A 17-year-old female patient had a history of advanced keratoconus and apical scarring; she had failed in both corneal GP and piggyback contact lens modalities. Uncorrected, her vision was counting fingers at one foot. Fortunately, her scleral lens fitting went smoothly, with an appropriate fit, good comfort, and best-corrected visual acuity (BCVA) of 20/50 OD and 20/60 OS.

She was thoroughly educated on appropriate wear and care of her lenses and was provided an information handout. Her follow-up visit was scheduled in two weeks. Unfortunately, she did not return for her appointment, and multiple attempts were made to contact the patient and her guardian to reschedule without success.

Ensuing Complications

Nine months later, the patient returned complaining of red, irritated eyes and mucous discharge (Figure 1). Questioning revealed that she wore her lenses overnight five days a week, used multipurpose soft lens solution to fill the lenses, and continued lens wear despite significant irritation. Upon lens removal, corneal neovascularization was noted OS > OD (Figure 2).

The patient was told to cease extended wear and to limit daytime wear. We educated her about the risk of permanent vision loss if she did not comply. She was reminded to use only appropriate filling solutions and was given samples. We also prescribed a topical antibiotic.

One week later, the eyes were white and quiet, but the neovascularization was significant OS > OD. A scleral refit was recommended OS due to keratoconus progression and insufficient corneal clearance (Figure 3). The patient’s mother agreed to return in two months when her insurance coverage renewed.

One year and eight months later, the patient returned. She denied lens wear while sleeping but admitted to using a generic preserved saline to fill them. Refitting the right lens yielded stable VA at 20/50. However, worsening neovascularization and scarring over the left pupil (Figures 4 and 5) required a corneal transplant for functional vision.

Learning Points from This Case

1. Extended wear of scleral lenses is not recommended; exceptions may be made for short-term use in non-healing corneal defects.
2. Provide patients with links to instructional videos and with handouts that have written instructions and images of appropriate solutions.
3. Have patients sign an informed consent policy outlining the risks of noncompliance, including vision loss, and document attempts to contact them. CLS