Dry eye syndrome has a wide variety of etiologies, and most of the symptoms are very common and have some overlap. However, one type of dry eye—limbal stem cell deficiency (LSCD)—stands out from the others in that it usually has specific characteristics (Figure 1), and it can elude some eyecare providers. In addition, specialty lenses can be helpful in these cases, but some may steer clear of them as a treatment option.

LSCD results from an insufficient microenvironment to support stem cell function or, more commonly, when limbal stem cells are lost due to a variety of etiologies. Common LSCD origins include Stevens-Johnson syndrome, chemical or thermal burns, ocular cicatricial pemphigoid, and soft contact lens use. With LSCD, normal cells responsible for corneal regeneration are lost or destroyed (Kim et al, 2020; Deng et al, 2019; Kim and Kim, 2015; and others. Full list available at www.clspectrum.com ).

Clinical manifestations of LSCD in the cornea depend on the severity of the disease, but it can progress to subepithelial scarring, conjunctivalization, neovascularization, ulceration, melting, and perforation. Because limbal stem cells do not regenerate, significant lifelong ocular manifestations can result, with symptoms including decreased vision, ocular redness and irritation, and photophobia. Treatment options include cessation of the offending agent if possible, frequent use of artificial tears, topical corticosteroids, punctal occlusion, autologous serum tears, amniotic membrane grafting, and limbal autografting.

Lens Management Options

Scleral lenses have been proposed as a plausible treatment for LSCD (Schornack, 2011) (Figure 2). Because they vault the cornea and are filled with fluid, they can provide a microenvironment that is hospitable to fostering function of the remaining limbal stem cells of the cornea. In addition, scleral lenses that vault the limbus where the stem cells are housed can provide potential mechanical protection to these vital cells. The fluid reservoir can neutralize the irregular cornea, which can aid in visual rehabilitation and also alleviate common symptoms (Kim et al, 2020). This same study showed a positive impact on vision and cessation of corneal scarring progression and dry eye symptoms though the use of scleral lenses.

While some may steer clear of a scleral lens for LSCD, a corneal GP lens could be an alternative to help improve vision due to the irregular surface that results from the disease. Additionally, hybrid lenses are certainly a viable option for this patient population.

Some eyecare providers may express concern regarding any or all of these types of lenses as a treatment option for this complex disease out of concern for hypoxia or mechanical corneal insult. Regardless of modality, when fitting these patients, I usually like to watch them closely to monitor their progress and for my own peace of mind. CLS

For references, please visit www.clspectrum.com/references and click on document #308.