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KERATOCONUS

Keratoconus Patient Wore Gas Permeable Contacts For Many Years

Thank you Dr. Ochiltree for this kind referral!

73 yo female has worn gas permeable lenses for many years due to keratoconus.

Keratoconus patients are not able to wear traditional contact lenses or glasses due to the irregular shape of their eye. Many times, corneal gas permeable lenses, hybrid lenses, custom soft lenses or scleral lenses are needed to improve their vision.

Over the past 8 years, we have successfully managed her with corneal gas permeable lenses.

In the last few months, she reported that the lenses were starting to slip and move around with increase in discomfort. She reported a long history of dry eyes with excessive mucous strands and her primary care optometrist (Dr. Ochiltree) told her that her gas permeable lenses had protein and deposits building up on the lens surface.

Upon our examination, she had several areas of dellen, SPK with staining, corneal neovascularization and pannus. We also found that her gas permeable lenses had heavy protein and lipid deposits and scratches.

At this point, we reviewed some of the options. The first option is we could keep her into the same corneal gas permeable lens type of lens. We also discussed some of the pros and cons of other lens designs such as hybrid lenses and scleral lenses. After discussing all designs, she chose the custom scleral lens.

Due her dry eye syndrome, corneal neovascularization and high scleral toricity, we felt that she would be most successful in a custom scleral lens.

Patients with dry eye may benefit from scleral lenses. This is due to the fact that there is a layer of liquid that bathes the eye all day. Gas permeable lenses rest directly on the cornea, so they can rub and irritate the eye surface. Scleral lenses do not touch the cornea at all, and rest on the white part of the eye, which has significantly less nerve endings. This results in a very comfortable lens for many dry eye patients.

With the help of Visionary Optics, we were able to design custom scleral lenses using 3D technology.

Switching between GP lens wear and scleral lenses can take some time to get used to. The patient was surprised at the stability of her vision when she looked toward her right and left. She could see 20/20 at distance out of each eye and she was happy with the comfort! Overall, she has been very happy with the change! We are excited to see how she progresses over the next few weeks.

OD corneaOS cornea

OD pannus at 800OS cornea and temporal conj irregularity

cornea OD

cornea OS

Latitude® Custom Scleral Lenses

OD OCT central clearance 152

OD OCT nasal edge

OD OCT temp edge

OS OCT central clearance 165

OS OCT nasal edge

OS OCT temp edge

The Use of Scleral Rigid Gas Permeable Contact Lenses in Keratoconus – A Case Report

A special thank you to Judy Tran for developing this amazing case report.

Introduction:

The prevalence of keratoconus (KCN) in the United States is approximately 8.8-229 per 100,000 affecting both men and women equally.1 KCN is a progressive disease resulting in ectasia of the corneal stroma. It is a noninflammatory process that causes a decrease in patient visual acuity (VA) from the changes in corneal shape that leads to an increase in myopia and irregular astigmatism. What causes KCN is still not completely understood but there are studies that show a correlation between the disease and environmental factors such as eye rubbing, a family history of the disease, and atopy. Age, ethnicity, contact lens use, as well as exposure to sunlight are also observed environmental risk factors for KCN. Genetically, there has been some evidence of genes VXX1 and SOD1 being highly associated with the pathogenesis of the condition which is autosomal dominant but can occur in a sporadic pattern.2

There is currently no cure for KCN, however corneal collagen cross-linking (CXL) has been shown to have promising results in slowing the progression of the disease especially in cases involving severe progressive KCN. CXL utilizes riboflavin and a photo-oxidative reaction to increase corneal stiffness by altering the collagen within the corneal tissue. The changes to the collagen consist of increasing the number of covalent bonds and increasing the resistance to enzymatic degradation.3 CXL has been widely used in many countries for managing KCN, but it was only just recently FDA approved in the United States April 2016 and this method of treatment is becoming increasingly popular since its approval. Before the development of CXL, a corneal transplant was the only treatment for KCN but is indicated only when the disease had progressed into more advanced stages. Even after a corneal transplant, patients are still at risk for developing KCN again in the transplanted cornea. Another major complication post corneal transplant is glaucoma. There is a significant risk for the development of glaucoma after a corneal transplant as seen in a study conducted by Zheng et al.4 Depending on the severity of glaucoma, treatment could be lifetime eye drops or even requiring another ocular surgery. Just like KCN, glaucoma is an uncurable condition that can lead to blindness. Even though CXL and corneal transplant are both FDA approved methods for treating KCN, they do not always help with the major side effect of the disease which is reduced vision.

Due to the optics of an irregular cornea often seen in KCN, spectacles often cannot correct the vision. Specialty contact lenses are typically used to help maximize vision. Usually, a corneal rigid gas permeable contact lenses (RGPCL) are often indicated initially but with recent advancements, scleral rigid gas permeable contact lenses (ScCL) have shown to be an excellent, safe, and effective alternative.5 Since the scleral contact lenses do not interact with the cornea, there is a therapeutic benefit to using the larger lens especially in patients with severe dry eye. There is a liquid layer between the ScCL and the cornea which can provide constant hydration to the corneal cells. ScCL are often reserved for more severe KCN but with their material and fitting advancements, it should be an option at any stage of the condition to help patients achieve their best potential VA as well as to delay the possible need for a corneal transplant.6 This case report supports the benefits of using a ScCL for a patient with a moderate and severe KCN. By using a more custom fitted ScCL, the patient was able to reach a VA of 20/20 with optimal comfort and the ScCL could potentially reduce their need for a corneal transplant later in life.

Case description:

Visit 1: The consultation. Patient DB, a 51-year-old Hispanic male, was referred to the Contact Lens Institute of Nevada after completing a comprehensive eye exam at a Sam’s Club Optical in May 2021. The referring optometrist diagnosed the patient with myopia, astigmatism, and bilateral keratoconus with the right eye being more severe than the left. There was no spectacle prescription recommended at this time due to the severity of the KCN. The patient was advised that a specialty contact lens would provide better vision than glasses.

DB’s medical history was unremarkable, the patient had denied any medical diagnosis, medications, and allergies. The patient was unaware of any KCN prior to the eye examination in May 2021. The patient had also denied any other ocular conditions and surgeries.
Entering unaided VA were OD 20/200 and OS 20/25. Anterior segment evaluation revealed corneal central inferior thinning with striae OU. Corneal thinning and striae were mild in OS and significantly worse in OD. Fluorescein dye evaluation revealed mild SPK staining over the cone apex of OD. There were nasal and temporal pingueculas noted OU. The rest of the anterior segment was unremarkable. Posterior health was evaluated via retinal imaging which was unremarkable. There were no signs of glaucoma, macular degeneration, or any retinal disease that could possibly contribute to the patient’s reduced vision.

A KCN pattern was observed in the topometric exam (Figure 1). An OCT and a scleral mapping (sMAP) were performed over DB’s naked eye (Figure 2). The results of the exam are listed in Table 1. Based on the topography and scleral elevation (Figure 3), a Europa diagnostic lens was selected for both eyes and the parameters of the diagnostic lenses are seen in Table 2. The suggested lenses are based on a sagittal depth (Table 1), the sMAP software determines the sagittal depth assuming a chord length of 16mm and incorporating a 300um buffer. The lenses were allowed to settle for approximately 5 minutes before assessing the vision and fit, as well as an auto-refraction/keratometry over the diagnostic lens (Table 3). The over-refraction (Table 3) was determined with the starting point measured with the auto-refractor.

Figure 1: Using the Medmont, corneal topography reveals a KCN pattern in both OD and OS.

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Figure 2: Images of DB’s naked eye with trace sodium fluorescence that was instilled prior. Photos were taken during the slit-lamp examination with the ION Imaging system.

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Figure 3: sMAP scleral elevation of DB’s OD and OS.

Measurements over naked eye OD OS
Pachymetry (OCT) 405um 491um
Keratometry (Topo) 56.43D @ 160°/ 71.61D 43.21D @ 2°/ 46.38D
Corneal Cylinder (Topo) 15.18D 3.17D
Scleral Toricity (sMAP) 214um 270um
Sagittal Depth 4479um 4456um

Table 1: Measurements taken over DB’s naked eyes.

Diagnostic Lens Parameters OD OS
Base Curve 45.00D 46.00D
Sagittal Depth 4560um 4660um
Power -1.50D -2.00D
Overall Diameter 16.0mm 16.0mm
Optic Zone Diameter 0.2mm 0.2mm
Center Thickness 0.4mm 0.4mm
Material HEXA100 HEXA100

Table 2: The Europa Lens made by Visionary Optics were the diagnostic lenses used.

Lens Assessment OD OS
Central Clearance 58um – over apex 388um
Limbal Clearance Present 360° Present 360°
Lens edges Flat 360° Flat 360°
Impingement or Blanching Negative 360° Negative 360°
Auto-refraction +0.25 -2.50×067 -1.50 -1.50×095
Auto-keratometry 43.50D @ 162°/ 43.75D 43.75D @ 161°/ 44.00D
Over-refraction in Phoropter -0.25 -2.50×080 -1.00 -1.75×095
VA with Over-refraction 20/20-2 20/20

Table 3: Fit and vision assessment of the diagnostic Europa Lens on the patient’s eyes.

Due to the DB’s high scleral toricity and high internal cylinder, a custom impression ScCL was recommended for both eyes to maximally optimize visual acuity and fit but other fitting modalities were also discussed to the patient. The patient had opted for the premium custom fit for their right eye, the eye with more severe KCN and the advanced custom fit for their left eye. The premium custom fit uses an impression of the eye, similar to a dental mold, to design a lens with a 3D scanner and utilizes three million data points from the mold (Figure 4). The advanced custom fit uses the scleral mapping scan of the eye, and that special software is able to design a lens from a million data points. Two impressions of the right eye for the custom EyePrint Prosthetic were completed in-office (Figure 5) and the sMAP images that were taken were sent to the Visionary Optics Lab for the advanced custom ScCL fit for the left eye. All images and the over-refraction were sent to both labs for the lens design.

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Figure 4: Front surface and back surface design of the custom EyePrint Prosthetic ScCL for DB’s right eye.

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Figure 5: A visual of how the eye impression is completed for the EyePrint Prosthetic. Note: the patient in the image is not the patient in the case report.

The patient was expected to return to clinic once the ScCL arrive for a training session before being dispensed.

Visit 2: Training and dispense. An EyePrint Prosthetic ScCL was ordered for the right eye and a Latitude ScCL was ordered for the left; lens design parameters are listed in Table 4. The ScCLs were inserted for DB shortly after their arrival (Figure 6). The lens was allowed to settle for approximately 10 minutes before checking VA (Table 5) and assessing the lenses (Table 6). The clearance was determined with an anterior segment OCT (Figure 7), which was checked at the center and limbus of the cornea. Before the training session, an over-refraction was completed with the auto-refraction as the starting point and VA was measured (Table 5). Throughout the over-refraction, the patient reported fluctuating vision with may have been due to the lens settling which affected the reliability of the over-refraction.

Lens Parameters OD (EyePrint Prosthetic) OS (Latitude Scleral Lens)
Base Curve 8.336mm (40.49D) 7.55mm (44.70D)
Sagittal Depth 5788um 5134um
Power +2.75 – 2.38×080 -1.67 -1.75×095
Overall Diameter 18.0mm 16.5mm
Center Thickness 0.527mm 0.30mm
Material Optimum Extra Optimum Extra

Table 4: Custom ScCLs parameters received by the manufactures.

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Figure 6: DB with custom EyePrint Prosthetic on OD and custom Latitude lens on OS.

Vision Assessment OD OS
Entering VA 20-20 20/50
Auto-refraction +1.50 -1.25×022 +0.25 -1.00×136
Auto-keratometry 40.25 @ 078/ 42.00 41.75 @ 069/ 42.50
Over-refraction in Phoropter +0.50 -1.50×120 +1.25 -1.50×126
VA with Over-refraction 20/25+2 20/20-1

Table 5: Vision assessment through custom ScCL.

Lens Assessment OD OS
Centration Centered Centered
Central Clearance 252um – over apex 396um
Limbal Clearance Acceptable 360° Acceptable 360°
Lens edges Flat 360° Mild nasal edge lift
Movement 0.25mm 0.25mm
Lens Marker Location 6:00 7:00
Impingement or Blanching Negative 360° Negative 360°
Conjunctival Prolapse None 11:00 to 1:00

Table 6: Lens assessment of the custom ScCL on DB’s eyes after 10 minutes of settling.

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Figure 7: Anterior segment OCT reveals central clearance of the ScCL on the eyes. Top photo: OD, bottom photo: OS.

After lens evaluation, DB was educated on how to properly insert and remove the scleral lenses by using a DMV to insert and a small plunger to remove. The patient was taught how to clean and store the ScCLs using Tangible Clean Multipurpose Solution and to use sodium chloride preservative-free saline to fill the lens bowl prior to insertion. DB had no difficulties with removing the lenses with the use of the small plunger. They were advised to stick the plunger inferiorly of the lens rather than directly center, this creates an uneven pressure of release for the lens to come off the scleral resting points. There were some difficulties with insertion, DB has deeper set eyes and larger hands, so they found it difficult to maneuver the lens into the eye when they used one hand to open the upper lid and the other hand to hold the lower lid and DMV plunger with the ScCL. The technique that was most comfortable for DB was using one hand to hold the upper and lower lid while the other hand solely guided the DMV and ScCL. A scleral stand was suggested to patient which would essentially act as a third arm allowing the patient to comfortably hold open the eyelids with both hands as the move towards the scleral stand that props up the DMV and ScCL. DB expressed feeling comfortable with insertion without the need of the scleral stand. DB successfully completed training by removing and inserting the ScCL once leaving the clinic with them on, and DB was scheduled to return to the clinic in a week for a follow-up to recheck their visual acuity and the fit. The patient was advised to wear the lenses as much as possible to allow for adaptation.

Visit 3: 1 week follow-up. Case History: DB had worn the ScCL OU for 4 hours prior to the appointment. Average wear time was about 1 to 2 hours, and this was due to their eyes feeling fatigued during wear. There were difficulties with reading and intermediate distance because their eyes felt like the vision was too overwhelming which caused the eyes to feel tired. DB reports seeing better at intermediate distances without ScCL. With lenses, OD vision is much clearer than OS vision. There was mild discomfort with the OS at the appointment but denies and redness from the ScCL. The patient also noted that there were some difficulties with insertion because they could not get their eyes wide enough, but ScCL removal was easy with the use of the small plunger. The fit of the ScCL was reassessed (Figure 8), clearance was determined with the anterior segment OCT (Table 7 and Figure 9), auto-refraction/keratometry was completed, and an over-refraction was measured with the auto-refraction as a starting point (Table 8).

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Figure 8: 1-week follow-up with custom ScCL with Eyeprint Prosthetic for OD and Latitude Lens for OS.

Vision Assessment OD OS
Entering VA 20/20-1 20/50
Auto-refraction +1.25 -1.00×012 +1.25 -2.75×109
Auto-keratometry 40.25 @ 078/ 41.75 41.50 @ 025/115
Over-refraction in Phoropter +0.25DS +0.75 -1.75×135
VA with Over-refraction 20/20-2 20/20-1

Table 7: Vision assessment through custom ScCL at 1 week follow-up.

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Figure 9: Anterior segment OCT after 4 hours of ScCL wear on the eyes at 1-week follow-up. Top photo: OD, bottom photo: OS.

Lens Assessment OD OS
Centration Centered Centered
Central Clearance 222um 340um
Limbal Clearance Acceptable 360° Acceptable 360°
Lens edges Flat 360° Flat 360°
Movement Minimal Minimal
Lens Marker location 6:00 8:00
Impingement or Blanching Negative 360° Negative 360°

Table 8: Lens assessment of custom ScCL after 4 hours of wear.

Since the patient had difficulties with near and intermediate vision, a monovision fit was discussed to maximize acuity at all distances and to improve patient visual comfort. However, with the monovision fit, it was discussed that distance vision may be reduced to compensate for near vision. It was also educated to the patient that with a monovision fit, depth perception will be reduced. A monovision fit was trial framed and DB could not adapt to the vision. The patient opted to best correct distance vision in the ScCL for part-time wear and was educated that an over-the-counter reading spectacle prescription will be necessary to optimize near vision.

The overall fit of the lenses was acceptable, the only modification needed was to change the prescription of the left eye since the patient entering visual acuity was 20/50. A new lens was ordered to adjust the lens prescription incorporating the over-refraction that was determined (Table 7). The patient will continue with the right lens to allow more time to adapt. Another modification that will be considered at the next dispense appointment is possibly making the OD ScCL a smaller diameter for easier insertion. The patient is to return to the clinic for a new OS latitude ScCL dispense when it arrives.

Discussion:

Before the development of the corneal topographer, the only way to diagnose KCN was through slit lamp observed clinical signs, therefore it was often not diagnosed until later stages. Corneal signs such as corneal protrusion, corneal apex thinning, Vogt’s striae, Fleisher’s ring, and possibly corneal scarring typically represent more advanced stages of the condition. In earlier stages of KCN, patient symptoms can include reduced vision due to an increase in myopia and irregular astigmatism, visual distortions, and light sensitivity. Because of the constant changes in vision, patients with KCN may need to frequently change their spectacle correction. Now that the corneal topographer is becoming increasing popular and more readily available, early stages of KCN can be more easily diagnosed with the technology and treatment such as CXL can be implemented sooner to slow down the disease progression, ultimately preserving the patients’ vision.1 A 10-year study conducted by Raiskup et al. showed that CXL treatment was effective in decreasing the progression of the disease as well as stabilizing the cornea long-term ultimately reducing the need for a corneal transplant. By decreasing the progression of the disease by stabilizing the cornea, vision is preserved. CXL provides treatment in early diagnoses especially in adolescents with less complications compared to a corneal transplant.7 The Nordstorm et al. study demonstrated that after a year post CXL treatment in KCN subjects had decreased corneal irregularities and improved vision. There was also no damage or any cell loss to the corneal endothelium. The study demonstrated that CXL treatment for KCN is not only effective in slowing the progression of the disease, that the procedure is also safe.8

In early stages of the disease, a spectacle correction can provide adequate vision, however as the disease progresses, glasses are unable to mask the irregular astigmatism that typically occurs. Corneal RGPCL are common for correcting keratoconus. However, ScCL are becoming increasing popular because of they provide better patient comfort compared to corneal RGPCL. In a study conducted by Levit, Benwell, and Evans, they found that although there was no significant difference in vision or vision quality of life, KCN patients preferred ScCL over corneal RGPCL because of the significant difference in comfort.9 ScCL are typically preferred over corneal RGP because of their design, they rest only on the sclera which allows the lens to vault over the cornea entirely. This minimizes any interaction between the cornea and the contact lenses. ScCL can also help reduced the need of a corneal transplant in patients with severe keratoconus, which was observed in a study by Koppen et al. A majority of subjects with severe KCN had a decreased need for a corneal transplant when they were successfully fitted with a ScCL. Subjects that underwent a corneal transplant even after a ScCL fit was due to their inability to tolerate the lens.6 By fitting KCN patients with ScCL rather than treating with a corneal transplant, this is reduced the complications associated with the surgical procedure such as glaucoma.

A retrospective study by Fuller and Wang assessed the prevalence of ScCL complications such as microbial keratitis, phlyctenulosis, cornea abrasion, contact lens-induced acute red eye, corneal infiltrates, pingueculitis, and hydrops. The complications were observed to be related to poor wetting, poor handling, reservoir fogging, lens intolerance, deposits in the eye, and broken lenses in the eye. Although the adverse effects occurred in a small percentage of subjects in the study, they can still occur with any ScCL, therefore proper ScCL fitting, and patient education is important to reduce the risk of any complications. Other management options for complications were adding a surface treatment to the lens, replacing the lens, and adjusting the wear time. Overall, the study concluded that ScCL for KCN patients are safe and effective.5

Most traditional ScCLs design assume that the sclera is a uniform, spherical shape, however, this is not the case for many individuals. With the use of a sMap3D corneo-scleral topographer, DeNaeyer et al. measured not only the elevation of the cornea, but the elevation of the sclera as well on 140 eyes. They determined that approximately only 5.7% of the eyes had a spherical scleral shape, 28.6% had a regular toricity, and actually 40.7% had asymmetric elevations and depressions. This means that a majority of the population have a non-spherical scleral yet, most practitioners continue to fit scleral lenses empirically with a traditional lens design. Common complications often seen with ScCLs that have a poor landing on the sclera is conjunctival blanching, conjunctival prolapse and can even potentially result in staining of the surface tissues.10 By determining the patient’s scleral shape at the initial visit, it can help potentially decrease fitting chair time and improve patient comfort with the ScCL.

In the case of DB, their stage of KCN was well advanced, especially in their right eye, therefore their reduced vision of 20/200 could not be corrected with glasses. Scleral lenses were selected over a corneal RGP lens for maximum comfort and optimal visual acuity. A more custom fit ScCL was chosen over a traditional fit because of the patients high scleral toricity that was determined initially at the consultation appointment. A well-fitted ScCL was achieved just after one visit and by using a more custom ScCL design, such as the Latitude and EyePrint Prosthetic ScCL, the patient was able to achieve 20/20 vision in the poorer 20/200 seeing eye while maximizing the lens comfort reducing any risk of ScCL complications. Hopefully, by fitting DB in a ScCL it reduces their need for a corneal transplant later.

Conclusion:

Fitting a ScCL can be intimating and has a poor stigma of being difficult and time consuming, requiring a lot of follow-ups and lens adjustments. However, with advancements in corneal imaging and mapping, diagnosing KCN and fitting ScCL is much simpler with less chair time. By gaining the confidence to fit ScCL, the care and services can be provided to KCN patients without the need for an additional referral. ScCL have been shown to be safe and effective for achieving optimal vision for KCN patients even after a couple of months post CXL treatment. By diagnosing KCN in earlier stages, CXL can be implemented to immediately stabilize the cornea before the disease progresses, then with the added ScCL fit, the potential need for a corneal transplant is significantly reduced along with the associated complications with the surgical procedure.

References:

  1. Leucci, M., & Carter, M. (2018). Clinical signs in keratoconus. Optometry Today (London), 58(11), 86.
  2. Hashemi, H., Heydarian, S., Hooshmand, E., Saatchi, M., Yekta, A., Aghamirsalim, M., Valadkhan, M., Mortazavi, M., Hashemi, A. & Khabazkhoob, M. (2020). The Prevalence and Risk Factors for Keratoconus: A Systematic Review and Meta-Analysis. Cornea, 39 (2), 263-270. doi: 10.1097/ICO.0000000000002150.
  3. Vinciguerra, R., Romano, M. R., Camesasca, F. I., Azzolini, C., Trazza, S., Morenghi, E., & Vinciguerra, P. (2013). Corneal cross-linking as a treatment for keratoconus: Four-year morphologic and clinical outcomes with respect to patient age. Ophthalmology (Rochester, Minn.), 120(5), 908-916. https://doi.org/10.1016/j.ophtha.2012.10.023
  4. Zheng, C., Yu, F., Tseng, V. L., Lum, F., & Coleman, A. L. (2018). Risk of glaucoma surgery after corneal transplant surgery in medicare patients.American Journal of Ophthalmology, 192, 104-112. https://doi.org/10.1016/j.ajo.2018.05.004
  5. Fuller, D. G. & Wang, Y. (2020). Safety and Efficacy of Scleral Lenses for Keratoconus. Optometry and Vision Science, 97 (9), 741-748. doi: 10.1097/OPX.0000000000001578.
  6. Koppen, C., Kreps, E. O., Anthonissen, L., Van Hoey, M., Dhubhghaill, S. N., & Vermeulen, L. (2018). Scleral lenses reduce the need for corneal transplants in severe keratoconus.American Journal of Ophthalmology, 185, 43-47. https://doi.org/10.1016/j.ajo.2017.10.022
  7. Raiskup, Frederik, MD, PhD, FEBO, Theuring, A., MD, Pillunat, L. E., MD, & Spoerl, E., PhD. (2015). Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: Ten-year results.Journal of Cataract and Refractive Surgery, 41(1), 41-46. https://doi.org/10.1016/j.jcrs.2014.09.033
  8. Nordström, M., Schiller, M., Fredriksson, A., & Behndig, A. (2017). Refractive improvements and safety with topography-guided corneal crosslinking for keratoconus: 1-year results.British Journal of Ophthalmology, 101(7), 920-925. https://doi.org/10.1136/bjophthalmol-2016-309210
  9. Levit, A., Benwell, M., & Evans, B. J. W. (2020). Randomised controlled trial of corneal vs. scleral rigid gas permeable contact lenses for keratoconus and other ectatic corneal disorders.Contact Lens & Anterior Eye, 43(6), 543-552. https://doi.org/10.1016/j.clae.2019.12.007
  10. DeNaeyer, G., Sanders, D., van der Worp, E., Jedlicka, J., Michaud, L., & Morrison, S. (2017). Qualitative Assessment of Scleral Shape Patterns Using a New Wide Field Ocular Surface Elevation Topographer: The SSSG Study. Journal of Contact Lens Research and Science, 1(1), 12-22. https://doi.org/10.22374/jclrs.v1i1.11

How to Deal with Contact Lens Discomfort

Do your eyes itch or burn when wearing contact lenses? There are several reasons why you may be experiencing contact lens discomfort. Discover the possible causes behind the problem and see what you can do to relieve your discomfort.

What Causes Contact Lens Discomfort?

Some of the top causes of uncomfortable contacts are:

Dry eyes

Dry eye syndrome is a common condition that arises when your tears can’t keep your eyes sufficiently lubricated due to an imbalance in the tear film. Certain diseases, medications and environmental factors, like high levels of dryness and wind, can cause or contribute to red, itchy or irritated eyes, especially when wearing contacts.

Allergies

Allergens are typically harmless substances that induce an allergic response in certain people. Pollen, mold, dust and pet dander are some of the most common airborne allergens that trigger eye allergies. Cosmetics and certain eye drops, such as artificial tears with preservatives, can also induce eye allergies, which can make contact lens wear uncomfortable.

Corneal irregularities

The cornea at the front of the eye may be irregularly shaped due to astigmatism, keratoconus, eye surgeries (i.e. LASIK or cataract surgery), eye injuries or burns, scarring, corneal ulcers and/or severe dry eye. Irregular corneas often prevent traditional contact lenses from fitting correctly and comfortably.

Symptoms of Contact Lens Discomfort 

  • Burning, itchy, stinging eyes
  • Sensation of something being stuck is in the eye
  • Excessive watering or tearing of the eyes
  • Unusual eye secretions
  • Redness of the eyes
  • Reduced sharpness of vision
  • Blurred vision, rainbows, or halos around objects
  • Sensitivity to light

How to Relieve Contact Lens Discomfort

Try Different Contact Lenses

Nowadays, there are many types of contact lenses on the market, including specialty contacts for dry eyes and astigmatism. Meet with our optometrist for a personalized eye exam for contacts.

With the variety of contact lens brands available, switching to a different contact lens may be the simplest answer if you’re experiencing discomfort that isn’t connected to improper fitting or issues with tear production. If your existing lenses fit well but still irritate and dry out your eyes, speak to us about trying a different design or brand of contact lenses, or changing your lens-wearing schedule. 

Artificial Tears or Eye Drops

Over-the-counter artificial tears or eye drops are a common way to temporarily relieve contact lens discomfort. However, it’s important to keep in mind that unless prescribed by an eye doctor, they may not be treating the root of the problem. 

Moreover, certain eye drops are incompatible with contact lenses, and may damage your contacts or harm your eyes. We also recommend staying away from products that claim to remove redness from your eyes, which temporarily reduce the size of blood vessels to lessen redness, but do not address the underlying cause of the condition, and can actually worsen it over time.  

Take Good Care of Your Lenses

Inadequate contact lens care leaves residue on your lenses, which can discomfort, harmful eye infections and inflammation. Below are a few important contact lens hygiene guidelines to follow:

  • Before handling your contact lenses, thoroughly wash and dry your hands.
  • Remove your lenses before showering, bathing or swimming to prevent infection. 
  • Do not sleep in your contact lenses (unless they are approved for sleeping). 
  • Replace your contact lenses according to the manufacturer’s instructions (e.g., don’t reuse daily wear lenses).
  • Regularly clean your contact lens case and ask your eye doctor when to replace it.
  • Only use a contact lens solution that is appropriate for your lenses. 
  • Never reuse or mix contact lens solutions.
  • Schedule regular appointments with your eye doctor.

If you are experiencing discomfort with your contact lenses, get in touch with The Contact Lens Institute of Nevada in Las Vegas today. We’ll get to the bottom of the problem and provide effective solutions for all-day comfort.

Q&A

What kinds of contacts are available?

Contact lenses are available in a wide range of materials and replacement schedules. Disposable contact lenses and extended wear contacts are the most convenient for many users.

I’ve already been fitted for contact lenses, so why did my optometrist ask me to come back?

If you’re asked to return a week later, it’s because your optometrist wants to rule out any issues, such as contact lens-related dry eye or irritation.

If it’s been around a year since your last eye checkup, you’ve likely been contacted to check whether your prescription has changed and to evaluate your eye health. The sooner problems are detected and treated, the better the outcome. 

Are Hard Contact Lenses Still Useful?

Are hard contact lenses still useful?

With the invention of scleral lenses, corneal gas permeable lenses may seem like a thing of the past. However, corneal gas permeable lenses still remain a very effective option for many patients.

We have the pleasure of seeing a patient with keratoconus. He was used to wearing a corneal GP lens for keratoconus, and wanted to remain in the same lens modality. His lens was 5 years old, however the fit still looked ok. There were some scratches and deposits on the lens surface, and there was some excessive touch on the apex of the cone.


Patient’s habitual contact lens (unknown parameters)

Based on the topography, we decided to try the Rose K 2 lens. This corneal gas permeable lens is great for patients with nipple cones and oval cones. He falls into the mild/moderate category of keratoconus, so we thought this was a good lens to try first.

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The topography shows a mild/moderate keratoconus with a nipple/central cone

Based on the fitting guide, we chose the base curve that we equal to his average K. The average K was 6.96mm so we selected the 6.9mm lens in the Rose K 2 fitting set.

When we placed the lens on the eye, it looked great! We were super happy with the fit and he was able to see 20/20 in this lens. Usually, we need to try several lenses on to get the perfect fit, but we really lucked out today! The lens was very well centered with good edge alignment. There is a very light feather touch on the apex of the cone, which is visible with the wratten filter.


The Rose K 2 lens was very well centered.

Stay tuned for his dispense!

NEXT: WHAT IS KERATOCONUS?

Can you use scleral lenses for sports vision?

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Topography of keratoconus patient’s right eye

Thank you Dr. Jen Burke for your kind referral!

Dr. Burke sent a 17 year old patient to use for a corneal consultation. Even though the patient can see 20/20 with glasses, he reports seeing “lines” in his vision when he looks at a light source, especially at night.

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Topography of keratoconus patient’s left eye

A topography was taken of each eye, and you can see that both eyes exhibit irregular astigmatism. The left eye has more irregularity than the right eye. The steeper area on the left eye is also displaced nasally, so as the pupil gets bigger at night, it gets into the steeper shape, which can cause even more distortion.

As a hobby, he races formula drift, so his visual quality is very important.

With glasses, he can achieve 20/20 in the right eye and 20/30+2 in the left eye. He reports that the letters on the left eye appear more blurry and distorted.

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Photo of patient’s right eye

His pachymetry readings do not show a super thin cornea, which is great news.

We trialed the Europa scleral lens today, to see if it improved his visual quality. With an over-refraction, he could see 20/15 in the right eye and 20/15 in the left eye. He noticed the distortion was gone in the left eye, too.

We decided that the Latitude custom scleral lens would offer him the best vision and comfort, so we took 3D images of both eyes today. That information was sent to the lab and will be used to design custom fit lenses for each eye.

We are hoping that scleral lenses will help him see better and help with some of the visual disturbances. Looking forward to seeing him at his dispense appointment next week!

Thanks again Dr. Burke for thinking of us!

Is there a genetic test for keratoconus?

Many patients ask us about some of the risk factors for keratoconus.

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Recently, a new genetic test for keratoconus launched, and we are incredibly excited to offer this service to patients! AvaGen is available to patients wanting to understand their genetic risk factor for keratoconus and other corneal dystrophies.

The process is very simple, easy, and pain free.

First, you will arrive to the office and answer a few questions about your medical history and family history. Then, you will rinse your mouth with warm water. This will remove any food or other particles from your mouth that may contaminate the test.

Next, the doctor or technician will gently swab the inside of your cheek with a cotton swab. Then this sample is sent to the laboratory for testing.

The laboratory will analyze your genetic sample and generate a report that allows us to view your genetic risk for keratoconus. This information can be very helpful to your doctor so they can manage your specific care at a customized level.

For instance, you maybe have been flagged as a keratoconus suspect in the past, but want to find out what your genetic risk for keratoconus is. If your results come back as “very high genetic risk,” your eye doctor may want to see you more frequently or perform additional tests during your visits.

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Think of it like this: If you have a family history of breast cancer, and your genetic risk factor is also deemed very high, your doctor may want to see you more often to ensure that you do not develop breast cancer. Or if you do develop breast cancer, you can be treated quickly, which is usually the key in stopping or slowing the disease in an early state.

Another example would be if you have keratoconus and you want to find out if your child is at risk. If your child ends up with a very low genetic risk for keratoconus, your eye doctor may feel comfortable seeing them on a less frequent schedule.

This information is incredibly helpful and useful for your eye doctor! If you have keratoconus and want to find out if your family members are at risk, please contact us today to find out more about this test!

Heartwarming story about a keratoconus patient

Touching stories like these will NEVER get old!

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We saw a 21 year old boy with keratoconus yesterday for a contact lens fitting. I had originally seen him at my office in Arizona a few months back for an initial consultation, and his father has worked very hard the past few months to save up money for the contact lens fitting.

He had corneal crosslinking in both eyes, and he also has intacs (plastic rings placed into the cornea) in the left eye. His best corrected visual acuity was 20/200 in the right eye and 20/400+2 in the left eye. He complained of very blurry and distorted vision, along with ghosting and issues with glare.

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We decided to fit him into the Ampleye scleral lens. With the 4200 sag on the right eye and 4400 sag on the left eye, we were able to achieve central clearance. Both lenses had excessive clearance, but instead of swapping out the lenses, I just consulted with the experts at Art Optical to adjust the vault.

With an over-refraction, he was able to achieve 20/20 vision in the right eye and 20/25 vision in the left eye! He was so amazed at how well he could see! His father was so happy that he started crying in the office. He told us “I just want my son to be able to see the stars.” What an amazing Dad!

Such an incredible and heartwarming case. We are so grateful and honored to help these patients achieve their best vision through specialty contact lenses.

Thanks again to the Art Optical team with your help designing the lenses.

We also recommended that his family members get screened for keratoconus by using a simple in-office test to find out genetic risk for keratoconus. If we discover a sibling’s genetic risk factor is very low, we might only need to see them for an eye exam yearly. If we discover a sibling’s genetic risk factor is very high, we may consider seeing them more than once a year. This is a great test to help doctors manage keratoconus risk at a very high level.

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Keratoconus patient sees clearly for the first time in years!

Keratoconus patients are so rewarding!

A 22 year old female was referred to us from Dr. Wellish. She has keratoconus in both eyes. She had corneal crosslinking in the left eye 3 months ago. She will be getting corneal crosslinking in the right eye next month.

She complains of blurry vision, distorted vision, and fluctuating vision. She states her left eye has been a lazy eye for quite some time and she remembers that her vision in that eye was able to achieve 20/40 at one point.

With glasses, she could achieve 20/80 vision in the right eye and 20/200 in the left eye.

After reviewing all of the options, she decided to proceed with the Latitude custom scleral lens. We took 3D images of the left eye and used a diagnostic scleral lens to determine her vision. To our surprise, she was able to achieve 20/20 vision!

We built a trial frame for her and let her roam around the office so she could get a sense of what her new vision would be! She was thrilled and her mom was thrilled too!

Such a fun case, we can’t wait to see her back for her dispense.

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Keratoconus Patient fit into custom scleral lens

Thank you Dr. Dadej for your kind referral of your keratoconus patient to our office!

This young man was diagnosed with keratoconus about 5 years ago and was fit into hybrid lenses. The hybrid lenses were not comfortable, so he was switched into scleral lenses a few years ago. Hybrid contact lenses are a lens type that combines a gas permeable contact lens with a soft contact lens. The middle of a hybrid lens is made with a gas permeable lens which is then surrounded by a soft contact lens skirt. Hybrid lenses are used for a lot of different patients. The Ultrahealth hybrid lens is intended for Keratoconus patients. Many patients do well with hybrid lenses.

This patient wore scleral lenses successfully for years.

Dr. Dadej did a great job fitting him into new scleral lenses this year, but because of the severity of his keratoconus, the lenses were still not fitting just right. He developed a corneal scar on the right eye and the left eye, and Dr. Dadej referred him to me right away to help prevent a central cornea scar. Central corneal scars can cause significant vision impairment, and may require a corneal transplant if severe enough.

After discussing the different contact lens options, we decided on the Latitude custom scleral lens. We took 3 D images of both eyes and sent the images to Visionary Optics to help design and fabricate Latitude custom scleral lenses for him. With a diagnostic Europa lens and over-refraction, he achieved 20/20 vision in each eye and he was very happy. I am excited for his dispense!

Thank you again Dr. Dadej for thinking of us to help this special patient!

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Keratoconus patient fit into custom scleral lens

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A nice patient was seen today for a specialty contact lens consultation. He was diagnosed with keratoconus 2 years ago at the age of 34 years old. He wore focus daily soft lenses for years, but 2 years ago, he noticed some changes in his vision, which led his optometrist to perform a topography. The topography revealed keratoconus OD>OS.

He gets Pentacam images every 3 months, and his corneas are both very stable, which is why he has not had corneal cross linking.

He was then fit into different scleral lenses which didn’t feel right (comfort wise) and the most recent lenses made him feel “wonky.” His main complaint was that his eyes suffer from ghosting, especially at night. With the current scleral lens, the ghosting is still apparent sometimes when the lens decenters.

We decided to perform a few tests and see for ourselves.

His scleral topography is interesting because the more elevated areas are at more of an oblique axis, which might explain why the traditional scleral lenses did not fit perfectly. With a diagnostic Europa lens, he still noticed some ghosting and accepted cylinder in his over-refraction. I performed an over topography to check for flexure, and it appears that it is possible that the lens shape could be contributing to the residual cylinder.

After analyzing all of the image, Sabrina from Visionary Optics helped me design a new lens for him. We decided to keep any cylinder out of the first pair, because that will make things more challenging if we need to alter the fit or Rx later. We are going to increase the optic zone to 9.0 mm to help with the ghosting as well. I am hoping that by order the custom Latitude scleral lens, the lens will center much better and will help to decrease or eliminate the ghosting.

Looking forward to his dispense. Thanks to the sMap team for their help with this fun case!

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Topography right eye

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left eye