strategic skill builders

Providing Patient Protection
Bandage 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.

Many 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 cascade.

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.

KEY DATA

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.

CHOOSING 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.

FITTING

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.

MANAGEMENT

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.

Silicone-based 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.

COMPLICATIONS

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.

CONTRAINDICATIONS

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.

POST-TREATMENT

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.

Patients 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 prevent recurrence.

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.