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Consider bandage contact lenses for corneal injuries
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BIRMINGHAM, Ala. — Eye care practitioners can forgo traditional pressure patches when treating many eyes for corneal injury or foreign body removal. Instead, use a bandage contact lens or no patch at all, say the experts.
Jimmy D. Bartlett, OD, professor of optometry and pharmacology here at the University of Alabama, said the use of pressure patches — two gauze pads se cured over the eye with adhesive tape — dates back at least a century. "This was applied to most ocular injuries and after many surgical procedures in the belief that it would improve patients' comfort and speed healing," Dr. Bartlett said.
Recent studies in the United States and in England reported that eyes without patches or with only a bandage contact lens heal at least as quickly as with a pressure patch.
According to Dr. Bartlett, "People like to see with both eyes during the healing process. So, as you can imagine, most patients are more comfortable without the patch," which can sometimes be painful to remove because of the adhesive tape.
Dr. Bartlett's standard therapy for small to medium corneal injuries and abrasions or following foreign body removal is an Acuvue (etafilcon A, Vistakon) contact lens as the bandage patch. At the initial visit, he applies 5% homatropine for cycloplegia and in creased patient comfort. Then he places the contact lens, which has a minimal power of -0.25 D or -0.5 D, on the injured eye. "After 10 or 15 minutes, I assess the fit, making sure the lens is not too tight or too loose and that it centers well," he explained.
Prevent infection
Next, he prescribes Polytrim (tri methoprim sulfate, polymyxin B sulfate, Allergan) or tobramycin eye drops to prevent infection, perhaps adding a topical nonsteroidal anti-inflammatory drug (NSAID), such as Acular (ketorolac tromethamine, Allergan) or Voltaren (diclofenac sodium, Ciba Vision), for pain control.
"Treating pain with eye drops instead of with systemic agents has the obvious advantage of decreasing systemic effects in patients who have contraindications to oral NSAIDs or opioid analgesics," Dr. Bartlett said. When the patient returns the next day for follow-up, Dr. Bartlett usually discontinues the bandage contact lens use. For patients experiencing photosensitivity, a common occurrence with corneal injuries, he advises them to rest, avoid the sun, and wear sunglasses if they need to go outdoors.
An alternative to a disposable contact lens for bandage purposes is the collagen shield, which is used less frequently because it is much more expensive. As with bandage lenses, patients wearing the shield can see, and the collagen dissolves within 24 to 72 hours.
Off-label use
According to Howard Purcell, OD, director of professional affairs for Vistakon, use of the Acuvue lens as a bandage lens is off-label; it is not approved by the Food and Drug Administration (FDA) for that purpose. He noted that although Ciba Vision has obtained approval for its Protek disposable lens as a bandage contact lens, his company has no immediate plans to pursue approval of the Acuvue lens for the same purpose. "But, practitioners have the right to use products as they see fit," he said.
James Aquavella, MD, clinical professor of ophthalmology at the Uni versity of Rochester in New York, said few, if any, companies pursue FDA approval for bandage lenses anymore. Most practitioners do not consider use of a plano or low-power contact lens to be off-label. "The lenses have become quite ge neric. Today, reproducibility of contact lenses is so good and disposable lenses cost so little that, rather than spending time fitting, we just put one on the patient and see how he or she does with it," he said.
"To call something an off-label use assumes that the only thing that anyone would ever do in the patients' best interest would be FDA approved," argued Joseph Barr, OD, editor of Contact Lens Spectrum and associate professor, assistant dean for clinical affairs, and chief of Contact Lens Services at Ohio State University. "If we only did what was FDA approved, we would not care for our patients as well as we possibly could. But if a doctor is really concerned about the liability issue and wants FDA ap proval, then he or she should use the Protek lens."
He added that because many practitioners customarily use trial lenses for bandage purposes without paying for them, some people might find such use to be unethical.
Other uses
In addition to corneal abrasions, Dr. Aquavella uses bandage lenses for nonhealing epithelial defects or erosions and before surgery for spastic entropion and conjunctival concretions. "Also, if a patient cannot use a hard contact lens, you might use a piggyback, cushion, bandage lens on the surface of the cornea and then fit a gas permeable or rigid lens over the soft lens," he said.
Dr. Aquavella added that one of the most frequent ap plications for hy drophilic bandage lenses is after re fractive surgery, e s pecially radial ker atotomy and pho torefractive keratectomy. "We don't patch eyes, and the contact lens helps mitigate some of the discomfort inherent in these procedures," he said.
While Dr. Aquavella has no favorite brand of lens, he recommends one that is at least 14 mm or more in diameter, because that size tends to fit the majority of patients.
Advantages of Protek
Marguerite McDonald, MD, of New Orleans, who developed the Protek lens with Rick Payor, OD, of Ciba Vision, advocates its use for this purpose. "A bandage lens is the standard of care following excimer surgery, although the Protek was labeled for general post-surgical use because it entered the market before approval of excimer lasers for refractive surgery. And with Protek, unlike with a patch, patients can apply topical NSAIDs themselves as needed," she said.
In the development of Protek, she and Dr. Payor studied about 60 lenses for use as bandage lenses. "We graded them for comfort, lack of complications, proper base curve, speed of re-epithelialization and other parameters. Based on these characteristics, we determined what we wanted in our own lens," she explained.
More common approach
Dr. Bartlett noted that the use of bandage lenses is becoming more common. "I talk to practitioners from all around the country, and they are doing the same thing. And now we have some good studies to support it."
However, optometrists also can choose not to patch at all. "In most cases, the eye will do fine. The patient derives as much comfort as with the bandage lens," Dr. Bartlett said.
He added that patching is contraindicated for any corneal injuries associated with the use of soft, especially extended-wear, contact lenses. Those patients run a much higher risk of Pseudomonasinfection of the cornea. "When the eye is patched, we provide a dark, moist environment in which bacteria will grow," Dr. Bartlett said. "The microorganism is a devastating gram-negative bacteria that can destroy a cornea in short order."
For these cases, Dr. Bartlett stops all lens wear and leaves the injured eyes unpatched.
For Your Information:
- Jimmy D. Bartlett, OD, is professor of optometry and pharmacology at the University of Alabama. He can be contacted at the University of Alabama at Birmingham School of Optometry, Birmingham, AL 35294; (205) 934-3036, fax: (205) 934-6758. Dr. Bartlett has received grant support from Allergan and Ciba Vision Ophthalmics.
- James Aquavella, MD, is clinical professor of ophthalmology at the University of Rochester and Genesee Valley Eye Institute, 919 Westfall Road, Rochester, NY 14618; (716) 461-8409, fax: (716) 461-8444. Dr. Aquavella has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Joseph Barr, OD, is associate professor, assistant dean for clinical affairs and chief of contact lens service at Ohio State University. He can be contacted at (614) 292-0437, fax: (614) 688-3285. Dr. Barr has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Howard Purcell, OD, FAAO, is director of Professional Affairs at Vistakon, Johnson & Johnson Vision Products Inc. He can be reached there at 4500 Salisbury Road, Suite 300, Jacksonville, FL 32216; (800) 876-6644; e-mail: hpurcell@visus.jnj.com. Dr. Purcell has a financial interest in Acuvue.
- Marguerite McDonald, MD, specializes in refractive surgery, with offices at Eye Ear Nose and Throat Hospital, 2626 Napoleon Ave., New Orleans, LA 70115; (504) 896-1250; fax: (504) 896-1251. Dr. McDonald has a financial interest in the Protek lens sold in the post-photorefractive keratectomy kit, and is a paid consultant for Ciba Vision Ophthalmics.