22 yo Caucasian female presenting from referral by local OD | Figure 1

22 yo Caucasian female presenting from referral by local OD for a corneal typography for RGP fitting. patient reports that she had a herpes keratitis infection at age 4 resulting in corneal scarring in both eyes, OS>OD.

Slit lamp findings:

Image is of right eye.

Questions:

  1. Referring doctor wants to use an RGP to help with the distortion. I'm wondering if the direct contact of an RGP on a scarred and uneven cornea might worsen scarring like it might in keratoconus. Could RGP worsen scarring?

  2. I would consider scleral lenses to avoid the corneal touch but that may have its own drawback as scleral lenses are thicker and the tear lens is thicker too so it would have less oxygen transmission in an eye that's already got a lot of corneal NV. Would scleral lenses be contraindicated?

  3. Patient reports that her previous OMD told her her chances of successful corneal transplant is 50%. Can any corneal specialist give an opinion?

Similar cases

HISTORY OF PRESENT ILLNESS
A 62-year-old female with no significant medical history presented to the ED complaining of seeing “floaters” and flashing lights in her right eye associated with loss of vision in the right inferolateral visual field (affecting only her right eye) for the past three days. She did not wear eyeglasses or contact lenses, and denied pain, redness or discharge from the eye. She denied trauma to the eye or headaches.

PHYSICAL EXAMINATION

Diagnosis:

What is your DDX? What is the cardinal symptom to support this? Anything on the Ultrasound?

A 55-year-old female from out of state presented with a chronic corneal perforation in her left eye.
Three months prior, an outside ophthalmologist had performed pterygium removal. Surgery was complicated by corneal perforation, which was glued. Despite a second surgery to glue the perforation, the cornea still leaked, causing constant tearing and fluctuating vision, putting the patient at risk for infection. She came to us for a second opinion.
At initial visit, there was a bandage contact lens in place over a large area of glue at the nasal limbus. The anterior chamber was shallow. After removing the contact lens, multiple leaks were noted at the edge of the glue. Careful examination of both eyes revealed subtle peripheral corneal thinning consistent with Terrien’s marginal degeneration, which was not previously documented and likely contributed to the perforation.
The glue was removed and revealed a very thin underlying cornea with multiple perforations and no evidence of infection. Cyanoacrylate glue was applied revealing new leaks outside the area of gluing. The new leaks were glued over, but the cornea remained Seidel positive. There were perforations noted in three clock-hours of peripheral cornea.
Surgeons discussed an unorthodox approach: an eccentric Descemet’s stripping endothelial keratoplasty (DSEK). Advantages of this approach included sparing corneal stroma, avoiding sutures into thin cornea and speeding visual recovery.
DSEK has been described as a treatment for central perforations and corneal hydrops, but not multiple peripheral perforations, as in this situation.

This patient has an ICE syndrome, progressive iris atrophy, combined with keratoconus. She has extreme photophobia and I was asked to fit a cosmetic contact lens to help with the photophobia.
We ended up trialing a scleral contact lens which improves her vision and significantly improves photophobia where a soft color lens only improved photophobia.

Unfortunately she intermittently develops corneal edema from the scleral lens. I ordered a higher oxygen material, made the lens thinner, and added a fenestration port. Her case is still ongoing as we try to prevent her cornea from swelling but she has done very well with the lenses so far.