Case Report: Scleral Lenses Aid Keratoconus Patient

The patient’s vision had deteriorated over a period of many years.

By Michael Fimreite

 

The patient discussed in this case report was first seen and diagnosed with keratoconus in 2003. The same optometrist at Paje Optometric, a private practice in Santa Ana, California, consistently conducted his progress and yearly monitoring.

 

—Section Editors Mile Brujic, OD, FAAO, and David L. Kading, OD, FAAO

The 23-year-old Mexican man presented at the Western University of Health Sciences College of Optometry with long-standing keratoconus in both eyes, which had slowly progressed over 12 years. The patient’s left eye as seen on this exam is shown in Figures 1 and 3 and the patient’s right eye is shown in Figure 2. His initial BCVA in 2003 was 20/25- OD and 20/25- OS with spectacle prescriptions of plano -6.00 × 030 OD and -0.25 -5.00 × 130 OS.

Figure 1. The patient’s left eye showing a prominent Fleischer ring. The Fleischer ring results from iron deposition in the basal cells of the corneal epithelium.

As his keratoconus progressed over the years, his spectacle and rigid gas permeable (RGP) contact lens prescriptions were adjusted accordingly. On April 11, 2015, my examination found his BCVA to be 20/80- OU, with spectacle prescriptions of -6.75 -6.50 × 030 OD and -7.00 -7.75 × 130 OS. His existing RGP lens prescription of -9.00 D sphere OU gave him slightly better BCVA of 20/60- OU.

In 2013, the patient had undergone corneal crosslinking surgery OS, which had successfully stopped the keratoconic progression in that eye. At his exam on April 11, 2015, he was waiting to hear from the surgeon to see whether he would be eligible to have the procedure done in his right eye as well.

The patient told me that he was beginning to struggle with depression due to his worsening vision. He was beginning to fall behind in school because he could not see well enough to do his homework, and he missed the freedom that came with the ability to drive, which he had lost roughly 1 year before this exam. He asked if there was anything else that could be done to help him get his vision back. We discussed various options, including scleral lenses. He decided to proceed with a scleral lens fit.

Figure 2. The patient’s right eye showing corneal hydrops. The thinning of the cornea has resulted in a rupture to Descemet membrane, allowing aqueous humor to enter the corneal stroma and cause edema and scarring.

Figure 3. The patient’s left eye showing well defined Vogt striae. Vogt striae are vertical folds appearing in Descemet membrane parallel to the meridian of greatest curvature.

The patient was fit using the Atlantis Scleral Fitting System (X-Cel Specialty Contacts). Following that fitting guide, with a trial lens, the patient achieved 20/40 OD and 20/25- OS with an over-refraction of -8.00 D OU. The same diagnostic lens parameters were used on each eye, which were as follows: type E lens, which has a power of -5.00 D, a base curve of 7.03 mm, a diameter of 15.00 mm, and a standard edge lift of 4.754.

After the lenses were allowed to settle on the patient’s eyes for 15 minutes, the left lens had about 350 µm of central corneal clearance, and the right lens had about 300 µm of central corneal clearance as estimated at the slit lamp. The patient stated that the right lens felt great and the vision was great, but the left lens felt a little tight, despite the vision being, as the patient described it, “phenomenal.” A flatter lens was selected for the left eye in an attempt to slightly decrease the central corneal clearance. The type E diagnostic lens was again used, with the same parameters; however, we chose a flatter edge lift of 4.704, which yielded the preferred 300 µm of clearance for the left eye. The over-refraction remained at -8.00 D.

The patient stated that the scleral lenses felt significantly more comfortable than any of the RGP lenses he had previously worn, and he was ecstatic about the quality of vision they gave him. After proper education on lens care, insertion, and removal, a pair of scleral lenses with the proper parameters were ordered. In the interim, the patient was allowed to wear the diagnostic lenses home to practice insertion and removal in preparation for when the finalized lenses arrived.

The custom-ordered lenses came in, and the patient wore them for 1 week. We had him come back to reevaluate the fit and quality of vision. His visual acuity remained at 20/40 OD and 20/25- OS, but now with no over-refraction, and the lenses were still feeling comfortable.

DISCUSSION

In patients with keratoconus, the benefits of scleral lenses cannot be overstated. A properly fitting lens can provide dramatic improvements in patients’ vision and quality of life. In addition, scleral lenses provide protection to the cornea in patients who tend to rub their eyes, such as those with atopic dermatitis, who have a significantly high incidence of keratoconus.

The best fitting technique will vary based on the type of scleral contact lens used, so following the appropriate guide and having a multistep plan in place for adjustments and reorders is paramount to achieving a successful outcome.

Proper patient education on the benefits of scleral lenses, along with a realistic description of the time required to successfully finalize a fit and prescription, will position the practitioner and the practice positively in the patient’s eyes. n

Section Editor Mile Brujic, OD, FAAO
• Partner, Premier Vision Group, Bowling Green, Ohio
• (419) 352-2502; mile@optometricinsights.com

Section Editor David L. Kading, OD, FAAO
• Partner, Specialty Eye Group, Seattle, Washington
• (425) 821-8900; dave@optometricinsights.com

Michael Fimreite
• OD candidate, class of 2016, Western University of Health Sciences College of Optometry, Pomona, California
michael.fimreite@gmail.com
• Financial interest: none acknowledged