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Case 1: Keratoconus - Intacs and SynergEyes

By: Dr. Bruce Anderson

Subject: 33-year-old Male/Police Officer

Brief History: History of keratoconus and was fit into new rigid lenses at our clinic January 2001. Because of contact lens intolerance and numerous attempts at refitting, he was placed in a soft lens piggy back wear in February 2004. Due to persistent discomfort with the piggy back lenses, on March 2007 he was seen for a possible fit to SynergEyes in the left eye. He was on hold for Intacs surgery in the right eye until the insurance coverage was in place.

Refraction:
2/24/2004
OD   -1.00 -1.50 x 023   20/70   Very variable refraction
OS   +2.00 -3.00 x 075  20/100

Slit Lamp: 2+ central corneal thinning, 1+ central scar, obvious Fleischer’s ring in both eyes.

Topography: From piggy back fit visit on 2/24/2004 - see below #1 and #2.

Topography #1

Topography #2

Presentation for fit into SynergEyes in the left eye: 3/12/2007

Topography: See Below #3 and #4

Topography #3

Topography #4

Trial Fitting with SynergEyes:
Left eye:
1) 6.1 / -12.00 / 8.2 / 14.5 3+ Steep fit
2) 6.5 / -8.00 / 8.5 / 14.5 1- Flat fit
3) 6.3 / -10.00 / 8.5 / 14.5 1+ Steep fit Over refraction -5.00 20/30-
    BC / Power / SC / Dia
Approx. 1/8 mm movement after 20 minutes

Lens Ordered:
SynergEyes
OS -14.50 / 6.3 / 8.5 / 14.5
Power BC SC Dia

The lens was dispensed on 3/28/07. The acuity was 20/40+ with an over refraction of +0.25. The centered well and exhibited about 1/4 to 1/8 mm movement. Next follow up was 4/4/2007. The over refraction was +0.25 sph. The lens was again centering well and was moving about 1/4 mm movement. The final fit and vision with the lens was very satisfactory to the patient.

Presentation for fit into SynergEyes in the right eye: 2/25/2008

Evaluation: Patient still wearing SynergEyes very successfully in the left eye. Presented for contact lens fit for the right eye into SynergEyes after Intacs surgery.

Slit Lamp: OD Intacs in a vertical orientation with no corneal staining associated. 1+ central scar with 1+ elevation of a nipple region of the cone.

Topography: See below #5 (OD only)

Topography #5

Trial Fitting With SynergEyes:
1) 7.1 / -3.00 / 8.1 / 14.5 2+ Steep fit
2) 7.3 / -3.00 / 8.3 / 14.5 1+ Steep fit
3) 7.4 / -3.00 / 8.7 / 14.5 1- Flat fit
    BC/ Power/ SC / Dia

Lens Ordered OD:
SynergEyes
7.5 / -6.25 / 8.5 / 14.5
BC Power SC Dia

Lens Dispensed: 3/3/2008
Lens centered well. Approximately 1/8 mm movement after 15 minutes. Central FL pooling, with a light touch at the nipple. Acuity 20/30 with +1.50 over refraction. Follow-up one week.

Case 2: Keratoconus - PRK

By: Dr. Bruce Anderson

The purpose of this case report is to illustrate the problems with unstable keratoconus, exacerbated by Laser refractive surgery. This patient had PRK at a time before the negative effects of the surgery were well known for keratoconus. This patient was very sensitive to the fit and feel of rigid contact lenses. He had a subsequent corneal transplant in the left eye, and wanted to avoid a transplant in the right eye if it was at all possible.

Subject: 56-year-old Male with a long history of keratoconus. Had PRK laser treatment to both eyes in 1996. Presented for contact lens refitting 9/19/1997.

First Contact Lenses:
OD 51.50 / 8.6 / 6.0 / -6.50 / .3/7.15 .3/7.80 .3/8.50 .4/9.50
OS 52.00 / 8.6 / 6.0 / -7.75 / .3/7.10 .3/8.25 .3/9.40 .4/10.40
      BC / Dia / OZ / Power / PC
      Lenticular Boston 7

Lens Fit:
OD 1+ Steep 20/40 Acuity
OS 1+ Flat 20/40 Acuity

Lens fit acceptable and comfortable to patient. Edges of the right contact lens had proper lift. The left lens edge was slightly flat.

Second Lens Refit: OS 1/19/1998

Patient reported no problems with the right contact lens. The vision was stable and wear was comfortable. However, there were complaints of the left eye being very irritated from the contact lens. The lens would not stay in place. Evaluation of the fit of the left eye revealed that it was fitting very flat with loose edges. A new lens was reordered:

OS 61.00/ -17.25 / 8.6 / 6.0 / .3/6.10 .3/7.30 .3/8.80 .4/10.25
BC Power Dia OZ PC
Lenticular Boston 7

The lens was dispensed on 1/27/1998. The fit was slight steep with light central touch. The edges were good with adequate slight lift.

Third Lens Refit: OS 3/9/1998

Patient complained that the left lens was shifting on his eye again. The right eye was doing well. The fit evaluation of the left eye showed that the lens was again fitting flat and starting to shift. There was increased edge lift. A new lens was ordered.

OS 62.00 / -19.00 / 8.6 / 6.0 / .3/6.10 .3/7.30.3/8.80 .4/10.00
BC Power Dia OZ PC
Lenticular Boston 7

Fourth Lens Refit: OU 6/3/1998

Patient presented with complaints of both lenses being uncomfortable with the left being the worst. Both lenses were looser in fit than noted when initially dispensed. The left lens was shifting more than the right. Two new lenses were ordered.

OD 54.00 / -9.25 / 8.6 / 6.0 / .3/7.00 .3/7.50 .3/8.00 .4/8.75
OS 64.00 / -21.00 / 8.6 / 6.0 / .3/6.20 .3/7.50 .3/9.00 .4/10.50
BC Power Dia OZ PC
Lenticular Boston 7

Fifth Lens Refit: OU 10/19/1998

OD 54.50 / -10.50 / 8.6 / 6.0 / .3/7.00 .3/7.50 .3/8.10 .4/8.90
OS 67.00 / -23.50 / 8.6 / 6.0 / .3/6.10 .3/7.40 .3/8.50 .4/9.50
BC Power Dia OZ PC
Lenticular SGP 2

2/11/1999 Refit:
OD 55.50 / -11.50 / 8.6 / 6.0 / .3/7.00 .3/7.50 .3/8.10 .4/8.90 BC Power Dia OZ PC

Patient discontinued all lens wear OS due to discomfort and changing cornea. Is now on a waiting list for a corneal transplant in this left eye. PKP done March 1999 OS.

6/2/1999 Refit:
OD 57.00 / -13.00 / 8.6 / 6.0 / .3/7.00 .3/7.50 .3/8.00 .4/8.80
BC Power Dia OZ PC

After the left eye was stable from the transplant, he was given a glasses Rx for the left eye with 20/30 acuity (without a contact lens). Left eye correctable to 20/30 with glasses.

9/9/1999 Refit:
OD 58.50 / -14.00 / 8.6 / 6.0 / .3/7.00 .3/7.50 .3/8.00 .4/8.85
BC Power Dia OZ PC

10/9/1999 Refit:
OD 59.00 / -16.00 / 8.6 / 6.0 / .3/7.10 .3/7.80 .3/8.40 .4/9.10
BC Power Dia OZ PC

Topography #1

Right eye fairly stable till 5/14/2003

5/14/2003 Refit:
OD 59.50 / -16.50 / 8.6 / 6.0 / .3/7.10 .3/7.75 .3/8.35 .4/9.10
BC Power Dia OZ PC

7/14/2003 Refit:
OD 60.00 / -16.50 / 8.6 / 6.0 / .3/7.10 .3/7.75 .3/8.30 .4/9.05
BC Power Dia OZ PC

Topography #2

Topography #3

7/15/2004 Refit:
OD 60.75 / -17.25 / 8.6 / 6.0 / .3/7.10 .3/7.75 .3/8.30 .4/9.05
BC Power Dia OZ PC

Topography #4

3/14/2005 Refit:
OD 61.75 / -18.00 / 8.6 / 6.0 / .3/7.10 .3/7.75 .3/8.35 .4/9.10
BC Power Dia OZ PC

12/1/2005 Refit:
OD 62.75 / -19.25 / 8.60 / 6.0 / .3/7.10 .3/7.75 .3/8.30 .4/9.05
BC Power Dia OZ PC

Topography #5

10/2/2006 Refit:
OD 64.00 / -20.75 / 8.6 / 6.0 / .3/7.10 .3/7.70 .3/8.35 2/9.00 .2/10.50
BC Power Dia OZ PC

10/31/2007 Refit:
OD 65.00 / -22.25 / 8.6 / 6.0 / .3/7.10 .3/7.70 .3/8.30 .2/9.00 .2/10.40
BC Power Dia OZ PC

Due to chronic lens irritation in the right eye and due to lens touch at the apex of the cone, a soft lens was dispensed for a piggyback wear on 11/15/2007. The soft lens given was -0.25/8.4/13.8 Ciba Night and Day. The patient reported a tremendous increase in comfort and wearing time. At the next follow up on 1/16/2008 there were again complaints of the lens not staying in place. Again there was a new lens ordered.

1/16/2008 Refit:
OD 66.00 / -23.00 / 8.6 / 6.0 / .3/7.10 .3/7.70 .3/8.30 .2/9.00 .2/ 10.50
BC Power Dia OZ PC

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