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Can Corneal Transplant Patients Wear Scleral Lenses?

Can corneal transplant patients wear scleral lenses?

We had the pleasure of seeing a kindly referred patient for a specialty contact lens consultation yesterday.

This 78 year old white female has a positive ocular history of radial keratotomy (RK) surgery in both eyes in 1990, followed by a corneal transplant in the right eye in 1995, and then had LASIK on top of the right transplant in 1998. Radial keratotomy was a surgery performed in the late 1980’s and early 1990’s to help correct patient’s vision. It has now been replaced with safer options such as LASIK and permanent contact lenses.

Both eyes underwent cataract surgery in 2014.

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Right eye corneal transplant

She complains that her vision is blurry, distorted and double. This is very common for patients who’ve undergone RK surgery. Because of the scalpel cuts into the cornea, this creates an irregular shape, which distorts the image coming into your eye. This results in fuzzy, wavy, fluctuating, blurry vision. She was kindly referred by her corneal specialist, Dr. Casey at Nvision, to our clinic for an evaluation.

With glasses, she can see 20/200 “double” in the right eye and 20/50 “double” in the left eye. The corneal transplant looked clear centrally with minimal neovascularization inferiorly. RK scars were present on both eyes. When I assess a corneal transplant, I make sure that the center of the transplant is clear. If there is major scar tissue or haze within the transplant, there may not be an opportunity for vision improvement. Luckily, for this patient, her corneal transplant is very clear.

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Left eye showing radial keratotomy (RK) scarring

When I am not sure if a patient will see better with a specialty lens, I always place a diagnostic lens on the eye. This will help us determine whether or not a specialty contact lens will improve your vision. If we put a diagnostic lens on and perform a few short tests, it will determine the best potential for vision improvement. For instance, let’s say you can only see the 20/400 line at the eye doctor (the big “E”). If we are not sure whether or not your vision will be helped with a contact lens, we will place a diagnostic lens on your eye and re-assess the vision. If your vision improves, it is certainly worth it to move forward with the fitting process.

Before that, we took sMap 3D images of each eye to map the shape of her sclera, the white part of the eye. Then, we placed diagnostic Europa scleral lenses onto the eyes to see what her best vision would be. There was superior touch with the diagnostic lenses on the right eye (see the OCT image), so we knew a traditional scleral lens may not be the best option for her. A more custom lens would be better suited for her unique eye shape.

oct+showing+superior+touch

OCT imaging showing superior touch

With scleral lenses, she could achieve 20/50 in the right eye and 20/40 in the left eye. When a patient doesn’t see better on the visual acuity chart, I always ask them to rate the “quality” of their vision. She stated the letters were much sharper and less distorted. Since the vision improved the overall quality and clarity of her vision, we decided to order the Latitude custom scleral lenses.

We are really hoping to improve her vision with these special lenses!

Thank you Dr. Casey for your kind referral of your patient to our clinic!

 

Radial Keratotomy Patient With Scleral Lenses

We recently had our first follow up with our 53 yo M with a history of RK in both eyes (right eye had 8 cuts and left eye had 16 cuts) since we dispensed his Ampleye Lenses. Radial Keratotomy (RK) is a type of eye surgery that was performed in the 1980’s and 1990’s. The purpose was to correct patient’s vision so that they did not have to wear glasses or contacts. Small cuts were made on the cornea which altered the corneal shape, resulting in clear vision without the need for glasses or contacts. Many patients who had RK surgery now suffer from vision issues such as blurred vision, distorted vision, double vision, ghosting, and other visual anomalies. This is due to the fact that the cornea now has an irregular shape (from the RK surgery) and now has irregular astigmatism. This results in the vision problems mentioned above.

Luckily, there are specialty contact lenses called scleral lenses or scleral contact lenses which can drastically improve the vision of RK patients. Scleral lenses are special contact lenses which are custom fit to the patient’s eye. The bowl of the scleral lens is filled with liquid, and then placed onto the eye. The gas permeable lens material creates a smooth surface, which results in much better visual quality. Often times, when RK patients are fit into scleral lenses, they state that their vision is much less distorted. Another benefit is that the vision fluctuates much less during the day. Many RK patients suffer from fluctuating vision, due to the constant change in their corneal shape during the day. Think of their eye like an accordion. Sometimes the shape is in one position and other times it is in a different position. Many RK patients have multiple pairs of glasses scattered all over their house! This is because as their prescription changes throughout the day, they have different prescriptions that help to improve their vision.

Scleral lenses have been an amazing technology that helps RK patients see much better. Whenever we see RK patients in the office, we always ask them if they have any issues like the ones mentioned above. If they do, it is worth it to attempt a scleral lens fitting. The scleral lenses are fit by one of the doctors in the clinic, and the fitting process usually takes about an hour. Several lenses are used from a fitting set until a proper shape is determined. Then, we check the prescription to see what prescription needs to be added to the lens. After, we consult with the laboratory, and we design the lenses together.

When the lenses arrive, we then schedule the patient for a dispense. At this visit, the doctor will insert the scleral lens to the patient’s eye and then perform a series of tests. This is to ensure the lens is fitting properly and also that the vision is satisfactory. If everything looks good, then the patient proceeds to a contact lens training, where they are shown insertion, removal and lens care. After a successful training, the patient goes home and then tries the lenses for about 2 weeks. After that, they return to the office for a follow up to check everything again.

This patient had poor vision, ghosting, and double vision before we fit him into scleral lenses.

He was interested in trying scleral lenses due to symptoms of fluctuating vision and dry eyes that have been worsening since he moved to Las Vegas.

For follow up visits, we typically like to see our patients after wearing their lenses for several hours to assess how their lenses settle on their eyes. At insertion, his lenses were looking pretty good. However, at his follow up visit, we saw some mid-peripheral touch in his right eye. Although he felt comfortable in the lenses, we definitely want to make some adjustments to allow vaulting over the entire cornea.

Scleral lenses are a great option for RK patients, and should be considered when patients have visual issues.

Radial keratotomy patient has drastic vision improvement with scleral lenses

We had the pleasure of seeing one of our patients back for a scleral lens fitting today!

We had previously seen this patient in July of this year. He was kindly referred by Dr. Stafeeva for a specialty contact lens consultation. He had radial keratotomy surgery (RK surgery) many years ago, which has distorted his vision over time. Radial keratotomy surgery was a procedure done in the 1980’s and 1990’s to help patients eliminate their need for glasses. It was a type of refractive surgery performed where a small scalpel was used to make tiny incisions onto the front part of the eye, called the cornea. The small incisions re-shape the eye, which corrects your vision and eliminates the need for glasses. RK was replaced by safer procedures such as LASIK and PRK. RK is not performed in the United States anymore.

Many patients who’ve undergone the RK procedure notice problems with their vision. Some of these problems include problems with glare, ghosting, double vision, fluctuating vision, and an overall decrease with vision.

With glasses, this patient can see 20/50 in the right eye and 20/100 in the left eye, and also reports ghosting and double vision in each eye.

We fit this patient into the Ampleye scleral lens to see what kind of vision we could achieve. With the scleral lenses, he was able to achieve 20/25 vision in the right eye and 20/40-2 vision in the left eye. Scleral lenses are filled with a preservative free saline solution, which reshapes the way light enters into the eye, providing much better vision. He also noticed that his double vision and ghosting was much improved with the scleral lenses.

There was a bit of excessive clearance in each eye, which will be adjusted when we order his lenses. He does also have excessive compression on the left eye, which will also be adjusted when we design and order the lenses.

Looking forward to seeing how this patient does at his dispense! Thanks again Dr. Stafeeva for trusting us with this special patient!

Scleral Multifocal Follow Up

Our 55 year old scleral multifocal patient arrived for her follow up today.

▪️As a refresher, she is a post LASIK patient with dry eyes and seeking a multifocal option. She has high demands at intermediate and near.

▪️She states her right eye feels uncomfortable near the superior temporal area of her eye. Left eye has no discomfort issues.

▪️Her distance vision is “great” but computer and reading are lacking at work.

▪️No issues with insertion and removal.

▪️Distance vision was 20/20 in each eye and 20/30 “double” at near.

▪️She did accept a +0.50 at distance in each eye with loose lenses. At near, she accepted +1.00.

▪️Slit lamp exam showed great central clearance and to me, the edges looked great. However it concerned me that she was having some discomfort in the right eye in the superior temporal area.

▪️You can see with the OCT images, there is a clear difference between the 11:00, 12:00 and 1:00 positions. There is excessive limbal vault and the transition to landing is harsh in that area.

▪️Once again, Keri from Blanchard Contacts helped me design some new lenses. We are adding +0.50 to each lens and also increasing the near power to +2.75 to try and help improve her intermediate and near. For the right eye, we are decreasing the limbal vault by 125 um and steeping the edge.

▪️Will keep you posted on her next dispense!

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Radial keratotomy and scleraL lenses

Update on our 79 year old patient!

▪️If you recall, our RK patient (with moderate cataracts OU and sutures OD) returned for her 2 week follow up after her dispense.

▪️With her Latitude custom scleral lenses, she was able to achieve 20/25- in the right eye and 20/20- in the left eye (despite the air bubble in the lens).

▪️She had adequate central clearance in each eye and the edges were still perfectly aligned.

▪️She had a few issues in the beginning with insertion but after the first 4 days she became proficient.

▪️We reviewed her lens care system and she was following the prescribed protocol perfectly.

▪️She is incredibly happy with her vision with the lenses, and she has recently started to make jewelry again.

▪️She saw Dr. Wellish the day prior, and he was pleased with the state of her eyes too!

▪️Grateful to be a part of this patient’s vision rehabilitation journey!

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