A 26-year-old Hispanic male was referred to our office for a scleral lens fitting. The case notes from the referral center showed a history of mild meibomian gland dysfunction (MGD), diffuse punctate epithelial erosions (PEE), and mild filamentary keratitis (Figure 1). The patient did not have any diagnosed systemic issues, but reported days of significant joint aches and pains that wax and wane. The referral center was starting on bloodwork to determine possible etiologies. 

Case Description

On first examination, he presented wearing soft bandage contact lenses in both eyes for the management of filamentary keratitis and one punctal plug in the right eye. He reported using artificial tears every waking hour, moxifloxacin 0.5% 3 times per day, and loteprednol 0.5% 3 times daily. He had been on this regiment for 1 week and noted no improvement. After removing the bandage lenses, his best-corrected vision was 20/50 OD and 20/40 OS. He had a diffuse 4+ PEE OD, 3+ PEE OS. Over the past 6 months, he had previously tried punctal plugs, other steroid eye drops, other artificial tears and gel, and chronic inflammatory dry eye drops. He was struggling to see well enough to drive to work and complete his work activities. He worked as a line cook on a 400°F griddle, and reported that vision and comfort were always worse after working a shift.

Discussion

We fit him in the standard Atlantis 15.5mm scleral lens (X-Cel Specialty Contacts) with a toric scleral zone. After 1 week of wear, the patient reported wearing the lenses for 8 to 10 hours daily. He was able to tolerate the lenses more comfortably than other remedies, and his VA improved to 20/30 OD and OS. Corneal staining had slightly improved. He complained of end-of-day dryness and middle-of-the day fogging. We noted tear film exchange in the vertical meridian with fluorescein dye tracking. Upon examination, he still had excessive sagittal clearance (350µm OD, 400µm OS) with mild inferior decentration and flat edges in the vertical meridian with approximately a +2.00 over-refraction OD and OS (near plano OR on day of dispense).

We discussed the changes with laboratory consultants, and it was decided that we would drop the sag 200 microns OD and OS, and steepen the vertical meridian 2 steps while incorporating the over-refraction. After 1 week of wearing the second set, he returned to clinic seeing 20/25 OD and 20/20 OS, with marked improvement in corneal staining
(1+ OD, Tr OS). He reported all-day comfort, but still noted fogging, especially on working days. 

At the follow-up, we noted no further tear exchange, but did note front lens surface non-wetting patches. On the third set, we tried removing coatings to prevent damage from the extreme heat. The front surface appeared better on follow-up, but due to the patient’s MGD, he still had wettability/transient fogging issues.

Conclusion

Ultimately, the patient requested that we return to the coated lenses, and at work he would wear goggles over the scleral lenses. On most recent follow-up, he was wearing the lenses most waking hours, vision was 20/20 OD and OS, and the front surfaces of the lenses were smooth and wettable. 

He was thrilled with the outcome and now has referred all of his family to us as we continue to run more tests to determine the underlying etiology of his keratitis. 

Nicholas McColley, OD, MBA, owns and practices at Hancock Eye Associates in Greenfield, Ind. He reports renumeration from X-Cel Specialty Contacts.