EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/137624
28 EW CORNEA June 2013 BostonSight PROSE treatment expands by Vanessa Caceres EyeWorld Contributing Writer Recent growth leads to greater interest in severe OSD treatment option P atients with severe ocular surface disease (OSD) are often on what seems to be a never-ending quest to relieve symptoms and improve their vision. The BostonSight PROSE treatment—PROSE standing for prosthetic replacement of the ocular surface ecosystem—is one possible treatment avenue for a number of OSD patients. In PROSE treatment doctors custom design and fit prosthetic devices to reduce OSD symptoms and help restore a healthy ocular surface, improve blurry vision, and prevent damage by protecting the cornea against the environment and eyelids, according to the website for the Needham, Mass.-based Boston Foundation for Sight, originator of the treatment. The BostonSight PROSE treatment (known before as the Boston Ocular Surface Prosthesis and the Boston Scleral Lens Prosthetic Device) has seen substantial growth as more research about the lens has been published and as the number of facilities offering BostonSight PROSE treatment has expanded, said Deborah S. Jacobs, MD, medical director, Boston Foundation for Sight. Focusing on growth and research In 1990, authors Oliver Schein, MD, Perry Rosenthal, MD, and Christopher Ducharme published a report of individually fabricated gaspermeable scleral contact lenses for visual rehabilitation in 15 patients, some of whom had ocular surface disease.1 Several hundred patients were fitted in the following decade. Dr. Jacobs said the number of patients treated skyrocketed from 173 in 2005 to almost 1,200 in 2012; in that period the Boston Foundation for Sight developed partner centers. In 2011, the number of new patients treated at partner centers exceeded the 398 treated in Needham, Mass. Dr. Jacobs said that for 2013 the projection is that 468 new patients will be treated in Massachusetts, and several times that number treated worldwide, bringing the total number of patients treated since inception to 5,400. The foundation has partnered with 11 academic centers around the U.S. and four in India and Japan. U.S. locations include Alkek Eye Center in Houston, Wilmer Eye Institute in Baltimore, Bascom Palmer in Miami, Illinois Eye and Ear Infirmary in Chicago, Doheny Eye Institute in Los Angeles, and the Cullen Eye Institute in Houston. Because there are now partner clinics and because the treatment has been around for a longer time period, there are more results to report. For example, a 2012 report in Contact Lens and Anterior Eye focused on the BostonSight treatment for corneal ectasia, which included a record review of 59 new patients seen over six months.2 Investigators reported on topographic indices, change in visual acuity, achievement of satisfactory fit, and the six-month change in Two BostonSight PROSE devices with orange application plunger and blue removal plunger visual function. Of the 89 eyes that qualified for treatment, all were successfully fitted, with 88% confirmed to be still wearing devices at six months. In 4% of eyes the wearing status was unknown, Dr. Jacobs said. The average National Eye Institute Visual Function Questionnaire-25 score improved 27.6 points on a 100-point scale at six months. Investigators concluded that the treatment is an alternative to penetrating keratoplasty in patients with corneal ectasia who cannot tolerate contact lenses. A report in the March 2012 issue of Ophthalmology focused on use of the treatment for severe periorbital thermal injuries.3 Investigators conducted a chart review of 10 patients (16 eyes) who had combat trauma and were treated with the lenses for exposure keratopathy. Ten of the 16 eyes achieved a corrected visual acuity of 20/70 or better, and five had a best corrected visual acuity of 20/40 or better. One eye required a penetrating keratoplasty to treat damage from an original thermal burn. Other recently published research about the lenses has focused on vision and higher-order aberrations, wavefront-optimized correction, and use of the PROSE treatment for other specific conditions, such as neurotrophic keratitis. How others are using the BostonSight treatment Another factor increasing availability is that more insurance carriers are beginning to cover the treatment, which is comparable in cost to that of surgical procedures, Dr. Jacobs said. Each partner clinic is developing plans with its insurance providers for this. Partner clinics that work with the Boston Foundation are reporting overall success with the PROSE treatment, which begins with a nineweek training program provided at the Needham location to prepare clinicians. "Some were skeptical at first, but now our entire corneal faculty utilizes this technology," said Stephen C. Pflugfelder, MD, professor of ophthalmology, Baylor College of Medicine, Houston. "It has been a major advance in the management of severe ocular surface disease and irregular astigmatism. It's a real game changer." Dr. Pflugfelder's clinic treated about 200 patients with the BostonSight in 2012. The clinic has offered the lens for about four years. Clinicians there offer it for severe dry eye, graft-versus-host disease, neurotrophic corneal ulcers, nonhealing corneal epithelial defects, irregular astigmatism from keratoconus, postLASIK ectasia, and post-radial keratotomy. More than 80% of patients respond well to treatment. Michelle Hessen, OD, instructor of ophthalmology, Ocular Surface Disease & Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, has fitted the device for more than a year for similar severe OSD problems like those treated at Baylor. "It's been working well for patients. The wear time varies to some degree per patient, but in general, they seem happy with it," she said. One thing that has helped her determine the right candidates is to begin with a 90-minute consult. Then, the patients wear the device at the hospital for a few hours to see if it reduces their symptoms. For patients who are successful during the one-day trial, about 90% go on to have success with the treatment, Dr. Hessen said. "That first exam is crucial to differentiate which patients this will work for versus patients with neuropathic pain. For the latter type of patients, I inform them that their chances are 50/50. If it's really just nerve pain, the device doesn't always help," she said. Dr. Hessen said her training to customize the device properly was helpful, and the only real learning