GP Lens Case Grand Rounds Troubleshooting Guide

Corneal Reshaping – An Alternative to LASIK: Michael J. Lipson OD, FAAO

Background

Patients often present to us looking for alternatives in types of vision correction. They may ask about changing from glasses to contact lenses, different types of contact lenses or having LASIK done. This is a case of a patient who explored LASIK and was looking for alternatives to surgery. We presented the option of overnight corneal reshaping (OCR) that she had heard about from her friend who was a patient of ours.

Tests, Procedures, Fitting, Design and Ordering

DJ, a 31 year-old female accountant, presented for a contact lens consultation stating she had been investigating having laser-assisted in situ keratomileusis (LASIK) performed due to her discomfort and dryness with her current soft lenses. She was not comfortable with glasses either. She had consulted with two LASIK surgeons, one who said she was a good candidate and one who said she was a high risk and should not have it performed. She had justifiable concern about going through the procedure. She wanted to be evaluated for the OCR process. Our comprehensive evaluation showed the results below.

Manifest Refraction and Visual Acuity:

OD: -3.25 -0.50 x 80 20/20
OS: -3.50 -0.50 x 105 20/20

Keratometry:

OD: 43.75 @ 080; 44.00 @ 170
OS: 44.00 @ 105; 44.37 @ 015

Corneal Diameter: 11.9 mm

Pupil Diameter: 6.5 mm (scotopic); 3.5 mm (photopic); equal reaction, no APD

Corneal Topography: Normal centrally with slight inferior steepening (Figure 1)

Pachymetry: OD: 529, OS: 525

Slit Lamp Biomicroscopy: trace inferior superficial punctate keratitis in both eyes, no evidence of thinning or striae

Schirmer Testing: OD: 12mm, OS: 14mm

IOP: OD: 14, OS: 13

Internal: Normal cupping, sharp disc margins and normal retinal background

We diagnosed sub-clinical keratoconus (Forme-Fruste) which was probably the reason one of the surgeons advised against LASIK. We discussed her condition and options at length. With no slit-lamp evidence of corneal thinning and normal pachymetry readings, we presented the details about OCR. She opted to proceed with OCR lenses with the results and lenses below:

Paragon CRT lenses:

	BCR	RZD	LZA
OD	8.50mm	550	33
OS	8.50mm	550	33

Patient Consultation and Education

DJ was concerned about proceeding with LASIK after getting conflicting opinions regarding her candidacy. We made her aware of the risks and the benefits of OCR and emphasized the fact that care, cleaning and compliance with all aspects of OCR was critical to long-term success. The fact that OCR is temporary is coincidentally, a disadvantage and an advantage. While lenses must be worn every night to maintain good daytime acuity, if there was ever a reason to discontinue OCR, one would return to the same pre-treatment myopia.

Follow-Up Care/Final Outcome

After lens dispensing and instruction, DJ was seen for follow-up care after her first night of wear, at one week, one month, three months and six months. We continue to see her for an annual evaluation and a six month check up. She is thrilled to be free of glasses and contact lenses during her work day and for her after-work activities. She reports her vision is possibly better than she had with her soft contact lenses and that it stays clear up until she inserts her lenses at bedtime. She reports that she has occasionally skipped a night of wear and that her acuity is slightly less the following day.

She wears lenses every night and retains good visual acuity during all her waking hours with significantly more comfort than with her soft lenses. We continue to see her every six months to monitor corneal stability, corneal health and condition of the contact lenses.

The results of her most recent follow-up visit included the following performed 7 hours after lens removal:

Wearing Time: She averages 7-8 hours/night, every night

Unaided Visual Acuity: OD: 20/20; OS: 20/20

Manifest Refraction:

OD: +.25 -.25 x 180 20/20+
OS: pl -.25 x 005 20/20+

Corneal Topography: Ideal well-centered central flattening (Figure 2)

Overall, she is very comfortable with the process of OCR and is also comforted by the fact she did not have LASIK.

Discussion/Alternative Management Options

Overnight corneal reshaping is a non-surgical refractive procedure that has been shown to temporarily reduce myopia and improve unaided visual acuity. Studies have shown it to be effective and patients have found it to be a very attractive option to traditional contact lenses. Safety is an important issue with OCR. As with any procedure, there have been reports of problems. While there are no published studies to evaluate the relative risk or incidence of adverse events while wearing OCR lenses, ophthalmic journals have published case reports of adverse events over the past seven years. The case reports do not establish the incidence of microbial infections related to corneal reshaping contact lens wear. Risk of severe complications with corneal reshaping contact lenses is present but may be no different than with other overnight wear contact lens modalities. OCR should be considered as an alternative to LASIK.

There are a number of alternatives for vision correction of myopic patients today. As eye care practitioners we are all aware of spectacle correction and contact lenses. We have numerous contact lens options available in terms of the different modes of wear and different materials for various vision and comfort demands. Refractive surgery has provided another alternative that many patients have pursued. However, we owe our patients the entire story as to all the options by presenting OCR as an alternative to other options.