Shortly after settling into the exam chair, it became apparent that our 57-year-old female patient was unable to blink or close her left eye. She had been suffering from severe, unilateral dryness for more than a decade after having a hematoma surgically removed from her left cheek. The surgery left her with a partially damaged facial nerve and the inability to blink. Since then, she has been using artificial tears multiple times every waking hour, which provide only momentary relief. Surprisingly, she had 20/20 monocular visual acuities. However, she remarked on the reduced crispness of the letters when viewing with her left eye. A slit lamp examination revealed dense and diffuse grade 2 corneal and conjunctival staining in the left eye only.
Adding even more topical medications would be futile; she was already frustrated with having to constantly use lubricating drops for the past 10 years, and she remained at risk for severe corneal damage and permanent visual impairment. Treating with amniotic membrane would likely improve the condition of her ocular surface quickly, but it wasn’t a long-term solution due to the absence of lid function.
Therefore, a scleral lens was recommended to provide constant lubrication and protection during the day. She was hesitant to wear a contact lens on an uncomfortable eye, so we gave her time to consider the option. In the meantime, in addition to her current daily regimen of copious artificial tears, we prescribed preservative-free topical ointment and moisture-retaining goggles for overnight protection. She returned in two weeks reporting substantial improvement in ocular comfort and readiness for a scleral lens fit.
The fitting, dispense, and initial follow-up visits were quick and uneventful. Her acuity was a crisp 20/15 in each eye, corneal integrity was restored in her left eye, and she reported a substantial improvement in symptoms. Despite this near-perfect treatment outcome, it was still imperative to continue monitoring her ocular surface.
At the one-month progress evaluation, grade 1+ punctate keratitis was noted in the left eye. She reported 16 hours of comfortable wear daily. She found it odd, however, that upon lens removal, there was always saline remaining in the right lens bowl, but the left lens bowl was always empty.
Partial damage to her facial nerve from surgery had led to her inability to blink or close her left eye. The resulting exposure keratopathy was not only causing severe chronic discomfort, but was also beginning to degrade her vision. Because the facial nerve is also involved in lacrimal gland secretion and the maintenance of an adequate tear lake, it made sense that the left scleral lens bowl was empty after many hours of wear; there was little to no aqueous production and, therefore, minimal tear exchange under the lens throughout the day. To address this issue, she was instructed to refill her left lens two to three times a day and to add several drops of preservative-free lubricant. This regimen has kept her left eye clear, comfortable, and seeing well.
This shows how a simple contact lens fit can dramatically change the quality of life for patients. Close monitoring and diligent evaluation remain critical even after a treatment is deemed “successful.” CLS