Conjunctival Hyperemia With Scleral Lens Wear: A Clinic-Microbiological Correlation and Management Varsha M Rathi Somasheila I Murthy L V Prasad Eye Institute Hyderabad, India The authors have no financial interest to disclose

Scleral contact lenses are large diameter rigid gas permeable (RGP) lenses which rest on sclera and vault the cornea ( no touch) Scleral lenses are filled with fluid (normal saline – preserved or unpreserved) before placing on the eye Usually worn as daily wear lenses Introduction. PROSE i.e. Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE from Boston Foundation for Sight, Needham Heights, MA, USA) is FDA approved scleral contact lens Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface prosthesis: an Indian experience. Indian J Ophthalmol 2011;59(4): Jacobs DS. Update on scleral lenses. Curr Opin Ophthalmol 2008;19(4):

Indications for Scleral lenses Scleral lenses have been shown to be effective in various ocular conditions To improve vision in corneal ectasias – Keratoconus – Pellucid marginal degeneration, – Intolerant to RGP lens wear – Unable to get an acceptable fitting of corneal RGP lenses because of advanced ectasia To improve comfort in ocular surface disease – Stevens Johnson Syndrome (SJS) – Limbal stem cell deficiency (LSCD) Pullum KW, Whiting MA, Buckley RJ. Scleral contact lenses: the expanding role. Cornea 2005;24(3): Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface prosthesis: an Indian experience. Indian J Ophthalmol 2011;59(4): Rathi VM, Sudharman Mandathara P, Vaddavalli PK, Dumpati S, Chakrabarti T, Sangwan VS. Fluid- filled scleral contact lenses in vernal keratoconjunctivitis. Eye Contact Lens 2012;38(3):203-6.

Safety of Scleral contact lens wear The scleral contact lenses are considered to be safer with fewer complications Rosenthal et al had shown infectious keratitis with scleral lens wear when the lenses were worn on continuous wear modality for persistent defect Acute Red eyes have been reported with miniscleral lenses when worn for keratoconus Purpose: The aim of this study is to report the occurrence of red eyes when the scleral lenses were worn as daily wear modality and the management. Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol 2000;130(1):33-41.

Methods Retrospective analysis of 10 eyes of 5 patients who had red eyes while using PROSE Fitting of scleral lens is described in literature - Training for lens insertion, removal, cleaning of the lenses and the plungers was explained Demographics, presenting symptoms, primary indication for fitting these lenses, duration of lens wear, cleaning regimen of the lenses, lens case, plungers that are used for lens insertion and removal, solution used, change of saline bottle, cleaning of were noted Rathi VM, Sudharman Mandathara P, Vaddavalli PK, Dumpati S, Chakrabarti T, Sangwan VS. Fluid- filled scleral contact lenses in vernal keratoconjunctivitis. Eye Contact Lens 2012;38(3):203-6.

Solution and Saline Saline used was normal saline to fill the lens prior to the application in the eye. – Saline bottle was used for three days and then discarded Solution used for lens care – single step RGP lens solution used in care and maintenance of RGP Plungers for insertion and removal – to be cleaned with Alcohol wipes prior to using for lens insertion and removal The insertion plunger (DMRV corp) is the one with the hole and the removal plunger is one without hole

Methods - continued When patients presented to clinic – Symptoms were noted and Slit lamp biomicroscopy was done for all eyes – Lenses and plungers were observed for deposits, scratches, edges. The fit was assessed – Conjunctival swab was taken From the lid margin and bulbar conjunctiva, From the scleral lens inner surface and plungers. – Patients were asked to discontinue the lens wear – Antibiotic eye drops (Moxifloxacin eye drops 0.5%, four times a day) were prescribed – Patients continued with lubricating eye drops or saline eye drops as lubricants Antibiotic sensitivity testing was done by Disc diffusion method

Results None of the patients was cleaning the plungers with alcohol swabs Lens broke – two during follow - up while cleaning Conjunctival hyperemia with lens wear 1 week later -Reduction in hyperemia with lens discontinuation & antibiotic eye drops

Results CaseEyeIndication Same lens worn for Surface of the lens Average daily wear SymptomsVisual acuity with lens Case1ODSJS 3 years Deposits 12h ( gap in between Redness and pain 20/80 OS 3 years Deposits 12h ( gap in between Redness and pain 20/100 Case 2ODSJS1year ( lens wear for 3years) Deposits6-7 hoursRedness discomfort 20/50 OS 3years Redness discomfort 20/40 Case 3ODKC with SJS2 yearsDeposit14h(gap)redness20/25 OS 2 yearsNo deposit 20/30 Case 4ODSJS10 months ( lens wear for 7 years) Good surface 12h(gap)No complaints CF1m OS 7 yearsMultiple depositis on lens surface 12 hNo complaints CF2m – 20/126 over follow up Case 5ODSJS 1.5 yearsFew deposits12h Redness, no discomfort OS Few deposits 12h Redness, no discomfort

Culture and Sensitivity Microorganisms grown – Conjunctival swab - Staphylococcus xylosis, Serratia marcescans PROSE - Nocardia, Klebsiella pneumoniae, Pseudomonas aeuroginosa, Unidentified fungus All plungers grew micro-organisms -Bacillus species, Staphylococcus xylosis, Propinobacterium acnes Sensitivity – The organisms were sensitive to all drugs – with intermediate sensitivity to Ceftazidime

Risk factors Poor compliance to the cleaning regimen despite using single multipurpose lens solution as two patients had lenses broken during the cleaning Not using alcohol wipes to clean plungers These lenses are worn on compromised ocular surface As scleral lenses cover the cornea, do not move on the eye, there is a built of debris in the fluid compartment,which can further increase the risk of inflammatory events Rathi VM, Mandathara PS, Dumpati S, Vaddavalli PK, Sangwan VS. Boston ocular surface prosthesis: an Indian experience. Indian J Ophthalmol 2011;59(4):

Discussion This is the first case series which shows the various organisms isolated from the Scleral contact lenses and the plungers The red eyes can be reduced when scleral lenses are worn –By adequate teaching of the care regimen –Cleaning of plungers with alcohol wipes –Replacing the lens case and the plungers frequently