Case 1: Refractive Surgery Ectasia
By Dr. Grohe
A 56-year-old communications executive presents with distorted vision consisting of halos, spoking and reduced scotopic vision. He has undergone seven GP refittings in the last ten years with ongoing GP intolerance.
Medical History: adult ADHD
Ocular History: significant for s/p Radial Keratotomy with 3 enhancements for each eye and bilateral cataracts.
CL History: PMMA x 21 years, EWSCL x 3 years & DWGP x 3 years.
Spectacle History: unsuccessful with four PAL.
Medications: Zoloft & Ritalin
Work History: heavy ( 8-10 hours per day ) computer and Blackberry user.
Keratometry: ( with -1.00 D extended range )
OD: 33.98 @ 26 x 32.69 @ 112 1+ distortion
OS: 37.62 @ 33 x 37.00 @ 115 Tr distortion
OD: +2.75 -1.25 x 115 = 20/40 with monocular diplopia
OS: +0.75 -1.00 x 80 = 20/60 with monocular oblique triplopia
OD: 8 incision RK with fibrotic recut channels and Tr ASC & 1+ PSC cataracts
OS: 8 incision RK with fibrotic recut channels and 1+ ASC & 1+ PSC cataracts
K = 34.80 x 33.00
Eccentricity = – 1.51
CCT = 426 microns
K = 37.30 x 36.70
Eccentricity = – 1.07
CCT = 453 microns
- unsuccessful with mini-scleral Jupiter 15.0 mm due to intolerance
- unsuccessful with Synergeyes due to severe residual monocular diplopia
- unsuccessful with piggyback of Ciba Night & Day with Envision 10.2 mm
- semi-successful with Rose K2 IC ( irregular cornea )
Rose K2 IC
Base curve: 9.20 mm ( 36.62 D. )
OAD: 11.2 mm
PC: standard flat
VA: 20 / 40 +2 ( trace monocular vertical diplopia )
Lens position: Central to Temporal with 2 mm movement
Rose K2 IC
Base Curve: 9.25 mm ( 36.62 D. )
OAD: 11.2 mm
PC: double flat
VA: 20 / 50 +1 ( 1 + monocular vertical diplopia )
Lens position: Central with 1-2 mm movement
Prior to the refitting, a long discussion outlined the benefits and lingering compromises we would experience with any contact lens. Given the past history of unsuccessful spectacle and contact lens fittings and the presence of cataracts, it was necessary to re-emphasize the need to compromise and that no contact lens could provide “perfect” vision. It was also stated that all day wearing time may be unrealistic given the heavy computer use and anti-depressant med which together would enhance a dry eye-like state. The patient begrudgingly agreed.
Success in this case was enhanced by the temporary use of Acular LS dosed:
QID x 1 week
BID x 1 week
QD x 2 weeks
Vision was acceptable and bilaterally resulted in 20 /40 -1 with intermittent but tolerable ghosting and residual diplopia, especially under scotopic lighting. The patient wears his GPs 6-12 hours per day, depending on his computer use. He also alternates between two pair of OTC readers ( +1.25 or +2.25 ) for near vision needs.
By Dr. Szczotka-Flynn
Example: Post DALK for KC
Post DALK: Piggyback/8.4 N&D
Post DALK: Piggyback/O2Optix
Post DALK: Piggyback/Oasys
Post DALK: SynergEyes A
Post DALK: SynergEyes KC
Post DALK: SynergEyes PS
Post DALK: Rose 2K IC