THURSDAY MORNING. Ordinary in its gray late-winter Canadian weather. Ms. Cooper has been referred to the University clinic for scleral lens fitting. Nothing new.

Yet…Ms. Cooper is a postmenopausal woman who has suffered from dry eye for almost 10 years. She has tried everything and consulted half the physicians in town. It is with little hope that she arrives to try the scleral adventure that her practitioner has described as “magical.” Now, I feel the pressure. Forget the ordinary morning.

Ms. Cooper had tried sclerals long before as her symptoms got worse, but to no avail. Was it a poor fit or a combination of circumstances that led to this failure? No one knows. But maybe scleral lenses were being considered under the wrong circumstances.

The Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) recommends that scleral lenses be considered in dry eye management as step three out of four (Jones et al, 2017), when other options have failed and inflammation reaches the highest levels. While it is logical to believe that maintaining a fluid reservoir throughout the wear period would help, the outcome may be different.

One study showed that a scleral lens reservoir accumulates large amounts of MMP-9 (inflammatory) and MMP-10 (tissue restoration), as well as other enzymes, affirmed the absence of significant tear exchange during lens wear (Walker et al, 2020). The increased concentration of MMP-10 should be viewed as an attempt by the ocular surface to self-regulate. Despite this response, the authors concluded that this surface could be significantly altered in the long term due to this increased concentration of pro-inflammatory by-products in the reservoir.

This is consistent with my own clinical experience. Unless the patient’s condition warrants it, it is my opinion that it is always better to treat inflammation before a scleral lens is applied. Not only does this prevent the accumulation of harmful inflammatory mediators in the reservoir, but it also facilitates the scleral lens fitting itself.

In fact, a severely dry and inflamed eye presents a modified ocular surface in terms of both of the structure of the conjunctival cells (Yamaguchi, 2018) and its microbiome (Gupta et al, 2023). Fitting is altered because of the change in the conjunctival structure (Yamaguchi, 2018) and infections are more likely to occur (Robertson, 2013).

In Ms. Cooper’s case, this is the recipe that was followed: To start, aggressive treatment of the inflamed ocular surface was initiated. Two months later, when the signs and symptoms of her condition had improved, the scleral lenses were successfully fit. A few drops of autologous serum, mixed with preservative-free tears with electrolytes, transformed this fitting into a “miracle” in the patient’s life. Pressure relieved.

The question that arises from this case is more global. Should we consider scleral lens use in dry eye at a much earlier stage? Intuitively, I would say yes, but we need more evidence-based work to justify it. CLS

References

1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017 Jul;15:575-628.
2. Walker MK, Lema C, Redfern R. Scleral lens wear: measuring inflammation in the fluid reservoir. Cont Lens Anterior Eye. 2020 Dec;43:577-584.
3. Yamaguchi T. Inflammatory Response in Dry Eye. Invest Ophthalmol Vis Sci. 2018 Nov 1;59:DES192-DES199.
4. Gupta N, Chhibber-Goel J, Gupta Y, et al. Ocular conjunctival microbiome profiling in dry eye disease: A case control pilot study. Indian J Ophthalmol. 2023 Apr;71:1574-1581.
5. Robertson DM. The Effects of Silicone Hydrogel Lens Wear on the Corneal Epithelium and Risk for Microbial Keratitis. Eye Contact Lens. 2013 Jan;39:67-72.