John Sheppard, MD, presents a dry eye case involving a 48-year-old female patient who has been using contact lenses for approximately three decades.
John Sheppard, MD: Hello, I’m Dr John Shepherd. I’m a professor of ophthalmology at Eastern Virginia Medical School. I’m a cornea and uveitis fellowship-trained ophthalmologist and a division medical director for eye care partners. I’m excited to share 2 patient cases that we discussed recently at an ophthalmology times roundtable.
Let’s start with the first case. I call this [patient] a frequent flyer. She’s a 48-year-old Asian female software engineer. She’s a bird-watcher chapter president. She’s myopic. She’s been in soft 30-day contact lenses for 34 years. She has a strict pescatarian diet and her [body mass index] is excellent at 19. There’s a history of familial hypertension and migraines. She’s used contraceptives in the past and she has 2 healthy children. She takes metoprolol for hypertension, hormone replacement therapy, vitamins, and ω-3s. She has had many treatments. She’s seen many doctors. She brings a Google search to the office about her ocular surface disease. She’s had thermal pulsation therapy. She’s had a variety of masks for warmth and for sleeping. She uses a variety of lid scrubs and she’s tried serum tears. Prescriptions she’s used include cyclosporine, [which] is Restasis emulsion; lifitegrast, [which] is Xiidra drops; loteprednol drops, [which] is Lotemax; and varenicline, [which] is Tyrvaya nasal spray. This is a typical case in a corneal referral practice. We see patients who’ve had long-standing problems and a multiplicity of risk factors.
We had hoped to intervene in a wise and targeted fashion. So based on this eye exam, what’s your impression of this case? Indeed, it’s complex and we think that it’s important to weed out the noise and to attack the most critical problems first. And I would suggest in this case to take away the biggest criminals if possible. One, at the top of the list is contact lenses. She’s been abusing contact lenses for many years. In fact, if we look at her ocular surface, we can see that there is significant staining patterns, and inferior staining, which may represent a lid component to her condition.
And this fact tells us that she feels better when the contact lenses are in because they mask her ocular surface irritation, which may prolong the insult and the hypoxia.
Her lid margin shows not only some collarettes but a few sleeves and the absence of normal meibomian gland orifices. This is alarming. It does tell me that there may be a meibomian gland component here. So we understand that this patient has dry eye disease. We understand there’s clearly a chronic contact lens use and perhaps and very likely a limbo stem cell deficiency component, and that there’s clearly a meibomian gland component as well with the absence of normal lid margin and anatomical components.
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