I am often guilty of thinking that the ocular conditions that I typically manage, such as keratoconus or graft-versus-host disease, are isolated events. Unfortunately, lightning can strike twice; in many cases, patients may suffer from not one vision-threatening condition but two or even three. While it is feasible to identify this early on, it is also plausible that things just don’t add up during the fitting process, which is when other diagnoses can reveal themselves.

What Often Goes Hand-in-Hand

Most commonly, specialty contact lens patients will also have atopic conditions. These patients will present with symptoms of itching but also may have heavy lens deposits; the blurred vision from these deposits may be what prompts the visit. Atopy impacts roughly 10% of children and may resolve in adolescence, but many persist into adulthood. Such patients may also suffer from allergic rhinitis or from asthma, and a quick check of overall symptoms will help guide your diagnosis. For our keratoconus patients, it is estimated that 6.2% to 16.2% of patients suffer from atopic conditions (Foster and Calonge, 1990; Tuft et al, 1991) (Figure 1).

Fuchs’ endothelial dystrophy has been shown to have a correlation with keratoconus patients as well (Mylona et al, 2020). Patient ages can range from 15 years old up to 82 years old. Fuchs’ has a slightly higher predilection for females versus males, with females at approximately 56.5% of diagnosed cases. It also has been found to be bilateral in 59.4% of patients (Mylona et al, 2020).

Unfortunately, patients who have suffered through the terrible sequelae of Stevens-Johnson syndrome can also be impacted by corneal ectasia. This is thought to result from a higher concentration of matrix metalloproteinases (MMPs). Ectasia is usually diagnosed after the onset of Stevens-Johnson syndrome (Saeed et al, 2016).

Additionally, although rare, some patients who have graft-versus-host disease may have a long-term history of keratoconus well before the diagnosis of their hematological malignancy. While these patients tend to do well with scleral lenses for the treatment of their dry eye, the presence of keratoconus and/or corneal scars can complicate the fitting process.

Of course, there are likely countless other situations in which patients are afflicted with two or more ocular conditions (Figure 2), but one may be more pressing compared to the other.

Fortunately, if we are able to identify the comorbidities early on during the fitting process, we have plenty of tools in our toolbox to conquer patients’ symptoms, including adding a mast cell stabilizer or a corticosteroid to the treatment plan. Using topography to rule in or to rule out ectasia can ease the fitting process and lead to better patient outcomes. While it is rare for lighting to strike twice, don’t think that it can’t happen. CLS

For references, please visit www.clspectrum.com/references and click on document #302.