Dry Eye Dx and Tx

Scleral Lenses: An Important Treatment Option for Dry Eye

BY JESSICA ROBINSON, BA, & AMBER GAUME GIANNONI, OD, FAAO

“My dryness is 90% better.” These words were spoken by a 51-year-old Hispanic female who suffers from severe keratoconjunctivitis sicca secondary to Sjögren’s syndrome and meibomian gland dysfunction. Several months of intensive therapy—including topical ophthalmic cyclosporine and corticosteroids, punctal plugs, warm compresses, lid scrubs, omega-3 supplements, bandage soft contact lenses combined with prophylactic topical antibiotics, and copious preservative-free artificial tears and gels—had failed to provide relief. Although these medications improved overall tear production and stability, she still suffered unremittingly from filamentary keratitis and non-resolving, grade 4+ patchy coalesced corneal staining in both eyes.

The true turning point in this patient’s treatment was the decision to fit her therapeutically in scleral contact lenses.

When All Else Failed

Fitting the patient with scleral lenses took some convincing as she couldn’t imagine wearing a contact lens when her eyes felt so terrible. Additionally, she didn’t have insurance that would pay for medically necessary contact lenses. To allow her to experience the modality, we invited her to wear scleral lenses from our fitting set around the office for two hours. She immediately realized that her eyes felt substantially better; the breeze created from simply walking down the hallway no longer caused her pain. She decided to proceed with a scleral lens fitting.

At every follow-up visit, the patient showed steady improvement in both signs and symptoms. By one month, we saw a dramatic improvement in corneal health (Figures 1 and 2). It was after two months of wear that she described her symptoms as being more than 90% improved.

Figure 1. Our patient’s cornea after several months of dry eye therapy and before scleral lens fitting.

Figure 2. Our patient’s cornea after approximately one month of scleral lens wear.

Our patient occasionally experiences mid-day lens fogging in her more progressed eye, but she is able to manage it by removing, rinsing, and reapplying the lens in the early afternoon. Other ways to manage scleral lens debris and fogging include reducing central clearance and modifying the edge profile (McKinney et al, 2013; Caroline and André, 2012).

Well Worth Considering

When utilized as a treatment option for ocular surface disease, scleral lenses can improve comfort and visual acuity as well as protect the ocular surface to resolve keratopathy (Schornack et al, 2013). They can be used as both first-line therapy or reserved for when other therapies fail. And, as our patient demonstrates, therapeutic scleral lenses can be absolutely life changing. CLS

For references, please visit www.clspectrum.com/references and click on document #231.

Jessica Robinson is a fourth year student at the University of Houston College of Optometry. She will graduate in May 2015. Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and the Co-Director/Co-Founder of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.