A 17-year-old female presented for her annual eye exam and contact lens evaluation. She was wearing soft toric lenses and noted that her vision fluctuated more than she would like with lens wear. She had no other complaints at this time. Her spectacle and contact lens prescriptions were significant for moderate to high with-the-rule astigmatism, as well as low myopia. Above is an image of her eyes. What options might she have to address her chief complaint?

The patient has congenital distichiasis, which is the finding of a second row of eyelashes. This second row can be partial or nearly complete. In this case, her second row of lashes was a complete full row of thinner shorter lashes. Congenital distichiasis a rare genetic mutation of the Forkhead box protein C2 (FOXC2) gene on chromosome 16. The second row of lashes develops as a result of epithelial cells morphing into hair follicles.

Treatment for congenital distichiasis is not necessary if there are no symptoms or significant findings. In this case, the patient was asymptomatic and demonstrated no corneal compromise. The second row of lashes did, however, create issues with soft toric lens stability, as the lashes would often cause the lenses to rotate out of position. Had she had issues with the way her eyes felt or if the corneas were showing signs of compromise, some options for trying to improve the distichiasis would be cryotherapy, electrolysis, lid splitting, or argon laser photoablation—all of which are intended to destroy the extra follicles and have potential complications.

A discussion of the options for vision correction with the patient included trying a different soft toric lens, perhaps even a custom lens that was larger than standard disposable lenses, as well as hybrid and scleral lenses. Initially, the patient opted to try other types of soft toric lenses to see whether any would provide better stability. After trying a few different lenses without improvement, the patient opted to try scleral lenses.

She was fitted in a pair of back-toric scleral lenses with dual SAGs due to the moderate to high astigmatism. The scleral lenses demonstrated a good fit and stable positioning. The patient was able to achieve good comfort with the scleral lenses and improved visual stability compared to the soft toric lenses that she had worn.

Congenital distichiasis is very rare and may look troublesome at first glance. In most cases, very little is needed to be done regarding the ocular health. The impact on contact lens fitting can be real, however, and may require a creative approach to getting the best outcome.