There’s nothing static about fitting keratoconus patients with specialty contact lenses. Everything is constantly changing: each patient’s disease progression as well as treatments, lens designs, and philosophical approaches to management.

One Patient’s Contact Lens Journey

In 2007, a 41-year-old keratoconus patient reported for evaluation. He was wearing corneal GP lenses on both eyes but complained of issues with the lenses intermittently decentering and falling out. After we discussed the advantages of scleral lenses, he was fit into 18mm lenses that had spherical landing zones and that were stable while providing him with near perfect visual acuity.

However, a major complaint with these lenses was frequent midday fogging that was significantly disrupting his vision. At one point in 2010, his wife called to report that he was taking his lenses out to rinse and refill them “40 to 50 times per day!” This was obviously an unacceptable situation. He was asked to switch from filling the lens with 0.9% NaCl saline (off label) to a more viscous lubricant (off label) in an attempt to slow influx of debris.

After this failed, the patient was successfully refit with hybrid contact lenses, which eliminated the midday fogging. He had no complaints or need for lens adjustments for the next five years.

In 2016, the hybrid lens of his right eye started to fit excessively tight (Figure 1), and the patient was no longer able to tolerate wear. Corneoscleral topography measurements revealed a significant nasal pinguecula. A 16mm diagnostic scleral lens with a spherical landing zone showed impingement of the pinguecula, with associated edge lift below it (Figure 2). It can be hypothesized that the patient’s previous failure with scleral lenses resulted from uptake of debris through the lifted lens edge.

Using updated technology and design, I fit the patient with a free-form customized 16mm lens that nicely vaults the pinguecula and aligns evenly with the bulbar conjunctiva (Figure 3). The patient had 20/25 vision with the lens and no reported midday fogging. He continued to wear the adequately fit left hybrid lens without any reported or observed complications. Corneal cross-linking has not been recommended, as he has shown no signs of progression, most likely because of his age.

Always Room to Improve

This case highlights that we need to continually evolve our fitting strategies as contact lens technology progresses. Advances in instrumentation, lens design, and manufacturing can be applied to help troubleshoot complications if they arise.

This patient probably could have “survived” with his previous corneal GP lenses or his original scleral lenses, but now he has improved vision without the disruption that their complications caused. CLS