Contact lenses for the treatment of ocular surface diseases

Abstract

Contact lens wear is useful in ocular conditions such as high refractive errors, irregular astigmatism, corneal ectasias, corneal dystrophies, post-keratoplasty, post-refractive surgeries, trauma, and ocular surface diseases. The new innovations of highly oxygen-permeable contact lens materials have broadened the applications of contact lens suitability. Therapeutic contact lenses are medically used in the management of a wide variety of corneal conditions and ocular surface diseases. These lenses aid in pain relief, enhance corneal healing, maintain ocular homeostasis, and act as a drug delivery system. Drug delivery applications of contact lenses hold promise for improving topical therapy. The modern rigid gas permeable scleral contact lens provides symptomatic relief in painful corneal diseases such as bullous keratopathy, corneal epithelial abrasions, and erosions. It has been useful in therapeutic management as well as visual rehabilitation by enhancing the ocular surface and protecting the cornea from adverse environmental conditions. This review provides a summary of contact lenses used for the treatment of ocular surface diseases based on the current evidence available in the literature. This can help enhance the understanding and management of ocular surface diseases with respect to contact lens use in our day-to-day ophthalmology practice.

The ocular surface acts as a barrier to prevent various disorders of the eye. Ocular surface disease (OSD) includes a wide variety of disorders affecting the ocular surface of the eye, resulting in discomfort, diminution of vision, and tear-film instability with progressive clinical and histopathologic changes in the ocular surface. Treating ocular surface disease can present a number of challenges since the local and systemic issues must be addressed hand-in-hand. It can be difficult to manage, causing patients discomfort and vision loss. In these cases, contact lenses play an important role in the therapeutic management of ocular surface diseases. Although contact lenses are typically considered an alternative option for correcting refractive error, they can also play a therapeutic role after trauma, surgery, and in treating ocular surface disease. Usually, soft contacts and scleral contact lenses are used for therapeutic purposes. They endeavor therapeutic benefit by forming a mechanical barrier between the cornea and the external environment. Therapeutic lenses are used to manage a wide variety of corneal conditions including bullous keratopathy, corneal erosions, corneal epithelial defects, and post-surgical conditions such as post-keratoplasty and post-laser vision correction.

Contact lenses provide millions of people with spectacle-free visual correction and ocular rehabilitation. These lenses play an important role in the management of ocular surface diseases (OSDs). The advent of new technology and research developments is quickly increasing the therapeutic scope of both soft and rigid gas permeable contact lenses.

In this focused review, we consider the extensive review articles and literature on the use of therapeutic, bandage, prosthetic and scleral lenses for the management of ocular surface diseases. This review article will explore the current therapeutic role of contact lenses in modern clinical ophthalmic practice as well as future applications.

Methods

The literature search was performed using the following headings and sub-headings: Therapeutic Contact Lens, Bandage Contact Lens, Prosthetic Contact Lens, Scleral Contact Lens, Ocular Surface Disease, Dry Eye, Stevens–Johnson syndrome, and its combinations. The literature search includes 51 publications from PubMed, Google Scholar, ResearchGate, J-Gate, Crossref, Academia, WorldCat, Publons, Scilit, and ICMJE and CORE search engines.

Indications of therapeutic contact lenses

The term “Therapeutic” is derived from the Greek word “Therapeuein” meaning to “Take Care Of or “To Heal.” Therapeutic contact lenses are used with the aim of attempting to maintain or restore the integrity of ocular tissues. Therapeutic contact lenses (TCLs) are often used in the management of a wide variety of ocular surface diseases. There are many indications for use of TCL in OSDs such as ocular pain relief, enhancing corneal wound healing, mechanical protection, maintenance of ocular surface hydration, and as an ocular drug delivery system [Table 1].[1]

Table 1.

Uses of therapeutic contact lenses

Indication	Conditions of OSDs	Modalities of TCLs
Ocular Pain Relief	Bullous Keratopathy (BK)	Minimal Movement of the Contact Lens
	Filamentary Keratitis FK)	Disposable Contact Lens
	Superficial Punctate Keratitis (SPK)	High Water Content
	Superior Limbic Keratoconjunctivitis (SLK) of Theodore	Large Diameter Contact Lens
	Epithelial Abrasions or Erosions	Disposable Contact Lens
	Post-Laser Vision Correction (Photorefractive keratectomy)	Bandage Contact Lens
Corneal Wound Healing	Recurrent Corneal Erosion Syndrome (RCES)	Disposable, Ultra-thin and High Water Content
	Traumatic Corneal Abrasions (TCAs)	Disposable Contact Lens
	Persistent Corneal Epithelial Defects (PCEDs)	Disposable or Corneal Collagen Shields (Multipurpose Ophthalmic Contact Lens)
	Chemical or Thermal Burns	Small Diameter and Low Water Content
	Post-operative: PRK, PPV& PKP	Disposable and Silicone Hydrogel Hybrid Contact Lens
	Herpes Simplex Metaherpetic Ulcer	Disposable and Silicone Hydrogel
	Filamentary Keratitis	Disposable Contact Lens
	Corneal Perforations, Corneal Stromal Melting	Larger Diameter, Silicone Hydrogel, and High-water Content
	Lamellar Laceration	Larger Diameter, Silicone Hydrogel, and High-water Content
Mechanical Protection	Post-operative Wound Leakage	Thin, Hydrogel, and Low Water Content)
	Post-operative Trabeculectomy Leakage	Larger Diameter and High Water Content
	Corneal Thinning: Descemetocele	Larger Diameter, Silicone Hydrogel, and High Water Content
	Exposure and Neurotrophic Keratopathy (EK & NK)	Scleral Contact Lens
	Entropion, Trichiasis, Tarsal Scarring & Ptosis	Larger Diameter and High Water Content
	Recurrent Corneal Erosions	Bandage Contact Lens
Maintenance of Ocular Surface Hydration	Cicatrizing Conjunctival Disease: Stevens–Johnson syndrome (SJS) and Mucous Membrane Pemphigoid (MMP)	Larger Diameter, Low-Moderate Water Content, and Silicone Hydrogel
	Chemical Burns	Mega Soft, Larger Diameter and Scleral Contact Lens
	Dry Eye	Scleral Contact Lens and Prosthetic Replacement of Ocular Surface Ecosystem (PROSE)
Vehicle for Drug Delivery	Antimicrobial Assay Antimicrobial Effectiveness Allergic Conjunctivitis	Modern Scleral Contact Lens & Disposable

Therapeutic Soft Contact Lenses

Silicone hydrogel contact lenses are advanced soft lenses that allow more oxygen to pass through the lens to the cornea than regular soft “hydrogel” contacts. These lenses enable up to 5–10 times more oxygen to reach the cornea than regular hydrogel lenses, even during sleep in comparison to lenses made from other materials.[2] Contact lenses consisting of silicone have some features that provide a healthy environment for the eye. In the last decade, very high Dk silicone hydrogel (Si-Hy) material and lenses have been developed and labeled specifically for therapeutic use in addition to cosmetic use. There have been reports of the utility of Si-Hy lenses as a therapeutic option across the spectrum of ocular surface disease.

These contact lenses should be used under close supervision, since their long-term continuous use may predispose the eye to bacterial keratitis and neovascularization. However, the introduction of silicon hydrogel extended-wear contact lenses, in recent years, has significantly increased the safety of long-term use of bandage contact lenses.

Bandage Contact Lenses

Bandage contact lenses protect the cornea from environmental conditions and counter the abrasive effects of eyelids. These lenses can help to repair corneal tissue, manage pain, and maintain visual acuity. Bandage contact lenses should be used as an adjunct to other treatment modalities since they stabilize the tear film, restoring epithelial cell turnover and insulating corneal nerves. Advances in contact lens design have enabled higher oxygen diffusion capabilities that allow for a longer period of uninterrupted wear. In painful corneal disease conditions like bullous keratopathy, epidermolysis bullosa, and epithelial abrasions/erosions, bandage contact lenses provide symptomatic relief. Post-operatively in photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASEK), BCLs also provide comfort. BCLs are used post-keratoplasty, post-trabeculectomy, and post-amniotic membrane transplantation to enhance healing. In patients with eyelid conditions such as trichiasis, distichiasis, ptosis, and tarsal scarring, BCLs are effective in forming a mechanical barrier to protect the cornea. These lenses promote corneal re-epithelialization and maintain the integrity of newly forming epithelial cells by forming a scaffold and improving the spread of tear fluid over the ocular surface.[3-10] Future therapeutic considerations include the use of contact lenses as surgical adjuncts as well as vehicles for ophthalmic drug delivery[1,2,5]

Prosthetic Contact Lenses

Prosthetic contact lenses can greatly enhance the visual appearance of a damaged or disfigured eye. These lenses can also help to improve vision in circumstances by reducing glare and recreating a round pupil, where the pupil is irregularly shaped. Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) is a repeated and integrated medical treatment model that restores vision promotes healing, reduces symptoms, and improves the quality of life for patients with complex corneal diseases. This is relevant in keratoconjunctivitis sicca, Stevens–Johnson syndrome, ocular cicatricial pemphigoid, Sjogren’s syndrome, rheumatoid arthritis, ocular graft-versus-host disease, and more.[11-15] It can also be used to treat non-specific dry eye, neurotrophic keratitis, and exposure keratopathy.[16,17] The oxygen-permeable lens is treated with tangible hydra-PEG, which improves wettability and lubrication, and reduces the deposition of proteins and lipids. This results in a lens that provides better comfort and quality of vision. The EyePrintPR is a prosthetic contact lens, which is similar to a scleral lens. It is made from the same oxygen-permeable material used for scleral lenses. Because of these similarities, the EyePrintPRO™ has similar uses and benefits as scleral lenses. It is made of the same FDA-approved oxygen-permeable materials, and the fit vaults the cornea while landing on the sclera. The comfort and visual benefits of scleral lenses are well known. This prosthetic device can provide clear vision and high levels of comfort to patients with irregularly shaped corneas. It has been used to treat and manage conditions such as corneal ectasias, irregular astigmatism, ocular surface diseases, trauma, thermochemical injuries, post-keratoplasty, post-LASIK ectasia, pinguecula, pterygium, and limbal stem cell deficiency.

Drug Delivery

Ocular drug delivery involves achieving therapeutic concentrations of medication at the ocular surface. The eye has many barriers that make it difficult to deliver drugs to the targeted ocular tissues with topical administration using eye drops. It is suggested that therapeutic lenses may be suitable for controlled and sustained drug delivery due to their extended-wear function and higher bioavailability than eye drop formulations. A drug-eluting contact lens is one of the more promising platforms for controlled ocular drug delivery, and the incorporation of novel polymeric vehicles with versatile features makes it possible to deliver the drugs in a sustained and extended manner.[18]

Scleral Contact Lenses

Scleral lenses can be prescribed for the management of corneal irregularity, high refractive error, and ocular surface disease. There are many potential therapeutic uses of scleral lenses in addition to providing similar benefits as corneal gas permeable lenses. Scleral contact lenses are a valuable therapeutic tool for patients with ocular surface disease as these lenses protect the ocular surface, and maintain the hydration of the ocular surface while providing an optimal visual correction. Rigid gas permeable (RGP) scleral contact lenses (ScCLs) are often used to enhance corneal healing and improve the symptoms of dryness. The new development of materials with high gas permeability together with various advanced technology innovations in the lens design and manufacturing of scleral lenses has opened new avenues for their use. These lenses available today have the potential to really improve the lives of patients not only by helping them see better but also by providing all-day comfort. There are instances that they have served as the only tool to provide better visual rehabilitation in severely distorted corneas and poor ocular surfaces.[3] The modern RGP scleral contact lenses are used to maintain therapeutic concentrations of medication on the ocular surface and for visual rehabilitation. The prescription of scleral lenses for the management of corneal irregularity, uncomplicated refractive error, and ocular surface disease has drastically increased.[19-23] Therapeutically, scleral contact lens is the latest option available for treating dry eye disease associated with various ocular surface disorders, as tabulated in Table 2.[24]

Table 2.

Therapeutic uses of scleral contact lenses for ocular surface disease[19]

Mucosal Disorder	Corneal Disorder	Corneal Protection	Cosmetic
Dry eye	Exposure keratitis	Ocular surface disease	Aniridia
Stevens–Johnson syndrome	Epithelial defects	Pain relief	Iris coloboma
Sjogren’s syndrome	Epithelial dysplasia	Nerve palsy	Irregular iris
Ocular cicatricial pemphigoid	Neurotrophic keratitis	Keratoconjunctivitis	Microphthalmos
Chemical burn	Filamentary keratitis	Trichiasis	Lagophthalmos
Pterygium	Drug delivery	Entropion
		Ptosis
		Persistent epithelial corneal defects
		Graft vs. Host disease

The 2017 TFOS DEWS II report recommended therapeutic contact lenses “soft bandage contact lenses and rigid scleral lenses” in step 3 of the management and treatment recommendations for dry eye disease.[25] The 2015 SCOPE survey of scleral lens prescribers reported similar findings; scleral lenses were reported to be prescribed by practitioners after topical lubricants, topical steroids, cyclosporine, and punctal occlusion.[23] For challenging medical conditions, scleral lenses can be used in combination with other therapies (topical lubricants, cyclosporine, topical corticosteroids, punctal occlusion, topical autologous serum, amniotic membrane grafting, and tarsorrhaphy) to delay or avoid surgery.[26-29] Scleral lenses are a valuable therapeutic tool for patients with ocular surface disease as they protect the ocular surface, provide continuous surface hydration and tear film stability while providing optimal visual correction, and can be used in conjunction with other therapies[12,20,21,30,31] Advancements in lens manufacturing technology, lens materials, and fitting techniques have expanded the spectrum of treating patients with compromised ocular surfaces. Several publications report on long-term outcomes and success in managing moderate to severe dry eye disease with scleral lenses. According to the tear film and ocular surface society (TFOS) Dry Eye Workshop DEWS II report, those who are symptomatic with signs of ocular surface disease may benefit from scleral lenses and show improvement in corneal punctate staining and filamentary keratitis. In OSDs, rigid gas permeable scleral contact lenses (RGP-ScCLs) are often used.

Various studies have shown the extensive use of scleral contact lenses (especially BOSP [Boston ocular surface prosthesis] and PROSE) in addressing the problems related to ocular discomfort, improving visual acuity and various ocular surface parameters such as Ocular Surface Disease Index (OSDI), visual function questionnaire 25 (VFQ-25), and National Eye Institute (NEI) grading in patients with various ocular surface diseases [Table 3].[1,32-44]

Table 3.

Scleral contact lenses for treatment of ocular surface disorder

Author/Year	Title	Study Design	Indication	Sample Size	Findings
Sah R et al./2021[32]	Scleral Contact Lenses for Treatment of Ocular Surface Disorders: A Narrative Review	A Review study	OSD	-	Scleral lenses improve visual acuity in irregular corneal astigmatism and decrease the symptoms associated with ocular surface disorders; increased wearing time, higher visual acuity, and a reduction in other problems (hypoxia, corneal vascularization, and epithelial edema): gas-permeable scleral contact lenses
Scanzera AC et al./2020[33]	Prevalence of Ocular Surface Disease and Corneal Irregularity and Outcomes in Patients Using Therapeutic Scleral Lenses at a Tertiary Care Center.	Retrospective	OSD & Corneal Irregularity	133 patients	OSD was a primary or secondary indication for ScCL (BostonSight, PROSE or JUPITER) evaluation in 85.7% (n=114) of patients evaluated for ScCL; scleral contact lenses improved visual outcomes in patients with both primary diagnoses of CI and OSD
Wang Y et al./2019[34]	Prosthetic Replacement of the Ocular Surface Ecosystem Treatment for Ocular Surface Disease in Pediatric Patients with Stevens–Johnson Syndrome.	Retrospective	Ocular Surface Disease & Stevens–Johnson Syndrome	27 female & 22 male (49 patients)	PROSE treatment is feasible in over two-thirds of pediatric patients with chronic ocular surface disease related to SJS/TEN and results in significant improvement in vision that is durable over a period of many years
Yuksel E et al./2018[35]	The Management of Refractory Dry Eye with Semi-Scleral Contact Lens	A review study	Dry Eye	-	The corneal findings resolved, and the quality of life improved with the aid of semi-scleral lens after 3 months
Harthan JS et al./2018[36]	Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations	A review study	Ocular Surface Disease	-	Scleral lenses are an effective therapeutic option in the management of OSD recalcitrant to traditional therapies; scleral lenses improve comfort and improve clinical signs of OSDs while supporting the ocular surface
Lee et al./2019[45]	Long-term effect of corneoscleral contact lenses on refractory ocular surface diseases	Retrospective	Severe/Refractory OSD	13 eyes	With SoClear corneoscleral CL improvement in BCVA, CFS score, and persistent epithelial defect was noted
Suarez et al./2018[46]	First experience with the ICD 16.5 mini-scleral lens for optic and therapeutic purposes	Prospective case series	Severe OSD, Irregular astigmatism, Keratoconus and Post-PK	39 eyes	Safety of ICD-16.5 mini-scleral CL in OSD
Chahal JS et al./2017[16]	Prosthetic Replacement of the Ocular Surface Ecosystem Scleral Lens Therapy for Exposure Keratopathy	Retrospective	Exposure Keratopathy & Ocular Surface Disease	18 patients	PROSE scleral lens therapy effective in patients with exposure keratopathy who had failed conventional therapies; can serve as an alternative to lid surgery
Carracedo G et al./2016[37]	Short-term Effect of Scleral Lens on the Dry Eye Biomarkers in Keratoconus	A pilot, experimental & short-term study	DED	26 patients	Short-term scleral lens wearing improves the symptomatology and some signs of dry eye, such as osmolarity and (Ap (4) A) concentration; increase in MMP-9 concentration could be caused by tear film stagnation and the use of preserved saline
La Porta Weber et al./2016[47]	The use of the Esclera Scleral Contact Lens in the treatment of moderate to severe dry eye disease	Prospective interventional case series	Moderate–severe DED	41 eyes	Significant improvement in BDVA, DES, and Quality of Life scores with Esclera CL
Guzman A et al./2016[38]	Dry Eye Treatment Based on Contact Lens Drug Delivery: A Review.	A review study	DED	-	Contact lenses are emerging as an alternative ophthalmic drug delivery system that provides an increased drug-eluting time, thus leading to enhanced bioavailability and more efficacious therapy
Bavinger JC et al./2015[39]	Scleral lens use in dry eye syndrome	A review study	DED	-	Scleral lenses are efficacious and well tolerated for use in severe dry eye syndrome; further research is needed to compare different sizes and types of lenses and to standardize outcome measures.
Schornack MM et al./2014[40]	Scleral lenses in the management of the ocular surface disease	Retrospective	Ocular surface disease	212 patients (346 eyes)	Commercially available scleral lenses can be successfully used in the management of moderate to severe OSD; the scleral lens fitting process can be completed efficiently for most eyes by using diagnostic trial lenses; scleral lenses improve visual acuity in patients with OSD
Heur et al./2014[48]	Prosthetic Replacement of the Ocular Surface Ecosystem scleral lens therapy for patients with ocular symptoms of chronic Stevens–Johnson syndrome	Retrospective interventional case series	SJS	27 eyes	Significant improvement in BDVA and OSDI scores with PROSE CL
Efron N et al./2013.[41]	Contact lens care and ocular surface homeostasis	A review study	Ocular surface disease	-	The mucin–glycocalyx plays an important role in ocular homeostasis; tear osmolarity may be increased in DED & may adversely affect the tear film; important to prescribe lenses that will have the least possible impact
Kalwerisky K et al./2012[42]	Use of the Boston Ocular Surface Prosthesis in the management of severe periorbital thermal injuries: a case series of 10 patients.	Retrospective	Thermal injuries & OSD	10 patients (16 eyes)	The BOSP can play an important role in the rehabilitation of the ocular surface for patients with severe thermal injuries and resultant exposure keratopathy; use of BOSP should be considered as a treatment option for these difficult cases
Rathi VM et al./2011[43]	Boston Ocular Surface Prosthesis: an Indian experience	Retrospective	Irregular cornea & Stevens–Johnson syndrome	32 patients (43 eyes)	BOSP improves BDVA in patients who have irregular astigmatism as in ectasias and RGP failures and improves vision and symptoms in patients with SJS
Siqueira AC et al./2010[44]	The scleral contact lens for ocular rehabilitation in patients with Stevens–Johnson syndrome	Retrospective	Stevens–Johnson syndrome	10 eyes (7 patients)	A successful adaptation of scleral contact lenses feasible on most patients, with relief of symptoms and better visual acuity; Scleral contact lenses, represent an important and accessible alternative to reduce the ocular discomfort caused by SJS
Tougeron- Brousseau et al./2009[49]	Vision-related function after scleral lens fitting in ocular complications of Stevens–Johnson syndrome and toxic epidermal necrolysis	Retrospective	SJS/TEN	67 eyes	Significant improvement in BDVA, NEI grading, OSDI and VFQ-25 scores with SPOT scleral CL
Jacobs & Rosenthal/ 2007[14]	Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease	Non-comparative Interventional case series	DED post-chronic GVHD	33 eyes	Boston scleral lens prosthetic device (BSLPD) provides improvement in pain, photophobia, and quality of life
Rosenthal & Croteau/2005[12]	Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty	Retrospective	Severe OSD	875 eyes	Improved vision and better healing of epithelial defects with reduced ocular pain and photophobia with Boston scleral CL

BDVA (Best-corrected distant visual acuity), DED (dry eye disease), GVHD (graft versus host disease), OSD (ocular surface disease), OSDI (Ocular Surface Disease Index), GP-SCL (gas permeable scleral contact lens), ScCL (scleral contact lens), SJS (Stevens–Johnson syndrome), Matrix Metallopeptidase-9 (MMP-9), Diadenosine tetraphosphate (Ap (4) A, BOSP (Boston ocular surface prosthesis), CI (corneal irregularity), BSLPD, NEI grading (National Eye Institute grading), Boston scleral lens prosthetic device; CFS (corneal fluorescein staining), CI (corneal irregularity), PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem), VFQ-25 (visual function questionnaire)

Conclusion

There are many indications and uses of TCLs in alleviating ocular pain, enhancing corneal healing, corneal protection, and ocular surface stabilization. The overall goal of prescribing TCLs for ocular surface disease is to improve comfort and improve clinical signs of surface disease. These lenses are an effective therapeutic option in the management of ocular surface disease recalcitrant to traditional therapies. Recent advances in technology and research have also shown contact lenses to be promising in their use for drug delivery. Nowadays, modern lenses have emerged as alternative ophthalmic drugs delivery systems that provide more convenient and effective therapy.

With continuous research, material innovation, and fabrication, the clinical use of contact lenses for the treatment of ocular surface disease has increased considerably. There is high scope for these lenses to be used as an ocular drug delivery system in treating eye diseases. Therapeutic contact lenses, hence, remain a popular option for the management of ocular surface diseases, enhancing the potential for visual recovery in these eyes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.