Dec 2017

etter! The epitheliopathy had mostly resolved (Fig
5) and crucially the patient found the lens easy to
wear all day long with only occasional lubrication.
Interestingly this patient had been told that due to
his MGD he could not wear contact lenses for his low
myopia. We have now fitted this patient successfully
into daily contact lenses (Proclear 1 day), that he
removes for sleep. I received an email from him
the other day: “Both of my eyes have been feeling
excellent since I last saw you. I have been wearing
the daily contacts most days and have felt relief even
without the contact lenses.”
SPECIALITY CL FORUM BY ALEX PETTY*
BANDAGE CONTACT LENSES
As contact lens fitters, too often we find
ourselves fixated over obtaining the very
best visual results for our patients. These
days we can specify a dizzying array of toric
powers and axes into our soft daily lenses. We can
incorporate spherical aberration correction and
multifocal optics into our scleral lenses. Heck we
can even customise an orthokeratology lens to
match a child’s pupil size. It is all very empowering.
Still, there is an important application for contact
lenses where the power and vision through the
lens is largely irrelevant: bandage contact lenses.
Bandage contact lenses (BCL) refers to the
application of contact lenses, typically soft silicone
hydrogel extended-wear lenses, for therapeutic
reasons such as facilitating corneal healing or
protecting a fragile corneal surface. The key concept
of a bandage contact lens is the relentless shearing
forces of our blinking lids is nullified during wear,
often offering immediate relief to patients (and
practitioner!) as soon as they are inserted.
The concept of a protective eye bandage
originated several millennia ago when a smart
chap called Celsus reportedly applied a honeysoaked
linen to the site of a pterygium removal
to prevent symblepharon development. Last
century the technique of pressure-patching had
traditionally been used when an eye needed
protection to heal. Interestingly, a study several
decades ago showed patients with traumatic
corneal abrasions healed significantly faster, had
less pain and had fewer reports of blurred vision
when they were not wearing a pressure patch.
Corneal abrasions due to removal of foreign bodies
showed similar results¹.
Contact lenses were first used as an alternative
to pressure patching following the development
of hydroxyethyl methacrylate (HEMA) soft contact
lenses in the 1970s. Bandage contact lenses were
superior to patching for a number of reasons:
vision could be maintained during wear, topical
medications could continue to be instilled, and the
cosmesis was far better. Let’s be honest, not too
many people enjoy stepping out into the world
with half a roll of gauze taped to their face! Today’s
modern bandage contact lenses provide the same
benefits as their predecessors – but with enhanced
convenience, improved healing and better corneal
health due to the high Dk materials we now use
– an important consideration if extended wear is
required.
The choice of lens design depends on a few
factors but, typically, a lens with a low modulus is
preferred as these will drape onto the underlying
tissue better and theoretically provide less
mechanical interaction. My preferred lenses are
those with a modulus below 0.8 MPa such as
Biofinity (Coopervision) for a monthly lens and
the fortnightly CAir (Coopervision) or Acuvue
Oasys (J&J) if a shorter duration of wear is
expected. For comparison, the Air Optix (Alcon)
and Purevision (Bausch + Lomb) lenses are made
of stiffer materials with a modulus above 1.0 MPa.
I have spoken with several clinics using these high
modulus lenses as BCLs and they report few issues.
If a custom bandage lens is required the SiHg
Definitive 74 material has a reasonable Dk of 60
Fatt units and a nice low modulus of 0.4 MPa.
There are a number of reasons to use a BCL:
• Protection: BCLs can offer convenient protection
of the ocular surface in the case of entropion,
trichiasis, tarsal scars, recurrent corneal erosion and
in the presence of exposed surgical sutures or knots.
• Pain relief: Reducing patient discomfort is a
useful application for a therapeutic contact lens.
Conditions like bullous keratopathy, epithelial
erosion or abrasion and filamentary keratitis can
be debilitating without a contact lens in place.
In the case of bullous keratopathy failure of the
endothelium leads to swelling of the cornea and
formation of epithelial blisters that can painfully
rupture over time. A BCL reinforces the damaged
tissue and protects the nerve endings from the
abrasive actions of the eyelids. They can also make
the wait for an endothelial graft more tolerable.
• Healing: The use of a BCL to improve the
healing response of the cornea is particularly
valuable in a number of conditions including
chronic epithelial defects, neurotrophic keratitis
and chemical burns. BCLs also play an important
role following corneal surgery, particularly
photorefractive or phototherapeutic keratectomy
(PRK/PTK), and following corneal cross-linking.
In these procedures, the epithelial is chemically
removed and can take up to a week to heal. A BCL
provides a protective scaffolding for the limbal
epithelial cells to redistribute centrally.
Let us also not forget the role the fluid reservoir
of a rigid scleral lens can play in protecting and
healing the fragile ocular surface in chronic dry
eye conditions. A study led by Romero-Rangel²
described the therapeutic benefits of scleral
contact lenses to patients with conditions
including Stevens-Johnson syndrome, ocular
cicatricial pemphigoid and Sjögren’s syndrome.
Improvement in quality of life as a result of a
reduction in photophobia and discomfort was
reported by 92% of the patients studied. At contact
lens conferences, I have come across reports of
extended wear scleral lenses being used effectively
to rehabilitate non-healing corneal ulcers. Sleeping
in these lenses, however, created significant
hypoxic oedema, requiring careful consideration of
the risk-benefit in extreme cases.
• Sealing: BCL also play a role in sealing leaky
wounds. A leaking bleb following trabeculectomy
surgery is a serious complication and has been
reported to be more likely with the popularity of
anti-fibrotic agents like 5-FU and mitomycin-C,
occurring in 5-30% of surgeries 3,4,5,6 . Blebs can
be sealed with a BCL although customised
larger diameter lenses are typically required
to cover the area. At Greenlane Clinical Centre,
optometrist Reuben Gordon tells me the team
use the amusingly nick-named ‘Floppy Johnson’
(presumably named after its pendulous designer)
custom soft lens for this purpose. The Floppy
Johnson has a flat base curve of 8.9mm and
large diameter of 16mm and is well loved by the
glaucoma surgeons as a bleb sealer. Literature
results are favourable demonstrating a 92%
success rate using 17.50mm soft bandage contact
lenses for this purpose 7 .
Several good examples of the benefits of
bandage contact lenses have arisen in my clinic
in recent months. The first was the case of an
electrician in his thirties who flicked a coil of wire
into his eye the day before presenting to me (Fig
1). Unsurprisingly, the eye was sore, watery and
photophobic, but it felt like it was improving as
the day went on. Examination revealed an anterior
stromal laceration to about 50% thickness with
a narrow, almost dendritic, epithelial defect
that appeared to be healing already. Vision
was excellent, there was no infiltrate and the
anterior chamber was quiescent. The patient was
prescribed regular prophylactic chloramphenicol
ointment with a review planned later in the week.
Unfortunately, the patient returned the next day
as, on waking, his eye suddenly felt significantly
worse. On re-inspection, the epithelial defect had
widened, presumably due to the actions of the lids.
A bandage SiHg soft contact lens (CAir +0.25D) was
inserted which gave immediate relief. He was asked
to use this lens for extended wear with prophylactic
chloramphenicol drops four times a day. One week
later the eye was feeling much better. On removal
of the bandage lens (taking care to lubricate the eye
and the lens with a drop of artificial tears before
removal to avoid re-aggravating the fragile surface)
the epithelial defect had healed beautifully (Fig 2).
The stromal laceration was still evident as we would
expect this tissue layer to take longer to heal fully.
My second example is a young chap in his
twenties with severe meibomian gland dysfunction
and secondary evaporative dry eye (Fig 3). He
was referred to my clinic by ophthalmology for
dry eye management. After treatment with oral
azithromycin, intense-pulsed light treatment,
omega-3 supplements and regular hot compresses
and digital meibomian gland expression we were able
to wean him off the FML drops he was dependent on
at presentation. His eyes felt less dry and he did not
need to use his non-preserved lubricants as often.
However, his right eye still had a significant area of
confluent corneal epitheliopathy inferiorly that had
not improved over the course of six weeks (Fig 4). His
tarsal conjunctiva had a very inflamed appearance,
which was most likely contributing to the chronicity
of the epitheliopathy, in much the same way a shield
ulcer forms in vernal keratoconjunctivitis.
I applied an extended wear bandage contact
lens (CAir) to the eye and reviewed him one week
later. The patient reported his eye had never felt
So, next time you are confronted with a
troublesome ocular surface, consider reaching for a
trusty bandage contact lens. You will be impressed
how successful this management can be for your
patients. Always be mindful of the risk of infection,
however, especially in a case with a significant
epithelial defect.
That’s all from me for another year. Thank
you to those with positive comments about the
columns, it is always nice to hear that people have
learnt something or changed how they practice
to ultimately help their patients. I look forward to
bringing you more thrilling specialty contact lens
escapades in 2018. Happy holidays and happy
contact lens fitting! ▀
References
1. Kaiser PK A comparison of pressure patching versus no
patching for corneal abrasions due to trauma or foreign
body removal. Corneal Abrasion Patching Study Group.
Ophthalmology. 1995 Dec;102(12):1936-42.
2. Romero-Rangel T, Stavrou P, Cotter J, et al. Gas-permeable
scleral contact lens therapy in ocular surface disease. Am
J Ophthalmol 2000;130(1):25-32.
3. Mandal, AK. Management of the late leaking filtration
blebs. A report of seven cases and a selective review of
the literature. Indian J Ophthalmol. 2001;49:247
4. Schuman, JS. Zaltas, MM. Management of the leaking
bleb. In:Ritch R, Shields, MB. Krupin, T. editors. The
Glaucomas. 2nd edition. St. Louis; C.V. Mosby Company
1996, pp 1737-44.
5. Ticho, U. Ophir, A. Late complications after glaucoma
filtering surgery with adjunctive 5-fluorouracil. Am J
Ophthalmol 1993;115:506-10.
6. Katz, GJ., Higginbotham, EJ. Lichter, PR, et al. Mitomycin
C versus 5-fluorouracil in high risk glaucoma filtering
surgery: Extended follow-up. Ophthalmology
1995;102:1263-69.
7. Shoham, A. Tessler, Z. Finkleman, Y. Lifshitz, T. Large soft
contact lenses in the management of leaking blebs. CLAO
J 2000 Jan;26(1):37-39.
ABOUT THE AUTHOR:
*See box story about Alex Petty this page
Petty awarded CCLS scholarship
Tauranga-based Bay Eye Care
optometrist, Alex Petty, has been
awarded the 2017 Cornea and
Contact Lens Society (CCLS) Scholarship
to further his knowledge in rigid
contact lenses.
Petty, a therapeutic optometrist
and contact lens (CL) specialist, with
interest in orthokeratology, myopia
control, dry eye and glaucoma, has
lectured locally and internationally
on contact lenses and ocular disease,
writes a popular column on specialty
CLs in NZ Optics and has published
several articles and case reports in
clinical optometry journals. In 2016, he
was one of the first New Zealanders to
become a fellow of the International
Academy of Orthokeratology and
is currently a board member of the
Fig 1. Beware malevolent coils of wire
Fig 2. The epithelial defect resolving with extended wear use of a BCL
Fig 3. Severe meibomian gland dysfunction with lid wiper
epitheliopathy and tarsal inflammatory conjunctivitis
Orthokeratology Society of Oceania
and the Fellowship Committee
of the International Academy of
Orthokeratology.
Alex has been awarded $1,000 by CCLS
to learn more about the manufacturing
process of rigid lenses – how they are
made and modified and what can be
done with coatings, edge and thickness
profiles and material properties – to
further his knowledge to benefit his
often, quite unique patients.
Graeme Curtis and his team at Corneal
Lens Corporation in Christchurch will be
helping Petty achieve his goal.
The annual CCLS Scholarship is
worth up to $2,500 to cover the costs
of upskilling and education in either
cornea and or CL specialty fields. For
more, visit www.contactlens.org.nz.
Alex Petty, 2017 CCLS scholarship awardee
Fig 4-5. Resolution of a significant patch of confluent epitheliopathy in
an MGD patient with a BCL
8 NEW ZEALAND OPTICS December 2017