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E W FEATURE 56 by Vanessa Caceres EyeWorld Contributing Writer Low infection rate with therapeutic silicone hydrogel BSCLs Patient selection and education are key to successful treatment T herapeutic bandage soft contact lenses (BSCLs) are used frequently for many purposes, including pain relief, enhanced corneal epithelial healing, and wound stabi- lization. But how common is microbial keratitis with newer silicone hydro- gel BSCLs? The rate is actually quite low; however, prophylactic antibiotics do not fully remove the risk for micro- bial keratitis in patients with silicone hydrogen BSCLs, according to a report in the September 2013 issue of Eye & Contact Lens. 1 Study investigators, led by Arvind Saini, MD, Eye Associates of Southern California, Temecula, Calif., performed a retrospective case series in 74 patients from the cornea service at Wills Eye Hospital. The pa- tients were treated with therapeutic BSCLs between 2006 and 2009 for complicated ocular surface disease. There were 102 intervals of BSCL use identified among the patients. The study's primary outcome measure was infection while wearing a BSCL; when this occurred, it was d efined as suspected microbial ker- atitis. Investigators collected all in- formation related to disease process, duration of contact lens placement, lens change frequency, lens type, epithelial defections, prophylactic topical antibiotic use, and topical steroid use. The majority of patients had b een placed in either an Acuvue Oasys (Johnson & Johnson Vision Care, Jacksonville, Fla.) or Focus Night & Day (CIBA Vision, Duluth, Ga.) lens. Examining the results When analyzing the patients, inves- tigators found a range of diseases for which the BSCLs were used, includ- ing post-penetrating keratoplasty, pseudophakic bullous keratopathy, neurotrophic disease, band keratopa- thy, epithelial basement membrane dystrophy, and others. The BSCLs were used for thera- peutic treatment only if other treat- ment modalities did not work. Seventy-three percent of the BSCL treatment intervals were treated with prophylactic topical antibiotics, with quinolones used in 92% of the cases. Antibiotics were used most often with neurotrophic and pseudophakic bullous keratopa- thy; however, antibiotic use particu- larly increased during intervals with epithelial defects. "Overall, 88% of BSCL intervals with [epithelial de- fects] were treated with antibiotic prophylaxis," Dr. Saini and co-inves- tigators wrote. The average BSCL wear time was 96 days. The average number of lens replacements was 2.6. Patients with epithelial basement membrane dys- trophy wore BSCLs for the shortest average interval, while those with post-penetrating keratoplasty or pseudophakic bullous keratopathy wore BSCLs for the longest length of time. Investigators identified two episodes of microbial keratitis in their study, one in a patient with recurrent corneal erosions and the other with limbal stem cell defi- ciency. Interestingly, both patients had epithelial defects and were on s teroids, but both patients also were on topical antibiotics. The results indicated an overall 2% rate of microbial keratitis and a 4.3% increased rate of microbial ker- atitis with antibiotics and steroids, although the latter was not statisti- cally significant compared to inter- vals without steroids and antibiotics. Clinical implications It is notable how few patients devel- oped microbial keratitis when you consider their ocular condition, Dr. S aini said. "These were patients who had been treated with more conser- vative therapy first. However, due to persistent epithelial defects or ocular surface pain, we were forced to at- tempt therapy with bandage soft contact lenses," Dr. Saini said. "So, all the patients had a poorly func- tioning ocular surface to start, and one could theorize that they were at a higher risk for infection." Still, patients wore their lenses for weeks or even months without infection. W. Barry Lee, MD, Eye Consult- ants of Atlanta/Piedmont Hospital, Atlanta, praised the investigators for examining a little-studied area within ophthalmology. "This study emphasizes that microbial keratitis can occur when using this treatment regardless of antibiotic prophylactic use, thus counseling and close follow-up are paramount for this treatment option," he said. Still, therapeutic BSCLs are usu- ally appropriate for many patients. "Clinically, I think this paper should make physicians cautious when using the triple therapy of steroid, bandage contact lens, and antibiotics, but this can be necessary in some situations, especially in the immediate postoperative period," said Melissa B. Daluvoy, MD, Department of Ophthalmology, Duke University, Durham, N.C. People with younger, healthy eyes with a straightforward corneal abrasion and a lot of pain can do well with a bandage contact lens. "They typically heal quickly, and the contact is only needed for a few days and makes them feel substantially more comfortable," Dr. Daluvoy said. S he is more apt to worry about noncompliant patients who are not able or willing to return for follow- up appointments. "The easy answer to which patients you should take a cautious approach with is 'everyone,' but in particular those with an impaired surface and weakened defense sys- t ems of the eye, which are found in limbal stem cell diseases like Stevens Johnson syndrome, ocular cicatricial pemphigoid, and burns," Dr. Daluvoy said. Dr. Lee agreed that BSCLs can be a useful treatment for ocular surface diseases with a breakdown of the corneal epithelium and associated p ain in the absence of known infec- tion. However, he does not like to use them for the treatment of pain from an infectious corneal ulcer and also sees them as more risky in severe ocular surface disease. "I agree with the authors to use antibiotic prophylaxis when an ep- ithelial defect is present, and when BSCLs are used for pain in the ab- sence of an epithelial defect, antibi- otic use can be more judicious," Dr. Lee said. Dr. Lee said that tarsorrhaphy is still the gold standard of treatment for persistent epithelial defects, neurotrophic keratopathy, and neuroparalytic keratitis. In those cases, BSCLs should only be a tem- porizing treatment option, he said. It's also crucial for practitioners to explain to patients any infection risk and signs of an infection with a BSCL, Dr. Saini said. EW Reference 1. Saini A, Rapuano CJ, Laibson PR, Cohen EJ, Hammersmith KM. Episodes of microbial keratitis with therapeutic silicone hydrogel bandage soft contact lenses. Eye & Contact Lens. 2013;39:324-328. Editors' note: The physicians have no financial interests related to this article. Contact information Daluvoy: missydaluvoy@gmail.com Lee: wblee@mac.com Saini: asaini2@hotmail.com February 2011 Corneal infections February 2014 AT A GLANCE • A recently published study examined rates of microbial keratitis in patients with ocular s urface disease who had used therapeutic silicone hydrogel b andage soft contact lenses. • The study found a low rate of infection; of 102 intervals of use, only two patients developed m icrobial keratitis. Both patients had used antibiotics as well as topical steroids. • Although microbial keratitis rates were low, the study indicates the importance of patient selection for therapeutic bandage contact lenses, discussing with patients any signs of infection, and considering tarsorrhaphy when appropriate in patients with persistent epithelial defects. 56-68 Feature_EW February 2014-DL2_Layout 1 1/30/14 10:44 AM Page 56