Form-Based Case Report
Name: Pam Satjawatcharaphong
Email: psatjawat@berkeley.edu
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.
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
OD -3.75-0.50x008 (VA 20/200)
OS -4.75-1.00x145 (VA 20/15)
Contact Lenses
Other
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
Ptosis due to gold weight
implant, lagophthalmos,
Gr 2+ plugged glands
Gr 2 hyperemia
Unremarkable
Gr 1 engorged vessels
Gr 4+ staining and
keratinization inferiorly
(Figure 1),
Gr 1+ arcus
Deep and quiet
Flat, blue
Gr 1+ nuclear sclerosis
Lids/Lashes
OS
Gr 1+ plugged glands
Bulbar Conjunctiva
Palpebral Conjunctiva
Sclera
Cornea
Unremarkable
Unremarkable
Gr 1 engorged vessels
Gr 1+ arcus
Anterior Chamber
Iris
Lens
Deep and quiet
Flat, blue
Gr 1+ nuclear sclerosis
Figure 1 – Severe staining with sodium fluorescein and Wrattan filter
Intraocular Pressure: Goldmann Tonopen
OD 18 mmHg OS 17 mmHg at 4:07 PM
Visual Field: OD Full OS Full
Dilation drops? Yes
NCT
Other
Type: Confrontation VF
No
3
Posterior Segment
OD
Distinct margins, choroidal
crescent
0.30H/0.30V
Present
Flat, even, avascular
Unremarkable
Normal caliber
Unremarkable
Unremarkable
Optic Nerve
C/D
Foveal Reflex
Macula
Posterior Pole
Vasculature
Periphery
Vitreous
OS
Distinct margins, choroidal
crescent
0.50H/0.50V
Present
Flat, even, avascular
Unremarkable
Normal caliber
Unremarkable
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
OD -3.75-0.50x008 (VA 20/200)
OS -4.75-1.00x145 (VA 20/15)
Contact Lenses
Other
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
41.00 (8.23)
Base Curve
N/A
Sagittal Depth
18.2/8.2
Diameter/OZ
-1.50
Power
Standard
Peripheral Curves
Modified:
300 um apical clearance,
Fit Description
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
20/40
VA
OS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
5
Ordered Lens Design: Jupiter Standard Scleral
OD
Lens Order
41.00 (8.23)
Base Curve
N/A
Sagittal Depth
18.2/8.2
Diameter/OZ
-4.75
Power
Standard
Peripheral Curves
Modified:Steepen PC4
Boston XO
Material
OS
N/A
N/A
N/A
N/A
N/A
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
OD -3.75-0.50x008 (VA 20/200)
OS -4.75-1.00x145 (VA 20/15)
Contact Lenses
Lens Design: Jupiter Standard Scleral
OD
41.00 (8.23)
Base Curve
N/A
Sagittal Depth
18.2/8.2
Diameter/OZ
-4.75
Power
Standard
Peripheral Curves
Modified:Steepen PC4
Boston XO
Material
300 um apical clearance,
Fit Description
full limbal clearance (Figure
3) with no vessel blanching
and good scleral alignment
(Figures 4a-4d)
20/40+2
VA
+0.25 (20/30)
Over-Refraction (VA)
Anterior Segment Notes:
OD No change from visit 2
OS No change from visit 2
Other
OS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Application and Removal Successful? Yes
No
Dispense Lenses? Yes
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
N/A
N/A
N/A
N/A
N/A
N/A
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
Material
No
OS
N/A
N/A
N/A
N/A
N/A
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
OD Scleral with overlay glasses (VA 20/20-)
OS Glasses (VA 20/15)
Other
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
20/20VA
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
N/A
N/A
N/A
N/A
N/A
N/A
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
Material
OS
N/A
N/A
N/A
N/A
N/A
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
OD Scleral with overlay glasses (VA 20/20-)
OS Glasses (VA 20/15)
Other
Average Comfortable Wearing Time: 12 hours Wearing Time On Day of Visit: 6 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, good
scleral alignment except
some mild blanching over
shallow temporal
pinguecula
20/20VA
N/A
Plano (No improvement)
Over-Refraction (VA)
N/A
O
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
N/A
N/A
N/A
N/A
N/A
N/A
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
Material
OS
N/A
N/A
N/A
N/A
N/A
N/A
11
Figure 6 –Moderate staining with sodium fluorescein over the inferior cornea
Assessment: Continued good vision and comfort with scleral lens OD. The fit remained
acceptable since the blanching over the pinguecula was focal and very mild; it did not cause
any bulbar hyperemia or other adverse effects so no lens parameter changes were needed.
Plan: Continue habitual routine with the scleral lens OD.
Return in 6 months for progress check.
12
Visit # 6 of 6
Date of Examination 5/3/2015
Chief Complaint/Purpose of Visit: 6 month scleral lens progress check. Patient reports
continued good comfort and vision.
Entering Vision: Uncorrected Glasses Contact Lenses
OD Scleral with overlay glasses (VA 20/20-2)
OS Glasses (VA 20/15)
Other
Average Comfortable Wearing Time: 12 hours Wearing Time On Day of Visit: 3 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, good
scleral alignment except
some mild blanching over
shallow temporal
pinguecula
20/20-2
VA
N/A
Plano (No improvement)
Over-Refraction (VA)
N/A
Anterior Segment Notes:
OD Improvement in corneal staining from Gr 2 to Gr 1 (Figure 7), otherwise no change
from visit 5
OS No change from visit 5
O
Dispense Lenses? Yes
No
N/A
Additional Instructions to Patient: N/A
New Lens Order? Yes
No
Lens Design: N/A
OD
N/A
N/A
N/A
N/A
N/A
N/A
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
Material
OS
N/A
N/A
N/A
N/A
N/A
N/A
13
Figure 7 –Mild staining with sodium fluorescein over the inferior cornea near the limbus
Assessment: Continued good vision, comfort and fit with scleral lens OD.
Plan: Continue habitual routine with the scleral lens OD.
Return in 6 months for annual contact lens examination.
14
Discussion
Final Diagnosis: Facial nerve palsy resulting in exposure keratopathy and irregular
corneal astigmatism
Description of ocular disease: Facial nerve palsy is a disorder of cranial nerve VII that
controls movement of the muscles in the face. Damage to this nerve typically causes
unilateral facial weakness or paralysis, though in about 10% of cases the paralysis is
bilateral. Symptoms experienced by the unilateral palsy patient include 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. This condition can result from a number of different etiologies including surgery for
an acoustic neuroma or parotid tumor, but when it is idiopathic it is termed a Bell’s Palsy.
Upon ocular examination afflicted individuals will exhibit a number of signs, including
punctate epithelial erosions of the inferior portion of the cornea, epithelial breakdown,
stromal melting which may lead to perforation, secondary ocular infection, and scarring.
Describe alternative treatment options: Recommended treatment of this condition has
been dependent on the nature of the corneal exposure, and includes a wide range of
options. Conservative management has included palliative treatment with non-preserved
artificial tears throughout the day with a lubricating ointment at night, taping the eyelid
shut, or bandage contact lenses. Medical management that can temporarily improve eyelid
closure has been documented with the use of botulinum toxin injection of the levator
palpebrae muscle. Permanent corneal exposure has been managed with surgical methods,
including tarsorrhaphy, palpebral spring implants, or gold weights inserted in the upper
eyelid. Of the aforementioned methods, gold eyelid weighting continues to be the most
widely used method of management despite a high rate of complications, including poor
cosmesis from visibility of the weight under the skin, migration, extrusion, allergy, and
astigmatism.
Describe final treatment option: Scleral GP contact lenses present a less invasive and
very effective way to treat patients suffering from the symptoms exposure keratopathy by
providing a protective barrier for the entire cornea. It can also improve vision if the cornea
has resultant irregularity from scarring.
Was the patient’s chief complaint resolved? Yes
No
Was the patient fit successfully for at least 3 months? Yes
No
If answer to either of the previous two questions is “No”, please explain why: N/A
15
Conclusion
Facial Nerve Palsy often results in severe dry eye and pain from exposure keratopathy.
Keratinization and corneal insult leading to irregular astigmatism can also decrease vision
of the affected eye. Scleral GP contact lenses present a viable alternative treatment option
to manage both ocular dry eye symptoms and decreased visual acuity that result from
these conditions, but patients should be followed regularly to ensure that corneal
physiological health is maintained. It would be beneficial to perform a study collecting data
regarding any complications that may result from wearing scleral GP lenses over long
periods of time in order to have a more complete understanding of scleral GP lens wear,
and thus enable practitioners to prescribe them with confidence.
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