A 28-year-old African American male was referred for a specialty contact lens fitting. The patient had a history of dry eye in both eyes with moderate symptoms of burning and blurring of vision. He used artificial tears with mild temporary relief. He previously used 0.05% cyclosporine with no improvement, but was taking several other medications including autologous serum, doxycycline, and 0.09% cyclosporine. Soft bandage contact lenses were trialed by the previous eyecare professional but fell out of his eyes per previous exam notes.

Exam Findings

Uncorrected visual acuities with scleral lenses were reduced at distance to 20/25 and 20/30 OD and OS, respectively. Slit lamp exam revealed moderate punctate epithelial erosions OD and OS with filaments present OD worse than OS (Video 1 for OD and Video 2 for OS). NaFl dye was instilled (Figures 1 and 2, Videos 3 and 4) and the filaments were debrided in office without complications. The diagnosis of filamentary keratitis was made, and the patient pursued a scleral contact lens fit. 

Discussion

Filamentary keratitis presents with corneal filaments that cause foreign body sensation and pain.¹ Although it can be seen with various conditions, dry eye is very common. N-acetylcysteine has been suggested to help, but there are few case reports or series documenting this.² Additionally, N-acetylcysteine is not commercially available and must be compounded for use.

Debridement of filaments will resolve acute symptoms, but rarely yields success long term for the patient. Scleral contact lenses have been helpful to mitigate the frictional stress of the cornea is some patients, but must be monitored for common complications such as corneal hypoxia or edema.^1,3

Conclusion

This patient has had several failed treatments for his filamentary keratitis. While scleral lenses may not work for all patients for filamentary keratitis, they should serve as an option to explore when other treatments have been unsuccessful.

References

1. Weiss M, Molina R, Ofoegbuna C, Johnson DA, Kheirkhah A. A review of filamentary keratitis. Surv Ophthalmol. 2022 Jan-Feb;67:52-59.
2. Crist AJ. Case Report: Management of Refractory Filamentary Keratitis with N-acetylcysteine. Optom Vis Sci. 2021 Jun 1;98:547-551.
3. Bhattacharya P, Mahadevan R. Case Report: Post-keratoplasty Filamentary Keratitis Managed with Scleral Lens. Optom Vis Sci. 2018 Aug;95:682-686.