DH, a 78 yom, needed to be fit with a contact lens post PK, OD. Refraction was a fuzzy 20/70 with +2.50 -6.50 x 80. His corneal topography revealed @ 9 D of corneal toricity. Figure A

Fig. A

Fig. B   Fig. C   Fig. D   Fig. E

Initially a few large flat diameter spherical lenses were trial fit to see if the positioning and fluorescein patterns were acceptable:

• Figure B is the Post Graft Lens from Lens Dynamics (BC 8.04 D/OZ 10.4/9.0).
• Figure C is the Post PK from Infinity Optical BC (8.04 D/OZ 11.0/9.5).

They were not. Both lenses decentered temporally, and from the fluorescein pattern it was clear that the amount of toricity was a factor. I decided a bitoric design might prove to be a better attempt.

The highest trial lens with a toric base curve (that I had) was a 3 D SPE lens. (However, I verified the lens, and it may have warped over time because it read closer to a 3.75 toricity. (Flat BC was 8.25, D/OZ 9.5/8.0.) Figure D When this was placed on the eye, it also decentered temporally, but the weight distribution was getting better.

The final lens design was a 4 D SPE bitoric and a larger D/OZ to aid in centration:

8.10/7.40  +.25/-3.75  11.0/9.5  2°  9.20/8.50 (.5)  3°  11.20/10.50 (.25)

It yielded a final acuity of 20/25. Figure E

CASE II - Dr. Cutler

MR, a 73 yowf, had a Penetrating Keratoplasty (for Fuch's), which resulted in 13.5 D of corneal astigmatism. Figure 1 She was referred to me to see if a contact lens was possible before sending her to another refractive surgeon who would perform LASIK on her transplanted eye.

Fig. 1

Visual acuity with pinhole was 20/300. Refraction was extremely difficult. Since a contact lens would eventually be placed on the eye, there was no real reason to attempt a low vision refraction.

A few bitoric corneal lenses with large amounts of toricity were attempted, but they would not center. Figures 2, 3 and 4 are an 8D SPE bitoric lens in different positions as the patient blinked. The lens had a tendency to decenter into the superior fornix or eject out of the eye. VA was 20/50. A 10 D SPE bitoric lens was also attempted, with the same results. A soft CL was piggybacked on TOP of the SCL to see if some level of stability would occur. This was also unsuccessful.

Fig. 2		Fig. 3		Fig. 4

MR was then fit with a Macrolens, a semi-scleral lens from C and H. Visual acuity was 20/40. After several trial lenses from the trial set (8.04, 7.94, 7.85), a lens was ordered. The final lens was eventually a steeper base curve (7.50).

Figures 5, 6, 7 and 8 are the same final lens. MR was very happy with this lens, but I was bothered by the SPK that I noted. Figures 7 and 8 Eventually I felt that some epithelial breakdown was occurring centrally within the graft. Her acuity went down @ 1 line to 20/50.

Fig. 5		Fig. 6
Fig. 7		Fig. 8

Fig. 9

She was refit with the Epicon lens to see if the corneal health would improve. It did.

Her final lens was a 6.80 BC with the steep periphery. Figure 9

Vision also returned to 20/40+.

 
 
CASE III - Dr. Szczotka

• PMD Dx at age 50
• Spectacle Refraction:   OD -3.75-3.25 X095 20/40   OS -0.75-3.75X076 20/40
• Pachymetry:   OD 556,553,555   OS 555,555,555
• Pupils 6 mm in normal illumination OU
• 1st GP fitting:   OD 7.50 9.9/8.5 -6.37 HDS   OS 7.40 9.9/8.5 -6.12 HDS
• OR:   OD +1.00-1.25 X068 (20/25)   OS +0.75 -0.75 X018 (20/25)
• Patient notices glare OU, and has adherence ring inferiorly when CL removed
• Also has significant spectacle blur when CL removed (see topography)
• Wears spectacles over with residual astigmatism

Topography of PMD patient after removal of corneal GP lenses

Several GP corneal lenses attempted with no success

Refit to Macrolens

Refit to Macrolens (see FL photo)

• OD 7.14, 0.8 "E", 7.60 periphery, -7.75, 3 fenestrations Macro A (20/30)
• OS 7.14, 0.8 "E", 7.76 periphery, -6.25, 3 fenestrations, Macro A (20/25)

Patient very happy with VA, no glare, but complains of pinching OD

(See topography after lens removal.) Lenses re-ordered with flattest edges available 1.0 "E", with no success in improving comfort.

Topography of PMD patient after removal of Macrolens

Refit to Lens Dynamics Intralimbal lenses:

• OD 7.34 BC, 12.2 OAD, 8.6 OZ, -8.00 (20/20)
• OS 7.34 BC, 12.2 OAD, 8.6 OZ, -6.00 (20/30)

Lenses have good pt touch, good movement, patient is comfortable, still had best VA with Macrolens. (See topography after lens removal.)

Now considering full scleral lens fitting

Orbscan topography of PMD after removal of Intralimbal lenses

 
 
CASE IV - Dr. Szczotka

• 36 yo, s/p RK surgery OU in 1984 complains of poor VA
• Slit lamp: 8 cut RK OU with 3-4 mm clear zone OU
• MR:   OD +5.00 (20/30)   OS +2.00-0.75X075 (20/40)
• See topo maps (without CL in place):

Topography of post-RK patient
Over-topography with Preference toric soft lenses on same post-RK patient

1st GP fitting:

Reverse Geometry lenses:

• OU Rx: 8.00 BC, 9.8 OAD, 7.0 OZ, 7.50 2ndary, 12.5/.3 peripheral, -3.00
• VA 20/30 OD, 20/60 OS
• OR:   OD PL -1.00 X125 (20/25)   OS -1.00 -2.50 X100 (20/30)

Lenses fit well OU, where is all the residual astigmatism coming from???

Advised against FS toric GP consider soft trial fit with Preference spheres:

Trial lenses:

• OD 8.4 +4.00
• OS 8.4 +1.50
• OR: OD +2.00-1.50X110 20/20!! OS +0.75-3.00X130 20/30+

Order torics:

• OD 8.4 +6.00-1.25 X110 Preference Toric 20/25
• OS 8.4 +2.25 -2.75X130 Preference Toric 20/30

Patient very happy