A 48-YEAR-OLD FEMALE reported to the office for a first-time comprehensive ocular examination. She was wearing biweekly replacement silicone hydrogel toric contact lenses. Her chief complaint was that she doesn’t really feel like her vision is as good as it could be for distance. She noted particular challenges with driving in the evening.
The patient’s entering visual acuity was 20/40 with the right eye and 20/40 with the left eye. There was no over-refraction that could improve her vision with the contact lenses. Patient’s manifest refraction without the contact lenses was OD –3.00 –2.25 x 110 20/30 and OS –3.00 –2.75 x 060 20/40.
Anterior-segment assessment was normal for the right eye, and there was questionable corneal thinning in the left eye, slightly inferior to the pupil. Posterior-segment assessment yielded healthy, normal findings in both eyes.
Topography and anterior-segment optical coherence tomography was ordered, providing corneal and epithelial thickness maps. Corneal irregularity was present, with thinning inferior temporally and inferior temporal steepening on the anterior surface of the cornea, demonstrating keratoconus.
The clinical findings were discussed with the patient, including options for vision correction. We discussed the advantages and disadvantages of the lens options, including the ones she was currently wearing, specialty soft lenses, corneal GP lenses, specialty GP lenses for keratoconus, hybrid lenses, and scleral lenses. After all the patient’s questions were answered, we proceeded with a scleral lens fitting.
Diagnostic fitting was performed that day. The best-corrected visual acuity with an over-refraction over the diagnostic lenses was 20/15 for both the right and left eyes at distance and OU 20/30 at 16 inches. The patient was fit with 16.5 mm diameter lenses with a 4,400 µm sagittal depth and a toric landing zone. Minor modifications were needed to optimize the landing zone and the central clearance of the lenses.
We prescribed scleral lenses with the appropriate fit characteristics and powers. The patient returned in 1 week for a scleral lens dispensing visit. Visual acuity was OD 20/15, OS 20/15 at distance and OU 20/30 at near. All fitting characteristics of the lenses were appropriate for lens dispensing. The patient was trained on how to apply and remove them. She returned 2 weeks later for a follow-up, and no alterations to the lenses were needed.
The Verdict
Practitioners are fortunate that large lens manufacturers provide correction options for most patients, but a significant number of individuals still require specialized lenses, whether they be customized soft, corneal GP, hybrid, or scleral lenses.
Appropriately identifying these individuals and providing them with specialty lens options, either through your office or by referring them to practitioners who are passionate about and equipped to provide specialty care, is essential. Specialty lens laboratories play a critical role for patients who have keratoconus and any other patients requiring specialty lenses.
Specialty lenses are very important to our practices because we embrace these individuals and offer them advanced solutions. If the end of specialty lens laboratories is the new normal, we don’t want to be normal.
