1 Case Report: Fitting of a Mini-Scleral Lens on a Post-RK and Post-LASIK Irregular Cornea Sonja Iverson-Hill Michigan College of Optometry Senior Intern
2 1 Case Report: Fitting of a Mini-Scleral Lens on a Post-RK and Post-LASIK Irregular Cornea Sonja Iverson-Hill Michigan College of Optometry Senior Intern Abstract Abstract BACKGROUND: The Blanchard BACKGROUND: Onefit lenses Astigmatism are mini-scleral is a type lenses of refractive designed error to be that supported causes by blur due conjunctiva to and tear film. The lens vaults an irregular entire shaped area cornea, of cornea lens, or and both. limbus. Astigmatism, The lens due material to its varying offers degree a minimum permeability of 100 Dk. Ideally of irregularity, central corneal can be clearance corrected is in several different microns, ways with a including limbal clearance soft and not gas greater permeable (GP) contact lenses. More specifically back toric GP lenses which than 40 microns. These lenses have been utilized in patients with keratoconus, irregular corneas, and post refractive surgery. have a front surface that is spherical and a back surface that is toric, allows for CASE REPORT: A 53 year old great Caucasian alignment female of with posterior a past history lens surface of RK giving and four optimal LASIK centration surgeries on presented for a contact lens fitting with a chief an astigmatic complaint patient. of severe daily fluctuating blur, distortion, and glare that worsened throughout day. Our goal CASE was REPORT: to obtain A a 24 functioning year-old female visual presented system to with regain high corneal patient s astigmatism activities of daily In both eyes, with a desire and high motivation to wear corrective lenses. living, and to provide an example of how an irregular cornea can be enhanced using a mini-scleral lens to improve a CONCLUSION: Despite some practitioners belief that fitting gas permeable compromised visual system s performance. CONCLUSION: The Onefit mini-scleral Lenses is too lens complex, proved fitting to be of an se effective lenses treatment is rar modality simple with for minimal distortion, blur, and glare induced by an irregular experience. post-refractive They cornea. provide The excellent lenses restored vision and are patient s deemed visual comfortable system by allowing her to perform activities of daily living. patient. The Patients lenses even presenting improved with corneal stability astigmatism of her vision greater post than lens 3.00D removal and for 3-4 with corneal and spectacle cylinders that are comparable, are successfully hours. [Acknowledgements] Special thanks to Doug Herriot, O.D. at Eye Care Associates of Lee s Summit for his guidance, insights, and help in care and management of patient. Background A 53 year old Caucasian female presented for a contact lens fitting with a chief complaint of severe daily fluctuating blur, distortion, halos, and glare that worsened and fluctuated throughout day. She reported a secondary complaint of intermittent moderate dry eye in both eyes for past few years. She had been unsuccessful in soft contact lenses in past and spectacles did not correct for daily fluctuation in blur. The patient s ocular history was significant for Radial Keratometry (RK) in 1992 and four LASIK refractive surgeries between years Review of personal medical history disclosed panic attacks and insomnia. Macular degeneration and hypertension was identified in
3 2 patient s mor. Arthritis, hypertension, and cancer were identified in her far. All or family medical history was unremarkable. Current medications included Concerta, Xanax, vitamin D, and Estrogen. Upon ocular examination best corrected visual acuities were 20/20 OU (both eyes) with distortion. Best corrected visual acuities were attained with x 097 OD (right eye) and DS OD (left eye). Pupils were equal, round, and reactive to light with no afferent defect in eir eye. Extraocular muscles of both eyes were full in range and smooth in motion. Visual fields were full to finger counting in all quadrants. Biomicroscopy examination of anterior segment was unremarkable except for cornea OU. Eight RK scars and a LASIK flap were noted in each eye along with a decreased tear film. See Figure 1 below for corneal scar images. Figure 1 Photography of corneal RK and LASIK scars. Goldmann Applanation Tonometry and dilated fundus exam were deferred at this visit due to a recent complete ocular health exam by her referring doctor. Test Procedures, Fitting/Refitting, Design & Ordering Keratometry and topography were obtained via Medmont Topographer. Keratometry readings were OD and 40.9D/39.9D091 OS. Initially patient was fit into Blanchard s Onefit diagnostic lens in following parameters: OD: 7.70 BC, 14.3 mm diameter, sph, standard edge OS 7.90 BC, 14.3 mm diameter, sph, standard edge
4 3 The OD lens had an area of excessive edge lift from 6 8 which caused a persistent influx of bubbles even after allowing adequate time for lens to settle. The OS lens had several areas of touch. A second diagnostic lens was trialed. Parameters were as follows: OD: 7.20 BC, 14.3 mm diameter, sph, standard edge OS: 7.30 BC, 14.3 mm diameter, sph, standard edge The OD lens continued to show an area of edge lift from 6 8 with an influx of bubbles to a lesser degree than diagnostic lens 1. The OS lens showed good central and limbal clearance, but also had an area of excessive edge lift from 4 8 with an influx of bubbles. Over refraction in left eye was sph and distance acuity was 20/20. A third diagnostic lens was trialed in right eye; parameters were 6.9 BC, 14.3 mm diameter, sph, and standard edge. Diagnostic lens 3 in right eye showed good edge and limbal clearance, but continued to show edge lift from 6 8:30 with a persistent influx of bubbles. Over refraction OD was sph with distance acuity of 20/20. The patient reported good vision and comfort with final diagnostic lenses. Due to persistent edge life and influx of bubbles despite orwise good fit, Blanchard lab was consulted for fitting suggestions. Based on consultant s advice, following lens parameters were ordered: OD: Onefit 6.9 BC, 14.3 mm diameter, sph, and customized edge lift of 2 steep OS: Onefit 7.3 BC, 14.3 mm diameter, sph, and customized edge lift of 2 steep At dispensing acuities were 20/25+2 OD and 20/20- OS at distance. The right lens showed a central clearance of 225 microns and good limbal clearance around 50 microns. No excessive edge lift was noted and no influx of bubbles was present. Over refraction was Plano with acuity of 20/25+2 at distance. The left lens also showed a good central clearance of 175 microns and a limbal clearance around 60 microns. Again no excessive edge lift was present and no influx of bubbles was observed. Acuity of 20/20 at distance was obtained with an over refraction of DS. The lenses were dispensed to patient for full-time wear with a gradual increase in wear time over course of first few days of lens wear. The patient was directed to return in one week for lens evaluation. Images of lenses at dispense are shown below in Figures 2, 3, and 4.
5 4 Figure 2 OD lens at dispense. Figure 3 OS lens at dispense. Figure 4 Anterior segment OCT images illustrating central clearance of lenses at dispense. OD lens (left) with a central clearance of 280 and OS lens (right) with a central clearance of 172. Patient Consultation and Education The patient was educated on effects cornea ectasia as a result from post surgical treatment. Insertion and removal techniques were demonstrated and proper contact lens hygiene was thoroughly
6 5 discussed. The importance of use of non-preservative saline solution to fill bowl of contact lens was stressed. We discussed using over counter readers for improved near vision and use of non-preservative artificial tears over contact lens for lubrication. A contact lens schedule was set-up with a gradual increase in contact lens wear-time over course of first week to allow her eyes to get accustomed to contact lens wear. Follow-Up Care/Final Outcome One week later patient presented with acuities of 20/20- OD and 20/20 OS at distance. She reported an average wear time of nine hours, good comfort and vision, and mild dryness at end of day. She also reported good night vision that seemed to last for up to four hours post lens removal. Good edge lift, central clearance, and limbal clearance was noted OU. No bubbles were observed OU. Over refraction OD was DS with distance acuity of 20/20- and plano OS. Refraction without lenses was DS OD with 20/20 acuity and DS OS with acuity of 20/20. Due to mild fluctuation in vision we directed patient to continue with full time wear and return in anor week to reevaluate stability in refraction. We recommended bifocals or over counter readers for improved near acuities and recommended non-preservative artificial tears over contact lens as needed for dryness. The patient returned for her two week post lens dispense evaluation with acuities of 20/20 OD and OS at distance. Acuities at near were 20/200 OU without an add. The patient reported good vision and comfort with a drastic decrease in fluctuating vision, glare, and distortion even up to 3 4 hours post lens removal. She reported satisfaction with over counter readers for near work. Mild impingement without constriction was noted nasally OU. Good central and limbal clearance and edge lift was noted OU. Over refraction was Plano in both eyes with lenses. Refraction without lenses was X 006 OD with 20/20 acuity at distance and DS OS with 20/20 acuity at distance. Topography was obtained via Medmont, images are shown in Figure 5 below. The lens prescription was finalized in both eyes and patient was directed to revisit in one year or sooner if any issues presented.
7 6 Figure 5 Medmont topography of pre-fitting and post-fitting corneas. Initial topography showed keratometry readings of OD and OS with cylindrical powers of 0.5D OD and 1.0D OS. Two week post-lens topography showed keratometry readings of OD and OS with cylindrical powers of 1.5D OD and 2.8D OS. Discussion The discovery of reported excellent vision post lens removal was a surprise. A corneal reshaping or reverse geometry effect may account for improved vision after removing lenses. Topography showed a central flattening and peripheral corneal steeping after two weeks of lens wear; however, re was no significant change in topography that may account for improvement in vision. The stability of patient s vision also significantly improved with lenses. The patient no longer experienced a daily fluctuation in vision and only complained of blur at near, which was correctable with a bifocal prescription. No significant change in over refraction was identified after one and two weeks of contact lens evaluations, and no significant change was noted when comparing morning over refraction at one week lens evaluation versus afternoon over refraction at week two evaluation.
8 7 The goal to obtain a functioning visual system to regain patient s activities of daily living was met and exceeded due to unexpected continued improvement in vision after lens removal. An irregular cornea can be enhanced using mini-scleral lenses to improve a compromised visual system s performance. When providing care for patients with irregular corneas suffering from fluctuating vision and blur, mini-scleral lenses, such as Blanchard s Onefit lens, should be considered. Scleral lenses are not only good for irregular corneas, but y have also been shown to be successful in or corneal diseases such as keratoconus where one study found 90.9% of ir severe keratoconic patients achieved 20/40 or less acuity via Snellen. 1,4,6 Post PRK patients have also proved to be successful 81.8% of time, obtaining an acuity of 20/40 or better via Snellen. 6 Over years studies have continued to show sclerals to be a good rapeutic treatment for severe corneal disease patients. It is important to continue se studies in order to determine long term effects se lenses may provide. 2,3,5 Conclusion The Onefit mini-scleral lenses proved to be an effective treatment modality for distortion, blur, and glare induced by an irregular post-refractive surgical cornea. The lenses restored patient s visual system allowing her to perform activities of daily living she orwise could not complete due to her drastic and debilitating daily fluctuation in vision. The lenses also improved patient s mental state, as she was suffering from severe depression from all failed surgical refractive enhancements. To improve patient complaint of dryness, Optive Refresh non-preservative tears were prescribed. This improved patient comfort and decreased dryness. A bifocal prescription of was prescribed to patient to correct for uncorrected blur at near.
9 8 References 1. Jacobs, D. S. (2008). Update on scleral lenses. Current Opinion in Ophthalmology, Romero-Rangel, T., Stavrou, P., Cotter, J., Rosenthal, P., Baltatzis, S., Foster, S. (2000). Gaspermeable scleral contact lens rapy in ocular surface disease. American Journal of Ophthalmology, Alipour, F., Kheirkhah, A., Behrouz, M. J. (2012). Use of mini-scleral contact lenses in moderate to severe dry eye. Contact Lens and Anterior Eye, Steele, C., Davidson, J. (2007). Contact lens fitting post-laser-in situ keratomileusis. Contact Lens and Anterior Eye, Romero-Jimenez, M., Flores-Rodriquez, P. (2013). Utility of a semi-scleral contact lens design in management of irregular cornea. Contact Lens and Anterior Eye, In Press. 6. Segal, O., Barkana, Y., Hourovitz, D., Behrman, S., Kamun, Y., Avni, I., et al. (2003). Scleral contact lenses may help where or modalities fail. Cornea,
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