GP lens eye Rounds

POST-SURGICAL: Post-Refractive Keratectomy (RK) Case

Allison Jussel Zagst OD, MS, FAAO

History

• HPI: 63 y/o 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

Examination

• 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

Decision-Making Process

Patient was initially hesitant to pursue CL fitting due to age and perceived difficulty of lens handling. However, 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.

Fitting and Evaluation

• • 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 clearance after ~15 minutes settling
      • 50 um limbal clearance 360˚
      • Edge Lift 360˚, movement on blink
      • Inferior decentration
      • Toric markings @ 10 & 4 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 clearance after ~45 minutes 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
      • Plan: dispense lens with LacriPure filling solution (Menicon), and perform application and removal training in office
  • One week f/u with lens OD only
    • • 150 um central 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 to Nutrifill (Contamac)
      • 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

Clinical Pearls

• • 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