or silicone hydrogel CL wearers in general. Young adult CL wearers should be routinely queried directly about specific aspects of CL wear in order to determine whether different lens types should be prescribed to avoid abandonment of CL wear.

Modern scleral lenses part I: clinical features.

PURPOSE: To evaluate the indications for modern scleral lenses and their clinical performance in patients who were fitted with scleral lenses at the authors' practices. METHODS: In this cross-sectional survey, all the necessary data were obtained at the first follow-up visit during the 5-month study period. There were four types of scleral lenses: spherical, front-surface toric, back-surface toric, and bitoric. The preformed scleral lens fitting technique developed at Visser Contact Lens Practice was used in all patients. The lenses were cut by precise Sub Micron Lathing from a Boston Equalens II blank at Procornea. Visual acuity and slitlamp findings were recorded. A specially designed classification for scleral lens fitting was used to investigate clinical performance. RESULTS: The largest proportion of the 178 patients (284 eyes) were diagnosed with keratoconus (143 [50.4%] eyes) followed by postpenetrating keratoplasty (56 [19.7%] eyes). The remaining diagnoses were irregular astigmatism, keratitis sicca, corneal dystrophy, and multiple diagnoses. The ratio of spherical to back-surface toric designs was 1:1.1. Clinical examination showed sharp increases in visual acuity (median increase, 0.45) and safe physiologic responses of the anterior eye. All the patients could continue to wear scleral lenses, with 79.2% with the same lens parameters. CONCLUSIONS: Several types of corneal abnormality were managed successfully with modern scleral lenses. The main indication was optical correction of an irregular corneal surface. Satisfactory clinical performance meant that all the patients could continue to wear their scleral lenses.

Costs and gains of complex procedures to rehabilitate end stage ocular surface disease.

BACKGROUND: The management of patients with end stage ocular surface disease sometimes requires extensive surgical treatment that can only be provided by specialised ophthalmology. The authors discuss the costs and gains of such complex techniques based on a case of bilateral corneal blindness secondary to Stevens-Johnson syndrome. METHODS AND RESULTS: Despite multiple lid surgery for trichiasis and repeated corneal grafting for perforations a white female patient became bilaterally blind at the age of 29 years. She also suffered from disabling discomfort in the right dry eye. At the age of 52 a two stage osteo-odonto-keratoprosthesis achieved visual rehabilitation in the left eye and microvascular transplantation of an autologous, submandibular gland resulted in sufficient lubrication to alleviate her severe discomfort in the right eye. As a result of these procedures she was able to take up a regular job again. The total costs of rehabilitation were pound 13 661 which compare with annual gains and regains for society of pound 13 497. An additional pound 4625 was saved annually in guide dog costs. CONCLUSION: This estimate shows that despite the expense of these complex techniques gains are made well within the second year after rehabilitation. In view of the benefit in quality of life for the patient and monetary savings for society these procedures should be funded by national health services at specialist centres.