Case no.4 Contact lenses: cause Subjective Caucasian female, 62 Y.O., consulting for a XXX opinion on her condition. Works as a lab technician for a veterenary surgeon No exposure to chemicals Had been wearing contact lenses for over 25 years RGP at the beginning then soft hydrogels then SiHy since 3 years Is currently wearing Acuvue Oasys for Presbyopia with success Compliant with replacement schedule Uses OFR as a care regimen, without rubbing steps. Subjective (2) General health is good Is taking hormone replacement therapy x 18 months Complaints of Gradual, progressive reduction in comfortable lens wear in the last 6-8 months (from 12 hrs to 8-9 hrs/day) Episodes of burning, FBS, tearing and mucoid discharge Lubrication with comfort drops did not help Temporary cessation of lens wear is sometimes required Visual acuity did not vary. Acceptable for her work, to read or to drive (day/night) 1
Objective Entering V.A. with contact lenses (+2,00 High add OU) Distance 6/9 +2 ; Near 0,50 M Fluctuant Not improvable with over-refraction Lenses slightly decentered inferiorly, with a good movement Heavily coated with deposits (lipids and proteins) Refraction OD +1,75-0,75 x 180 (6/7.5) OS +2,25 1,00 x 15 (6/7,5-1) Add +2,50 - OD dominant Objective Slit lamp findings Corneal infiltrates with SPK grade 2 Negative fluoresceins staining in superior cornea Conjunctival hyperemia grade 1+ Superior lid eversion Hyperemia grade 2 Papillae grade 2 TBUT : 5 sec OU unstable tear film NO MGD Slit lamp findings 2
Objective Topo maps Slight distortion (warpage) Fundus examination Trace of macular degeneration (drusens, pigmentary changes) Visual fields No defects Assessment Contact lenses: cause or remedy??? Diagnosis Hyperopia with astigmatism (non corrected) and presbyopia Unstable tear film (not evaporative) Contact lens surface issues Infiltrative keratitis with SPK Giant Papillary Conjunctivitis Epithelial Basement Membrane Dystrophy (EBMD) Establishing priorities Plan Restoring anterior seg surface Keratitis GPC Cogan To stabilize tear film Refit of the lenses if corneal health is improved Prevention for Dry Macular Degeneration 3
Infiltrative keratitis CLAIK Related to lens-material interaction Often seen with senofilcon A and OFR combination Preservative and Buffer side-effects Options Lubrication: wait and follow OR More aggressive : Steroïds Concomitant GPC tx at the same time! In combination with antibiotics? AB coverage HS? Dosage : QID x 2 weeks then BID x 4-6 wks (GPC) Loteprednol is preferred for such a prolonged usage GPC: Management Protocol Initial Therapy 1) Remove CLs for 2 weeks Recommend daily disposable lenses to patients who are not willing to wear eye glasses 2) Topical steroids Loteprednol 0.5% (Lotemax ) q.i.d.x 2 wks, then b.i.d. with lens wear x 2-4 more wks 3) Consider to add combination allergy medications long term Loteprednol 0.5% is the only steroid that has been shown to be an effective and safe treatment for GPC*. Long-Term Management Move to more frequent replacement or daily disposable contact lenses AND Educate patient on compliance and proper lens hygiene Note: GPC 30% eradicated but 70% inactive after 3-4 weeks *Friedlaender MH, Howes J. Am J Ophthalmol 1997; 123:455-64. Cogan dystrophy Can Contributes to tear film instability Cause topographic modifications Alter visual acuity Initiate FBS and eye dryness symptoms Erosions are always a concern CL handling is an issue CL can exacerbate the condition (not a cause but ) 4
Cogan s dystrophy Treatment options According the the severity of the disease Lubrication Hyperosmotic agent Not a long-term answer OFF LABEL CYCLOSPORINE A Is considered for this patient Improves tear film stability over time Cyclo vs CL wear gives good results Contact lens refits Importance to correct refractive astigmatism and to deal with corneal surface irregularity RGPs are better than soft to achieve this RGP vs Cogan?? Sclerals / Hybrids Duette Multi-focal can be a good option Daily disposable can also be an option Monovision Not possible here: patient had to rely on 3D vision for her work Macular Degeneration Prevention Based on genetic background Roterdam and Women s Health studies No smoking Life hygiene (nutrition, exercise) Vitamins??? Omega 3s??? Follow-ups 5
Summary of this case Medication Steroids (x 6 wks) AB nightly coverage (x 1 wk) Cyclosporine (x 1 year at least) C.L. refits Patient decided to remain in glasses Daily disposable lenses for outdoor /social activities Monovision AMD + tear film Omega 3s : 2000 mg /day TG, fish oil 6