Sjögren’s Syndrome: Melissa Barnett, OD, FAAO, FSLS
A 50-year-old Caucasian female presented for an eye examination and evaluation for contact lenses. She complained that she experienced a sandy sensation and intermittent red eyes. Nicole has a history of glasses for full time wear. She previously wore biweekly soft contact lenses. Contact lens wear was discontinued due to dry eyes with the lenses. She worked as a budget analyst with extensive computer and reading requirements of 10 hours per day. At the time of presentation, ocular history was significant for dry eyes. Cyclosporine 0.05% was used twice a day in both eyes. Preservative-free artificial tears were used as needed. Medical history was significant for Sjögren’s disease. Plaquenil 200 mg was taken twice daily. Family history was positive for rheumatoid arthritis (mother).
Test Procedures, Fitting/Refitting, Design and Ordering
Visit #1 and 2: Initial Visit and Dispense
Best Corrected Visual Acuity
OD: 20/20 (distance), J1 (near)
OS: 20/20 (distance), J1 (near)
Ocular Health Evaluation
Slit lamp examination revealed meibomian gland dysfunction and irregular eyelid margins in both eyes. Nasal and temporal sodium fluorescein staining was present in both eyes, moderate in the right eye and severe in the left eye. Lissamine green staining was in both eyes, moderate in the right eye and severe in the left eye. Mild inferior corneal staining was present in the right eye; significant nasal, temporal and inferior corneal staining was present in the left eye. Tear break-up-time was reduced in both eyes; three seconds in the right eye and two seconds in the left eye. Both eyes had normal intraocular pressures and a normal dilated retinal examination. Additionally, color vision and Amsler grid testing was normal in both eyes. Optical coherence tomography (OCT) of the macula and a 10-2 visual field was normal in both eyes.
Different management options were discussed. Eyelid hygiene, including warm compresses for five minutes daily, was advised. Topical cyclosporine 0.05% was continued two times a day in both eyes. In addition, non-preserved artificial tears were recommended to use four times a day or as needed; lubricant ointment was advised at night. Good hydration and frequent breaks on the computer were also recommended. Additionally, the patient was started on HydroEye Omega 3 fatty acids. This supplement contains gamma linolenic acid (GLA), a unique Omega targeted to treat dry eye and meibomian gland dysfunction. GLA reduces inflammation and thus provides a necessary building block to support both aqueous and mucin production (via PGE1).1 Contact lens and scleral lens options were discussed. As the patient was interested in full-time lens wear, she opted to be fit with multifocal scleral lenses. There are numerous options for multifocal scleral lenses that can be used for both regular and irregular corneas.2
Diagnostic Lens Selection
OD: 41.00D / plano / 16.2mm / 9.0mm / Sag 4.35
OS: 42.00D / -1.00 / 16.2mm / 9.0mm / Sag 4.39
Scleral lenses are designed to completely vault the cornea including the limbus without touch. Both lenses had minimal central and limbal clearance. No blanching nor impingement was present peripherally. With an over-refraction of -2.00D in the right eye and -2.25D in the left eye, 20/20 vision was obtained in each eye.
Final Lens Order
Aspheric multifocal scleral lenses were ordered for both eyes with an increased sagittal depth and diameter
OD: 41.00D / -2.00 / 16.4mm / 9.2mm / Sag 4.55
OS: 42.00D / -3.25 / 16.4mm / 9.2mm / Sag 4.59
Application, Removal, and Care Education Scleral lens insertion and removal training was performed and DMV applicators were dispensed. The patient was advised to use preservative-free application solution and hydrogen peroxide solutions.
Patient Consultation and Education
Visits #3 and 4: Follow-up Appointment and Dispense of Scleral Lenses #2
On follow-up examination, the patient reported good vision in general; however, she reported that reading vision was better some days than others. Average wearing time was 10 hours per day. Lenses were worn for four hours on the day of examination. She reported excellent comfort with scleral lenses with an improvement in dryness symptoms. With the current scleral lenses, vision was 20/20-2 in each eye and 20/20 binocularly. J2 vision was present in each eye and binocularly. No over-refraction was present in the right eye. An over-refraction of +0.25D was present in the left eye. Both lenses demonstrated adequate central and limbal apical clearance. Both lenses had peripheral blanching in all meridians. New scleral lenses were ordered and dispensed.
Scleral Lens Order #2
OD: Scleral Aspheric multifocal 41.00D / -2.00 / 16.4mm / 9.0mm / Sag 4.55 / flatter peripheral curves
OS: Scleral Center Progressive multifocal 42.00D / -3.25 / 16.4mm / 9.2mm / Sag 4.59 / flatter peripheral curves
Follow-Up Care and Final Outcome
Visit #5: Follow-Up
At follow-up, good vision was reported at all distances. Average wearing time was 12 hours per day. Lenses were worn for five hours on the day of examination. She reported excellent comfort with scleral lenses with a continued improvement in dryness symptoms. Vision was 20/20 in each eye and 20/15+1 binocularly. J2 vision was present in the right eye and J1 vision was present in the left eye and binocularly. No over-refraction was present in the either eye. Both lenses demonstrated adequate central and peripheral corneal clearance. No peripheral blanching nor impingement was present.
Four Years after Initial Fitting
Over the past four years, this patient’s dry eye symptoms have been well managed with scleral lenses and her current regimen. In addition, a humidifier was added at night to use as needed to provide added relief.
Discussion/Alternative Management Options
In addition to topical therapies including artificial tears, lubricant ointment, autologous serum, topical cyclosporine, topical lifitegrast, topical steroids or eyelid hygiene treatments, adjunctive therapies may be utilized. These include nighttime moisture eyewear, daytime dry eye relief, humidifiers, oral supplementation and/or scleral lenses. Scleral lenses are beneficial for patients with Sjögren’s Syndrome as the post-lens fluid reservoir continuously bathes the ocular surface during lens wear.
In patients with severe ocular surface disease, one of the most frustrating challenges is non-wetting, or poor surface wetting, of the scleral lens anterior surface. This is relatively common during scleral lens wear and can result in suboptimal or “cloudy” vision.3 Strategies to improve surface wettability include verifying good hand hygiene and confirming that lotions and makeup are applied after lens insertion. Scleral lens removal, cleaning to eliminate deposits and reapplication may be done during the day, but may be time-consuming and inconvenient. On-eye surface cleaning with a saline moistened cotton swab, eye shadow applicator or wet DMV applicator can be used to remove surface debris. Additionally, increased lubrication over the lens with preservative-free artificial tears over the lens throughout the day may be beneficial.
A novel treatment option is United States Food and Drug Administration (FDA) approved Tangible Hydra-PEG, a 90% water PEG-based polymer mixture that is permanently bonded to the surface of the contact lens. Tangible Hydra-PEG encapsulates the lens, creating a mucin-like wetting surface which shields the lens from the ocular surface and tear film. Lenses treated with Hydra-PEG result in a surface with optimal wettability, lubricity, tear film stability, and resistance to deposits.4 Hydra-PEG is a problem solver for patients experiencing dryness or discomfort associated with scleral lens wear.
In recent years, there are additional strategies to provide ocular relief for our patients Sjögren’s Syndrome. Scleral lenses may be used to provide constant lubrication to the ocular surface as well as visual correction, including multifocal options. Early detection and treatment of Sjögren’s Syndrome is imperative to prevent lymphoma or other systemic complications. Coordination of care with rheumatology is particularly useful if Sjögren’s Syndrome is suspected.
- Johnson M, et al. Dietary supplementation with GLA alters fatty acid content and eicosanoid production in healthy humans. J Nutr 127:1435-44, 1997.
- Barnett M, Johns LK. Contemporary Scleral Lenses: Theory and Application. Bentham Science 2017. Volume 4 ISBN: 978-1-68108-567-8. 130-156.
- Barnett, M, Toabe, M. Scleral Lens Care and Handling for Scleral Lenses: Understanding Applications and Maximizing Success. Supplement for Contact Lens Spectrum. October 2016.
- Walker, M, Redfern, R. Scleral lens surface coating improves vision and comfort. Poster presented at the 8th International Conference of the Tear Film and Ocular Surface Society (TFOS); September 2016. Montpellier, France.
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