Dry eye syndrome can increase the likelihood and severity of contact lens keratoconjunctivitis. Dr. Colin Chan presents a case that demonstrates the benefits of taking a comprehensive approach to treatment.
Loss of best-corrected visual acuity (BCVA) and corneal irregular astigmatism can be permanent if not treated promptly. In older patients a refractive lens exchange is a reasonable alternative to laser especially in the presence of dry eye. However, dry eye can still be exacerbated by cataract surgery so it is important to optimise the ocular surface prior to surgery. Postoperative measures to minimise dry eye include punctual plugs, omega three supplements and a more prolonged topical steroid course.
A 56-year-old self employed woman was referred by her optometrist with a several year history of dry eye and contact lens tolerance issues. Previous treatments had included theratears drops, theratears flaxseed and fish oil supplement, zaditen and warm compresses; all of which had provided some relief. Serology testing was negative for Sjogrens syndrome. She ultimately wanted to consider a refractive lens exchange because of her contact lens issues and her unsuitability for laser given her underlying dry eye condition.
Initial slit lamp findings were mild subtarsal papillary changes and limbal injection in both eyes. There was significant lid margin disease and insippation of the meibomian glands; tear film break up time (TBUT) was three seconds in both eyes. Manifest refraction in the right eye was +2.75/-0.25 x 125 giving 6/7.5 and in the left was +2.75/-0.50 x 180 yielding 6/7.5. Corneal topography showed regular with the rule astigmatism in both eyes. A diagnosis of dry eye secondary to meibomian gland dysfunction and contact lens keratoconjunctivitis/ hypersensitivity was made.
The patient represented later that year with markedly reduced vision eye and increased irritation especially in the right eye
The patient responded well to an initial pulse of FML tds for three weeks. Zaditen tds was reinitiated and the patient asked to continue the omega three supplements and warm compresses. TBUT increased to five seconds in both eyes with a decrease in limbal injection.
The patient re-presented later that year with markedly reduced vision eye and increased irritation especially in the right eye. She advised that her condition had worsened following recent home renovations and a trip to New Zealand. She had worn her contact lenses minimally. Manifest refraction in the right eye was +1.50/-0.75 x 151 yielding 6/45 only and in the left eye +2.25/-0.25 x 86 giving 6/18. There was superior haze in her right cornea with overlying punctuate defects and diffuse nummular opacities in her left eye (see Figure 1 and 2). Topographies showed induced corneal irregular astigmatism (see Figure 3).
The woman had a severe episode of contact lens keratitis with minimal contact lens usage. Prednefrine forte tds, zaditen tds and minocycline 50mg daily were prescribed. Resolution of the corneal haze and irregular astigmatism took two months.
Recommended Treatment
The recommended treatment for both severe dry eye syndrome and contact lens keratitis is pulse topical steroids, as inflammation is a key component of both these conditions. A dual action antihistamine and mast cell stabiliser such as zaditen or patanol is a useful adjunct both for its anti-allergy properties and anti-inflammatory properties. The case also illustrates that other treatments can be used for dry eye including omega three supplements, and minocycline. Omega three supplements have anti-inflammatory properties and change the lipid profile of meibomian gland secretions.
Dr. Colin Chan is a Clinical Senior Lecturer at the Central Clinical School, University of Sydney and an ophthalmic surgeon at Vision Eye Institute, Bondi Junction and Chatswood. He runs a specialized dry eye clinic (www.dryeyeclinic.com.au).
