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Airline pilot with keratoconus

We had the pleasure of seeing a white female patient for a contact lens consultation. She has a history of hard contact lens and gas permeable lens wear for the past 35 years. She originally wore orthokeratology lenses, but once she was diagnosed with keratoconus, she was switched into a different lens modality. She was also diagnosed with keratoconus in the left eye a few years ago, and she does notice that the left eye has more vision problems than the right eye.

She is a commercial airline pilot, so she needs to achieve 20/20 vision in each eye to maintain her pilot license.

With her habitual gas permeable lenses, she was able to achieve 20/25- in the right eye and 20/40 vision in the left eye. The right lens was decentered nasally, but did exhibit good lens movement and peripheral clearance. The left lens was lid attached and well centered with some mid peripheral bearing and good peripheral clearance. I did an over-refraction on top of her existing gas permeable lenses to check her vision potential. With an over-refraction of +1.25 in the right eye, she could see 20/20-1 and +1.50-0.25x086 in the left eye, she could see 20/30.

She does have 2+ nuclear sclerotic and cortical cataracts in each eye. The topography does show mild keratoconus in each eye, with the left eye being worse than the right eye.

Her pachymetry does not show much thinning, and the retinas in each eye are unremarkable. The corneas do not have any scar tissue, but the left eye has a small amount of haze inferiorly.

If this patient did not have such demanding vision goals, I would have attempted a new contact lens fitting, using lenses specifically designed for keratoconus. However, due to her need to achieve 20/20 vision, I felt it was best to refer her for cataract surgery in order to achieve her best vision. After cataract surgery, I will re-fit her with some new contact lenses to help get her to her 20/20 vision goal.