Description
Gas permeable scleral contact lenses, which are also known as ocular surface prostheses, are formed with an elevated chamber over the cornea and a haptic base over the sclera. Scleral contact lenses are being evaluated in patients with corneal disease, including keratoconus, Stevens Johnson syndrome, chronic ocular graft-versus-host disease (GVHD) and in patients with reduced visual acuity after penetrating keratoplasty or other types of eye surgery. The literature on gas-permeable scleral contact lenses consists of a number of large case series that enrolled more than 100 patients. The largest series was a retrospective review of more than 538 patients with more than 40 different clinical indications who were fitted with the Boston Ocular Surface Prosthesis. These case series report an improvement in health outcomes in patients who have failed all other available treatments. These uncontrolled studies are suggestive of benefit, but the lack of controlled trials precludes a definite conclusion on treatment benefit.

Clinical input was obtained and supports the medical necessity of the gas-permeable scleral contact lens in cases of corneal ectatic disorders, corneal scarring and/or vascularization, irregular corneal astigmatism and ocular surface disease with pain and/or decreased visual acuity when all other available treatments have failed. For patients with ocular surface diseases who have not responded adequately to topical medications, there is a lack of alternative treatments. For patients with corneal ectatic disorders and irregular astigmatism who have failed standard contact lens, the alternative of corneal transplant surgery is associated with risks. Therefore, the gas-permeable scleral contact lens may be considered medically necessary in these patient populations. 

Background
Scleral contact lenses create an elevated chamber over the cornea that can be filled with artificial tears. The base or haptic is fit over the less sensitive sclera. A scleral contact lens has been proposed to provide optical correction, mechanical protection, relief of symptoms and facilitation of healing for a variety of corneal conditions. Specifically, the scleral contact lens may neutralize corneal surface irregularities and, by covering the corneal surface in a reservoir of oxygenated artificial tears, function as a liquid bandage for corneal surface disease. This may be called prosthetic replacement of the ocular surface ecosystem (PROSE).

The development of materials with high gas permeability and technologic innovations in design and manufacturing has stimulated the use of scleral lenses. The Boston Ocular Surface Prosthesis^™ (Boston Foundation for Sight) is a scleral contact lens that is custom fit using computer-aided design and manufacturing (i.e., computerized lathe). Another design is the Jupiter mini-scleral gas-permeable contact lens (Medlens Innovations and Essilor Contact Lens). The Jupiter scleral lens is fitted using a diagnostic lens series. The Procornea (Eerbeek) scleral lens was developed in Europe. There are four variations of the Procornea: spherical, front-surface toric, back-surface toric and bitoric. Lenses are cut with submicron lathing from a blank. The Rose K2 XL lens (Menicon, Japan) is a semi-scleral lens.

Regulatory Status
The Boston Ocular Surface Prosthesis, which is the prosthetic device used in PROSE (prosthetic replacement of the ocular surface ecosystem), was approved by the U.S. Food and Drug Administration (FDA) in 1994. The first generation Rose K^™ lens received FDA approval in 1995.

Related Policies
90305 Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
90314 Implantation of Intrastromal Corneal Ring Segments

Policy
Rigid gas-permeable scleral lens may be considered MEDICALLY NECESSARY for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions:

Policy Guidelines 
There are CPT codes for prescription and fitting of corneoscleral lens (92313 and 92317), which depend on the level of involvement of the physician.

Insertion of a gas permeable scleral contact lens might be reported with the unlisted ophthalmological service or procedure code (92499). Modification of contact lens may be reported using CPT code 92325 when performed separately.

Effective in 2012, code 92071 is available for fitting of contact lens for treatment of ocular surface disease and code 92072 for fitting of contact lens to treat keratoconus.

There are specific HCPCS codes for scleral lenses:
S0515 Scleral lens, liquid bandage device, per lens
V2531 Contact lens, sclera, gas permeable, per lens

Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and, thus, these devices may be assessed only on the basis of their medical necessity.

Rationale
Searches of the MEDLINE database through July 17, 2014, identified case series with gas permeable scleral contact lens. The largest series are described next.

Boston Ocular Surface Prosthesis
A retrospective analysis of 875 eyes (538 patients) fitted with a Boston scleral lens was reported in 2005 by Rosenthal (founder and president of the nonprofit Boston Foundation for Sight) and Croteau.¹ Rigid gas-permeable corneal contact lenses either were not tolerated or were contraindicated in all eyes. Patients who failed a trial period were not fitted and were excluded from this study. Follow-up ranged from two months to 18 years. Of 501 eyes that were fitted primarily to improve vision, 262 had corneal ectasia, and 130 eyes were fitted due to inadequate best corrected visual acuity (BCVA) after penetrating keratoplasty. The primary indication was to maintain the integrity of the corneal epithelium in 374 eyes with severe ocular surface disease, including corneal stem-cell disorders (Stevens Johnson syndrome, corneal ectasia, chemical, ocular cicatricial pemphigoid, aniridia), neurotrophic corneas (congenital corneal anesthesia, acquired cranial nerve V paresis, after acoustic neuroma surgery, after trigeminal ganglionectomy, after herpes simplex keratitis, after herpes zoster keratitis) and severe dry eye syndrome (graft vs. host disease [GVHD], Sjögren syndrome, corneal ectasia, rheumatoid arthritis, radiation), dermatological-associated disorders, exposure and corneal neuropathic pain. Scleral lenses were found to improve vision, promote healing of persistent epithelial defect, and in patients with dry eye syndrome, reduce ocular pain and disabling photophobia. Attenuation of symptoms was insufficient to continue wearing the prosthesis in eyes with neuropathic pain and in eyes with corneal edema before fitting.

In 2010, Stason et al. reported use of the Boston Ocular Surface Prosthesis in a series of 101 patients with corneal disease who had not responded satisfactorily to conventional treatments and were seen at a tertiary care clinic.² The fitting procedure was not completed or was deferred in 21 patients; 80 patients were fitted with a prosthesis in one or both eyes. Of those fitted with a prosthesis, the principal eye diagnosis was corneal ectasia or irregular astigmatism in 42 patients and ocular surface disease (e.g., dry eye syndrome, chronic GVHD) in 38 patients. Sixteen patients had undergone a previous corneal transplantation, and three had undergone laser in situ keratomileusis (LASIK). About half were experiencing photophobia and one-third reported eye pain at baseline. At six-month follow-up after fitting, BCVA improved by a change in mean logarithm of the angle of resolution (logMAR) of -0.39 with a change of -0.54 logMAR units in patients with ectasia or astigmatism and -0.22 logMAR in patients with ocular surface disease. For all 141 fitted eyes, 27 percent had no significant change in vision, 35 percent gained one line, 23 percent gained two lines, and 14 percent gained three lines or more. Mean composite visual functioning scores on the Visual Functioning Questionnaire (VFQ) increased from 57.0 to 77.8 for patients who received a prosthesis (measured in 69 of 80 patients) and were not significantly improved in patients (measured in 12 of 21 patients) who did not (from 65.1 to 69.3). There was significant improvement in all of the vision-related subscales on the VFQ, which included the categories of vision, activities and ocular pain (from 49.9 at baseline to 72.8 with a prosthesis). Lower baseline VFQ scores were strong predictors of subsequent improvement in visual functioning. The report concluded that controlled clinical studies will be needed to confirm the effectiveness of the Boston Ocular Surface Prosthesis and to compare it with corneal transplantation, tarsorrhaphy or other techniques in patients with advanced ectasia or ocular surface disease.

Baran et al. from the Boston Foundation for Sight reported six-month outcomes from prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in a series of 59 patients with corneal ectasia.³ The primary diagnosis was keratoconus in 83 percent of patients (98 eyes). Fifteen patients (21 eyes) had previously undergone penetrating keratoplasty. Sixteen of the 118 eyes were considered noncandidates because conventional correction was adequate. No devices were dispensed in another 13 eyes due to little improvement in vision during the six-hour trial period (n = 12) or low endothelial cell count (n = 1). There was significant improvement in visual acuity; of 102 candidate eyes, 95 (93.1 percent) achieved visual acuity of 20/40 or better. At mean nine-month follow-up, the sclera contact lens was being worn in 88 percent of the 89 eyes that had a satisfactory fit. For patients still wearing a device at follow-up, the National Eye Institute Visual Function Questionnaire score improved by 27.6 points on a 100-point scale. Reasons for not wearing the device included discomfort (n = 4), lack of motivation to follow the insertion and removal regimen (n = 2) and limited improvement in visual acuity (n = 1).

Jacobs and Rosenthal published patient-reported outcomes from 33 consecutive patients with severe dry eye from chronic GVHD who were fitted with the Boston scleral lens.⁴ All patients had been previously treated with various conventional therapies including punctal occlusion, topical cyclosporine, topical and systemic steroids and partial tarsorrhaphy. The questionnaire results were obtained between one week and greater than two years after the lenses were dispensed. All but one patient reported reduction in eye pain, with 27 patients (82 percent) reporting that pain was moderately to greatly reduced. Photophobia was resolved or greatly improved in 20 patients (62 percent). Ninety-one percent of patients reported moderate to great improvement in quality of life, with 20 of 24 patients (83 percent) reporting moderate to outstanding improvement in driving and 25 of 28 patients (89 percent) reporting moderate to outstanding improvement in reading. Two patients (6 percent) reported that they were not wearing their lenses on a regular basis. One had discontinued because of no improvement while the other discontinued wear because of improvement in symptoms over the prior four months.

Jupiter Scleral Lens
In 2000, Jupiter and Katz reported the management of irregular astigmatism in 48 eyes (29 patients) with rigid gas-permeable contact lenses.⁵ The corneal diagnosis included keratoconus, postkeratoplasty, pellucid marginal degeneration, interstitial keratitis, traumatic scarring, trachoma, rosacea keratitis, keratoglobus, Terrien degeneration, measles keratitis, postlamellar keratectomy, microbial keratitis, herpes simplex keratitis, postcataract surgery astigmatism, postepikeratophakia, post raidal keratotomy and Wegener granulomatosis. In this study, nearly one-third of the patients with irregular astigmatism had BCVA of 20/25 or better with spectacles. Patients with 20/40 spectacle visual acuity achieved a two-line average improvement, patients with 20/50 to 20/200 achieved a four-line average improvement and patients with 20/400 achieved a six-line average improvement with the scleral lens.

Pecego et al. reported a series of 63 patients (107 eyes) who were fitted with the Jupiter sclera lens.⁶ The most common primary diagnoses included keratoconus (42 percent of eyes), postkeratoplasty astigmatism (30 percent) and pellucid marginal degeneration (7 percent). Patients gained a mean of 3.5 lines of vision compared with previous contact lens or glasses correction. A mean of 3.2 lenses per eye were needed to obtain the ideal sclera lens, with a mean number of return to clinic visits of 6.2 over a period of three to 17 months. After at least three months of wear, 78 percent of patients reported the lenses to be comfortable, with wear discontinued in 25 eyes (23 percent).

Schornack and Patel described use of the Jupiter scleral lens in a retrospective review of patients with keratoconus in 2010.⁷ Of 209 patients evaluated for possible scleral lens wear, 52 eyes of 32 patients (15 percent) had keratoconus and were included in the report. The primary reason for scleral lens evaluation was contact lens intolerance. At the time of presentation, 16 patients were wearing spectacle correction, eight were wearing corneal rigid gas-permeable lenses, one was wearing hydrogel toric lenses, three were wearing piggyback systems, and four were wearing no correction. Successive diagnostic lens were placed until a lens was applied that had complete limbal and corneal clearance and had a fluid reservoir depth between 0.15 and 0.4 mm. At follow-up visits, revised lenses were ordered as needed to achieve optimal vision, comfort and fit. The authors noted that at the time of publication, no specific fitting guidelines for scleral lenses have been validated or published. After the initial consultation, 12 patients (20 eyes) chose not to proceed with the fitting process primarily due to a lack of visual benefit compared with habitual correction. Nineteen patients (30 eyes) were fitted with Jupiter lenses in an average of 2.8 visits (range, 2 – 4) with an average of 1.5 lenses (range, 1 – 3). Standard lens designs were prescribed for 23 eyes (77 percent), and seven eyes required a custom design to optimize the scleral lens fit. With an average follow-up of 22.5 months (range, 5 – 34 months), the median BCVA improved in these eyes from 20/40 at baseline to 20/20 with the scleral lens, with an average improvement of 2.9 lines. A 2014 report by the same authors described the successful fitting of the Jupiter scleral lens in 188 eyes of 115 patients.⁸ The most common indications were undifferentiated ocular surface disease, exposure keratopathy and neurotrophic keratopathy. The goals of treatment, achieved in all but two patients, were improved ocular comfort, ocular surface protection and resolution of epitheliopathy. Visual acuity improved from 20/42 to 20/26. Of the patients with at least 12 months of follow-up, 63 percent reported continued lens wear and 37 percent had discontinued lens wear.

Procornea Scleral Lens
Visser et al. reported a prospective study of the indications and clinical performance of the Procornea lens in 2007.⁹ All of the 178 patients (284 eyes) included in the study had been referred to the tertiary clinic for one of a variety of corneal conditions that had not responded to other contact lenses or therapeutic management. Patients with either fit or early wearing failure were excluded from the study. About half of the patients (50.4 percent) were diagnosed with keratoconus and 19.7 percent were post-penetrating keratoplasty.  

Other forms of irregular corneal surface included eyes with scars related to herpes simplex keratitis (n = 8), other forms of keratitis (n = 2), trauma (n = 5), irradiation (n = 3), pellucid marginal degeneration (n = 7), pterygium (n = 2) and macula corneae (n = 1). There were four types of corneal dystrophy: map-dot-fingerprint (n = 5), Fuchs endothelial (n = 2), Reis-Bucklers (n = 2) and lattice (n = 1). Primary keratitis sicca was diagnosed in four eyes, neurotrophic keratitis in seven, ocular cicatricial pemphigoid in two eyes and Sjögren syndrome in two eyes. The primary indication was for visual correction in 249 (87.7 percent) eyes. Median visual acuity was 20/100 without a scleral lens and 20/28 with the lens.

Clinical Input Received From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from one physician specialty society and three academic medical centers while this policy was under review in 2011. The input supported the medical necessity of the rigid gas permeable scleral contact lens for corneal ectatic disorders, corneal scarring and/or vascularization, irregular corneal astigmatism and ocular surface disease with pain and/or decreased visual acuity in cases that had failures of all other available treatments (i.e., topical medications or standard contact lens fittings). One reviewer commented that the prosthesis can help to avoid potentially blinding complications with ocular surface disease and that the alternative for patients with keratoconus and other forms of irregular astigmatism would be cornea transplant surgery, which involves a lifetime of close medical monitoring and significant risk.

Summary of Evidence
Gas-permeable scleral contact lenses, which are also known as ocular surface prostheses, are formed with an elevated chamber over the cornea and a haptic base over the sclera. Scleral contact lenses are being evaluated in patients with corneal disease, including keratoconus, Stevens Johnson syndrome, chronic ocular graft-versus-host disease (GVHD) and in patients with reduced visual acuity after penetrating keratoplasty or other types of eye surgery. The literature on gas permeable scleral contact lenses consists of a number of large case series that enrolled more than 100 patients. The largest series was a retrospective review of more than 538 patients with more than 40 different clinical indications who were fitted with the Boston Ocular Surface Prosthesis. These case series report an improvement in health outcomes in patients who have failed all other available treatments. These uncontrolled studies are suggestive of benefit, but the lack of controlled trials precludes a definite conclusion on treatment benefit.

Clinical input was obtained and supports the medical necessity of the gas-permeable scleral contact lens in cases of corneal ectatic disorders, corneal scarring and/or vascularization, irregular corneal astigmatism, and ocular surface disease with pain and/or decreased visual acuity when all other available treatments have failed. For patients with ocular surface diseases who have not responded adequately to topical medications, there is a lack of alternative treatments. For patients with corneal ectatic disorders and irregular astigmatism who have failed standard contact lens, the alternative of corneal transplant surgery is associated with risks. Therefore, the gas-permeable scleral contact lens may be considered medically necessary in these patient populations.

Practice Guidelines and Position Statements
The American Academy of Ophthalmology published a July 2012 guide to diagnosis and treatment of corneal ulcers.¹⁰ Scleral contact lenses were mentioned as a treatment option for improving vision without surgery after a bacterial infection has resolved and the ulcer has scarred over. There is no discussion on the efficacy of scleral contact lenses.

U.S. Preventive Services Task Force Recommendations
Use of scleral contact lenses is not a preventive service.

BlueCard is a registered mark of this health plan. Boston ocular Surface prosthesis and Rose K are not trademarks of this health plan.

References

1. Rosenthal P, Croteau A. Fluid-ventilated, gas-permeable scleral contact lens is an effective option for managing severe ocular surface disease and many corneal disorders that would otherwise require penetrating keratoplasty. Eye Contact Lens. May 2005;31(3):130-134. PMID 15894881
2. Stason WB, Razavi M, Jacobs DS, et al. Clinical benefits of the Boston Ocular Surface Prosthesis. Am J Ophthalmol. Jan 2010;149(1):54-61. PMID 19878920
3. 3. Baran I, Bradley JA, Alipour F, et al. PROSE treatment of corneal ectasia. Cont Lens Anterior Eye. May 24 2012;35(5):222-227. PMID 22633003
4. Jacobs DS, Rosenthal P. Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease. Cornea. Dec 2007;26(10):1195-1199. PMID 18043175
5. Jupiter DG, Katz HR. Management of irregular astigmatism with rigid gas permeable contact lenses. CLAO J. Jan 2000;26(1):14-17. PMID 10656303
6. Pecego M, Barnett M, Mannis MJ, et al. Jupiter Scleral Lenses: the UC Davis Eye Center experience. Eye Contact Lens. May 2012;38(3):179-182. PMID 22543730
7. Schornack MM, Patel SV. Scleral lenses in the management of keratoconus. Eye Contact Lens. Jan 2010;36(1):39-44. PMID 20009945
8. Schornack MM, Pyle J, Patel SV. Scleral lenses in the management of ocular surface disease. Ophthalmology. Jul 2014;121(7):1398-1405. PMID 24630687
9. Visser ES, Visser R, van Lier HJ, et al. Modern scleral lenses part I: clinical features. Eye Contact Lens. Jan 2007;33(1):13-20. PMID 7224674
10. American Academy of Ophthalmology (AAO). Confronting corneal ulcers. 2012; http://www.aao.org/publications/eyenet/201207/feature.cfm. Accessed June, 2014.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology^© American Medical Association. All Rights Reserved" 

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