|Year : 2020 | Volume
| Issue : 1 | Page : 3-8
The Use of Bandage Contact Lens for Epithelial Healing in Corneal Epithelial Defect
Miratasya Zulkarnaen, Umar Mardianto MD
Faculty of Medicine Universitas Indonesia, Ophthalmology Department, Dr. Cipto Mangunkusumo Kirana Hospital, Jakarta, Indonesia
|Date of Submission||25-Nov-2019|
|Date of Decision||26-May-2020|
|Date of Acceptance||31-May-2020|
|Date of Web Publication||07-Sep-2020|
Jl. Kimia no. 8, Jakarta, 10320
Source of Support: None, Conflict of Interest: None
Context:Corneal epithelial defect cause pain that leads to significant subjective complain, severe morbidity, and medical leave. Management of uncomplicated corneal epithelial defect using bandage contact lens (BCL) has many advantages compare to the pressure patching (traditional treatment). The use of BCL as an alternative therapy in uncomplicated epithelial defect is not yet declare as a standard protocol of treatment. Aims: To evaluate the efficacy of bandage contact lens use in patients with corneal epithelial defect compared to pressure patching in term of level of comfort, visual acquity, and wound healing period. Methods and Material: The literature search was conducted from online database. All relevant studies were reviewed based on Level of Evidence developed by Oxford Centre for Evidence-based Medicine Levels of Evidence 2011. The articles were divided into baseline characteristics and outcomes table. Details regarding the author, year of publication, level of evidence, number of samples, age, gender, follow up duration were recorded. Results: Six out of seven studies concluded that BCL is the better treatment for corneal abrasion due to trauma or related to ocular surface surgery. Four systematic reviews did not recommend pressure patching as corneal epithelial defect treatment. Conclusions: BCL was found to be superior in treating corneal abrasion compared to pressure patching. The BCL group showed significantly faster healing time, pain level reduction, and epithelial defect size reduction compare to the pressure patching group.
Keywords: Bandage contact lens, corneal epithelial defect, pressure patching
|How to cite this article:|
Zulkarnaen M, Mardianto U. The Use of Bandage Contact Lens for Epithelial Healing in Corneal Epithelial Defect. Niger J Ophthalmol 2020;28:3-8
Bandage contact lens was proven to be superior in treating corneal abrasion compared to the traditional pressure patching. The BCL outcome shows faster healing time, and lower pain level in the reduction of epithelial defects compare to the pressure patching group.
| Introduction|| |
The bandage contact lens (BCL) can be used for an uncomplicated corneal epithelial defect, as it prevents direct contact between cornea and eyelid thereby protecting the corneal epithelium underneath, speeding up the healing process, and reducing pain.
The use of BCL as an alternative to conventional therapy is not established, as there is no protocol of treatment up until now. This study aimed to compare the efficacy of BCL with pressure patching, the patient’s level of comfort and pain, and the visual acuity in two groups.
| Subjects and Methods|| |
The literature search was conducted from online database which include Clinical Key, Pubmed and Ophthalmology Advance (Ophsource) using various combination of term.
The search was limited to articles with human sample and that published in English. If the full text articles were not available online, manual search in the Central Library and Department of Ophthalmology Library Faculty of Medicine University of Indonesia were conducted. Reference list from the included studies was also checked for potentially relevant articles.
Study selection and criteria
In the beginning of articles selection process, abstracts were evaluated to choose affiliated articles that represent the study purposes, based on keywords stated above. Full-text articles related to the adopted abstracts were then screened based on the inclusion and exclusion criteria. Inclusion criteria were all studies analysing soft bandage contact lens on corneal epithelial defect. Exclusion criteria were all studies with no data of corneal epithelial defect and untraceable full-text articles, articles not in English, animal subject, single case reports, disease treated concomitantly with multiple medications, disease with unsuccessful prior treatment, disease with the presence of infection sign, inaccessible journal, non-ophthalmology journal, and review articles were excluded.
We included patients with corneal epithelial defect that never been treated before, to our study. All relevant studies were reviewed based on Level of Evidence developed by Oxford Centre for Evidence-based Medicine Levels of Evidence 2011. The trials included in this review is the level of evidence of IV or higher.
Data processing and presentation
The extracted information was processed through a data sheet. The articles were divided into baseline characteristics and outcomes table. Details regarding the author, year of publication, level of evidence, number of samples (eyes), age, gender, follow up duration were recorded. The outcome of this review include the corneal abrasion reduction size, the pain scale, medical leave days, residual of corneal opacities, the number of usage of analgesic due to pain.
| Results|| |
We identified 424 articles from the keywords, and 417 were excluded: 307 were duplicates, 85 used animals as subjects, and 25 were non-English articles. There were seven studies reviewed in this paper, published between year 1987 and 2014. Number of the samples vary from the smallest by Buglisi et al. with total patients of 15, to the largest group with a total of 63 patients by Daglioglu et al. [Table 1]. Majority of the studies were randomized control trials (six studies), and one case series. Five studies focused on the use of BCL on traumatic corneal abrasion, while the other two studies focused on the use of BCL after corneal surface-related surgery.
In the traumatic corneal abrasion group with randomized control trial method and the corneal surface related surgery group, the pressure patching was the control variable. The baseline characteristics of each group are summarized in [Table 2].
The baseline characteristics between the PP and BCL from all of these studies were similar, in the study that conducted among subject with corneal abrasion due to trauma, Buglisi et al. had the youngest participant age range 25.75 ± 4.2 years, this is a case report study with USA soldiers in Afghanistan as the subject, meanwhile the oldest participant was found on the Acheson et al. study with subject’s age range 38.28 ± 5.77 years old. In the group that focused on the corneal surface-related surgery there was certain gap on the age between these two studies, the study by Daglioglu et al. had the younger participants (42.66 ± 5.58 years old) compare to the study by Chen et al. (69 ± 13 years old). There are four studies that provide the gender data, these studies showed that male was the dominating gender with ratio ±2:1 compare to female.
There were four studies that recorded the initial size of the epithelial defect, the biggest defect was found on the study by Triharpini et al. with epithelial defect size 27.25 ± 17.5 mm2, the smallest defect was found on Menghini et al. study with epithelial defect size of 3.6 ± 3.4 mm2. The initial pain level was also recorded by three studies with different pain scale tools.
The outcome of these studies is the reduction of the epithelial defect size and the decrease level of the pain that the patients experienced due to the corneal epithelial defect because of trauma or after corneal surface-related surgery. There are three studies that recorded the epithelial defect size reduction by comparing the size of the initial visit and 24 hours after therapy, two out of three studies were conducted in randomized control trial method. Study by Menghini et al. showed there is no significant difference in the reduction of corneal abrasion size and pain level in pressure patching group compare to the BCL group, yet this study also stated that the preference of using either pressure patching or BCL is depended on the patient and their threshold of pain. Triharpini et al. reported a significant difference on the reduction of the size of the corneal defect and the pain level between two groups, this result contradicted the result of the Menghini et al. Triharpini et al. also subtracted the reepithelization time, in the pressure patching group it shows that the percentage of total healing in 24 hours is 62.5%, meanwhile in BCL group it is slightly smaller, 56.25%, yet in the next 72 hours, all of the subject on the BCL group had regained complete healing meanwhile in pressure patching group there are 25% of patient who had not totally healed. This showed the ability of reepithelization time of 72 hours was bigger in the BCL group. The reduction level of the pain is also significantly different between these two groups as the BCL provided immediate comfort after application.
Buglisi et al3 who conducted their research on battle field environment reported the average reduction size of the epithelial defect was ± 6.7 mm2, he reported this result as a satisfactory achievement as it helped the soldiers as they went back to the battle field immediately. Buglisi et al. also reported that more than half of the subject regained their complete corneal healing on the first 24 hours, meanwhile the rest was resolved in 48 hours. The VAS was also decreasing from average 6.26 at the initial trauma time to 1.8 after application of bandage lens.
Donnenfield et al7and Acheson et al6 also supported the positive result of the application of BCL compare to pressure patching. Both of these studies stated that the average days required for the cornea to heal were faster on the BCL group. The pain that the subject experienced was also better on the BCL group.
| Discussion|| |
Corneal abrasions are superficial defects of the epithelium of the cornea. This condition happens mostly due to mechanical injuries to the cornea, it could also occur due to corneal surface-related surgery, such as pterygium removal surgery, keratoplasty, photorefractive surgery, photorefractive keratectomy, laser assisted in situ keratomileusis and so on., According to data in one eye hospital in Hong Kong, corneal abrasion was ranked as the eight most common eye condition that brings people to the emergency room. Corneal foreign bodies are also often associated with corneal abrasions as, once removed, an epithelial defect remains. Corneal abrasion can leads to significant morbidity and lost productivity. A major United States automotive corporation found an annual incidence of 15 eye injuries per 1000 employees, with one third of workers unable to resume normal duties for at least one day. In this systematic review we looked at seven articles and five of them discussed treatment outcomes between pressure patching and BCL in corneal abrasion due to trauma, the other two reviewed studies had similar outcome with different condition, they focused on corneal abrasion after corneal related surgery.
Up until now there is no standard protocol for corneal abrasion treatment.,, It is a global condition that depends on the clinical judgement and the facility of the eyecare center. The traditional way of treatment was pressure patching with antibiotic eye ointment or eyedrop. There were some systematic reviews that did not recommend pressure patching as corneal abrasion treatment. The most recent systematic reviewed by Lim et al. conducted in 2016 concluded that patching the eye is not useful for the treatment of simple traumatic abrasions. They reviewed 12 studies from the year 1960 to 2013, where antibiotic eyedrops were used as the control group. The outcome that they measured was similar to this literature review, which is epithelial healing time and level of pain.
Lim et al. study was only stressing the effect of pressure patching that restated the conclusion from the three previous review studies that were done by Flynn et al. in 1998, Yamada et al. in 2001 and Turner and Rabiu in 2009. Our reviews are one of the effort to seek other better technique to treat corneal abrasion by using popular bandage lens.
The pressure patching is believed to promote corneal healing, by limiting eyelid blinking so that the wound healing cascade, especially the migration of the healthy epithelia to cover the defect will not be interrupted by the blinking eye. It is also believed to relieve pain, as the pressure patch would put the affected eye to rest.
In all of seven studies reviewed, every treatment arm used the application of antibiotic eyedrop or eye ointment from different classes such as ofloxacin, levofloxacin, ciprofloxacin, polymixine B sulfate/trimethoprim sulfate, combination of polymyxin B + neomycin + garamicidin.,,,,,, Topical antibiotic application is a must as a prophylaxis to infiltration and infection of the cornea with microbes.,
Six out of seven studies concluded that BCL is a better treatment for corneal abrasion due to trauma or related to ocular surface surgery. One of the most debated issue is the oxygenation that will be needed during corneal healing, Triharpini et al. stated that one of the disadvantages of pressure patching was the reduction of corneal oxygenation that is important during the healing process. The adequate oxygenation is vital.,,, Triharpini et al. used the Senofilcon A, a type of silicon hydrogel BCL with 38% water content and oxygen permeability of 107 Dk and oxygen transmissibility of 147 Dk/t. The clinical manual of contact lenses book recommend Senofilcon A for 2 weeks., The most used lens in this study was the Balafilcon A, a silicon hydrogel with water content 36% and oxygen permeability of 91 Dk and oxygen transmissibility of 130 Dk/t, this lens were used in study by Menghini et al., Daglioglu et al., and Chen et al. and recommended for monthly use. The other lens was Etafilcon A that was used by Donennfield et al. with 58% water content and 28 Dk oxygen permeability and oxygen transmissibility of 20 Dk/t13. The use of Etafilcon A is maximum for 1-2 weeks duration. Another one was Ocufilcon D that used by Buglisi et al3 which has 55 % of water content and 19.7 Dk oxygen permeability and oxygen transmissibility 20 Dk/t. The Ocufilcon Dcan be used for 1-2 weeks duration. We couldn’t retrieve any information about the BCL that was used in the Acheson et al. study. The high oxygen permeability will make sure that the anoxia of corneal do not happen, hence helping the corneal healing cascade.,
The U.S Food and Drug Administration (FDA) classifies soft contact lenses into four groups for the U.S. Market according to the water content percentage and the ionic status. Senofilcon A is classified as group A which is low water percentage with nonionic polymer, Balafilcon A is classified as group 3 with low water with ionic polymer, Etafilcon A and Ocufilcon D is in group 4, high water with ionic polymer. Each group has its own advantages and disadvantages. Contact lens with higher water contents, higher Dk and higher Dk/t can be used for a longer duration. In this study we can see that senofilcon A and balafilcon A can be used longer (extended use) compare to etafilcon A and ocufilcon D (short time use). Unfortunately, senofilcon A and balafilcon A were cost higher, one senofilcon A or balafilcon A equal to three etafilcon A or two oculofilcon D.,
In these seven studies, the fastest follow up was done by Menghini et al5 that measure the pain after 3 hours of treatment from both arms, this study was the only study that contradicted the other six. This study had the fourth highest number of sample, this study focused on corneal abrasion due to trauma with the size of relatively small size of abrasion (4.2 ± 4.0 mm2) compare to the study by Triharpini et al. (27.2 ± 17.5 mm2) and Buglisi et al. (8.5 ± 8,39 mm2), this discrepancy between studies could actually be the reason why the study by Menghini et al. did not find a significant different between both arms of treatment. In the study by Triharpini et al. the abrasion size on both arms were significantly different after 24 hours. The BCL arm had an average of 17.75 mm2 abrasion healing compared to the pressure patching group that had 10.50 mm2 abrasion healing size in 24 hours. Buglisi et al3 also showed significant healing based on the reduction of epithelial abrasion size to ± 6.7 mm2 in 24 hours after BCL application.
When it comes to the pain level, most of the studies use visual analogue scale for measurement. Menghini et al. also stated no significant different between pain level on both arms, they stated in their study this could also related to the small size of abrasion. Menghini et al. also stated that their limitation on their study was the small sample number and the size of the corneal wound. On their pressure patching group, most of the subject complained about their disturbed binocular vision and uncomfortable pressure of the patch, yet it did not affect the pain level. In the study by Buglisi et al., the soldiers favour the usage of BCL because it helped them with the pain, it is documented on the VAS scale at the initial visit which is 6.26 on average that decreased to 1.8 on average after the application of BCL.3
Donnenfeld et al.7] and Acheson et al. measure the efficacy of BCL by documenting the average number of days that required to heal completely. Both studies favoured the BCL arm treatment. Donnenfield et al6 also stated that the pain reduction was higher on the BCL group.
Both of these studies stated that the limitation of both of these studies were the number of the subject, they also did not provide the data of the initial epithelial defect size. One of the reason why they did not provide the initial epithelial defect sixe data was due to the cost of the bandage lens and the complication.,
In the study by Donnenfeld et al., they found one patient from the BCL arm that experienced corneal ulcer, in the study by Buglisi et al. they also experienced the same, two patients with corneal ulcer, they explained this condition happened due to the unhygienic environment on the battle field that increase the chance of infection. There are several disadvantage of bandage contact lens use for example deposit formation that could lead to giant pupillary conjunctivitis, greater chance of bacterial contamination that increased with noncompliance, problem with oxygen transmission with hydrogels lenses and limited durability, that is why when a physician decided to use BCL the benefit need to be always bigger than the risk, the usage of BCL needs a strict follow up. Secondary infection is the most unwanted complication that could lead to permanent disability, the usage of bandage lens will increase the chance of infection if it is not well monitored and properly used. Infection and other complication could also occur if the patients do not follow the factory or doctor’s instruction.
Both of this study stated, even though they favoured the BCL arm, the use of this particular treatment is very dependent on the patients. According to the clinical manual and contact lenses book, the usage of BCL was very dependent on the subject individually. The ability to keep the schedule on time of putting antibiotic eyedrop, hygiene issue, the ability to come on strict follow up, and the necessity to have clean environment are few education pearls that needed to be informed to the patient.1
The studies by Chen et al. and Daglioglu et al. that specifically focused on the treatment of corneal abrasion after pterygium removal showed a significant result on the average time to heal and the reduction of pain. The Daglioglu et al4 stated that the average time to heal after the pterygium removal on BCL arm was 48 hours, this was faster compared to Chen et al. that was approximately 93 hours. This was most likely related with the size of the original abrasion, both studies did not mention the size and the location of the pterygium (if it was double head or single head pterygium). The bigger the size of the pterygium, the more abraded the cornea was, hence the longer the healing time will be. In the study by Triharpini et al., they stated that the position of the corneal erosion and the depth of the erosion is an important factor that will determine the healing process. None of these studies mention the position or the depth of the erosion. If the erosion placed centrally, it will heal longer than the one placed peripherally due to the closer distance to the limbus and its stem cell. This factor needed to be documented and calculated for further study.
At this moment there are several theory of other adjunct therapy that will speed up the corneal epithelial healing, such as the consumption of high vitamin C to help promoting the healing process by providing sufficient amount of anti-oxidant and the use of artificial tears accompanied by antibiotic eyedrops. None of this adjunct therapy is used in the seven studies that were discussed above.
| Conclusion|| |
Bandage contact lens was proven to be superior in treating corneal abrasion compared to the traditional pressure patching technique. The outcome shows the healing time, epithelial defect size reduction was significantly faster and bigger compared to the pressure patching group. The other outcome was the pain level that significantly decreased on the initial installment of BCL on the injured eyes. The downside of the BCL is the complication, it requires strict follow up and cooperative patient with good hygiene insight to prevent further infection, another downside is the price. Further study should be conducted more specifically mentioning the position, the depth, and the size of each corneal abrasion before treatment. Another study also need to be conducted in order to make a clinical guideline regarding the treatment of corneal abrasion with BCL. We recommend the use of BCL on patient with corneal abrasions, for the relatively bigger wound, as documented on Triharpini et al. study, the application of BCL is preferably use for a longer duration (extended use), for the smaller abrasions we can use short duration (1-2 weeks duration) BCL that comes with lower price compared to the extended use.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
White PF, Scott CS. Contact lenses. In: Yanoff M, Duker JS. Ophthalmology. 4th ed. Philadephia: Elsevier Saunders; 2014. p. 52-6.
Buglisi JA, Knoop KJ, Levsky ME, Euwema M. Experience with bandage contact lenses for the treatment of corneal abrasions in a combat environment. Military Medicine 2007;172:411-3.
Daglioglu Coskun M, Ilhan N, Tuzcu EA, Ilhan O, Keskin U et al.
The effects of soft contact lens use on cornea and patient’s recovery after autograft pterygium surgery. Contact Lens & Anterior Eye 2014;37:175-7.
Menghini M, Knecht PB, Kaufmann C, Kovacs R, Watson SL, Landau K et al.
Treatment of traumatic corneal abrasions: a three-arm, prospective, randomized study. Ophthalmic Research 2013;50:13-8.
Triharpini NN, Gede JIW, Handayani AT, Widiana IG. Comparison between bandage contact lenses and pressure patching on the erosion area and pain scale in patients with corneal erosion. Asia-Pacific Journal of Ophthalmology 2015;4:97-100.
Donnenfield XX, Selkin BA, Perry HD, Moadel K, Selkin GT, Cohen AJ et al.
Controlled evaluation of a bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating traumatic corneal abrasions. Ophthalmology 1995;102:979-84.
Acheson XX, Joseph J, Spalton DJ. Use of soft contact lenses in an eye casualty department for the primary treatment of traumatic corneal abrasions. British Journal of Ophthalmology 1987;71:285-9.
Chen X, Lian Y, Li J, Ma Y, Shen M, Lu F. Monitor corneal epithelial healing under bandage contact lens using ultrahigh-resolution optical coherence tomography after pterygium surgery. Eye & Contact Lens 2014;40:175-80.
Scott R. The injured eye. Philosophical Transactions of the Royal Society B: Biological Sciences 2011;366:251-60.
Tomás-Juan J, Murueta-Goyena Larrañaga A, Hanneken L. Corneal regeneration after photorefractive keratectomy: a review. Journal of Optometry 2015;8:149-69.
Vaziri K, Schwartz SG, Flynn HW, Kishor KS, Moshfeghi AA. Eye-related emergency department visits in the United States. 2010. Ophthalmology 2016;123:917-9.
Stepp MA, Zieske JD, Trinkaus-Randall V, Kyne B, Pal-Ghosh S, Tadvalkar G et al.
Wounding the cornea to learn how it heals. Experimental Eye Research 2014;121:178-93.
Katzman LR, Jeng BH. Management strategies for persistent epithelial defects of the cornea. Saudi Journal of Ophthalmology 2014;28:168-72.
Lim CHL, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database of Systematic Reviews 2016.
Flynn CA, DAmico F, Smith G. Should we patch corneal abrasions? A meta-analysis. Journal of Family Practice 1998;47:264-70.
Yamada M, Kawai M, Mashima Y. Treatment of corneal erosions. Folia Ophthalmologica Japonica 2001;52:911-6.
Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database of Systematic Reviews 2004.
Sun Y-Z., Guo L, Zhang F-S. Curative effect assessment of bandage contact lens in neurogenic keratitis. International Journal of Ophthalmology 2014;7:980-3.
Farjo AA, Brumm MV, Soong HK. Corneal anatomy, physiology and wound healing. In: Yanoff Duker JS. Opthalmology. 4th ed. Philadelphia: Elsevier Saunders 2014. p. 163-7.
Hui A. Contact lenses for ophthalmic drug delivery. Clinical and Experimental Optometry 2017;100:494-512.
Henry VA, DeKinder JO. Soft lens material selection. In Bennett ES, Henry VA. Clinical Manual of Contact Lens. 4th Ed. Philadeplhia: Lippincott Wiliams & Wilkins; 2014. p. 251-70.
ER documentation in ophthalmology emergency RSCM. 2017.
[Table 1], [Table 2]