IMPROVING VISION for patients who have corneal irregularity is often managed with the use of a corneal GP or scleral lens. Especially as patients get older, they often have other comorbidities, including dry eye, that need to be addressed concurrently.

CASE DETAILS

A 79-year-old female was referred for specialty lens evaluation because of decreased vision secondary to corneal scarring. The patient had a history of radial keratotomy (RK) in both eyes 30 years prior. Subsequently, she had phototherapeutic keratoplasty in both eyes and a corneal transplant OS. She complained of increasing dry eye symptoms—her eyes became progressively drier during the day, to a degree that she couldn’t read or watch TV.

She had been prescribed 5% lifitegrast ophthalmic solution b.i.d. in both eyes and artificial tears as needed. However, she felt that these drops were not beneficial after years of treatment. Manifest refraction was –0.75 –0.50 x 090 20/40 OD and –3.00 –1.25 x 035 20/25 OS.

Slit lamp examination revealed RK incisions and scarring OD (Figure 1) and clear corneal transplant OS. Both eyes exhibited punctate corneal keratitis secondary to poorly managed dry eye. The topography exhibited significant irregularity of her right cornea.

After discussion of management options, it was clear that scleral lenses would be able to simultaneously manage her corneal irregularity and disabling dry eye disease. Free-form scleral lenses with a diameter of 16.5mm were designed from corneoscleral topography and dispensed. Visual acuity measured 20/25 for her right and left eyes, and the scleral lenses had adequate central corneal clearance, with landing zone alignment (Figure 2) in both eyes.

At her follow-up exam, she reported that her overall condition had improved, although she had some continued lens awareness in her left eye. Slit lamp exam revealed mild movement of her left scleral lens with blinking. Sphero-cylindrical over-refraction measured +0.50 –1.25 x 076 20/20 OS. We ordered a replacement exchange lens that incorporated the over-refraction OS and tightened the landing zone of the left lens by two steps.

At the subsequent follow-up, she reported improved satisfaction with the comfort and visual acuity with the updated left lens. She also reported that she had discontinued her prescribed 5% lifitegrast ophthalmic solution because she did not have any subjective improvement and the scleral lenses now provided her relief from her dry eye symptoms.

CONCLUSION

Scleral lenses offer a dual management option for patients who have corneal irregularity and dry eye disease. An endpoint management goal is for improved visual acuity and increased comfort, which this patient achieved with successfully fitted scleral lenses.

This case highlights that not every dry eye patient responds favorably to topical immunomodulatory agents. This can be especially evident when there is immediate relief of symptoms with successful scleral lens wear. Caution is advised, however, because the discontinuation of prescription dry eye medications can lead to disease progression for some patients (Rao, 2011).

REFERENCES

1. Rao SN. Reversibility of dry eye deceleration after topical cyclosporine 0.05% withdrawal. J Ocul Pharmacol Ther. 2011 Dec;27:603-609.