• HPI: 63-year-old WF with history of RK surgery x 20 years; monovision, OD dominant
• CC: Blurry DVA OU, Blurry NVA OD, prefers no correction OS for reading, notes fluctuating vision, haloes, difficulty driving at night, constant watering of eyes
• Modifying factors: (+)distance vision only specs, (+)Fish oils

• Entering visual acuities:

• Manifest Refraction:

OD +5.25 -1.50 x 144, 20/25^–
OS -1.75 -0.50 x 071, 20/20
ADD +2.50D

• Slit Lamp Examination OU:

• Corneal Topography (Figure 1: OD left photo; OS right photo)

• • Dilated Fundus Examination: Lattice degeneration OU, Posterior Vitreous Detachment (PVD) OS
  • 3 month Rx check:

OD: +4.00 -0.75 x 146 20/25
OS: -1.75 -0.50 x 070 20/20

• The patient was initially hesitant to pursue CL fitting due to age and perceived difficulty of lens handling.
• Following a discussion at the three month Rx check, in which the patient experienced a large fluctuation in their spectacle refraction, it was decided to initiate contact lens fitting.
• The patient elected to initially fit the right eye only, with an option to fit the left eye in the future to address Ocular Surface Disease.
• Both patient and practitioner elected to pursue scleral fitting for best comfort, due to severe irregularity of ocular surface, and to help address OSD.

• Diagnostic Fitting of scleral lens OD
  • • Initial lens selection: BC 8.40mm, OAD 16.0mm, Power Plano, Sag 3400 um, Periphery 38D-44D
    • 400 um central post-lens fluid reservoir clearance after ~15 minutes settling
    • 50 um limbal clearance 360˚
    • Edge Lift 360˚, movement on blink
    • Inferior decentration
    • Toric markings @ 10 o’clock
    • ORx: -2.25 -1.50 x 171 VA OD: 20/20^-2
    • Plan: Order first lens OD only
• Ordered lens parameters: BC 8.40mm, OAD 16.0 mm, Power -3.00DS, Sag 3300 um, Periphery 42D-48D
  • • 200 um central post-lens fluid reservoir clearance after ~45 minutes settling
    • 50 um limbal clearance 360˚
    • Good landing, (-)edge lift, (-)impingement 360˚
    • Good centration
    • Toric markings @ 10 o’clock
    • ORx: plano VA OD: 20/20
    • Plan: dispense lens with preservative-free filling solution, and perform application and removal training in office
• One week f/u with lens OD only
  • • 150 um central post-lens fluid reservoir clearance after ~4 hours settling
    • 50 um limbal clearance 360˚
    • Good landing, (-)edge lift, (-)impingement 360˚
    • Good centration
    • Toric markings @ 10 & 4 o’clock
    • ORx: plano VA OD: 20/20
    • Mild mid-day fogging
    • Plan: Finalize lens OD for monovision fit OD dominant, switch filling solution
    • Patient reports stable vision, significant decrease in haloes/glare, and increased visual comfort; she will consider fitting of fellow eye due to success of first eye

• Don’t be afraid to customize for the patient! Monovision, multifocals, and single vision are all options just as with soft lenses!
• Scleral lenses can be utilized for more than one purpose!
• Patient education and support through the application and removal process can make lenses available for all ages and stages.
• Asthenopia due to aniseikonia may be mitigated with specialty lenses post RK