Article

THE SCLERAL LENS VAULT

DRY EYE GRAND ROUNDS

An appealing aspect of scleral lenses is their ability to manage a wide range of conditions including ocular surface disease (OSD). The complexity of successfully treating our OSD patients is secondary to the numerous variables that contribute to their signs and symptoms. Many patients who have moderate-to-severe OSD continue to suffer despite maximum topical therapy. The following cases describe a variety of OSD patients who were successfully managed with scleral lenses after initial treatment strategies failed.

Three Cases of Severe OSD

Case 1 The first patient was diagnosed with severe dry eye of unknown etiology of his left eye. Previous treatments included warm compresses, lubricating drops and ointment, punctal plugs, topical cyclosporine, topical steroids, and lateral tarsorrhaphy. The patient’s correctable vision measured 20/250, and slit lamp exam revealed severe corneal staining, scarring, and an epithelial defect (Figure 1). He was referred for a scleral lens fitting.

Figure 1. The Case 1 patient’s left eye exhibiting significant staining.

Corneo-scleral topography showed a sagittal height plot with 449 microns of asymmetric differential at a 16mm chord (Figure 2). A custom-back-surface, multi-meridian, 16.5mm scleral lens was designed from corneo-scleral topography and dispensed to the patient. At a three-week follow-up visit, the patient’s subjective comfort was significantly improved, and his visual acuity was 20/40 with his successfully fitting scleral lens.

Figure 2. Sagittal height plot at a 16mm chord with 449 microns of circumferential scleral asymmetry.

Case 2 The second patient was a 34-year-old female who has severe dry eye secondary to Sjögren’s syndrome. Her dry eye signs and symptoms persisted despite treatment with artificial tears, cyclosporine, and lifitegrast. She was referred for scleral lens fitting.

Her entering visual acuity was OD 20/50 and OS 20/30, and slit lamp exam revealed punctate corneal erosions. The patient was successfully fit from corneo-scleral topography with 16.5mm scleral lenses with back-surface haptic toricity. The scleral lenses improved her visual acuity to OD 20/25 and OS 20/20. She reported significant dry eye relief with scleral lens wear.

Case 3 The third patient was a 66-year-old female who suffered from ocular cicatricial pemphigoid. She failed with artificial tears, cyclosporine, and autologous tears. She had a history of entropion and trichiasis. She was currently co-managed by cornea, retina/uveitis, and oculoplastics specialists. The patient was referred for scleral contact lens fitting.

She was fit with 16mm back-surface-toric lenses designed from corneo-scleral topography. Her visual acuity improved to 20/25 OU with successfully fit scleral lenses. The patient reported significant relief from her dry eye symptoms, and she discontinued her serum drops.

Benefits for Severe OSD

All of these patients had improved subjective wellness and reduced dryness complaints after being fit with scleral lenses. Additionally, every patient had improved visual acuity with their scleral lenses, which also mask surface irregularities secondary to OSD. Concurrent co-management with patients’ other specialty eyecare practitioners is critical for long-term success. CLS