Creative Contact Lens Management of Keratoconus with Scleral Lens and
A Pinguecula Notch
A 35-year-old African-American male presented with complaints of blurry vision, eye strain, watery eyes and photophobia. The patient reported that his right eye seemed worse than his left and that the symptoms of decreased vision started over 10 years ago. He has been without glasses for over a year. The patient also reported that two years prior he was fit with soft contact lenses but wore them for only one month due to discomfort and poor vision. He had a prior diagnosis of keratoconus, OD > OS.
Uncorrected visual acuity:
OD: plano -8.00 x 045, 20/25 (ghosting)
OS: +0.25 -1.75 x 105, 20/20
OD: 51.87/48.50 @ 060, grade 4 distortion
OS: 46.25/45.25 @105, grade 3 distortion
Topography revealed slightly temporal cones, OD > OS (Figure 1).
Slit lamp evaluation:
There were nasal and temporal pingueculae OD and OS as well as mild corneal thinning, OD > OS and no scarring/Fleischer ring/striae OD and OS.
Initial lenses tried with this patient were Rose K2, Rose K2IC, Rose K2IC piggybacked (Blanchard/Menicon) with Johnson & Johnson Acuvue Oasys, and the SynergEyes KC hybrid lens. With all of these lenses, the patient complained of decreased vision and dryness after only 2-3 hours OU as well as irritation and redness, OD worse than OS, immediately after lens insertion. A decision was made to try a Jupiter lens OD. At the same time a successful fit was achieved OS with a Johnson & Johnson Acuvue Advance for Astigmatism lens (base curve 8.6, power plano -1.75 x 100, diameter 14.0). This lens provided visual acuity of 20/15 with good fit and comfort.
The Jupiter (Medlens) diagnostic lens (base curve 5.82, power -9.12, diameter 15.0) had adequate vault with clearance centrally and compression at 3 and 9 o’clock (Figure 2). Visual acuity was 20/20 with an over-refraction of -5.00 D. Loosening the haptic resulted in a desirable fit with good tear exchange. However, after 4-6 hours of wear, the lens sealed off with mid-haptic compression 360° around and increased edge lift. The central vault clearance appeared to have decreased and there was faint touch corresponding to an area of 2+ staining inferior nasal with adjacent limbal injection. We increased the overall diameter to 15.6mm and flattened the first peripheral curve to prevent seal off of the lens. Fit evaluation of the new lens revealed temporal displacement secondary to a nasal pinguecula. The lens showed compression at 10 o’clock with adjacent impingement on the sclera. The vault was also decreased nasally, resulting in corneal touch. The final lens ordered had a pinguecula notch cut into it to accommodate the irregular conjunctival tissue of the pinguecula (Figure 3). This resulted in better centration. The lens diameter was also increased to 16.2mm to decrease lid-lens interaction and to allow for the pinguecula notch to be cut without compromising the integrity of the lens.
OD: Jupiter, base curve 5.82, power -13.25, diameter 16.2
OS: Johnson & Johnson Acuvue Advance for Astigmatism, base curve 8.6,
power plano -1.75 x 100, diameter 14.0
In patients who cannot succeed with corneal lenses because of poor lens centration, poor lens fit or lens intolerance and in patients who are not good surgical candidates, scleral lenses are an underappreciated alternative. In some instances you may need to be creative to fit these patients, as in our case with the use of a pinguecula notch. This modification can even be adapted to help accommodate a patient with a filtering bleb. Thus, innovative and imaginative contact lens management of corneal diseases can make a big difference in a patient’s quality of life.
Special thanks to the late Dr. Robert Breece for all his help and support with the design of this lens. His guidance was instrumental in the successful treatment of this patient.
Emily Kachinsky is a graduate of Cornell University and completed a Master’s Degree in Psychophysical Vision Research at the University of Chicago prior to enrolling in optometry school. She graduated from the New England College of Optometry in 2008 as co-valedictorian. After graduation, she completed a residency in Cornea and Contact Lenses and was awarded the Dr. Sheldon Wechsler Contact Lens Residency Award. She currently works at two different private practices, one of which is a contact lens specialty practice. She is a member of the American Optometric Association and the American Academy of Optometry.