A 36-YEAR-OLD MALE was referred by a local ophthalmologist because his keratoconus GP lenses “didn’t look like they fit right.” The patient described that his vision was OK, but the lenses were uncomfortable, he dropped them often, he couldn’t find them, and replacement lenses were expensive. Additionally, he reported that he had been told that he wouldn’t tolerate glasses and soft contact lenses would not work.
Keratoconus patients referred to practitioners often come in with the notion that their only options are corneal GP or scleral contact lenses. This often occurs when a patient does a simple internet search on “contact lenses for keratoconus” and, at first glance, they find the following statements:
“Soft contact lenses will not optimize vision for keratoconus.”
“Soft contact lenses are not a typical choice for keratoconus patients.”
“Disposable or soft contact lenses are not a typical option for keratoconus patients.”
“The first line of treatment is usually to correct the irregular cone with rigid GP lenses.”
“Scleral lenses are the best option in treating keratoconus.”
While some of these statements have a bit of truth, this isn’t really the entire story. Routinely, an unhappy GP or scleral lens patient comes in who can see 20/20 to 20/30 in a soft toric contact lens. These patients said they were told soft lenses wouldn’t work.
Here’s a challenge: Consider a soft contact lens before jumping a patient into a rigid lens. Why? Options. The greatest gift to patients is vision, but our most important mission is to make our patients as functional as possible. To be functional, they must see well but also be comfortable physically. Soft contact lenses should always be discussed as an option for visual rehabilitation. Additionally, soft lenses can be used as their primary management and as a supplement to rigid GP lenses.
Soft lenses can be broken into two categories when talking about keratoconus patients: generic versus custom. Generic or commercial options would include daily, two-week, or monthly lenses for astigmatism. Custom lenses would include those that can be made in many different materials, designs, and lens parameters.
In a scenario in which the patient is not pushing for soft contact lenses but is open to guidance from the practitioner, consider the following.
1. Through an irregular corneal refraction, use large increment changes in sphere and cylinder to reach the best-corrected visual acuity. Allow patients to spin the astigmatism dial to find their sharpest vision.
2. Offer to order soft “generic” trial lenses that have the patient’s parameters. These have limited cost and often arrive in two to three weeks.
3. Prepare the patient mentally so he or she sees soft toric lenses as one option of many, but the simplest and possibly the most comfortable. If the patient doesn’t find the vision adequate, the option of scleral or corneal GPs is available.
4. When the lenses arrive, put them on and have the patient sit for 10 to 15 minutes before checking vision.
5. Remind the patient that this is one option of many and may be useful for certain circumstances (e.g., traveling, swimming, etc.).
Anyone who fits lots of keratoconus patients tends to have favorite lenses. In the case of a commercial/generic soft toric lens, I find monthly lenses to be more durable and stable. In my practice, monthly toric extended range lenses are the go-to first lens. Patients are often told that if “good” functional vision is achieved with these, we can always attempt to move to a two-week or daily soft toric lens in the future.
The 36-year-old patient landed on a monthly toric extended range lens OD with 20/25- vision and a soft spherical lens with 20/20 vision after years of being told he “had to wear hard lenses.”
