Alison was 12 years old when I first examined her. She was anisometropic—plano in one eye and –4.00D in the other. Her mother had several concerns, the most prominent being Alison’s rapidly progressing myopia in one eye, and so she was referred to me for a consultation. The examination and fitting went without a hitch. Alison adapted to a monocular orthokeratology (ortho-k) contact lens seamlessly, and her binocularity improved with time…and that would have been the end of a nice story, but life is not often so cut-and-dry.

An Unexpected Development

Six months into wearing her ortho-k contact lens, the eye wearing the lens became red. Subjectively, she experienced no discomfort or photophobia, and she had no complaints other than monocular redness. Objectively, mild perilimbal superficial punctate staining and a reduced tear breakup time were noted. The fellow eye, the one not wearing a contact lens, was white and quiet. “A tight lens!” I thought to myself. But, despite several lens modifications, the monocular redness would return upon reinstituting ortho-k.

The Plot Thickens

After giving Alison a long break, I reintroduced contact lens wear, this time using a soft daily disposable lens. The redness returned! I was stumped, but fortunately both Alison and her mom were undeterred. As a matter of fact, they encouraged me to not give up. I extended their ortho-k program one year, and Alison took a three-month break.

What Should Have Been Obvious

After the break, the etiology was staring at me through the biomicroscope: both eyelids manifested severe meibomian gland dysfunction (MGD). Although the condition was subclinical, wearing the contact lens exacerbated the dry eye, causing the ocular redness. If I had taken my own advice from my July 2020 Orthokeratology Today column, I would have noted Alison’s clogged eyelid pores during her initial consultation. Because her symptoms were monocular and corresponded with the eye wearing the contact lens, I did not look at the fellow eye until after she took a long break from lens wear.

Whether it’s due to increased screen time or to mask wearing, I’ve noted MGD much more among my ortho-k patients during the pandemic. Ethnicity may also play a role. Asian patients may suffer more from ocular surface disease when compared to their Caucasian counterparts (Craig et al, 2019); most of my patients who wear ortho-k lenses are of eastern Asian descent.

The Solution

I kept Alison out of contact lenses for an additional three months and prescribed a bilateral MGD resolution protocol. Nothing special: hot compresses followed by rigorous eyelid massage, one-to-three times a day. I monitored her weekly until I was certain that she complied fully. When Alison stumbled by skipping her eyelid massages, I guided her back into a routine. Once I was confident that the MGD was under control, I reinstated soft contact lens wear. The conjunctival injection did not return. Interestingly, her myopia began to creep in both eyes, as it had been a year since we stopped ortho-k contact lens wear.

With time, I gained enough confidence and refit her with an ortho-k contact lens in the more myopic eye. Six months into wearing the lens, the dryness and subsequent redness have not returned. Now, Alison is happy, mom is elated, and I’m relieved. I’ve made a point to tell her that if she stops the nightly eyelid massage, the redness will likely return.

The Lesson

Listen to me carefully, but don’t watch me too closely. I’m somewhat embarrassed by overlooking the obvious. I needed this patient to remind me that a clue to solving a good mystery is often staring us in the face, and sometimes it’s one that we’ve encountered before. CLS

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