Case History

Robert Ryan received his Doctorate in Optometry from the Pennsylvania College of Optometry in 1989 and is presently in group practice in Rochester, New York. Robert has been appointed Clinical Associate in Ophthalmology at the University of Rochester School of Medicine and frequently lectures and publishes on issues pertaining to anterior segment topics. He actively participates as a FDA Clinical Investigator for many contact lens manufacturers in addition to providing consultative services.

Our practice has had substantial experience with Silicone Hydrogel (SH) materials dating back to our participation in FDA clinical studies in 1996. As our comfort level grows with continuous wear (CW) success in the presence of exceedingly low rates of infiltrative and/or infectious keratitis, we find our indications and applications expand. I would like to share with you a case in which a SH material (lotrafilcon A, CibaVision) provided significant relief in a situation where conventional therapy proved inadequate. Please recognize that, at present, therapeutic use as bandage lens therapy represents an off-label application of this category of materials.

A forty-seven year old healthy woman (CF) presented to my office on August 22, 2002 complaining of scratchy eyes with mucous discharge involving the left eye to a greater degree than the right. This situation had been present for more than ten days and was being treated by her Primary Care Practitioner (PCP) with gentamicin ophthalmic solution qid OU. As CF noted little if any improvement, she was referred for consultation. Systemic history was notable for a recent Upper Respiratory Infection (URI) and stress induced by a failing relationship. This contributed to frequent crying episodes and poor sleeping patterns, but had yet to warrant any systemic medications. External evaluation revealed a calm and pleasant woman with mild pre-auricular lymphadenopathy of the left side. Biomicroscopic examination demonstrated a grade 2 punctate epithelial keratitis (PEK) inferiorly OD, and a grade 3 PEK centrally OS. In addition, a filamentary keratopathy was noted OU, as well as rather diffuse bulbar conjunctival stippling bilaterally. The palpebral conjunctiva appeared uninvolved upon lid eversion and the balance of the anterior segment exam was non-contributory. The diagnosis of keratoconjunctivitis sicca (KCS) was made (perhaps superimposed upon a mild adenoviral conjunctivitis) and a treatment plan formulated including mechanical debridement of the corneal filaments and punctal occlusion of the left lower lid. The gentamicin drops were discontinued and replaced with TheraTears non-preserved lubricating drops OU q1-2 hours.

Re-evaluation six days later confirmed a subjective improvement in symptomatology for CF. However, persistent diffuse stippling was noted in each eye and careful attention to the lid margins revealed inspissation of the meibomian glands of all four lids. The decision was made to introduce bandage lens therapy in an attempt to enhance the efficacy of the current lubrication regimen. As the findings suggested an evaporative component to the ocular surface disease, I felt a low water content polymer may prove more stable in this environment (lotrafilcon A = 24%). The patient was accordingly fitted with Focus Night & Day (CibaVision) 8.6 / 14.0 -0.25 OS on a continuous wear (CW) schedule and directed to continue with copious lubrication.

In seven days time a substantial decrease in the corneal surface insult was noted in the left eye. The only change to report was the recent initiation of Effexor to treat the emotional hardship the patient was experiencing. I suggested she increase the frequency of her topical lubrication as well as her systemic intake of water, while minimizing any caffeine consumption. Three more weeks passed prior to the next visit, at which time CF continued to exhibit corneal stippling OU. I initiated oral Doxycycline 100mg bid po for one month to attend to the meibomian gland dysfunction, but discovered CF was unable to tolerate this due to a resultant Urinary Tract Infection? (UTI) from Candidiasis. Warm compresses and Doxycycline 100mg qd po have been well tolerated without side effects.

CF is presently functioning well and is symptom-free nearly all of her waking hours. She removes the SH shield every two weeks and discards/replaces the lenses monthly. I am convinced the bandage lens is a critical component of her therapy and indeed, she articulates improved comfort when the lens is in place. My only regret is that she must continue to use spectacles in addition to the SH lens as her refractive error includes mixed astigmatism and presbyopia. As toric lens designs become available in SH materials it will only serve to increase the already expanding applications this exciting category has provided eye care practitioners.