• HPI: 21-year-old Caucasian male with history of mild keratoconus, OS > OD. Routine follow-up was not consistent over time, but upon more frequent examination with corneal tomography at age 23, progressive keratoconus was confirmed OS. US Food and Drug Administration (FDA) – approved corneal cross-linking (CXL) was performed OS following insurance review and approval.
• CC: Severe blur OS, with glare and shadows particularly at night, which had become progressively worse over the last few years.
• Modifying factors: Patient presented with no vision correction, as a soft contact lens trial fitting performed years prior was not successful. Corneal cross-linking (CXL) had been performed OS, a few months earlier.

• Entering visual acuities (without correction):

OD: 20/25⁺¹

OS: 20/60

• Manifest Refraction:

OD: pl +0.50 x 030, 20/20^-3

OS: -1.00 +2.50 x 170, 20/20^-3

• Slit Lamp Examination:

• Corneal Tomography (performed six weeks after CXL OS)(Figure 1)

OD: 42.5/46.6 D, Kmax 55.4 D; CCT 454

OS: 45.4/51.4 D, Kmax 66.3 D; CCT 419

• Anterior Segment Optical Coherence Tomography (AS-OCT)
  • • AS-OCT (performed six weeks after CXL OS)(Figure 2).

• Dilated Fundus Examination: WNL, no holes, tears, breaks OU

The patient elected to proceed with scleral lens fitting OS after the GP trial was unsuccessful. No contact lens was necessary in the fellow eye, as the patient was satisfied with his uncorrected VA OD. Topical allergy eye drops were prescribed to address chronic allergic conjunctivitis and the patient was counseled to avoid eye rubbing due to its potential impact on keratoconus progression.

• A scleral lens was designed and dispensed to the patient after successful application/removal training, about six months following CXL OS. 1st scleral lens parameters: 17.5 mm OAD, 8.5 OZD, 5.53 sag, 7.67mm BCR, -3.50D, 200 microns toricity.
• After wearing the 1st lens for three weeks, it was determined to have a slightly steep landing zone and minimal central clearance (< 100 microns) after settling for seven hours.
• The next lens was flattened 30 microns all around the landing zone and the central vault was increased by 150 microns. The 2nd and final lens: 17.5 mm OAD, 8.5 OZD, 5.65 sag, 7.34mm BC, -5.50D, 190 microns toricity, Optimum Extra material.
• BCVA with scleral lens OS was 20/20^– with significant improvement to halos and glare as compared to spectacles. A spectacle prescription was also released for use as needed.

• Frequent and careful follow-ups are indicated in young patients with mild keratoconus (1).
  • • Due to the COVID-19 pandemic, this patient’s follow-up visit was delayed for 18 months. Once progressive keratoconus was confirmed, it took another six months before CXL could be performed due to challenges with insurance approval.
• Cross-linking should be discussed with patients and guardians early, so they are aware of intervention for progressive disease.
• Asymmetry between eyes can mask disease progression, as patients may be fully functional with good vision from one eye alone.
• Contact lenses can be fit or re-evaluated about one month after CXL, or slightly longer (two months) in new lens wearers due to possible micro-trauma from the training process (2).
• Glasses and soft contact lens prescriptions often change due to corneal remodeling after CXL
• While changes may also occur with GPs and scleral lenses following CXL; it is often less than with glasses or SCLs.