Description

We describe two patients with jelly-bump deposits on the therapeutic contact lens used for corneal protection postptosis surgery. The first was a woman in her 20s who underwent uneventful left levator resection surgery for moderate simple congenital ptosis. Dry eye and lagophthalmos were ruled out preoperatively. Senofilcon-A therapeutic bandage contact lens (BCL) (Johnson & Johnson) was placed at the end of surgery for protection against corneal exposure. Carboxymethyl cellulose 1% eye-drops 2 hourly, and ofloxacin 0.3% ointment over the skin were prescribed. She was lost to follow-up. Six weeks later, she reported with decreased vision. Her best-corrected visual acuity (BCVA) had decreased to finger counting at 1 m. Examination revealed a congested eye, a retained contact lens with large jelly-bump deposits, and mucoid film over the BCL (figure 1A, B). She had 3 mm lagophthalmos with minimal corneal exposure (figure 1C). The underlying cornea revealed multiple superficial infiltrates. Microbiological evaluation of BCL and corneal scrapings did not reveal any micro-organisms. Intensive broad-spectrum topical antibiotics were started, and the corneal lesions decreased in intensity in 3 days, improving the BCVA to 20/40, with residual corneal infiltrates. Subsequently, she followed up locally and her vision improved to 20/20.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Case 1 (A) and (B) showing circumciliary congestion with large, jelly-bump deposits in the left eye. (C) Postoperative lagophthalmos with upto one-third cornea exposed.

The second case was a teenaged female who underwent repeat levator resection surgery for right residual simple congenital ptosis. Senofilcon-A BCL (Johnson & Johnson) was placed at the end of the surgery. There was good Bell’s phenomenon and no dry eye preoperatively. Two weeks later, BCVA dropped from 20/20 to 20/400. Examination revealed large jelly-bump deposits over the BCL and 3 mm lagophthalmos (figure 2A–C). The BCL was replaced with resultant improvement in the visual acuity to 20/20.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Case 2 (A) Jelly-bump deposits over the bandage contact lens involving the visual axis, highlighted as (B) negative uptake of fluorescein stain. (C) Postoperative lagophthalmos with reduced blink rate.

First described in 1970s, ‘jelly-bump’ deposits, also known as mulberry spots or lens calculi, are discrete or confluent, elevated lesions on contact lenses; comprising cholesterol and waxy esters.1 2 Senofilcon-A CLs used for extended wear have higher oxygen transmissibility however they also have higher propensity for jelly-bump deposition compared with conventional soft CL. Factors known to cause rapid deposition on the lens include concurrent dry eye, meibomian gland dysfunction, and systemic disease.3 In an oculoplastic setting, therapeutic CLs have been commonly used for cornea protection and enhance patient comfort following ptosis repair.4 The current cases developed CL deposits despite the use of lubricants and in the absence of dry eye, leading to sterile corneal infiltrates in the first case. The authors attribute postoperative impaired blink reflex and insufficient lid closure as the possible mechanism for the accelerated and exuberant deposits. Reduced blink reflex impedes the movement of the lid over the ocular surface permitting accumulation of tear-mucous material. This promotes microbial colonisation which potentially can lead to microbial keratitis.

Following ptosis surgery, the improvement in the ocular surface parameters is gradual.5 The early postoperative period is crucial, necessitating a contact lens in select cases. This is the first report illustrating the postoperative development of jelly-bumps over therapeutic CLs following ptosis surgery. This finding may perhaps be overlooked due to lack of knowledge about this entity and its implications.