Form-Based Case Report Name: Pam Satjawatcharaphong Email: [email protected] Address: 200 Minor Hall, Berkeley, CA 94720 Case Report #: 1 of 2 Management of Exposure Keratopathy Secondary to Facial Nerve Palsy with a Scleral Gas Permeable Contact Lens Introduction Facial nerve palsy is a disorder of cranial nerve VII that controls movement of the muscles in the face. Damage to this nerve typically results in unilateral facial weakness or paralysis. Patients may experience drooping of one side of the face, drooling, dry mouth, loss of sense of taste, inability to close the affected eye, and twitching of the facial muscles. Ocular sequelae of this condition include ptosis, lagophthalmos, exposure keratopathy, epiphora, ulceration of the cornea, and decreased vision.1 Recommended treatment of this condition has been dependent on the nature of the corneal exposure, and includes options ranging from palliative lubricants to surgical lid procedures. Taking into account the considerable risk of complications with medical and surgical modes of management, scleral GP contact lenses present a less invasive and very effective way to treat patients suffering from the symptoms of paralytic lagophthalmos and exposure keratopathy. 1 Case Report Patient Demographics & History Patient initials: JC Patient age, race, and gender: 50 year old Caucasian female Occupation: Unemployed Personal ocular history: Acoustic neuroma surgery at age 25 resulting in cranial nerve VII damage and permanent right facial paralysis. Gold weights were subsequently implanted in the upper lid. Personal medical history: Acid reflux disease Current medications: Protonix Drug allergies: None Family ocular history: Unremarkable Family medical history: Arthritis, cancer Other notes: N/A Examination Findings Visit # 1 of 6 Date of Examination 8/1/2012 Referral? Yes No Chief Complaint/Purpose of Visit: Constant severe dryness OD Entering vision: Uncorrected Glasses Contact Lenses Other OD -3.75-0.50x008 (VA 20/200) OS -4.75-1.00x145 (VA 20/15) Refraction: OD -3.75-0.50x008 (VA 20/200) OS -4.75-1.00x145 (VA 20/15) Pupils: PERRL (-)APD Extraocular Muscles: Full OU 2 Anterior Segment OD OS Ptosis due to gold weight Lids/Lashes Gr 1+ plugged glands implant, lagophthalmos, Gr 2+ plugged glands Gr 2 hyperemia Bulbar Conjunctiva Unremarkable Unremarkable Palpebral Conjunctiva Unremarkable Gr 1 engorged vessels Sclera Gr 1 engorged vessels Gr 4+ staining and Cornea Gr 1+ arcus keratinization inferiorly (Figure 1), Gr 1+ arcus Deep and quiet Anterior Chamber Deep and quiet Flat, blue Iris Flat, blue Gr 1+ nuclear sclerosis Lens Gr 1+ nuclear sclerosis Figure 1 – Severe staining with sodium fluorescein and Wrattan filter Intraocular Pressure: Goldmann Tonopen NCT Other OD 18 mmHg OS 17 mmHg at 4:07 PM Visual Field: OD Full OS Full Type: Confrontation VF Dilation drops? Yes No 3 Posterior Segment OD OS Distinct margins, choroidal Optic Nerve Distinct margins, choroidal crescent crescent 0.30H/0.30V C/D 0.50H/0.50V Present Foveal Reflex Present Flat, even, avascular Macula Flat, even, avascular Unremarkable Posterior Pole Unremarkable Normal caliber Vasculature Normal caliber Unremarkable Periphery Unremarkable Unremarkable Vitreous Unremarkable Additional Testing Figure 2 - Medmont Corneal Topography Showing Irregular Astigmatism OD and Regular With-the-rule Astigmatism OS 4 Assessment: 1. Exposure keratopathy OD 2. Irregular astigmatism secondary to corneal keratinization OD (Figure 2) 3. Glaucoma suspect based on asymmetric C/D Plan: 1-2. Return in 1 week to initiate scleral lens fitting OD to improve both ocular comfort and vision 3. Refer for glaucoma work-up Contact Lens Fitting Visit # 2 of 6 Date of Examination 8/8/2012 Chief Complaint/Purpose of Visit: Scleral lens fitting Entering Vision: Uncorrected Glasses Contact Lenses Other OD -3.75-0.50x008 (VA 20/200) OS -4.75-1.00x145 (VA 20/15) Anterior Segment Notes: OD No change from visit 1 OS No change from visit 1 Trial Lens Design: Jupiter Standard Scleral Length of time trial lens settled before fit assessment: 30 minutes OD Trial # 1 of 1 OS 41.00 (8.23) Base Curve N/A N/A Sagittal Depth N/A 18.2/8.2 Diameter/OZ N/A -1.50 Power N/A Standard Peripheral Curves N/A Modified: 300 um apical clearance, Fit Description N/A full limbal clearance, trace edge lift at the 3 o’clock and 9 o’clock lens margins, and no blood vessel blanching -7.50 Over-Refraction N/A 20/40 VA N/A 5 Ordered Lens Design: Jupiter Standard Scleral OD Lens Order OS 41.00 (8.23) Base Curve N/A N/A Sagittal Depth N/A 18.2/8.2 Diameter/OZ N/A -4.75 Power N/A Standard Peripheral Curves N/A Modified:Steepen PC4 Boston XO Material N/A Assessment: Ordered first scleral lens OD. Since the patient wanted to continue to wear her current spectacles over the contact lens to protect her eyes, the contact lens power that was ordered was adjusted to compensate for her spectacle lens power. The fourth peripheral curve was steepened slightly due to the edge lift noted with the trial lens. Plan: Return in 2 weeks for scleral lens dispense and training. 6 Visit # 3 of 6 Date of Examination 8/24/12 Chief Complaint/Purpose of Visit: Scleral lens first dispense and training Entering Vision: Uncorrected Glasses Contact Lenses Other OD -3.75-0.50x008 (VA 20/200) OS -4.75-1.00x145 (VA 20/15) Lens Design: Jupiter Standard Scleral OD OS 41.00 (8.23) Base Curve N/A N/A Sagittal Depth N/A 18.2/8.2 Diameter/OZ N/A -4.75 Power N/A Standard Peripheral Curves N/A Modified:Steepen PC4 Boston XO Material N/A 300 um apical clearance, Fit Description N/A full limbal clearance (Figure 3) with no vessel blanching and good scleral alignment (Figures 4a-4d) 20/40+2 VA N/A +0.25 (20/30) Over-Refraction (VA) N/A Anterior Segment Notes: OD No change from visit 2 OS No change from visit 2 Application and Removal Successful? Yes No Dispense Lenses? Yes No Solution Recommended for Cleaning/Disinfection/Storage: Boston Simplus Solution Recommended for Filling Lens: Unisol 4 Additional Instructions to Patient: N/A New Lens Order? Yes No Lens Design: N/A OD Lens Order OS N/A Base Curve. N/A N/A Sagittal Depth N/A N/A Diameter/OZ N/A N/A Power N/A N/A Peripheral Curves N/A N/A Material N/A 7 Figure 3 – Scleral lens filled with sodium fluorescein showing corneal and limbal clearance Figures 4a-4d—Proper alignment of the contact lens with the sclera in all quadrants Assessment: Good initial comfort, fit, and vision with scleral OD. Plan: Dispensed scleral to patient. The patient was instructed on proper cleaning regimen and to allow for an adaptation period when first wearing this lens—starting with 6 hours gradually increasing wear time until full-time wear was achieved. The patient was also told not to sleep in the lens, so in order to continue to provide corneal protection, JC used a lubricating ointment for her right eye before bedtime. Return for 2 week follow-up appointment. 8 Visit # 4 of 6 Date of Examination 9/7/2012 Chief Complaint/Purpose of Visit: 2 week scleral lens follow-up. Patient reports significant subjective improvement in dryness symptoms and vision OD. Entering Vision: Uncorrected Glasses Contact Lenses Other OD Scleral with overlay glasses (VA 20/20-) OS Glasses (VA 20/15) Average Comfortable Wearing Time: 12 hours Wearing Time On Day of Visit: 4 hours Lens Design: Jupiter Standard Scleral OD OS 41.00 (8.23) Base Curve N/A N/A Sagittal Depth N/A 18.2/8.2 Diameter/OZ N/A -4.75 Power N/A Standard Peripheral Curves N/A Modified:Steepen PC4 Boston XO Material N/A 200 um apical clearance, Fit Description N/A full limbal clearance, no vessel blanching and good scleral alignment, some mucus strands on surface 20/20- VA N/A +0.25 (No improvement) Over-Refraction (VA) N/A Anterior Segment Notes: OD Improvement in corneal staining from Gr 4+ to Gr 3. Also improvement in ptosis as scleral acts as crutch for upper lid (Figure 5a-b). Otherwise, no changes from visit 3. OS No change from visit 3 Dispense Lenses? Yes No N/A Additional Instructions to Patient: N/A New Lens Order? Yes No Lens Design: N/A OD Lens Order OS N/A Base Curve. N/A N/A Sagittal Depth N/A N/A Diameter/OZ N/A N/A Power N/A N/A Peripheral Curves N/A N/A Material N/A 9 Figure 5a - Eye without scleral (left) Figure 5b – eye with scleral showing improvement in ptosis (right) Assessment: Improved vision and comfort with scleral lens OD. Plan: Continue with current OD lens, and discussed with patient that improvement in vision likely due to improved corneal staining. Patient can use rewetting drops over scleral or remove lens to clean as needed. Patient should continue to use ointment at night. Return in 2 months for progress check. 10 Visit # 5 of 6 Date of Examination 11/9/2012 Chief Complaint/Purpose of Visit: 2 month scleral lens progress check. Patient reports continued good comfort and vision. Entering Vision: Uncorrected Glasses Contact Lenses Other OD Scleral with overlay glasses (VA 20/20-) OS Glasses (VA 20/15) Average Comfortable Wearing Time: 12 hours Wearing Time On Day of Visit: 6 hours Lens Design: Jupiter Standard Scleral OD OS OS 41.00 (8.23) Base Curve N/A N/A Sagittal Depth N/A 18.2/8.2 Diameter/OZ N/A -4.75 Power N/A Standard Peripheral Curves N/A Modified:Steepen PC4 Boston XO Material N/A 200 um apical clearance, Fit Description N/A full limbal clearance, good scleral alignment except some mild blanching over shallow temporal pinguecula 20/20- VA N/A Plano (No improvement) Over-Refraction (VA) N/A Anterior Segment Notes: OD Improvement in corneal staining from Gr 3 to Gr 2 (Figure 6), otherwise no change from visit 4 OS No change from visit 4 Dispense Lenses? Yes No N/A Additional Instructions to Patient: N/A New Lens Order? Yes No Lens Design: N/A OD Lens Order OS N/A Base Curve.