Carla, a 32-year-old female, is a white-collar office worker. Myopic and astigmatic, she hates wearing glasses but was experiencing difficulty wearing her soft contact lenses. Her optometrist made several attempts to improve her condition (changing care regimen, switching to daily disposables). On her side, Carla tried to improve her environment. She was also using various brands of artificial tears. Nothing was really effective.

Carla’s symptoms were most common in the workplace, in restaurants, and in public malls; they were much less at home and never occurred outside except when she was jogging. She does not take any medications, her general health being good. She admits that her face flushes easily—as soon as she is exposed to the sun and if she drinks alcohol or eats spicy food. Her Ocular Surface Disease Index (OSDI) score was 15.

The clinical examination revealed an osmolarity of 318 mOsmol/L, a cotton thread test of 12mm/15 seconds, a thin lipid layer of 65nm, and a non-invasive tear breakup time of 6 seconds OD and OS. Slit lamp examination revealed telangiectasia at the lid margin. The meibum was easy to express but appeared turbid. There was no corneal staining or signs of Demodex.

I diagnosed grade 2 meibomian gland dysfunction, most likely associated with rosacea. Rosacea is a chronic, systemic disorder usually occurring in fair-skinned people of European descent (Di Marchi et al, 2014). Underdiagnosed, it is a frequent cause of eye problems such as conjunctivitis, chronic blepharitis, chalazion, keratitis, or iritis.

According to the Tear Film and Ocular Surface Society Dry Eye Workshop II (Jones et al, 2017), the first stage in managing dry eye disease (DED) is to educate the patient about her condition, change her local environment, ensure healthy nutrition, and encourage frequent use of artificial tears. It is also recommended to add eyelid hygiene, with warm compresses. If this strategy proves ineffective, the second stage is to add topical medication (corticosteroids, cyclosporine, or lifitegrast). Scleral lenses are not recommended until the third stage, if symptoms or clinical signs remain significant.

Why Wait So Long?

There are two aspects to consider here. On one hand, DED is an inflammatory condition (Wei and Asbell, 2014), and scleral lenses can trap inflammatory mediators in the reservoir. On the other hand, practitioners often overlook the fact that quality of life (QOL) and productivity can be significantly reduced even with mild-to-moderate DED, with which sclerals can help. During the evaluation and follow-up of DED patients, questionnaires oriented toward QOL are often little used. The Impact of Dry Eye on Everyday Life (IDEEL) or the National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) (Wolffsohn et al, 2017) tests should then be considered as valuable tools in our diagnostic evaluation.

In the case of Carla, I recommended lid hygiene and nonpreserved lipid-based artificial tears to start. This slightly improved her condition. Tolerance to contact lens wear was still limited, and her QOL score did not improve. Two options were on the table: medication or scleral lenses. Inflammation was not identifiable at that time, and the patient was reluctant to commit to a lifetime of topical medication. We agreed to try scleral lenses.

The results were amazing, with an almost instant “wow” effect not only on the eye but on her QOL. Carla was now able to work without discomfort all day, then go jogging without feeling like she had sand in her eyes. She could go out with friends and take full advantage of the activities from which she was previously restricted due to the discomfort from her lenses.

The message here is simple: beyond the signs and symptoms and the DEWS II grading, we need to care about the QOL of our patients. This is also a part of caring for them. And scleral lenses, used wisely, can help to greatly improve this aspect of their lives. CLS

For references, please visit www.clspectrum.com/references and click on document #296.