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Corneal Irregularity in a Contact Lens Wearer
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A 30-year-old, longtime wearer of soft contact lenses presents with complaints of decreased vision in both eyes. He first presented to his prescribing optometrist 6 weeks ago. His contact lens wear was discontinued, and he was referred to an ophthalmologist for evaluation of dry eye, an unspecified corneal problem. Conservative management was unsuccessful, and the addition of topical cyclosporine and artificial tears 1week prior was of no benefit. Visual acuity with spectacle correction was 20/20 and 20/25 in the right and left eyes, respectively. Intraocular pressures were normal, and corneal thicknesses were 562 mm and 563 mm in the left and right eyes, respectively. Slit lamp examination is as shown in the figure.
Diagnosis
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This patient has advancing wavelike epitheliopathy (AWE). AWE is most commonly seen in contact lens wearers with engorged superior conjunctival and limbal vessels, but the most characteristic finding is the presence of an advancing “wave-like” area of irregular epithelium toward the central cornea. The epithelium is highly irregular in contour and slightly opaque and probably represents noncorneal epithelium in the form of a sectoral limbal stem-cell deficiency. The condition is largely progressive and painless and can result in decreased vision both from the indirect inducement of irregular astigmatism or direct involvement of the visual axis. This condition is seen most commonly with chronic contact lens use or abuse and is thought to be due to either chronic contact lens–related trauma, sensitivity to the lens or contact lens disinfectants, or hypoxia.
Differential Diagnosis
Several disorders can result in limbal stem-cell deficiency, but the irregularity’s superior location significantly reduces the differential diagnosis. In developing countries, trachoma may commonly result in superior limbal and corneal involvement secondary to upper lid scarring, not seen on this patient. A related disorder also caused by chlamydiae, adult inclusion conjunctivitis, may also cause superior conjunctival findings, but those findings are normally much less severe. Allergic conditions, such as vernal and atopic keratoconjunctivitis, as well as giant papillary conjunctivitis should also be considered. None of these conditions was present here. Finally, superior limbic keratoconjunctivitis (SLK) also can result in straight, engorged superior conjunctival vessels, an irregular superior corneal limbus with fluorescein and rose bengal staining, and epithelial changes. Thyroid function tests were normal in this case.
Primary treatment is discontinuation of contact lens wear for weeks or months, which should result in stabilization and eventual incomplete regression of the irregular epithelium. Superficial keratectomy may be considered if the lesion is approaching the visual axis, but only once the underlying disorder has been addressed. It is unclear whether future contact lens wear is advisable, but lens type, lens-wearing schedule and lens care will all need to be evaluated before reinstituting contact lens wear. Corticosteroids may have a role, but time should be allowed for spontaneous resolution before surgical intervention in the form of serial limbal debridements, amniotic membrane grafting or limbal stem cell transplantation is considered.