Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations 治疗眼表疾病的巩膜接触镜的应用：患者选择和特别考虑事项
This article was published in the following Dove Press journal: 本文发表在以下 Dove Press 期刊上：
Clinical Optometry 临床验光学
Jennifer S Harthan' 詹妮弗·S·哈瑟恩Ellen Shorter 艾伦·肖特 'Illinois College of Optometry, 伊利诺伊眼科医学院Chicago, IL, USA; University of Illinois 芝加哥，伊利诺伊州，美国； 伊利诺伊大学at Chicago, Chicago, IL, USA 在美国伊利诺伊州芝加哥市
Correspondence: Jennifer S Harthan Illinois College of Optometry, 324I S. Michigan Avenue, Chicago, IL 606I6, USA Tel +I 3129497137 通讯：詹妮弗·S·哈瑟恩 伊利诺伊州验光学院，南密歇根大道 324I 号，芝加哥，IL 606I6，美国 电话 +1 3129497137
Email Jharthan@ico.edu 电子邮件 Jharthan@ico.edu
Abstract 摘要
Scleral lenses are being prescribed for the management of corneal irregularity, uncomplicated refractive error, and ocular surface disease. There are many potential therapeutic uses of scleral lenses in addition to providing similar benefits as corneal gas permeable lenses Scleral contact lenses are a valuable therapeutic tool for patients with ocular surface disease as these lenses protect the ocular surface, provide continuous corneal hydration while providing optimal visual correction, and are often used in conjunction with other therapies. 巩膜镜被用于管理角膜不规则、简单屈光不正和眼表疾病。除了提供与角膜气体透过性镜片相似的好处外，巩膜镜还有许多潜在的治疗用途。巩膜接触镜是眼表疾病患者的重要治疗工具，因为这些镜片可以保护眼表，提供持续的角膜水合作用，同时提供最佳的视觉矫正，并且通常与其他疗法结合使用。
The prescription of scleral lenses for the management of corneal irregularity, uncomplicated refractive error, and ocular surface disease is increasing. The large diameter of the medical device completely covers the cornea protecting it with a fluid reservoir creating an ideal ocular surface environment and making these lenses particularly useful for ocular surface disease. The Scleral Lenses in Current Ophthalmic Practice Evaluation (SCOPE) study group in 2015 reported that of scleral lenses are currently being prescribed for ocular surface disease, for corneal irregularity, and for uncomplicated refractive error. More than of scleral lens prescribers reported fitting their first lens after 2005 and after This increase may be due to innovations in technology, advancements in educational platforms, and increased availability of commercial lenses from laboratories. There are many therapeutic uses of scleral lenses in addition to providing similar benefits as a corneal gas permeable lens by masking irregular astigmatism and reducing higher order aberrations in patients with corneal irregularity. The precorneal fluid reservoir hydrates the cornea while mechanically protecting the ocular surface from the shearing forces of the lids and environment. This review focuses on one of the least used indications for scleral lenses, ocular surface disease. 用于管理角膜不规则、简单屈光不正和眼表疾病的巩膜镜处方正在增加。 这种医疗设备的大直径完全覆盖角膜，保护角膜并形成液体储存区，创造理想的眼表环境，使这些镜片在眼表疾病中尤为有用。2015 年，当前眼科实践评估的巩膜镜研究小组（SCOPE）报告称， 的巩膜镜目前用于眼表疾病， 用于角膜不规则， 用于简单屈光不正。 超过 的巩膜镜处方者报告称在 2005 年后开始配镜， 在 之后。这一增长可能是由于技术创新、教育平台的进步以及实验室商业镜片的可用性增加所致。 除了提供与角膜气体透过镜相似的好处，通过掩盖不规则散光和减少角膜不规则患者的高阶像差，巩膜镜还有许多治疗用途。 前房液体储存器在为角膜提供水分的同时，机械性地保护眼表免受眼睑和环境的剪切力。 本综述重点讨论硬性隐形眼镜最少使用的适应症之一——眼表疾病。
Scleral lenses differ from corneal gas permeable lenses based on lens diameter and fitting characteristics. Corneal gas permeable contact lenses are supported exclusively by the cornea and do not extend past the limbus. Scleral lenses are large-diameter gas permeable contact lenses that are supported by a tear reservoir, rest on the conjunctival tissue overlying the sclera, and vault the cornea and limbus. These lenses are unique when compared to corneal gas permeable contact lenses in that they maintain a fluid reservoir between the back surface of the contact lens and 巩膜镜与角膜气透镜在镜片直径和配戴特性上有所不同。角膜气透性隐形眼镜仅由角膜支撑，不会超出角膜缘。巩膜镜是大直径的气透性隐形眼镜，由泪液储存区支撑， resting on the conjunctival tissue overlying the sclera, and vault the cornea and limbus. 这些镜片与角膜气透性隐形眼镜相比具有独特性，因为它们在隐形眼镜的背面和眼睛之间保持液体储存区。
the front surface of the eye. The Scleral Lens Education Society classifies scleral contact lenses based on diameter: semi-scleral ( ), mini-scleral ( ), and large scleral ( ). To simplify this, scleral contact lenses are defined as large-diameter rigid gas permeable lenses that rest entirely on the sclera ranging from 14 mm to in diameter. 眼睛的前表面。巩膜镜教育协会根据直径对巩膜接触镜进行分类：半巩膜（ ）、迷你巩膜（ ）和大巩膜（ ）。为了简化这一点，巩膜接触镜被定义为完全位于巩膜上的大直径刚性气体透过镜片，直径范围从 14 毫米到 。
Scleral lenses were initially made out of glass until polymethyl methacrylate was available in the 1940s. Due to the low oxygen permeability ( Dk ) of the materials used, signs of corneal hypoxia were common. Rigid gas permeable scleral contact lenses were not readily available until the 1980s when Ezekiel demonstrated improved comfort and performance with higher oxygen permeability and reduced corneal hypoxia. In addition to the use of the materials with higher Dk, the risks of hypoxia can also be reduced by minimizing lens thickness and tear reservoir. Visser et al described the availability of toric scleral lenses in 2006 enabling more precise fitting and improved patient comfort. 最初，巩膜镜是用玻璃制成的，直到 1940 年代聚甲基丙烯酸酯问世。由于所用材料的低氧透过率（Dk），角膜缺氧的迹象很常见。 硬性气体透过性巩膜隐形眼镜直到 1980 年代才开始普及，当时以西基尔展示了更高的氧透过率和减少角膜缺氧所带来的舒适性和性能的改善。 除了使用具有更高 Dk 的材料外，通过最小化镜片厚度和泪液储存量也可以降低缺氧的风险。 Visser 等人在 2006 年描述了圆柱形巩膜镜的可用性，使得更精确的配戴和改善患者舒适度成为可能。
Scleral lenses may be designed with spherical, frontsurface toric, back-surface toric, and bitoric platforms to optimize both scleral alignment and visual acuity. Multifocal scleral lens designs are also available to improve near visual acuity for presbyopic patients. When fitting scleral lenses for ocular surface disease, materials with high Dk values are recommended to minimize corneal hypoxia. Advancements in materials, lens designs, fitting techniques, and industry innovations have led to improved performance, increasing the indications for which they are being prescribed by eye care practitioners. 巩膜镜可以设计为球面、前表面散光、后表面散光和双散光平台，以优化巩膜对位和视觉清晰度。 还提供多焦点巩膜镜设计，以改善老花患者的近距离视觉清晰度。在为眼表疾病配戴巩膜镜时，建议使用高 Dk 值的材料，以减少角膜缺氧。 材料、镜片设计、配戴技术和行业创新的进步，导致了性能的提升，增加了眼科医生开处方的适应症。
Patient selection 患者选择
There are many patients with ocular surface disease who could potentially benefit from scleral lenses. The Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop II (DEWS II) report defined and classified patients based on their symptoms and signs of ocular surface disease. Individuals who are symptomatic with signs of ocular surface disease as well as those with neurotrophic conditions who have signs of ocular surface disease without symptoms are excellent candidates. These individuals will show clinical improvement in corneal punctate staining and filamentary keratitis with scleral lens use. A third group that may benefit from scleral lens therapy are individuals with keratoneuralgia or neuropathic pain who have symptoms of dry eye without signs of ocular surface disease. Neuropathic pain is often chronic due to damage or disease affecting the somatosensory nervous system, and neurosensory dysfunction may account for the lack of association between signs and symptoms in some patients. It has been suggested that ocular surface pain that develops following corneal nerve disruption represents a hypersensitivity of the ocular somatosensory nerves. In addition, patients may experience increased or exaggerated conjunctival and scleral pain due to secondary hyperalgesia. Scleral lenses may help mitigate symptoms and disrupt the pain cycle in some of these patients even though they present with a "normal" appearing ocular surface. 许多患有眼表疾病的患者可能会从巩膜镜中受益。泪膜与眼表协会（TFOS）干眼工作坊 II（DEWS II）报告根据患者的症状和眼表疾病的体征进行了定义和分类。 具有眼表疾病症状和体征的个体，以及那些有神经营养性疾病但没有症状的眼表疾病体征的个体，都是优秀的候选者。这些个体在使用巩膜镜后，角膜点状染色和丝状角膜炎的临床表现将会改善。第三组可能从巩膜镜治疗中受益的是那些有角膜神经痛或神经性疼痛的个体，他们有干眼症状但没有眼表疾病的体征。 神经性疼痛通常是由于影响躯体感觉神经系统的损伤或疾病而导致的慢性疼痛，神经感觉功能障碍可能解释了某些患者体征与症状之间缺乏关联的原因。 有人提出，角膜神经损伤后出现的眼表疼痛代表了眼部躯体感觉神经的过敏反应。 此外，患者可能会因继发性痛觉过敏而经历结膜和巩膜疼痛的增加或加剧。 尽管这些患者的眼表看起来“正常”，但巩膜镜可能有助于缓解症状并打断部分患者的疼痛循环。
While there are many potential benefits of scleral lenses for patients with ocular surface disease, they are not generally recommended as the initial therapy. In the past, therapeutic soft lenses have been recommended as a primary therapeutic lens option for some ocular surface conditions due to well-described fitting processes of soft contact lenses, the wide availability of the lenses, and well-documented results in the literature. There are also therapeutic soft lenses that are approved by US Food and Drug Administration for overnight or extended wear. These lenses are inexpensive and readily available, and multiple reports have shown the clinical benefits of them for patients with chronic ocular graft-versus-host disease (GVHD). However, for patients with significant ocular surface disease such as nonhealing epithelial defects, scleral lenses have proven to be beneficial in retaining a fluid-ventilated design allowing oxygenated precorneal fluid reservoir providing continuous corneal hydration with minimal corneal contact. Patients who are diabetic, are immunocompromised, or have nonhealing epithelial defects should be closely monitored for potential complications related to scleral lens use. Concomitant prophylactic antibiotic use can be considered in patients using therapeutic lenses; however, their use remains controversial. 虽然巩膜镜对眼表疾病患者有许多潜在好处，但通常不建议作为初始治疗。在过去，治疗性软镜因其良好的配戴过程、广泛的可获得性以及文献中有充分的结果记录，被推荐作为某些眼表疾病的主要治疗镜片选择。 还有一些获得美国食品和药物管理局批准的治疗性软镜，适合过夜或延长佩戴。这些镜片价格便宜且易于获得，多项报告显示它们对慢性眼部移植物抗宿主病（GVHD）患者的临床益处。 然而，对于有显著眼表疾病的患者，如不愈合的上皮缺损，巩膜镜在保持流体通风设计方面被证明是有益的，能够提供氧化的前房液储存，持续保持角膜水分，且与角膜接触最小。 糖尿病患者、免疫功能低下者或有不愈合上皮缺损的患者应密切监测与巩膜镜使用相关的潜在并发症。在使用治疗性镜片的患者中，可以考虑同时使用预防性抗生素；然而，其使用仍然存在争议。
The overall goal when fitting patients with scleral lenses for ocular surface disease is to mitigate symptoms, and several case series have demonstrated that patients experience relief from or resolution of dryness, pain, irritation, and photophobia when wearing scleral lenses. The 2017 TFOS DEWS II report recommended therapeutic contact lenses (soft bandage contact lenses and rigid scleral lenses) in step 3 of the management and treatment recommendations for dry eye disease. SCOPE survey of scleral lens prescribers reported similar findings; scleral lenses were reported as being prescribed by practitioners after topical lubricants, topical steroids, cyclosporine, and punctal occlusion. For challenging medical conditions, scleral lenses can be used in combination with other therapies (topical lubricants, 为眼表疾病配戴巩膜镜的总体目标是减轻症状，多个病例系列表明，患者在佩戴巩膜镜时能够缓解或消除干燥、疼痛、刺激和畏光等症状。2017 年 TFOS DEWS II 报告在干眼病的管理和治疗建议的第 3 步中推荐了治疗性隐形眼镜（软绷带隐形眼镜和硬性巩膜镜）。SCOPE 对巩膜镜开处方者的调查报告了类似的发现；巩膜镜被报告为在局部润滑剂、局部类固醇、环孢素和泪点堵塞之后由医生开处方。对于复杂的医疗状况，巩膜镜可以与其他疗法（局部润滑剂）结合使用。
cyclosporine, topical corticosteroids, punctal occlusion, topical autologous serum, amniotic membrane grafting, and tarsorrhaphy) to delay or prevent surgery. Scleral lenses are a valuable therapeutic tool for patients with ocular surface disease as they protect the ocular surface, provide continuous corneal hydration while providing optimal visual correction, and can be used in conjunction with other therapies. 环孢素、局部皮质类固醇、泪点堵塞、局部自体血清、羊膜移植和睑合术）以延迟或预防手术。 硬性隐形眼镜是眼表疾病患者的重要治疗工具，因为它们可以保护眼表，提供持续的角膜水合作用，同时提供最佳的视觉矫正，并且可以与其他疗法结合使用。
There are no age restrictions when fitting scleral lenses. Pediatric patients may be fit, and parents or caregivers may be trained to assist with safe device application and removal. Geriatric patients should not be excluded due to advanced age. A study of patients fit with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE; BostonSight, Needham, MA, USA) devices found no difference in time required for application and removal of devices between young and older age-groups. All patients could apply devices in minutes by week 5 and remove devices in minutes by week There are also a number of tools such as light-emitting diode light sources and device stands that can be used to assist patients with safe application and removal if there are issues with poor best-corrected visual acuity or hand dexterity. 配戴巩膜镜没有年龄限制。儿童患者可以配戴，父母或看护者可以接受培训，以协助安全地应用和移除设备。老年患者不应因年龄较大而被排除在外。一项关于配戴眼表生态系统假体替代装置（PROSE；BostonSight，马萨诸塞州尼达姆，美国）患者的研究发现，年轻和老年患者在设备的应用和移除所需时间上没有差异。所有患者在第 5 周时都能在 分钟内应用设备，并在第 周时在 分钟内移除设备。如果存在最佳矫正视力差或手部灵活性差的问题，还有许多工具，如发光二极管光源和设备支架，可以帮助患者安全地应用和移除设备。
Initial lens selection and evaluation 初步镜头选择与评估
When fitting scleral lenses for patients with ocular surface disease, it is first essential to select a lens that is large enough to completely clear and vault the cornea and limbal area. The diameter of the lens is often dependent on the surface area of the ocular surface that needs rehabilitation. It may be beneficial to fit a large overall diameter to provide a greater area of protection from surface dryness and desiccation. Patients with a partial tarsorrhaphy or areas of symblepharon may necessitate a smaller diameter scleral lens. Once an initial lens is fit on the patient's eye, the practitioner must ensure that there is no central corneal touch or application bubbles. 在为患有眼表疾病的患者配戴巩膜镜时，首先必须选择一个足够大的镜片，以完全清除并覆盖角膜和睑缘区域。镜片的直径通常取决于需要修复的眼表面积。配戴较大直径的镜片可能有助于提供更大的保护区域，以防止表面干燥和脱水。对于部分睑合或有粘膜结合的区域的患者，可能需要较小直径的巩膜镜。一旦初始镜片配戴在患者眼睛上，医生必须确保没有中央角膜接触或气泡产生。
The amount of clearance between the central cornea and the lens should be evaluated using an optic section at the slit lamp or with optical coherence tomography imaging. At the slit lamp, clearance can be estimated by comparing the center thickness of lens to the thickness of the post-tear film reservoir. Fluorescein dye can be placed in the bowl of the lens, and white light optic section can be used to help identify areas of corneal or limbal touch. If there is excessive central vaulting, a diagnostic lens with lesser sagittal depth or a flatter base curve should be tried, and if there is central touch, a diagnostic lens with higher sagittal depth or steeper base curve should be selected. 中央角膜与镜片之间的间隙应通过裂隙灯的光学切片或光学相干成像进行评估。在裂隙灯下，可以通过比较镜片的中心厚度与泪膜后储液的厚度来估算间隙。可以在镜片的碗中放置荧光素染料，并使用白光光学切片来帮助识别角膜或缘部接触的区域。如果中央拱起过高，应尝试使用较小矢状深度或较平基弯曲的诊断镜片；如果有中央接触，则应选择具有较高矢状深度或较陡基弯曲的诊断镜片。
Several studies have looked at lens settling over time and have reported that, for most lens designs, there is likely a loss of central clearance of microns over the course of hours of lens wear, usually plateauing around 2 hours of wear. It has also been reported that the viscosity of the solution used to fill the bowl of the lens does not influence the amount of lens settling on the eye. 几项研究探讨了镜片随时间的沉降，并报告称，对于大多数镜片设计，镜片佩戴 小时后，中心间隙可能会损失 微米，通常在佩戴约 2 小时后趋于平稳。 还报告称，用于填充镜片碗的溶液的粘度不会影响镜片在眼睛上的沉降量。
A study by Otchere et al evaluating scleral lenses of varying sagittal depth reported clearance loss after 1 hour of lens wear using the Visante optical coherence tomographer. The amount of settling has been reported to vary depending on wear time and lens design varying from microns after 1 hour, a decrease in 83 microns, and 113.7, 133.7, and 88.1 microns depending on design and diameter after 8 hours. Another study reported no difference in lens settling in scleral lenses filled with nonpreserved saline versus more viscous nonpreserved gel and found 36.7 microns of central settling after 30 minutes and approximately double this amount, 70.0 microns, after 6 hours. There was no statistically significant change in subjective overrefraction after hours of wear. Scleral lenses should be fit with minimal but complete corneal clearance. Giasson et al used scleral lenses with 400 micron versus 200 micron clearance to demonstrate an in vivo reduction in oxygen tension available to the cornea from of to . Otchere 等人的一项研究评估了不同矢状深度的巩膜镜，报告在使用 Visante 光学相干断层扫描仪佩戴镜片 1 小时后出现清晰度损失。 沉降量据报道因佩戴时间和镜片设计而异，佩戴 1 小时后为 微米，减少了 83 微米，8 小时后根据设计和直径分别为 113.7、133.7 和 88.1 微米。 另一项研究报告称，使用非保存性生理盐水填充的巩膜镜与更粘稠的非保存性凝胶相比，镜片沉降没有差异，发现 30 分钟后中心沉降为 36.7 微米，6 小时后约为此量的两倍，70.0 微米。 在佩戴 小时后，主观过度屈光度没有统计学显著变化。 巩膜镜应以最小但完全的角膜清晰度进行配戴。Giasson 等人使用 400 微米与 200 微米清晰度的巩膜镜，展示了在体内 角膜可用氧气张力的减少，从 到 。
Once the central clearance is deemed appropriate, ensure that there is sufficient limbal clearance of . The lens edge or haptic should also be modified to align with the sclera in each quadrant. If there are areas of excessive edge lift, the lens diameter can be decreased or a toric peripheral landing area can be used. Similarly, if the lens is too tight or vascular compression is observed, it can be loosened. Many patients will achieve superior scleral alignment by using a toric peripheral system that often has four quadrants. Patients with ocular surface disease often benefit from a large-diameter scleral lens, requiring toric haptics as the sclera has more toricity (Figure 1).. 一旦中央间隙被认为合适，确保有足够的角膜缘间隙 。镜片边缘或支撑臂也应进行调整，以与每个象限的巩膜对齐。如果有过度的边缘抬起区域，可以减小镜片直径或使用圆柱形周边着陆区。同样，如果镜片过紧或观察到血管压迫，可以进行放松。许多患者通过使用通常具有四个象限的圆柱形周边系统来实现更好的巩膜对齐。患有眼表疾病的患者通常会从大直径巩膜镜中受益，这需要圆柱形支撑臂，因为巩膜具有更多的圆柱度（图 1）。
Figure I Scleral lens with nasal vascular compression that would benefit from toric peripheral system. 图 I 具有鼻侧血管压迫的巩膜镜，受益于圆柱形周边系统。
Safe handling 安全处理
Scleral devices require daily application, removal, and disinfection. It is important to instruct patients on proper application and removal with DMV® (DMV Corporation, Zanesville, OH, USA) scleral cups. Patients are instructed to fill their devices with preservative-free saline solution to prevent potential medicamentosa or toxicity to the ocular surface related to preservatives. There are a number of single-use preservative-free saline solutions as well as larger 4-oz bottles of preservative-free saline available. ScleralFil (Bausch + Lomb, Bridgewater, NJ, USA) is a unit-dose, buffered, nonpreserved saline solution indicated for rinsing and filling scleral lenses. LacriPure (Menicon Co. Ltd., Kasugai, Japan) is a unit-dose, nonbuffered, nonpreserved saline solution also indicated for rinsing and filling scleral lenses. Sodium chloride inhalation solution is an off-label, unit-dose, preservative-free solution, and PuriLens Plus saline (The LifeStyle Company, Inc., Freehold, NJ, USA) is a sterile, preservative-free, buffered saline solution; both solutions are used for filling and rinsing scleral lenses. Patients with severe ocular surface disease and those who are very sensitive may have a toxic response to buffer agents, and in most cases, a nonpreserved, nonbuffered solution is considered optimal. 巩膜装置需要每日应用、取出和消毒。重要的是要指导患者如何正确使用和取下 DMV®（DMV 公司，俄亥俄州扎恩斯维尔，美国）巩膜杯。患者被指导用无防腐剂的生理盐水填充他们的装置，以防止与防腐剂相关的潜在药物性或毒性对眼表的影响。有多种一次性无防腐剂生理盐水以及更大容量的 4 盎司无防腐剂生理盐水可供选择。ScleralFil（博士伦，纽泽西州布里奇沃特，美国）是一种单位剂量、缓冲、无防腐剂的生理盐水，适用于冲洗和填充巩膜镜。LacriPure（美能达株式会社，日本春日井）也是一种单位剂量、无缓冲、无防腐剂的生理盐水，适用于冲洗和填充巩膜镜。氯化钠吸入溶液是一种非标签、单位剂量、无防腐剂的溶液，而 PuriLens Plus 生理盐水（生活方式公司，纽泽西州弗里霍尔德，美国）是一种无防腐剂、无菌、缓冲的生理盐水；这两种溶液均用于填充和冲洗巩膜镜。 患有严重眼表疾病的患者以及对缓冲剂非常敏感的患者可能会对缓冲剂产生毒性反应，在大多数情况下，非保存性、非缓冲的溶液被认为是最佳选择。
After lens removal, a daily cleaner or multipurpose gas permeable solution can be prescribed to clean and disinfect lenses. Although manufacturer's directions and of scleral lens prescribers' report instructing patients to use tap water to rinse lenses, consideration should be made to instruct patients to rinse their lenses with saline. Hydrogen peroxide disinfection systems or multipurpose gas permeable lens solutions should be prescribed for overnight storage. It is not uncommon for individuals with severe dry eye or incomplete lid closure to report cloudy vision and lens fogging. These patients may need to use artificial tears or remove and reapply their lenses during the day. Removing and reapplying lenses with fresh preservative-free saline may be enough for some, while others may need to use a daily cleaner before reapplication. Patients with ocular surface disease often have surface nonwetting or deposits and may also benefit from Menicon Progent (Menicon) biweekly cleaner or from surface coatings such as Hydra-Peg (Tangible Science LLC, Menlo Park, CA, USA) to help improve wettability, decrease friction, reduce surface deposits, and increase patient comfort. 在取下镜片后，可以开具每日清洁剂或多功能气体透过性溶液来清洁和消毒镜片。尽管制造商的说明和角膜接触镜处方者的报告指示患者使用自来水冲洗镜片，但应考虑指导患者用生理盐水冲洗镜片。过氧化氢消毒系统或多功能气体透过性镜片溶液应开具用于过夜存储。对于严重干眼或眼睑闭合不全的个体，报告视力模糊和镜片起雾并不罕见。这些患者可能需要使用人工泪液，或在白天取下并重新佩戴镜片。对于某些人来说，使用新鲜的无防腐剂生理盐水取下和重新佩戴镜片可能就足够了，而其他人可能需要在重新佩戴之前使用每日清洁剂。 患有眼表疾病的患者通常会出现表面不润湿或沉积物，并且可能会受益于 Menicon Progent（Menicon）每两周使用的清洁剂或表面涂层，如 Hydra-Peg （Tangible Science LLC，位于加利福尼亚州门洛帕克，美国），以帮助改善润湿性，减少摩擦，降低表面沉积物，并提高患者舒适度。
Patients with ocular surface disease can use preservativefree artificial tears directly over the lens as needed throughout the day. Topical prescription medications should be used before or after scleral lens use, and patients should be instructed to wait at least 10 minutes before applying their lenses after their use. In patients with ocular surface disease, special consideration should be given to eliminate all benzalkonium chloride-preserved artificial tears and medications, particularly for those on glaucoma medications, as there are numerous alternative therapies available. 患有眼表疾病的患者可以在需要时全天候直接在镜片上使用无防腐剂的人工泪液。处方药物应在使用巩膜镜之前或之后使用，患者应被告知在使用药物后至少等待 10 分钟再佩戴镜片。对于眼表疾病患者，应特别注意消除所有含苯扎氯铵的防腐剂人工泪液和药物，特别是对于正在使用青光眼药物的患者，因为有许多替代疗法可供选择。
Patients who wear scleral lenses on an extended use basis such as in cases of persistent epithelial defects (PEDs) require very close medical monitoring. In a retrospective review of seven patients with PEDs, the patients were successfully treated with a standardized regimen of 24-hour PROSE device wear with daily office visits to remove, disinfect, and replace the fluid reservoir with preservative-free saline and a fourthgeneration fluoroquinolone antibiotic until re-epithelialized. 佩戴角膜塑形镜进行延长使用的患者，如持续性上皮缺损（PED）病例，需要非常密切的医疗监测。在对七名 PED 患者的回顾性研究中，患者通过标准化的 24 小时 PROSE 设备佩戴方案成功治疗，每天到诊所进行取出、消毒和更换无防腐剂生理盐水的液体储存器，并使用第四代氟喹诺酮抗生素，直到上皮再生。
Therapeutic indications 治疗适应症
Sjögren's syndrome (SS) 干燥综合症 (SS)
SS is a chronic, progressive multisystem autoimmune disease that causes lymphocytic infiltration of the exocrine glands. The most common presenting symptoms are dry eye and dry mouth as the disease affects the lacrimal and salivary glands. As the disease progresses to extraglandular manifestations, patients have a risk of developing non-Hodgkin's B-cell lymphoma. Patients with SS often have severe ocular surface disease requiring preservative-free artificial tears, punctal plugs, topical cyclosporine, and scleral lenses. SS 是一种慢性、进展性多系统自身免疫疾病，导致外分泌腺的淋巴细胞浸润。 最常见的表现症状是干眼和口干，因为该疾病影响泪腺和唾液腺。 随着疾病进展到腺外表现，患者有发展为非霍奇金 B 细胞淋巴瘤的风险。 患有 SS 的患者通常有严重的眼表疾病，需要无防腐剂的人工泪液、泪道栓、局部使用环孢素和巩膜接触镜。
Exposure keratopathy 暴露性角膜病
Exposure keratopathy may result from eyelid malposition due to trauma, surgery, ectropion, entropion, Bell's palsy, proptosis, and systemic diseases (Graves' disease). Inadequate or incomplete closure of the lids can result in ocular surface desiccation and breakdown of the corneal epithelium. Patients with exposure keratopathy typically complain of foreign body sensation, epiphora, blurred vision, photophobia, and varying levels of ocular discomfort. Common clinical signs include lagophthalmos, decreased tear meniscus height, reduced tear breakup time, filamentary keratitis, punctate epithelial erosions, and epithelial defects. If the condition is left untreated, patients with exposure keratopathy may have permanent vision loss due to neovascularization, corneal scarring, and stromal thinning. In extreme cases, corneal ulceration and perforation may occur. 暴露性角膜病可能是由于眼睑位置异常引起的，原因包括创伤、手术、外翻、内翻、贝尔麻痹、眼球突出和系统性疾病（格雷夫斯病）。眼睑闭合不充分或不完全可能导致眼表干燥和角膜上皮破坏。暴露性角膜病患者通常会抱怨异物感、流泪、视力模糊、畏光和不同程度的眼部不适。常见的临床体征包括眼睑闭合不全、泪液弧度降低、泪液破裂时间缩短、丝状角膜炎、点状上皮侵蚀和上皮缺损。如果不加以治疗，暴露性角膜病患者可能因新生血管形成、角膜瘢痕和基质变薄而导致永久性视力丧失。在极端情况下，可能会发生角膜溃疡和穿孔。
Traditional therapies of exposure keratopathy include a combination of artificial tears, gels and ointments, punctal plugs, topical steroids and antibiotics, moisture goggles, lid taping, gold eyelid weights, soft therapeutic lenses, partial or complete tarsorrhaphies, amniotic membrane grafts, or BOTOX injections to the levator muscle. Scleral lenses 暴露性角膜病的传统治疗方法包括人工泪液、凝胶和药膏的组合、泪道栓塞、局部类固醇和抗生素、湿润护目镜、眼睑贴合、金眼睑重物、软性治疗性隐形眼镜、部分或完全睑合术、羊膜移植或肉毒杆菌注射到提睑肌。巩膜镜。
offer an alternative to tarsorrhaphy that has poor cosmesis and often results in loss of binocularity. In cases of extreme lagophthalmos, soft therapeutic lenses may displace on the eye due to dehydration. Scleral lenses have been successful in the management of patients with exposure keratopathy as the lens creates a liquid bandage shell, protecting the cornea from further desiccation, increasing hydration, and promoting epithelial surface healing (Figure 2). 提供了一种替代睑合术的方法，后者的美容效果差，且常常导致双眼视力丧失。在极端的闭眼不全情况下，软性治疗性隐形眼镜可能因脱水而在眼睛上移位。 硬性隐形眼镜在治疗暴露性角膜病患者方面取得了成功，因为这种镜片形成了一个液体绷带壳，保护角膜免受进一步干燥，增加水分，并促进上皮表面的愈合（图 2）。
Neurotrophic keratopathy 神经营养性角膜病
Neurotrophic keratopathy results from impaired corneal innervation due to damage to the trigeminal nerve. Decreased corneal sensitivity or complete corneal anesthesia can result in epithelial keratopathy. The most common causes of neurotrophic keratopathy are herpes simplex and herpes zoster infections. Trigeminal neuralgia surgery, acoustic neuromas, diabetes, and toxicity from the chronic use of topical 神经营养性角膜病是由于三叉神经损伤导致角膜神经支配受损所致。角膜敏感性降低或完全角膜麻痹可能导致上皮角膜病。神经营养性角膜病最常见的原因是单纯疱疹和带状疱疹感染。三叉神经痛手术、听神经瘤、糖尿病以及长期使用局部药物的毒性也可能导致此病。
Figure 2 Patient with exposure keratopathy and poor lens surface wetting Improvement was made with the addition of Hydra-Peg (Tangible Science LLC Menlo Park, CA, USA). ocular medications may also result in corneal anesthesia. Anesthetic corneas are at risk for PEDs. Therapy options for neurotrophic corneas include preservative-free artificial tears and ointments, punctal plugs, partial tarsorrhaphy, topical antibiotics in cases of large epithelial defects, amniotic membranes, topical cyclosporine, oral doxycycline, therapeutic soft lenses, and scleral lenses. The protective liquid corneal bandage that the scleral lenses provide can heal the surface and prevent recurrence of the epithelial defect while preserving vision (Figure 3A-C).. 图 2 患者出现暴露性角膜病和镜片表面润湿不良。通过添加 Hydra-Peg （Tangible Science LLC，位于美国加利福尼亚州门洛帕克）取得了改善。眼部药物也可能导致角膜麻痹。 麻痹的角膜面临 PEDs 的风险。神经营养性角膜的治疗选择包括无防腐剂的人工泪液和药膏、泪道栓塞、部分睑合术、在大上皮缺损情况下使用的局部抗生素、羊膜、局部环孢素、口服多西环素、治疗性软镜和巩膜镜。巩膜镜提供的保护性液体角膜绷带可以愈合表面并防止上皮缺损的复发，同时保持视力（图 3A-C）。
Limbal stem cell deficiency 角膜缘干细胞缺乏
Limbal stem cell deficiency occurs due to congenital diseases such as ectodermal dysplasia or aniridia or can be acquired later in life. Inflammatory conditions such as StevensJohnson Syndrome or superior limbic keratoconjunctivitis, chemical or thermal injuries, chronic contact lens wear, and toxicity from topical medications may cause limbal stem cell deficiency. Patients with limbal stem cell deficiency can present with complaints of decreased vision and light sensitivity and will have conjunctival epithelium growing onto the cornea with neovascularization and corneal scarring. The first step in the management of these patients is to eliminate all chemical preservative exposure and soft contact lens use. If there is no clinical improvement, antiinflammatory therapies should be considered and surgical limbal stem cell transplantation for more severe cases. Scleral lenses that completely vault the limbus are also an 角膜缘干细胞缺乏症可因先天性疾病如外胚层发育不良或无虹膜症而发生，也可能在后天获得。炎症性疾病如史蒂文斯-约翰逊综合症或上角膜缘角结膜炎、化学或热损伤、长期佩戴隐形眼镜以及局部药物的毒性可能导致角膜缘干细胞缺乏症。 患有角膜缘干细胞缺乏症的患者可能会出现视力下降和光敏感的症状，并且结膜上皮会生长到角膜上，伴有新生血管形成和角膜瘢痕。 这些患者管理的第一步是消除所有化学防腐剂的接触和软性隐形眼镜的使用。如果没有临床改善，应考虑抗炎治疗，并对更严重的病例进行外科角膜缘干细胞移植。 完全覆盖角膜缘的巩膜镜也是一种选择。
Figure 3 Patient with neurotrophic keratopathy whose nonhealing epithelial defect improved with therapeutic scleral lens use. Notes: (A) Non-healing epithelial defect; (B) scleral lens; (C) resolution of epithelial defect after I month of scleral lens therapy 图 3 患有神经营养性角膜病的患者，其不愈合的上皮缺损在使用治疗性巩膜镜后有所改善。注释：（A）不愈合的上皮缺损；（B）巩膜镜；（C）使用巩膜镜治疗 1 个月后上皮缺损的愈合情况。
excellent option for these patients. The lens can protect the limbus from mechanical trauma while maintaining a welllubricated ocular surface (Figure 4A-C). 这些患者的优秀选择。该镜片可以保护角膜缘免受机械损伤，同时保持眼表的良好润滑（图 4A-C）。
GVHD
GVHD, an inflammatory disease that may be acute or chronic, is a complication following allogeneic stem cell transplantation for cancer. These individuals are at a risk of long-term immunosuppression and delayed healing. Keratoconjunctivitis sicca is a common sequela and is reported to affect of individuals with chronic GVHD. These individuals may also have scleroderma-like findings including eyelid thickening, filamentary keratitis, and corneal ulceration. These patients present with complaints of ocular pain, foreign body sensation, blurred vision, photophobia, burning, and stinging associated with decreased quality of life and high morbidity. Therapeutic scleral lens therapy promotes healing of surface epitheliopathy while improving pain and photophobia associated with chronic ocular GVHD. Treatment is targeted to restore and maintain ocular surface homeostasis and reduce patients' symptoms and traditionally has included: topical lubricants, topical steroids or antibiotics, topical cyclosporine, punctal occlusion, autologous serum, and soft bandage contact lenses. Autologous serum tears have been shown to promote healing in patients with GVHD, and, although more studies are needed, they can be used to fill the device or diluted in the device with preservative-free solution. Scleral lenses can optimize vision, improve comfort, and protect the ocular surface in patients with GVHD (Figure 5A-C). GVHD 是一种可能急性或慢性的炎症性疾病，是癌症异体干细胞移植后的并发症。这些个体面临长期免疫抑制和愈合延迟的风险。干眼症是常见的后遗症，报告显示 的慢性 GVHD 患者受到影响。 这些个体可能还会出现类似硬皮病的表现，包括眼睑增厚、丝状角膜炎和角膜溃疡。 这些患者常常抱怨眼部疼痛、异物感、视力模糊、畏光、灼烧感和刺痛感，伴随生活质量下降和高发病率。 治疗性巩膜接触镜疗法促进表面上皮病的愈合，同时改善与慢性眼部 GVHD 相关的疼痛和畏光。 治疗旨在恢复和维持眼表的稳态，减轻患者的症状，传统上包括：局部润滑剂、局部类固醇或抗生素、局部环孢素、泪道阻塞、自体血清和软性绷带隐形眼镜。 自体血清泪液已被证明可以促进 GVHD 患者的愈合 ，尽管还需要更多研究，但它们可以用于填充设备或与无防腐剂溶液稀释后在设备中使用。巩膜镜可以优化视力，改善舒适度，并保护 GVHD 患者的眼表（图 5A-C）。
Post-penetrating keratoplasty (PK) 后穿透性角膜移植 (PK)
While scleral lenses can play an important role in healing or maintaining the ocular surface in individuals with a previous PK, they must be closely monitored. The use of scleral lenses for individuals after PK can be controversial due to the unknown long-term effects of scleral lenses on the graft and endothelium. The fluid-filled device allows for healing of the corneal epithelium as well as masking of irregular corneal astigmatism improving best-corrected visual acuity. Patients should be very closely monitored for signs of corneal edema and acute corneal graft rejection. In addition to careful slit lamp examination, evaluating baseline and follow-up corneal pachymetry and specular microscopy may be considered. Normal endothelial cell density in a healthy adult patient is between 2000 and 2500 cells . The endothelium begins to decompensate when the cell count drops cells , leading to corneal edema, stromal haze, and reduced vision. If there are signs of corneal swelling or hypoxia, the patient may benefit from modification to the scleral lens fit including a change by decreasing 虽然巩膜镜在以前接受角膜移植的个体中可以在愈合或维持眼表方面发挥重要作用，但必须进行密切监测。由于巩膜镜对移植物和内皮的长期影响尚不明确，故在角膜移植后使用巩膜镜可能存在争议。充满液体的装置可以促进角膜上皮的愈合，并掩盖不规则的角膜散光，从而改善最佳矫正视力。 患者应密切监测角膜水肿和急性角膜移植物排斥的迹象。除了仔细的裂隙灯检查外，还可以考虑评估基线和随访的角膜厚度测量和镜面显微镜检查。 健康成人患者的正常内皮细胞密度在 2000 到 2500 个细胞之间 。当细胞计数下降到 个细胞 时，内皮开始失去补偿能力，导致角膜水肿、基质混浊和视力下降。 如果出现角膜肿胀或缺氧的迹象，患者可能需要调整巩膜镜的配合，包括通过减少镜片的改变。
Figure 4 Patient with limbal stem cell disease managed with scleral lenses. Improvement was noted after 3 months of scleral lens wear. 图 4 患有角膜缘干细胞疾病的患者使用巩膜镜进行管理。佩戴巩膜镜 3 个月后，观察到改善。
Notes: (A) LSCD prescleral lens wear; (B) scleral lens fit; (C) improvement in LSCD post-scleral lens wear 注意事项：（A）LSCD 前巩膜镜佩戴；（B）巩膜镜配戴；（C）佩戴巩膜镜后 LSCD 改善情况
Abbreviation: LSCD, limbal stem cell deficiency. 缩写：LSCD，角膜缘干细胞缺乏。
A
B
Figure 5 Patient with chronic graft-versus-host disease whose lissamine green staining improved following scleral lens therapy. 图 5 患有慢性移植物抗宿主病的患者，在接受巩膜镜治疗后，其利萨敏绿染色改善。
Notes: (A) Lissamine green staining; (B) scleral lens fit; (C) improvement in corneal staining following 3 months of daily scleral lens wear. 注释：（A）利萨敏绿色染色；（B）巩膜镜配戴；（C）每日佩戴巩膜镜三个月后角膜染色改善。
the sagittal profile, by flattening the peripheral haptic profile, by increasing the Dk of the material of the lens, by shortening patient wear schedule, or even by using fenestrations. 矢状轮廓，通过扁平化周边触觉轮廓，通过增加镜片材料的 Dk 值，通过缩短患者佩戴时间表，甚至通过使用窗孔。
PEDs
Patients with ocular surface disease and PEDs are difficult to manage as they are typically resistant to traditional therapies. PEDs occur when a damaged area of the cornea does not reepithelialize in the expected time frame and are associated with corneal dystrophies, neurotrophic keratitis, herpetic infections, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, ocular trauma, or surgery. Patients may present with decreased vision and pain with episodes of recurrence taking months to resolve. PEDs must be treated aggressively as they can lead to corneal haze, irregular astigmatism, infectious keratitis, corneal melting, or perforation with loss of vision. Scleral lenses and PROSE devices have been shown to be beneficial in these refractory cases protecting the cornea from the shearing forces of eyelid blinking, maintaining a stable tear film, and promoting reepithelialization in patients with nonhealing epithelial defects. 患有眼表疾病和 PED 的患者难以管理，因为他们通常对传统疗法具有抵抗力。PED 发生在角膜受损区域未能在预期时间内再生上皮，并与角膜营养不良、神经性角膜炎、疱疹感染、史蒂文斯-约翰逊综合症、眼部瘢痕性天疱疮、眼外伤或手术相关。患者可能会出现视力下降和疼痛，复发的发作可能需要几个月才能缓解。PED 必须积极治疗，因为它们可能导致角膜混浊、不规则散光、感染性角膜炎、角膜溶解或穿孔，导致视力丧失。巩膜镜和 PROSE 设备已被证明在这些难治病例中有益，能够保护角膜免受眼睑眨眼的剪切力，维持稳定的泪膜，并促进非愈合上皮缺损患者的再生上皮。
When prescribing any lens as an extended wear therapeutic option, the benefits must outweigh the risks. Several case reports have identified patients with PEDs who have successfully worn scleral lenses overnight without complications while promoting reepithelialization. There have been other cases of microbial keratitis in patients who have worn extended wear scleral lenses for PEDs. However, more recent case series using a prophylactic antibiotic have shown decreased risks associated with healing PEDs. There are reports on using two sets of scleral devices to heal PEDs Guidelines for prescribing scleral devices in this manner include filling the device with preservative-free saline and preservative-free, fourth-generation fluoroquinolone antibiotics. Patients are instructed to remove, clean, and replace the solution every 12 hours during continuous wear with daily monitoring. Successful use of scleral lenses has been described in patients with PEDs as the postlens fluid chamber created by corneal vaulting is filled with nonpreserved saline to constantly lubricate the ocular surface, promoting healing of the epithelial defect. 在开处方任何作为延长佩戴治疗选项的镜片时，益处必须大于风险。一些病例报告已确定有佩戴角膜塑形镜的患者在夜间成功佩戴巩膜镜而没有并发症，同时促进了上皮再生。 还有其他病例报告显示，佩戴延长使用的巩膜镜的患者出现了微生物性角膜炎。 然而，最近的病例系列使用预防性抗生素显示与愈合 PEDs 相关的风险降低。关于使用两套巩膜设备来愈合 PEDs 的报告也有。以这种方式开处方巩膜设备的指南包括用无防腐剂的生理盐水和无防腐剂的第四代氟喹诺酮抗生素填充设备。患者被指示在连续佩戴期间每 12 小时取下、清洁并更换溶液，并进行每日监测。 在 PEDs 患者中成功使用巩膜镜的案例表明，由角膜隆起形成的镜后液体腔充满无防腐剂的生理盐水，以不断润滑眼表，促进上皮缺损的愈合。
Patient-reported poor vision or lens fogging 患者报告视力差或镜片起雾
Due to their underlying ocular surface disease, these patients are at an increased risk of poor lens wetting or lens fogging later in the day. Patients should be closely monitored for meibomian gland disease and treated aggressively. If patients complain of poor vision immediately after lens application, 由于其潜在的眼表疾病，这些患者在一天后期面临镜片润湿不良或镜片雾化的风险增加。应密切监测患者的睑板腺疾病并进行积极治疗。如果患者在镜片佩戴后立即抱怨视力不佳，
consideration should be given to current lens care recommendations. A separate alcohol-based lens cleaner can be prescribed in addition to an overnight hydrogen peroxide-based system. Individuals who use a lubricating ointment at bedtime may also benefit from an eye wash with a preservative-free saline prior to lens application in the morning. When patients complain of blurred vision or fogging later in the day, it is helpful to evaluate the patient later in the day after a few hours of continuous lens wear. At the slit lamp, evaluate whether there is lens surface nonwetting or if there is postlens tear film debris. Surface nonwetting can be improved with new surface coatings available or lens removal with cleaning and reapplication. Visser et al reported increased wear time and patient-reported comfort in toric scleral lenses compared with spherical scleral lenses. In our experience, toric peripheral systems can help limit debris formation, edge lift, and fogging. In addition, more viscous preservative-free filling solutions can be placed in the bowl of the lens to try to further delay fogging time. 应考虑当前的镜片护理建议。可以在过夜的过氧化氢系统之外，开处方单独的酒精基镜片清洁剂。晚上使用润滑药膏的个人，早晨在佩戴镜片前也可能受益于无防腐剂的生理盐水洗眼。当患者抱怨视力模糊或在一天后期出现雾化时，评估患者在连续佩戴镜片几小时后的情况是有帮助的。在裂隙灯下，评估是否存在镜片表面不润湿或镜片后泪膜残留物。不润湿的表面可以通过新型表面涂层改善，或通过取下镜片进行清洁和重新佩戴。Visser 等人报告称，与球面巩膜镜片相比，散光巩膜镜片的佩戴时间增加，患者报告的舒适度也提高。根据我们的经验，散光周边系统可以帮助限制残留物形成、边缘抬起和雾化。此外，可以在镜片的碗中放置更粘稠的无防腐剂填充溶液，以进一步延迟雾化时间。
Discussion 讨论
Individuals with signs of surface disease and symptoms who have failed traditional therapies are ideal candidates for scleral lens therapy. Therapeutic scleral lenses are also an option for individuals who are asymptomatic, but with signs such as neurotrophic keratopathy. While scleral lenses are often reserved as a later option when traditional therapies have failed, they are an important tool to heal the corneal epithelial and improve patient comfort as recommended in the 2017 TFOS DEWS II report. 表面疾病和症状明显且未能通过传统疗法治疗的个体是巩膜镜治疗的理想候选者。治疗性巩膜镜对于无症状但有神经营养性角膜病等迹象的个体也是一种选择。虽然巩膜镜通常在传统疗法失败后作为后续选项，但它们是治疗角膜上皮并改善患者舒适度的重要工具，正如 2017 年 TFOS DEWS II 报告中所推荐的。
The therapeutic effects of scleral lenses have been well documented. Individuals with keratoconjunctivitis sicca, limbal stem cell deficiency, neurotrophic keratitis, exposure keratitis, PEDs, and cicatrizing conjunctivitis can all benefit from therapeutic scleral lenses. Scleral lenses can play an important role as an adjunct to traditional therapy or as an alternative when traditional therapies fail. Scleral lenses may have advantages over traditional soft bandage lenses for the management of severe ocular surface disease recalcitrant to previous aggressive therapies. The unique design of a scleral lens allows the cornea to be completely vaulted while the lens rests entirely on the sclera. The postlens fluid reservoir filled with nonpreserved sterile saline constantly hydrates the cornea, facilitating the healing process of the ocular surface, preventing further desiccation of the ocular surface while simultaneously achieving optimal visual acuity. Scleral lenses also protect the ocular surface from keratinized or irregular lid margins and cicatricial entropion, increasing patient comfort. Management of patients with severe ocular surface disease often requires communication between health care providers as systemic conditions play a significant role in the healing process of the ocular surface. Patients who wear scleral lenses for ocular surface disease often require close follow-up and observation as compared to those who wear them for corneal irregularity or uncomplicated refractive error. The practitioner must understand the underlying disease process and determine whether the patient's symptoms at follow-up examination are due to the disease process or due to the lens fit. 治疗性巩膜镜的疗效已得到充分证明。患有干眼症、角膜缘干细胞缺乏、神经性角膜炎、暴露性角膜炎、眼睑内翻和瘢痕性结膜炎的个体均可从治疗性巩膜镜中受益。巩膜镜可以作为传统疗法的辅助工具，或在传统疗法失败时作为替代方案。对于那些对以往激进疗法无反应的严重眼表疾病，巩膜镜可能比传统软性绷带镜具有优势。巩膜镜的独特设计使角膜完全拱起，而镜片则完全放置在巩膜上。镜片后方的液体储存室充满无防腐剂的无菌盐水，持续为角膜提供水分，促进眼表的愈合过程，防止眼表进一步干燥，同时实现最佳视力。巩膜镜还可以保护眼表免受角化或不规则眼睑边缘和瘢痕性内翻的影响，提高患者的舒适度。 严重眼表疾病患者的管理通常需要医疗提供者之间的沟通，因为全身状况在眼表的愈合过程中起着重要作用。与因角膜不规则或简单屈光不正而佩戴巩膜镜的患者相比，因眼表疾病佩戴巩膜镜的患者通常需要更密切的随访和观察。医生必须了解潜在的疾病过程，并确定患者在随访检查时的症状是由于疾病过程还是由于镜片适配问题。
Patients with ocular surface disease often benefit from a scleral lens with a larger overall diameter, which subsequently requires advanced toric peripheral systems in order to align with the sclera. When fitting scleral lenses in patients with ocular surface disease and especially those with PEDs, close medical monitoring is important to evaluate epithelial integrity and to ensure complete corneal and limbal vault. One model of fitting suggests erring on the side of fitting larger and looser versus a lens that is smaller in diameter and has a shallower sagittal depth. There are many options to enhance scleral lens wettability and decrease lens deposits. High-Dk materials are recommended when fitting these complex corneas, as well as detailed communication regarding safe wear and handling, as these patients often have multiple therapies that they are using. As scleral lenses create a postlens tear reservoir between the lens and the cornea, these lenses are thicker than corneal gas permeable lenses, potentially contributing to physiological edema at a subclinical level. Another model of fitting proposed by Michaud et al stated that the postlens tear layer should be no microns in order to avoid corneal edema using a high-Dk ( ) lens with a maximum central thickness of 250 microns. Regardless of preferred fitting methodology, careful observation is needed to monitor the long-term effects of scleral lenses on patients with ocular surface disease. 患有眼表疾病的患者通常从直径较大的巩膜镜中受益，这需要先进的周边散光系统以便与巩膜对齐。在为患有眼表疾病的患者，尤其是那些有 PED 的患者配戴巩膜镜时，密切的医学监测非常重要，以评估上皮完整性并确保角膜和缘部的完全拱顶。一种配镜模型建议在配镜时倾向于选择较大且较松的镜片，而不是直径较小且矢状深度较浅的镜片。有许多选项可以增强巩膜镜的润湿性并减少镜片沉积。在为这些复杂角膜配镜时，推荐使用高 Dk 材料，并进行详细的沟通以确保安全佩戴和处理，因为这些患者通常正在使用多种治疗方法。由于巩膜镜在镜片与角膜之间形成了一个后镜泪液储存区，这些镜片比角膜气体透过镜更厚，可能在亚临床水平上导致生理性水肿。 另一种由 Michaud 等人提出的配戴模型指出，后镜片撕裂层应不超过 微米，以避免使用高 Dk（ ）镜片时出现角膜水肿，且最大中央厚度为 250 微米。无论首选的配戴方法如何，都需要仔细观察，以监测巩膜镜对眼表疾病患者的长期影响。
Conclusion 结论
Scleral lenses are an effective therapeutic option in the management of ocular surface disease recalcitrant to traditional therapies. The overall goal when prescribing scleral lenses for ocular surface disease is to improve comfort while supporting the ocular surface and improving clinical signs of surface disease. Patients who are symptomatic with clinical signs and those who are asymptomatic but have clinical signs (neurotrophic keratopathy) are excellent candidates for longterm therapy with scleral lenses. 巩膜镜是治疗对传统疗法顽固的眼表疾病的有效治疗选择。为眼表疾病开处方巩膜镜的总体目标是提高舒适度，同时支持眼表并改善眼表疾病的临床表现。那些有临床症状的患者以及无症状但有临床表现（神经性角膜病）的患者都是长期使用巩膜镜的优秀候选者。
Disclosure 披露
Jennifer S Harthan - Allergan, Inc., Shire Pharmaceuticals, Metro, Tangible Science, and Ellen Shorter reports no conflicts of interest in this work. 詹妮弗·S·哈瑟恩 - 艾尔健公司、夏尔制药、Metro、Tangible Science 和艾伦·肖特在此项工作中没有利益冲突的报告。
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