Download Scleral Lens Fit for Ocular Surface Disease Associated with Graves

Scleral Lens Fit for Ocular Surface Disease
Associated with Graves Disease.
Anthony Van Alstine O.D.
Home:
1460 Oakcrest Drive #2205
Columbia SC 29223
[email protected]
Work:
6439 Garners Ferry Rd., Optometry Clinic
WJB Dorn VAMC
Columbia, SC 29209
INTRODUCTION
Graves disease, or thyrotoxicosis, is an autoimmune disease affecting the thyroid. Of
patients with Graves disease 25-50% suffer from thyroid eye disease (TED). TED involves
inflammatory cell infiltration of much of the eye including the extra-ocular muscles, tissues of
the ocular surface and the lacrimal gland.1 TED results in, among other complications,
exophthalmos and dry eye syndrome. According to the report of the Dry Eye Workshop held in
2007 the definition of dry eye is “ a multifactorial disease of the tears and ocular surface that
results in symptoms of discomfort, visual disturbance, and tear film instability with potential
damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and
inflammation of the ocular surface.” 2 A recent study has shown that subjects with Graves
disease, when compared to normal subjects, have decreased tear production and increase ocular
surface damage confirmed by histological examination of conjunctival biopsies. 3 Scleral lenses
have been successfully used to manage a wide variety of ocular surface disorders, in this case
study we see dry eye syndrome associated with Graves disease successfully treated with scleral
lenses.
CASE REPORT
DP is a 64 year old Caucasian male veteran. His pertinent medical history includes
Graves disease, type II diabetes mellitus, and dry eye syndrome. His pertinent medications are
glipizide 5mg PO QD for Diabetes and a low dose of levothyroxine PO QD to treat
hypothyroidism that resulted from a total thyroidectomy he had a few months before presentation
to the eye clinic. He was using 1% carboxymethylcellulose and lacrilube ophthalmic ung
frequently to combat his dry eye symptoms. DP was not satisfied with the amount of relief he
received from lubrication therapy and presented to the eye clinic for examination. The findings
of this examination were as follows:
C/C: Pt Had thyroid removed 2 mo ago. AT QID. Eyes red all the
time and tearing despite frequent AT use. Doesn't like lacrilube at
night stating it is a burden to use and didn't seem to help.
(+) Graves disease dx
O:
VA OD: 20/20cc
OS: 20/20PERRL -APD
EOM- superior restriction OD, pt reports slight discomfort looking
up and right, SAFE OS
CVF FTFC OD OS
Habitual Rx
OD:+1.00-1.75x080
OS:+0.25-0.50x115
+2.50
SLE
L/L: mild UL retraction OD
CONJ: 2+ diffuse injection OU
CORNEA: tr SPK OU
A/C: (-) cell/flare ou
ANGLES: 4/4 by VH ou
IRIS: normal ou
Tap: OD 19
OS 19
@ 11:34am
-----------------Exophthalmometry:
OD: 21
OS: 19
Base 124
-------------------A:
1. Type II DM without retinopathy OU
2. Graves disease with ocular manifestations OD>OS
(+) exophthalmos (21/19 at base 124)
(+) dalrymple's sign OS (widened palpebral fissure 2* to eyelid
retraction)
3. DES
4. Blurred Vision OU
P:
1,4. Not assessed today
2-3. Pted on findings. Pt to use Refresh 1% AT to use qid or
more OU during the day. Pt opted to try scleral lenses to see if help with
DES symptoms. Will RTC this afternoon for fit.
RTC- This afternoon for scleral lens fit
The patient was scheduled in the specialty contact lens clinic to be fit with scleral lenses to
manage his dry eye syndrome. The presence of dry eye syndrome can be seen by the superficial
punctuate keratitis and grade 2+ injection to the bulbar conjunctiva OU. Beyond these findings
the patient was asked to complete the Ocular Surface Disease Index (OSDI) questionnaire to
subjectively quantify his symptoms. The patients responses to the questionnaire resulted in a
score of 87.5 indicating severe dry eye based on the design of the OSDI scoring system.4 The
initial fit was performed with an Essilor Jupiter fitting set and the findings can be seen below.
C/C: Scleral CL fit.
DIAGNOSIS: DES 2 Graves Dz
Previous form of correction used: Specs
TRIAL LENS #1
OD:
Lens company: Essilor Jupiter
Power: -6.00
Base Curve: 45.98
Diameter: 15.6
Assessment: will fit with larger diameter
OS:
Lens company/material: Essilor Jupiter
Power: -7.00
Base Curve:47.01
Diameter: 15.6
Assessment: superior temporal corneal touch, large fissures, will try
steeper with larger diameter
TRIAL LENS #2
OD:
Lens company: Essilor Jupiter
Power: -10.00
Base Curve: 50.00
Diameter: 16.6
Assessment: 2+ CCT vaulting
OS:
Lens company: Essilor Jupiter
Power: -10.00
Base Curve: 50.00
Diameter: 16.6
Assessment: 1.5 CCT corneal vaulting and good limbal clearance, will
consider flatter BC by 1 D with lens order, no blanching, pt states excellent
comfort
Over-refraction: +1.50 20/20-2
TRIAL LENS #3
OD:
Lens company/material: Essilor Jupiter
Power: -8.00
Base Curve: 48.01
Diameter: 16.6
Assessment: 1.5 CCT
Over-refraction: not performed
TRIAL LENS #4
OD:
Lens company/material:
Power: -6.00
Base Curve: -45.98
Diameter: 16.6
Assessment: 1 CCT good vaulting and limbal clearance, no blanching,
pt states excellent
comfort
Over-refraction: +1.50 20/20
The lab was contacted and an order was placed for custom scleral lenses. The lens
parameters and findings when the patient returned to have the fit assessed can be seen below.
O:
VA OD: 20/20
OS: 20/20
cc (scleral lenses)
TRIAL LENS #1
OD:
Lens company/material: Essilor Jupiter Tyro-97 SCL
Power: -4.50
Base Curve: 7.34
Diameter: 16.6
Subjective: "feel pretty good"
VA: 20/20
Assessment: good corneal vaulting and limbal clearance,
zero-minimal blanching present, good tear exchange
OS:
Lens company/material: Essilor Jupiter Tyro-97 SCL
Power: -7.50
Base Curve: 6.89
Diameter: 16.6
Subjective: "feel pretty good"
VA: 20/20
Assessment: good corneal vaulting and limbal clearance, zero-minimal
blanching
Present, good tear exchange
The patient was given insertion and removal training and educated on lens hygiene. He
was then sent home with the lenses. The patient was contacted by telephone approximately 1
month later and stated he was happy with his scleral contact lenses and that he was wearing them
approximately 10 hours each day. Slightly longer than three months from the initial fit the
patient was called by phone again and once again stated he was very happy with his lenses. He
was asked the questions on the OSDI questionnaire by phone and his answers resulted in a score
of 14.5 suggesting a dramatic improvement in his dry eye symptoms.
DISCUSSION
Graves disease can lead to severe dry eye symptoms that significantly affect a patients
quality of life. This case exemplifies the excellent results that are possible when scleral lenses
are used to manage dry eye syndrome. The ability of the scleral lens to protect the cornea and
bathe it in a soothing fluid reservoir throughout the day succeeded with this patient where topical
drops and ung did not. These findings make theoretical sense when considering the reduced tear
production that Graves disease patients have been shown to exhibit. The dramatic resolution of
symptoms seen by a 73 point decrease in the patients OSDI score also give evidence to the
success this patient has had with scleral lenses.
CONCLUSION
In Graves disease patients with associated dry eye syndrome scleral contact lenses can be
an excellent method to manage ocular surface symptoms.
REFERENCES
1. Kanski, J. Clinical Ophthalmology: a Systematic Approach. 6th ed. 2007.
2. Dry Eye Workshop (DEWS) Committee. 2007 Report of the Dry Eye Workshop
(DEWS). Ocul Surf. April 2007;5(2):65-204.
3. Gürdal C, Saraç O, Genç I, Kırımlıoğlu H, Takmaz T, Can I. Ocular surface and dry eye
in Graves' disease. Curr Eye Res. 2011 Jan;36(1):8-13.
4. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and
validity of the ocular surface disease index. Arch Ophthalmol. 2000; 118:615-621.