Trevor J. Fosso is an optometrist and Director of Contact Lens Services at a practice in Minnesota.
Download the poster (.pdf), which was originally shared at the Global Specialty Lens Symposium (GSLS), 2017.
BACKGROUND
Dry eye syndrome is broadly classified into two subgroups, aqueous deficient and evaporative dry eye. The classic cause of aqueous deficient dry eye (ADDE) is Sjogren’s syndrome (SS), which is a disorder of one’s immune system, that can be associated with one of a variety of autoimmune disorders such as rheumatoid arthritis and lupus. In SS, the mucous membranes and moisture-secreting glands of the eyes and mouth are affected resulting in the decreased production of tears and saliva. This gives rise to the two most common symptoms associated with SS, dry eyes and dry mouth. The primary treatment goal for ADDE is to increase tear volume, which is classically accomplished by either adding to the volume or decreasing the outflow of the tears. In some cases of severe ADDE, these classical treatment modalities, even in combination, are not enough to quench the irritation, thus practitioners must look to other treatment modalities outside the standard methods.
CASE REPORT
SKS, a 69-year-old Caucasian female, presented to the clinic on August 25, 2016 with a chief complaint of severe ocular discomfort and photophobia. SKS has a history of rheumatoid arthritis, Sjogren’s syndrome related keratitis, filamentary keratitis, and photophobia. She had recently undergone cataract surgery June 6 and June 20, OD and OS, respectively and had all four puncta thermal occluded June 20 as well. Since her procedures, SKS had noticed her vision had not been improving as expected and her photophobia had been much worse as of late. She reported having to wear dark sunglasses and a large brimmed hat at all times when outdoors and could only function comfortably outside when in the shade. Her current ocular medications included Restasis QID, FML BID, and maxitrol ung QHS OU. She was also taking oral Doxycycline 100mg daily.
Entering visual acuities were OD 20/40 and OS 20/80. Entrance testing was limited due to severe photophobia. Slit lamp exam revealed 3-4+ superficial punctate keratopathy (SPK) over the entire corneal surface, OU. Examination of the anterior chamber, iris and posterior chamber was limited secondary to the dense SPK. SKS was diagnosed with severe keratitis secondary to Sjogren’s syndrome. SKS was educated on the condition and scleral contact lenses as a possible treatment option for her dry eye. She was instructed to continue her current medications and was scheduled for a scleral contact lens fitting.
SKS returned on September 2 for a scleral contact lens fitting. She was fit with Ampleye scleral contact lens by Art Optical. After proper assessment, lenses were ordered and SKS was scheduled for a follow up dispense appointment. SKS returned on September 16 for insertion and removal training and contact lens assessment. Due to her severe photophobia and ocular sensitivity, SKS struggled with insertion and removal of the contact lenses, but after much practice she was able to successfully insert and remove the contact lenses herself.
The lenses were determined to fit appropriately and the prescription was determined to be accurate, so the lenses were dispensed to SKS to begin normal wear. Throughout the fitting process, SKS noted appreciation for improved comfort while wearing the scleral lenses, even after only a few minutes. After the initial dispense visit, SKS returned on October 10 and reported significantly improved ocular comfort and decreased photophobia after being able to wear the scleral lenses daily for several hours.
CONCLUSION
The primary treatment goal for patients with ADDE is increasing hydration of the ocular surface. For patients who suffer from severe ADDE and have tried the classical treatment options to no avail, scleral lenses offer an excellent option by providing a fluid reservoir which bathes the ocular surface continuously.
