NEW PROMISING THERAPEUTIC APPROACH FOR REFRACTORY PERSISTENT EPITHELIAL DEFECTS: A CASE REPORT

Persistent corneal epithelial defects are unable to heal within the usual two-week time span, generally develop in the setting of significant ocular surface disorders and are frequently resistant to conventional therapies. Recently, a custom-designed, gas permeable, fluid-ventilated scleral lens, the PROSE device, has been used as an effective therapy in refractory cases, typically during the daytime. However, the elevated costs and need for specialized manufacture equipment make its use unpracticable in a public health setting. The purpose of this case report is to describe a case of continuous wear of a gas-permeable mini scleral contact lens with a fluid reservoir of autologous serum combined with autologous serum drops, as a successful empirical and accessible alternative therapeutic option for persistent epithelial defects.

Clinical case report of a patient followed in the Ophthalmology Department of Centro Hospitalar Universitário S. João.

A 61-year-old woman with severe dry eye disease and bilateral neurotrophic keratopathy of uncertain etiology, had been followed by cornea specialists from our hospital since 2002. Her past ophthalmological history included 3 penetrating keratoplasties in the left eye (in 2003, 2010 and 2016) and multiple episodes of bilateral persistent epithelial defects over the years, that ultimately responded to conventional treatment. In 2017, the patient developed a refractory neurotrophic ulcer in the right eye, complicated 1 year later with fungal and subsequent bacterial infection and finally managed with a therapeutic penetrating keratoplasty, performed in October 2018. Nevertheless, 2 months later, the patient developed a 6x6mm persistent epithelial defect unresponsive to all traditional therapeutic strategies, including artificial tears and ointments, bandage soft contact lens, autologous serum drops, topical antibiotics, oral tetracyclines, cacicol®-RGTA and nerve growth factors. After months of unsuccessful treatments, we decided to empirically try the use of a gas-permeable mini scleral contact lens with a fluid reservoir of autologous serum in combination with hourly autologous serum drops. The lens was worn continuously for 48h, being removed only for cleaning and replacing the fluid reservoir with new autologous serum. After 2 weeks, the corneal epithelium eventually started to regenerate, and 4 weeks later the cornea was completely epithelized. The continuous usage was then reduced to a 24h period, and there are no signs of recurrence of the epithelial defect, thus far.

This case highlights the potential value of continuous wear of a gas-permeable scleral contact lens combined with autologous serum drops, as a novel and promising alternative approach to conventional treatments for refractory persistent epithelial defects. Notwithstanding, our clinical experience with this empirical approach remains limited and further investigation is required to clinically validate this therapeutic option.