Graves’ disease is an autoimmune disorder that primarily affects the thyroid gland and can result in Graves’ ophthalmopathy (GO) in 25% of cases (Subekti and Pramono, 2018; Bartalena, 2013). GO causes extraocular muscle and orbital adipose tissue enlargement that results in orbital compression (Bahn, 2003). Exophthalmos occurs as a natural way to decompress the confined space of the orbit, which leads to lid retraction and lagophthalmos. Other primary causes for lagophthalmos include trauma or nerve palsy. Incomplete lid closure can result in anterior ocular surface desiccation and scarring. Patients who have GO and who have lagophthalmos will often experience significant discomfort and vision loss. Protection of the anterior ocular surface is necessary for successful short- and long-term management.

Case Details

A 51-year-old female patient reported for specialty lens evaluation. She had a history of long-standing Graves’ disease, GO, keratoconus, dry eye, and cataract surgery OD. Previous treatment for GO included multiple orbital decompressions and partial tarsorrhaphy of her left eye. Ophthalmic treatment included Restasis (Allergan) b.i.d. in both eyes and artificial tear ointment. Best-corrected visual acuity of her right eye was +0.25 –1.00 x 135, 20/60 and of her left eye was count fingers. A 16.5mm scleral lens was successfully fit for her right eye that provided 20/20 acuity.

After discussion, her ophthalmologist removed her left eye tarsorrhaphy (Figure 1) for scleral lens fitting. A 16.5mm scleral lens OS initially gave her 20/20 vision, but she was then lost to follow up.

Upon her return, she reported that she had discontinued scleral lens wear OS secondary to overnight dryness, and she had a repeat partial tarsorrhaphy. The patient had continued daily wear of her scleral lens OD without complaints.

After discussing the possibility of wearing a soft bandage lens overnight for continued protection of her left eye, her ophthalmologist increased the aperture opening of her tarsorrhaphy to accommodate a contact lens. Her left eye was refit with a 16.0mm scleral lens that she was able to successfully apply, giving her 20/30 vision (Figure 2).

After a few weeks of daily wear using the scleral lens, her left eye was also fit with a bandage soft lens that she was to apply after removal of her scleral lens for overnight wear. She is now able to wear scleral lenses for both eyes on a daily wear schedule, which has improved her visual function.

Conclusions

Lagophthalmos can result in acute ocular discomfort and decreased vision. Protection of the anterior ocular surface from chronic exposure is critical to improve comfort and to prevent corneal scarring. Tarsorrhaphy has traditionally been a surgical option for patients, but it often reduces patients’ visual function and is cosmetically unappealing.

Scleral lenses offer an alternative option to successfully maximize protection and vision. As in this case, extended-wear bandage soft lenses can be prescribed for continued protection while sleeping. CLS

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