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DD is a 65-year-old white female referred by her ophthalmologist for a consult for medically necessary contact lenses. She has a history of epiretinal membrane OU, anterior basement membrane dystrophy (ABMD) OU, meibomian gland dysfunction (MGD) OU, amniotic membrane treatment OU, and punctal plugs RLL and LLL. Her surgical history was remarkable for laser repair of a retinal tear with prophylactic laser barricade, vitrectomy, epiretinal membrane peel, and cataract surgery OU s/p YAG capsulotomy OU.

On the day of her consult with us, she complained of monocular diplopia, which was worse with corrective lenses, as well as ghosting, starbursts around light, and poor night vision. She saw 20/20 OD, 20/25+ OS with a mild astigmatic habitual prescription in both eyes. Spectacle refraction that day was:

OD -0.25-1.00x017, 20/20 OD
OS +0.25-1.00x003, 20/25+ OS

Placido disc topography showed irregular astigmatism in each eye (see Figures 1 and 2).

We then ran OCT topographies on both eyes (see Figure 3).

We discussed that the patient may not be an appropriate candidate for scleral lenses because elevation-based topographies showed relative regularity, but we ultimately decided to place trial scleral lenses on each eye. With these lenses, we were able to refract to 20/20 OD, 20/20 OS. The patient commented that this was not a large enough difference to justify scleral lens wear, so we instead referred her to our dry eye specialist and gave her the names of optometrists who focus on treating MGD, for other expert opinions.

Discussion

Upon initial appraisal with Placido disc topography, it appeared as though this patient had irregular astigmatism secondary to ABMD. However, OCT topography does not rely on reflection of mires; rather, it is a true elevation map of the corneas. The OCT topography showed little effect of the ABMD and relative regularity. By exclusion, this would leave her MGD as the prime reason for her symptoms. As we know in the scleral lens world, when a patient has MGD as their primary diagnosis, we cannot solve anything by fitting sclerals. Doing so only exchanges the surface that is dry from the cornea to the front surface of the scleral lens. This patient will be much better served by aggressively treating her MGD. OCT topography saved us from a potential bad outcome with sclerals where expectation could not be met.