Case One

Male, age 30

Dx KC 8 years ago.

Habitual GPs:

• OD 7.18 8.9/7.5 -5.37 (20/20)
• OS 6.65 8.7/7.0 -7.25 (20/40)

SIM K's

• OD 48.84@062/40.87@152
• OS 60.75@086/48.75@176

Fit analysis: epithelial imprints OU, GP drop low OU, central corneal staining over apex OU, repeated abrasions OU, low edge lift OU.

Series of attempts made to steepen lenses to minimize apical touch to prevent abrasions and to improve centration and movement.

Best Fit GPs:

• OD 6.90 8.8/6.8 -7.50
• OS 6.30 8.8/6.4 -11.00

Excellent fit of above, feather apical touch well centered OU, patient comfortable with no recurrence of abrasions, but VA dropped to 20/30 OU.

Over-refraction has RA:

• OD +0.50 -1.50 x135 (20/20)
• OS +0.50 -1.50 x006 (20/25)

NEW GP ORDERED WITH ABOVE RA INCORPORATED, ALL OTHER SPECS THE SAME.

DISPENSING VISIT VISUAL ACUITY:

• OD 20/20
• OS 20/25

Patient reports much improved visual acuity.

Prior to 2 week FU patient lost lenses, said they both popped out of his eye because they were too thick.

Wants to go back (and has!) to his older, flatter lenses, 6 months later (wearing the old lenses) significant scarring was noted at the apex of the cone OD>OS.

WHAT to think about?

1) Did the flatter lenses cause scarring to increase?
2) Did RA develop with the steeper fitting lenses?
3) Should I insist on steeper fitting lenses which have worse VA?
4) Should I insist on steeper fitting lenses with residual astigmatism in spectacles over?
5) Should I try a different prism ballast lens to decrease mass?

Case Two

This patient presented for a LASIK consult and noted blurred vision in the right eye for several months.

Previous spectacles (3 years old) were:

• OD -3.00 -0.50 x180
• OS -2.75 -1.00 x180

Slit lamp exam:
No scarring, Vogt's striae, or Fleischer's ring noted OU.

Based on this topography image, does this patient have Keratoconus?

Cases Three and Four