Management of GP-Induced Corneal Warpage in a Keratonic Patient through Deadaptation and Scleral Lens Fitting

A 56 year old male with keratoconus presents with blurred vision and uncomfortable lenses. Corneal topography shows warpage and poor gas permeable fit. Deadaptation of cornea important to obtain optimal vision through scleral lenses.

I. Case History o Demographics § 56 year old Native American Male o Chief Complaint § Presents to WW Hastings Diabetic Clinic on 08/15/16 complaining of blurred vision OS>OD § History of Keratoconus and Corneal GP lenses • Recently fit with new lenses 4 months ago at outside clinic § Decreased vision since last fitting • Patient intentionally wearing lenses in opposite eyes after subjective observation o Noted better vision OD o No improvement OS

o History § Ocular: Keratoconus § Medical: Diabetes Mellitus, Hypertension, Sinusitis, Asthma, Benign Prostatic Hyperplasia, Acid Reflux § Medication: Potassium Chloride, Doxazosin, Fenofibrate, Furosemide, Losartan, Simvastatin, Dicyclomine, Hydrochloride, Omeprazole, Insulin, Refresh Plus Artificial Tears § Allergies: Codiene - rapid pulse

II. Pertinent Findings o Initial Exam 08/15/2016 § VA c Corneal RGPs (wearing on the incorrect eye) • OD 20/40 OS 20/150 • Pinhole acuity: OD 20/30 OS 20/40-2 § EOMs: Full range of motion OU § Confrontation fields: Full OU § Pupils: Equal, Round, Reactive, no afferent defect OU

o CL assessment (Lens Parameters unknown, patient fit at outside clinic) § Decenters inferior temporally after blink OU § Fluorescein patterns show central bearing OU o Anterior Segment § Adnexa: Miebomitis OU § Bulb Conj: Injection 2+ OU § Cornea: SPK-diffuse --suggests poorly fitting lenses OU, Fleischer ring and striae OU § Lens: Nuclear Sclerosis 1+ OU PSC 1+ OS § All other findings unremarkable § GAT OD 12 OS 12 o Posterior Segment: § OD unremarkable § OS Cotton wool spot inferior temporal to optic nerve head

o First Follow Up Exam 8/19/2016 § VA with Corneal GP contact lenses • OD 20/25 -1 OS 20/150 -2 • Other Chair skills unchanged from 8/15/2016 § Topography (IMAGE) • Irregular patterns with steepening inferiorly OU • Corneal Keratometry o OD 46.07D @036 / 46.24D @126 o OS 44.96D @107 / 46.51D @017 § CL Assessment • OD Apical touch, inferior temporal decentration • OS Apical pooling, inferior decentration • Dispensed Acuvue Oasys Lenses BC 8.4 DIA 14.0 o OD -7.50 20/40 o OS -10.00 20/30

o Second Follow Up Exam 9/2/2016 § VA with Acuvue Oasys CLs • OD 20/70 OS 20/50 • Other Chair skills unchanged from 8/15/2016 § Topography (IMAGE) • Positive improvement from previous examination. Smoother contours with inferior temporal steepening OU • Corneal Keratometry o OD 47.26D @045 / 48.02D @135 o OS 45.01D @114 / 46.53D @024 • Trial Lenses (OCT IMAGE OF FIT) o OD: Prolook Scleral Dia 16.6 BC 48.00 (assessed after 30 mintues) § 200 microns of vault centrally, adequate vault over limbus, (+) blanching 360 degrees § OR -2.00 -0.50 x 110 VA 20/30 o OS: Jupiter Reverse Geometry Scleral Dia 16.6 BC 47.01 (assessed after 30 minutes) § 600 microns of vault centrally, adequate vault over limbus, (-) blanching 360 degrees § OR -3.50 -1.00 x 120 VA 20/40 o Topography over lenses found no flexure

III. Differential Diagnosis o Contact Lens induced Corneal Warpage o Keratoconus o Pellucid Marginal Degeneration 3 o Post surgical corneal complications

IV. Diagnosis and Discussion o Primary Diagnosis: Contact lens induced Corneal Warpage § Most commonly noted in PMMA wearers due to lens rigidity. Also has a high prevalence in rigid gas permeable lens wearers and in some cases, soft contact lens wearers.1,4,5 o Unique features of this case § Corneal topographies show lens indentation on ocular surface from unknown RGP lenses. No previous lens or topographical history makes for unique management and prognosis.

V. Treatment and Management o Treatment Options § Immediate discontinuation of lens wear and new contact lens fit when cornea has stabilized. § Slow tapering of current contact lens wear and new contact lens fit when cornea has stabilized. § Immediate new contact lens fit. 2 • This treatment has been indicated to have the best prognosis and highest patient compliance. o Management of Patient § Initial visit • Patient referred to Cornea and Contact Lens Clinic at NSUOCO.

§ First Follow-up • Patient to immediately discontinue hard contact lens wear. o While some literature suggests this is not the initial treatment of choice. Accurate baseline topographies are needed for successful contact lens fit. • Patient scheduled to return for serial topographies to determine corneal stabilization . o Fit in soft Acuvue Oasys lenses for best correction and least amount of corneal interaction until follow up.

§ Second Follow-up • Based on improved corneal topography, patient fit diagnostically with trial scleral lenses. • Parameters ordered o Essilor Jupiter Reverse Geometry Scleral Dia 16.6 BC 44.50 Power: -6.75 o Essilor Jupiter Reverse Geometry Scleral Dia 16.6 BC 44.50 Power: -8.50 • Continue wearing Acuvue Oasys lenses until scleral lens follow up/dispense.

VI. Conclusion o Contact lenses have the refractive technology to restore sight in advanced cases of anterior segment ocular disease. However, when fit improperly, these medical devices also have the potential to cause additional visual complications. It is important to recognize when a lens is fitting improperly and causing corneal warpage. It is also imperative to take the necessary steps to allow the cornea to deadapt to ensure optimization of visual potential.

References

1. Bennett, Edward S., and Vinita Allee. Henry. "Gas Permeable Lens Problem Solving." Clinical Manual of Contact Lenses. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2014. N. pag. Print.

2. Efron, Nathan. "Chapter 26." Contact Lens Complications. 3rd ed. Edinburgh: Elsevier/Saunders, 2012. 259-71. Print.

3. Gerstenblith, Adam T., and Michael P. Rabinowitz. "Cornea." The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2012. 98-100. Print.

4. Maeda N, Klyce SD, and Hamano H: Alteration of corneal asphericity in rigid gas permeable contact lens induced warpage. CLAO J 1994; 20: pp. 27-31

5. Ruiz-Montenegro J, Mafra CH, Wilson SE, et al: Corneal topographic alterations in normal contact lens wearers. Ophthalmology 1993; 100: pp. 128-134