tough keratoconus fit

I've been referred for contact lens fitting of a 20 yo wm keratoconus
patient who has never worn CLs

Unaided acutities R 20/400 L 20/400-

Existing SRx (2 yo):

R 0.00 - 7.00 x 19 20/60+ -
L 0.00 - 6.00 x 135 20/60++

My refraction:

R +2.00 -12.00 x 38 20/30- -
L 0.00 -6.50 x 134 20/40 -

Ks were

R 46.25@20 55.00 4+ distorted (egg shaped) mires
L 45.00@165 57.00 4+ distorted (egg shaped) mires

Corneas have a classical cone shape, but are otherwise normal; no
scarring or dangerous thinning.

I will ordering trial RGP torics for him, and was wondering if anyone
has any suggestions on the fit. Also, would you even attempt a
spectacle Rx as a back up or just leave it alone? Can a normal lab even
fabricate a 12 cyl? Thanks

w.stacy, o.d.

 

Far out stuff. I doubt if this 20 yo will want to go to B. hills or to
Geneva any time soon... I think I'll start with the RGPs and see how we
do. Let us know when you've got the pics. How much astigmatism did the
10 D. cone have, or was 10 D. the cyl? Have you seen intacs alone
straighten out much cyl?

w.stacy, o.d.

 

Thanks. Think I'll just wait and see if he can wear the CLs. If so,
that might (and hopefully will) have some ortho effect. Probably wishful
thinking. Can you imagine wearing a 10 or 12 cyl in glasses? The
words squishy and squashy come to mind. I remember getting my first
glasses. They had 1.5 cyl. and I almost fell flat on my face as I
walked out of the office...

w.stacy, o.d.

Robert Martellaro wrote:

 

If this patient has never worn contact lenses before, then he will be
in for a rude awakening. Keratoconus fits tend to deviate quite a bit
from the ideal.

My recommendation would be to try Macrolenses in a keratoconus design.
They are as large as a soft lens and about as comfortable. Since they
rest partially on the sclera, they tend to center well. I know there
are some other manufacturers making these large lenses as well.

DrG

 

I've heard of those and will ask my cl lab about them. Decentration is
probably going to be the issue with ordinary lenses, but we shall see.
I'll post my results. Can the Macrolens be popped out like orginary RGP
or do you need a suction cup? Given the geometry, there's probably a
fair amount of tear pooling under there.

w.stacy, o.d.

 

The Macrolens is a patented design by C&H Contacts, Dallas, Texas. The
blanks required are very large, and are probably not going to be
available at a lab near you. It was just a suggestion. I know that
the Rose K is a popular design, but it is still intralimbal. As such,
it will never match the comfort of a cornea-scleral design. The larger
lenses can be removed using the "scissors" method, or with a plunger.
A fair amount of pooling will occur, but careful attention to base
curve will keep it to a minimum. Of course, you will need to invest in
a trial lens set to get started. However, once you have made the
investment, this type of lens will open up other opportunities -- for
example tough soft toric fits with corneal cylinder can be put into a
Macrolens.

DrG

 

Dr. Leukoma wrote:

Of course, you will need to invest in

Of course. Just what I need, more trial lenses. Any idea on the cost?

Thanks

w.stacy, o.d.

 

I personally am not familiar with "konus" lenses by "Falco."

Macrolenses range in diameter from 13.5 mm up to 15.0 mm. They are
very large. Any lens of approximately that size is called a
cornea-scleral lens. A "mini-scleral" is about 16 mm to 18 mm, and a
scleral lens larger still.

DrG

 

Tell me about it. I haven't any idea of the cost of the trial lenses.
I have about 5 Macrolens kits. Half of them were given to me to play
with.

With 12 diopters of cylinder, you've got quite a case.

DrG

 

The cyl was 10.00 D

If C3-R makes it through peer review, treatment for keratoconus will
be significantly changed. I'm sure you already know about Intacs, but
the ones in the US only correct up to 3.00 D myopia, so not all of the
correction could have been just the Intacs.

I assumed that the additional correction was due to the different
nature of the keratoconic cornea, but I also have received topos of
C3-R only, and see the same kind of normalization.

In any case, RGPs are and probably always will be the first line of
defense.

I hope to have the updated website published by Monday, which will be
just in time for our 3 millionth visitor.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

 

At issue with the costs, to physician and patient alike, contact
lenses for keratoconus are not correcting refractive state, but are a
prosthetic for a diagnosable disease. As such, they should be covered
under the patient's major medical insurance plan.

Most optometrists don't deal with much more than an Knox-Keene type
plan like VSP, so wading into the ever deepening waters of medical
insurance reimbursement is not for the faint of heart. Additionally,
staff will always initially deny reimbursement for contact lenses so
every case will need to go to appeal.

Our organization has just put together an ad hoc committee to create
guidelines for medical directors of insurance plans to help define and
justify when treatment for keratoconus - including contact lenses -
should be covered under the plans. Hopefully this will help patients
get the reimbursement they deserve and give physicians a road map to
reimbursement.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

 

Bill,

I don't know whether the same system is available in the States but in the
UK the licensed maunfacturers of the Rose K2 lens will let you borrow a
fitting set FOC. I have started using this system for the odd keratoconic I
see and find the lens gives very good results, with advantage of talking to
the manufacturers they can tweek the lens in many ways to give a good fit.

Regards


Ian Hodgson - Isle of Man

 

Thanks for all the responses. I've ordered the k.c. set from C% H.
They have loaner lenses and even loaner sets, but after talking to them,
I'm going for the $400 fitting set. It should make the fitting a lot
quicker and easier than dinking around a lens or 2 at a time. If I like
how it works on this case, I might even go for the regular set and the
post refractive surgery set, designed for problem cases. Maybe a niche
developing here...

w.stacy, o.d.

 

I think Dr. Gemoules has shown that there is most certainly a niche
for fitting post refractive RGPs and keratoconus patients.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

 

My advice is that if your current cl's are fitting well, with
good vision and comfort, leave well enough alone. Sometimes, doing
a re-fit just because there is something "newer" out there
will result in problems that didn't exist before.

frank

 

Excuse me if I don't post a link to it, but I will if pressed, but at
least one study showed that significant endothelial apoptosis resulted
following this ultraviolet light treatment. This has made me a bit
leery of trying it out on post-RS patients. I think that if the next
stop for a keratoconus patient is a corneal transplant, then the
combination of Intacs and C3-R might sound like a pretty game option to
try first.

DrG

 

The study is probably the one where UVA with riboflavin was performed
on rabbit eyes. The amount of endothelial loss varied greatly with
the amount of light applied, the distance the light was from the eye,
the timing of the riboflavin drops, and the thickness of the cornea.
More light,closer light, less drops, and thinner corneas caused more
damage.

The consensus on C3-R seems to be that if the patient is looking down
the barrel of a transplant, then there is not much risk of doing C3-R.
If the patient has moderate keratoconus, Intacs alone seem to be best,
when the patient becomes contact lens intolerant.

If (and this is a big "if") endothelial cell loss is found with all
C3-R, but C3-R resolves the refractive changes and stabilizes the
cornea, and if (another big one) the patient is moderately advanced,
then the use of C3-R with Deep Lamellar Endothelial Keratoplasty
(DLEK) may (a very big "may") be appropriate.

It is very early in C3-R's life cycle. It holds promise, but we all
need to look closely. Trust, but verify.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

 

....plus several more using rabbit and porcine corneas and demonstrating
keratocyte apoptosis. I am often astounded by the speed with which
some doctors go from the animal model to the human.

DrG

 

The speed is even more amazing where there are problems in the animal
eyes.

Glenn Hagele
Executive Director
Council for Refractive Surgery Quality Assurance

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.