Bilateral conjunctival epithelial flaps: a case study
The benefits of increased oxygen transmissibility with silicone hydrogel lenses are well documented, as are the clinical findings that these lenses decrease bulbar and limbal conjunctival redness, ghost vessels and corneal oedema. Signs and symptoms associated with silicone hydrogel lenses so far include corneal and lid responses, issues surrounding comfort, and most recently conjunctival epithelial flaps.
In this case study, we present a patient who developed bilateral conjunctival epithelial flaps within 1 week after transferring from conventional hydrogel daily wear to silicone hydrogel extended wear.
Our patient was a 35 year old male caucasian. He had been wearing daily wear conventional hydrogel lenses for about 3 years with no complications. He had no ocular abnormalities, no remarkable medical history and was taking no regular medications. He occasionally used an antihistamine for hayfever.
His refraction and visual acuities were:
OD -3.00/-0.25x70 6/4.8 OU 6/3.8-2
OS -3.00/-0.50x70 6/4.8-2
He was prescribed OD -3.00 OS -3.25 spherical silicone hydrogel lenses to be worn overnight and was followed up for 3 months of extended wear. Lens fitting in terms of movement and centration was optimal for this wearer and no signs or symptoms were observed apart from mild sensations of dryness at his 3 month visit. Visual acuity was stable overtime with negligible over refraction.
Slit lamp biomicroscopy findings were unremarkable at all visits except for the presence of bilateral conjunctival epithelial flaps within the first week of extended wear. Both eyes had large epithelial flaps in the inferior conjunctiva and a smaller flap in the superior nasal (OD) and superior temporal (OS), as can be seen in the videos .
As the patient was generally asymptomatic and the significance of conjunctival epithelial flaps remains largely unknown, the patient resumed lens wear and was monitored closely. The conjunctival epithelial flaps were not detected a week later, but were present in a similar location in both eyes at the 1 and 3 month visits.
This patient is now wearing silicone hydrogel lenses on a daily wear basis. At the last follow-up, the conjunctival epithelial flaps had resolved.
Discussion
Conjunctival epithelial flaps are a benign clinical finding in which the exact clinical relevance is at this stage unknown.
Although the patient in this case study had large conjunctival flaps in both eyes, he was otherwise asymptomatic and developed no further signs. He was able to continue silicone hydrogel lens wear without any intervention. While the aetiology of conjunctival flaps is unknown, it is thought to be a pressure effect from the edge of the silicone hydrogel lens; the higher modulus of the silicone hydrogel may also contribute, as may tight fitting lenses or lenses without a rounded edge. Should practitioners wish to intervene when observing epithelial flaps, management strategies could include minimizing the mechanical interaction of the lens with the ocular surface using lens lubricants, re-fitting with a looser lens if a second parameter is available, changing the wear schedule and/or reducing wearing time or changing to a different silicone hydrogel lens with a different lens modulus, fitting relationship to the cornea or edge shape.
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