Scleral Perforation A
Complication
of the Soft Contact Lens
Stuart I. Brown, MD, Joel Rosen, MD \s=b\ A large area of conjunctiva and a smaller area of full thickness sclera eroded immediately adjacent to the edge of a soft contact lens. The soft lens was worn to protect the epithelium of a corneal graft in an alkali-burned eye. The conjunctiva-sclera necrosis appears to be a complication of a distorted and tightly fitting lens.
(Arch Ophthalmol 93:1047-1048, 1975)
only serious complication that has been reported to be as¬ sociated with wearing therapeutic soft contact lenses is corneal infec¬ tion.1-2 We describe a case of scierai necrosis following the use of the soft lens. This occurred two years after
The
Submitted for publication April 13, 1974. From the Department of Ophthalmology, University of Pittsburgh School of Medicine, and the Eye and Ear Hospital, Pittsburgh. Dr. Rosen is now with the Jewish General Hospital, Montreal, Quebec, Canada. Reprint requests to Department of Ophthalmology, Eye and Ear Hospital, 230 Lothrop St, Pittsburgh, PA 15213 (Dr. Brown).
corneal transplantation in burned eye. A
an
alkali-
REPORT OF A CASE had had
fourteen-year-old boy
a se¬
alkali burn of the cornea and sur¬ rounding limbus of his left eye in October 1971. He was treated with topically applied 2.5% cysteine and patching for three months until his injured cornea was com¬ pletely overgrown with conjunctiva. In January 1972, he underwent a 7.5-mm diameter penetrating corneal transplant and conjunctival recession. The corneal transplant remained transparent, but the graft epithelium repeatedly eroded. The cornea was covered with a soft contact lens two months postoperatively. The erosions healed only to recur six weeks later. A soft lens with a steeper base curve was fitted and the erosions healed. Four lens changes were necessary during the first year post¬ operatively for epithelial erosions. During the following 1% years, there were no fur¬ ther erosions and the graft remained transparent (Fig 1). The soft lens that was successful in maintaining the integrity of the corneal epithelium for this period was relatively tight, ie, there were minimal exvere
Fig 1 .—Two years postoperative appearance of transparent graft protected by soft contact lens in severely alkali-burned eye. Note blanching of vessels at edge of lens.
Fig
2.—Scierai
cursions with blinking. This lens was changed twice for lenses with the same di¬ mensions in the last year because the len¬ ses lost their original shape. The eye was examined bimonthly when the lenses were cleaned by boiling for 20 minutes and bacterial cultures were taken. Topically applied medications postopera¬ tively varied from 1% methylcellulose to corticosteroids, antibiotics, and methyl¬ cellulose. In November 1973, one week after a pre¬ vious examination, the patient complained of discomfort, and an examination showed a semicircular erosion of the conjunctiva adjacent to the edge of the lens that ex¬ tended approximately 120° of the lens' cir¬ cumference. In addition, there was a full thickness loss of sclera that was approxi¬ mately 3x8 mm within the area of the conjunctival erosion (Fig 2 and 3). The lens was removed and found to be dis¬ torted in shape (Fig 4). The rest of the ex¬ ternal eye appeared surprisingly free of inflammation. Bacterial cultures that were taken of both the lens and the conjunctiva at this time eventually proved to be nega¬ tive. The patient was brought to the oper-
perforation
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/22/2015
at
edge
of soft lens.
Fig 3.—Without lens, scierai perforation, thinning, and con¬ junctival ulcération with scierai exposure in circular area corre¬ sponding to edge of soft contact lens.
Fig 5—Postoperative appearance after scierai graft (arrow) to perforation. Graft was reinforced with bridge conjunctival flap. close
by the previous alkali burn and the subsequent surgery. During the origi¬ nal surgical procedure, subcon¬ junctival tissue was removed to the fornices. The pericorneal tissue exter¬ nal to the sclera was accordingly thin¬
ating
room and a free-hand scierai graft fashioned to close the scierai defect. A bridge flap of conjunctiva was taken from the inferior fornix and was brought up to cover the scierai graft (Fig 5). Four months postoperatively, the conjunctiva and the scierai graft appeared to be healed and the corneal graft was transparent. was
ner, which may have facilitated ero¬ sion through the conjunctiva to the sclera. Another and possibly the most important factor in the genesis of the scierai necrosis was the loss of lens shape that exaggerated the relatively tight fit. This may have caused pres¬
COMMENT A tightly fitted soft contact lens has been repeatedly recommended for healing of epithelial erosions.' * It has been our experience that relatively tight lenses are also frequently neces¬ sary to maintain an intact epithelium on corneal grafts in severely alkaliburned eyes. A tight soft lens, however, can fre¬ quently cause the conjunctiva to be¬ come painfully inflamed and edema¬ tous adjacent to the edge of the lens. Coincident with these signs is an imprint ring in the conjunctiva that corresponds to the edge of the tight lens. These signs can be seen as early as 30 minutes after fitting the lens. If this lens is allowed to remain on the eye, the corneal epithelium may be¬ come edematous and erode. This tight-lens syndrome has been the most common complication in our ex¬ perience with soft lenses. Treatment is simply to remove the lens and wait for the inflammation to subside. Thereafter, a lens with a flatter di¬ mension can be tried. The tight-lens syndrome can also develop if the lens loses its original dimensions. This usually occurs after
necrosis of both the conjunctiva and sclera. Consequently, we recom¬ mend close examination of both the conjunctiva and the shape of the lenses in eyes with tightly fitting lenses. sure
This study was supported in part by National Eye Institute grant EY01489-01. Dr. Rosen is the recipient of a grant from the Canadian National Institute for the Blind, E. A. Baker Foundation for Prevention of Blindness.
References 1. Dohlman
Fig 4.—Misshapen
soft contact lens.
six months of wear and is probably due to an alteration in the basic prop¬ erties of the lens material. It is possible that the complication in this case may have been facilitated
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/22/2015
CH, Boruchoff SA, Mobilia
EF: in use of soft contact lenses in corneal disease. Arch Ophthalmol 90:367-371, 1973. 2. Gasset AR, Kaufman HE: Bandage lenses in the treatment of bullous keratopathy. Am J Ophthalmol 72:376-380, 1971. 3. Aquavella JV: Chronic corneal edema. Am J Ophthalmol 76:201-207, 1973. 4. Uotila MH, Gasset AR: Fitting manual for Bausch & Lomb and Griffin lenses, in Gasset AR, Kaufman HE (eds): Soft Contact Lens Symposium and Workshop of the University of Florida, Gainesville. St. Louis, CV Mosby Co, 1972, pp 310-312.
Complications
Complication
of the Soft Contact Lens
Stuart I. Brown, MD, Joel Rosen, MD \s=b\ A large area of conjunctiva and a smaller area of full thickness sclera eroded immediately adjacent to the edge of a soft contact lens. The soft lens was worn to protect the epithelium of a corneal graft in an alkali-burned eye. The conjunctiva-sclera necrosis appears to be a complication of a distorted and tightly fitting lens.
(Arch Ophthalmol 93:1047-1048, 1975)
only serious complication that has been reported to be as¬ sociated with wearing therapeutic soft contact lenses is corneal infec¬ tion.1-2 We describe a case of scierai necrosis following the use of the soft lens. This occurred two years after
The
Submitted for publication April 13, 1974. From the Department of Ophthalmology, University of Pittsburgh School of Medicine, and the Eye and Ear Hospital, Pittsburgh. Dr. Rosen is now with the Jewish General Hospital, Montreal, Quebec, Canada. Reprint requests to Department of Ophthalmology, Eye and Ear Hospital, 230 Lothrop St, Pittsburgh, PA 15213 (Dr. Brown).
corneal transplantation in burned eye. A
an
alkali-
REPORT OF A CASE had had
fourteen-year-old boy
a se¬
alkali burn of the cornea and sur¬ rounding limbus of his left eye in October 1971. He was treated with topically applied 2.5% cysteine and patching for three months until his injured cornea was com¬ pletely overgrown with conjunctiva. In January 1972, he underwent a 7.5-mm diameter penetrating corneal transplant and conjunctival recession. The corneal transplant remained transparent, but the graft epithelium repeatedly eroded. The cornea was covered with a soft contact lens two months postoperatively. The erosions healed only to recur six weeks later. A soft lens with a steeper base curve was fitted and the erosions healed. Four lens changes were necessary during the first year post¬ operatively for epithelial erosions. During the following 1% years, there were no fur¬ ther erosions and the graft remained transparent (Fig 1). The soft lens that was successful in maintaining the integrity of the corneal epithelium for this period was relatively tight, ie, there were minimal exvere
Fig 1 .—Two years postoperative appearance of transparent graft protected by soft contact lens in severely alkali-burned eye. Note blanching of vessels at edge of lens.
Fig
2.—Scierai
cursions with blinking. This lens was changed twice for lenses with the same di¬ mensions in the last year because the len¬ ses lost their original shape. The eye was examined bimonthly when the lenses were cleaned by boiling for 20 minutes and bacterial cultures were taken. Topically applied medications postopera¬ tively varied from 1% methylcellulose to corticosteroids, antibiotics, and methyl¬ cellulose. In November 1973, one week after a pre¬ vious examination, the patient complained of discomfort, and an examination showed a semicircular erosion of the conjunctiva adjacent to the edge of the lens that ex¬ tended approximately 120° of the lens' cir¬ cumference. In addition, there was a full thickness loss of sclera that was approxi¬ mately 3x8 mm within the area of the conjunctival erosion (Fig 2 and 3). The lens was removed and found to be dis¬ torted in shape (Fig 4). The rest of the ex¬ ternal eye appeared surprisingly free of inflammation. Bacterial cultures that were taken of both the lens and the conjunctiva at this time eventually proved to be nega¬ tive. The patient was brought to the oper-
perforation
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/22/2015
at
edge
of soft lens.
Fig 3.—Without lens, scierai perforation, thinning, and con¬ junctival ulcération with scierai exposure in circular area corre¬ sponding to edge of soft contact lens.
Fig 5—Postoperative appearance after scierai graft (arrow) to perforation. Graft was reinforced with bridge conjunctival flap. close
by the previous alkali burn and the subsequent surgery. During the origi¬ nal surgical procedure, subcon¬ junctival tissue was removed to the fornices. The pericorneal tissue exter¬ nal to the sclera was accordingly thin¬
ating
room and a free-hand scierai graft fashioned to close the scierai defect. A bridge flap of conjunctiva was taken from the inferior fornix and was brought up to cover the scierai graft (Fig 5). Four months postoperatively, the conjunctiva and the scierai graft appeared to be healed and the corneal graft was transparent. was
ner, which may have facilitated ero¬ sion through the conjunctiva to the sclera. Another and possibly the most important factor in the genesis of the scierai necrosis was the loss of lens shape that exaggerated the relatively tight fit. This may have caused pres¬
COMMENT A tightly fitted soft contact lens has been repeatedly recommended for healing of epithelial erosions.' * It has been our experience that relatively tight lenses are also frequently neces¬ sary to maintain an intact epithelium on corneal grafts in severely alkaliburned eyes. A tight soft lens, however, can fre¬ quently cause the conjunctiva to be¬ come painfully inflamed and edema¬ tous adjacent to the edge of the lens. Coincident with these signs is an imprint ring in the conjunctiva that corresponds to the edge of the tight lens. These signs can be seen as early as 30 minutes after fitting the lens. If this lens is allowed to remain on the eye, the corneal epithelium may be¬ come edematous and erode. This tight-lens syndrome has been the most common complication in our ex¬ perience with soft lenses. Treatment is simply to remove the lens and wait for the inflammation to subside. Thereafter, a lens with a flatter di¬ mension can be tried. The tight-lens syndrome can also develop if the lens loses its original dimensions. This usually occurs after
necrosis of both the conjunctiva and sclera. Consequently, we recom¬ mend close examination of both the conjunctiva and the shape of the lenses in eyes with tightly fitting lenses. sure
This study was supported in part by National Eye Institute grant EY01489-01. Dr. Rosen is the recipient of a grant from the Canadian National Institute for the Blind, E. A. Baker Foundation for Prevention of Blindness.
References 1. Dohlman
Fig 4.—Misshapen
soft contact lens.
six months of wear and is probably due to an alteration in the basic prop¬ erties of the lens material. It is possible that the complication in this case may have been facilitated
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/22/2015
CH, Boruchoff SA, Mobilia
EF: in use of soft contact lenses in corneal disease. Arch Ophthalmol 90:367-371, 1973. 2. Gasset AR, Kaufman HE: Bandage lenses in the treatment of bullous keratopathy. Am J Ophthalmol 72:376-380, 1971. 3. Aquavella JV: Chronic corneal edema. Am J Ophthalmol 76:201-207, 1973. 4. Uotila MH, Gasset AR: Fitting manual for Bausch & Lomb and Griffin lenses, in Gasset AR, Kaufman HE (eds): Soft Contact Lens Symposium and Workshop of the University of Florida, Gainesville. St. Louis, CV Mosby Co, 1972, pp 310-312.
Complications
