Patient Case #2: 67-Year-Old Woman With Dry Eye Disease
Mile Brujic, OD, FAAO, presents a patient case of a 67-year-old woman with dry eye disease and a history of radial keratotomy (RK) surgery.
Mile Brujic, OD, FAAO: This was a 67-year-old female. She works from home approximately 12 hours a day on the computer, and she has a history of RK [radial keratotomy] surgery that was done about 20 to 30 years ago. She’s a new patient to our practice. She recently moved here from the Houston [Texas] area, and she’s originally from our area. Her current refraction is +3.00 –1.00 x 70 in the right eye and +4.00 –1.50 x 20 in the left eye. Now, what’s important to note here is that her best corrected visual acuity in both eyes is approximately 20/40. Her internal ocular health is remarkable for mild nuclear sclerosis. Patient does have some arthritis, and she’s currently using ibuprofen just as needed for that. She’s currently using artificial tears several times a day. Sometimes she feels like she needs them more so than others. And her anterior segment exam is remarkable for prominent RK scars. She has mild corneal staining, inferiorly and loose lid apposition. And this is really a more detailed perspective of what I saw when I did my slit lamp evaluation.
So she did have a mild incomplete lid seal. The meibomian gland length was good, no dropout but she did have mild meibomian gland dysfunction, [which] just means that upon attempted expression with a finger, I had a little bit of a difficult time seeing wells come out of those glands. The palpebral conjunctiva showed mild hyperemia. Tear film breakup time was 2 to 3 seconds in both eyes, measured or assessed with fluorescein dye, cobalt blue light and a Wratten No. 12 filter. The tear film again, we saw that it was reduced. There was mild, inferior corneal staining on both eyes. And you could certainly see the presence of the post RK scars in both eyes. And there was a small anterior central stromal scar in the left eye. The anterior chamber was clear, the iris was flat and healthy, and the lens did show mild nuclear sclerosis. So additional testing that we did that day was a SPEED (standardized patient evaluation of eye dryness) questionnaire, which was a 14. The meibomian gland infrared imaging confirmed no dropout. There was a topography that was performed on the patient that day, and there certainly was a flattening that we see consistent with post–refractive surgery patients. But it wasn’t anything that was highly irregular. There were some mildly irregular patterns in the reverse geometry curves around the periphery of the cornea, but there was nothing dramatic or drastic.
Here’s where it starts to get a little bit interesting. There are 2 findings that I want to go over in a little more detail here. The inflammatory testing was negative in both eyes, but when we assessed the anterior segment obesity, which we do on post–refractive surgery patients, we did find an interesting finding in this individual, and we tend to see this in some of our patients. And what you’ll see here, for those of you who aren’t familiar with or don’t look at anterior segment of CT scans, this is one of those things that we become much more cognizant of as particular looking at [the] epithelial thickness map. So, for example, the skin of the right eye, which you can see on the left-hand side of the screen, you have a total pore chemistry scan here on the bottom left. And then on the bottom right you can actually see the epithelial thickness mapping where you can see some regions where there is much thicker epithelial regions than you would expect on the left eye, which is located on the right side of the screen. You can actually see there are regions or areas that have substantially thicker regions than you would expect. And to put things into perspective, we typically think of epithelial thickness maps to be between 50 to 59 microns. Would that mean being approximately 55 microns? And we expect to see it looking very regular where in this individual, it looks very irregular. So the question then becomes, what would we do next with this patient? Well, the first thing I wanted to do was I wanted to see if we could get this patient seeing better. And just based on what we saw with the epithelial thickness maps and our experience with individuals who do have thickened and irregular epithelial thickness maps and placing a special lens on the eye, we found that these individuals, we can help them see much better.
So, we discussed the options and we proceeded with a scleral lens fitting that day. And what’s remarkable in this individual is even with diagnostic lenses, we were able…to get them to see 20/20. That’s our first win for this patient. Now, the second thing we did was we discussed the incomplete lid seal with loose lid apposition. So, we prescribed a sleep mask for this patient. And then what we did was we gave her preservative-free artificial tears to use as needed, and we switched [out] the preserved tears that she was using. And we discussed punctal occlusion as option. Now, why do we discuss punctal occlusion? Well, this individual’s dryness seemed to be much more lid-related than it was tear film production–related. So we realized that if we could keep the tears that the patient was producing on their eyes for a longer period of time through the placement of punctal plugs, we could potentially make this patient more comfortable.
But here’s where it also starts to get even more interesting, because if this individual had higher levels of MMP-9 measured, we probably would have gone a different route with this individual. But because she measured negative, this became an option for her. So we placed collagen plugs in her eyes that day as well. And then what we did was we saw her back in a few weeks for a few reasons. One, to follow up with the collagen dissolvable, short-term intracranial ocular plugs to see how she was doing and also to dispense and really train her on how to place and remove the scleral lenses that we had fit that day after they were ordered. Now, when we think about punctal occlusion and this is on the prepping the puncture, we have different tools to actually expand and prep the puncta for punctual plug placement. And what I did here and what I like to use is jeweler’s forceps for this. I know there are specific forceps designed for punctal plug placement, but I like to use the fine-tip jeweler’s forceps. Why? Because it functions for 2 purposes. The first, you can actually expand the actual puncture itself, making the placement of the plug easier. And the second thing it gives us the ability to do is then simply grab the plug with the same set of forceps and place the plug appropriately into the inferior puncture and intricate molecular tract, which is exactly what you’re seeing done here on the far-right hand side.
When the patient came back, interestingly, the first 7 to 10 days, she reported that her eyes felt a lot better. And then she said it felt like the symptoms came back, so she doesn’t think that the plugs are going to work. And we always have to reeducate patients about this, that these are temporary plugs, and they were there for the test. And what she did by confirming that her symptoms actually worsened over the last little bit or period of the plug placement was that she was a prominent or good plug responder. So, we placed 6-month plugs in the eyes at that visit.
What we also did was we then dispensed her scleral lenses too, with some mild landing-zone modifications to the lens. The beautiful part about the scleral lenses is it acts as a moisture chamber for the cornea. So even though we oftentimes think about contact lenses as potentially being a challenge for these individuals, in this patient in particular, we actually found that it does wonders for this individual, acting as a moisture chamber and keeping that ocular surface hydrated throughout the day. So not only does she see better with the scleral lenses, [but] we’re also protecting the cornea as well. Again, this case really demonstrates several things: 1, the importance of the lids and the lid assessment. And 2 is understanding the importance of inflammation levels on the eyes and how that may set different treatment patterns for us. And the third thing is really looking at specialty lenses as a potential therapeutic for patients with these problems and issues.
Transcript is AI-generated and edited for clarity and readability.
