RGPs After RK: Managing
the Reluctant Patient

BY KARLA ZADNIK, O.D., Ph.D.
JULY 1996

One of the foremost applications of specialty rigid gas permeable contact lenses is fitting the post-radial keratotomy cornea.

Recently, I've realized that, in addition to the specialized fitting techniques necessary for post-RK cases, the contact lens practitioner must also employ specialized patient management techniques. Most of these patients never expected to have to wear contact lenses, let alone rigid contact lenses, after refractive surgery. In fact, it's very likely that some were previous RGP wearers who experienced lens intolerance, which may have been their motivation for seeking refractive surgery.

So, the contact lens practitioner is confronted with a difficult-to-fit cornea and an angry patient. How should we deal with this dilemma?

EDUCATING THE RK CANDIDATE

One solution may be better patient education before surgery. The possibility of postoperative contact lens wear may only be included in the 'fine print' of the surgeon's consent form along with warnings about severe complications such as corneal perforation, endophthalmitis and blindness. Thus, the radial keratotomy patient who finds herself in the examination chair of a skilled contact lens practitioner about to undergo a rigid lens fitting considered the need for contact lenses just about as likely as a devastating ocular infection.

FIG. 1: VIDEOKERATOGRAPHIC IMAGE OF A PATIENT WHO DEVELOPED KERATOCONUS AFTER RADIAL KERATOTOMY.

Figure 1 shows postoperative videokeratographic images of a post-radial keratotomy patient who developed keratoconus, complete with Vogt's striae and the requisite corneal irregularity. In addition to the sheer difficulty of the contact lens fitting required, the patient (an attorney, no less!) was not pleased to be in my office, with or without keratoconus. He simply had not acknowledged that postoperative RGP lenses were a possibility.

Fortunately, since his initial visit to my office, we have fitted him with RGP lenses, including a bitoric on the left eye, and corrected him to 20/20, and he is pleased with his vison. Admittedly, he might have come to my office without the RK when his keratoconus manifested, but his attitude -- and my ability to administer the care he needed -- might have been more positive if he had known that RGP lenses might be in his future.

POST-RK STATISTICS

The 10-year results of the Prospective Evaluation of Radial Keratotomy (PERK) Study, published in 1994, provide useful information on the long-term course of patients undergoing RK. Although the study describes the PERK patients' postoperative use of distance correction (30 percent need correction), the results do not indicate how many patients chose spectacles versus contact lenses, nor do they tell us what percentage of the patients required or chose RGPs at 10 years.

There are those who consider radial keratotomy an obsolete technique, and others who believe the PERK protocol is no longer current given more modern operative procedures. Yet others believe that radial keratotomy will continue to be part of the refractive surgeon's armamentarium for a long time to come. Regardless, patients undergoing refractive surgery of any type deserve a realistic picture of their postoperative course, including the possibility of RGP lens wear. Fortunately, rigid lenses offer some of these patients the perfect option for excellent postoperative, best corrected vision. Their attitudes toward RGP lens correction should not limit our ability to provide such correction.

Surgeons, referring doctors, pre- and postoperative comanagers -- all professionals who advise refractive surgery patients -- should make it clear that some cases require postoperative vision correction that may include the exacting fit of RGP contact lenses. CLS

Dr. Zadnik is an assistant professor at The Ohio State University College of Optometry in Columbus.