SPECIALTY CONTACT LENSES, specifically scleral lenses, have become a mainstay treatment for managing corneal irregularities caused by trauma, degenerations and dystrophies, infectious and autoimmune-related scarring, iatrogenic etiologies, inflammatory diseases such as Sjögren’s and graft-versus-host-disease (GVHD), and other ocular surface disorders (Harthan and Shorter, 2018). However, successful long-term lens wear and therapeutic benefit are highly dependent on how well underlying pathology is treated and managed. This case highlights the importance of managing atopy-related inflammation in a scleral lens-wearing pediatric patient who has keratoconus (KCN).

A 12-year-old Caucasian male presented with complaints of blurred vision OS > OD and significant ocular burning and itching. His entering best-corrected visual acuity was 20/25 OD and 20/50 OS. He was diagnosed with KCN OS > OD nine months prior and underwent corneal cross-linking (CXL) in the worse eye (OS) three months after his diagnosis.

He is an avid baseball player who spends most of his time outdoors, which exposes him to allergens, dirt, sweat, and sun. Figure 1 shows his topography at the initial evaluation. Biomicroscopy revealed three-plus giant papillae in the upper tarsal plate with trace conjunctival fibrosis, trace superior pannus, and perilimbal superficial punctate keratitis without evidence of perilimbal Horner-Trantas dots in both eyes.

He reported frequent and forceful eye rubbing accompanied by mild mucous discharge. Although his symptoms were described as perennial, a diagnosis of vernal keratoconjunctivitis (VKC) was made due to his age, flare-ups in the summer and spring, clinical tarsal presentation, and associated KCN.

He was prescribed cyclosporine ophthalmic emulsion 0.1% b.i.d. and alcaftadine ophthalmic solution 0.25% q.a.m. to control inflammation and minimize the risk of progression. At his four-week follow-up, he was fitted in a pair of scleral lenses (14.8mm diameter, 3,900μm sagittal depth, toric peripheral curve, prolate design) to improve his vision and provide continuous moisture to the ocular surface. He reported immediate comfort and his vision improved to 20/20 in both eyes.

We discussed the chronic nature of atopy-related disease, how it contributes to his condition, and the importance of avoiding eye rubbing. He was referred to an allergy specialist for systemic atopic control. We are closely monitoring his topography, refractive status, and ocular surface on a four- to six-month basis to determine when the next cross-linking procedure in his fellow eye will be needed.

Scleral lenses have revolutionized the treatment and management of complex ocular surface and corneal disease. However, we must remain vigilant of underlying ocular pathology when prescribing these medical devices to maximize their therapeutic benefit, improve the patient’s quality of life, and prevent further corneal deterioration. CLS

References

1. Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auckl). 2018 Jul 11;10:65-74.