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Managing Contact Lens Comfort Issues for Keratoconus Patient
1. BY:
•Noor Munirah bt Awang Abu Bakar
•Optometrist (Moc No: O-869)
CASE STUDY :KERATOCONUS
2. 58 years old /Male
Occupation: Office worker
Nature of work: Extended use of Visual Display Unit (VDU) equipment in
air-conditioned environment.
Chief complaint:
BE irritation and dry eyes since 4 months ago with previous and newly replaced
RGP lenses wear .
Wear RGP for bilateral keratoconus.
Irritation immediately upon lens insertion.
The sensation aggravates under air-conditioned environment.
Frequent use of tear supplement but no improvement.
Vision is not stable.
HISTORY –1ST
CONSULTATION
3. Ocular history:
Start wearing RGP since age 33 years old for bilateral keratoconus.
Presented to this optometry clinic since 2 years ago.
Health history:
Has hypertension and on Manopril medication.
Has depression and currently on Paxtine and Valpro medication.
Also has asthma and on Q-Var medication.
Family ocular and health history: Unremarkable.
HISTORY - 1ST
CONSULTATION
4. NO EXAMINATION RE LE
1 VA (aided with RXD lens) 6/12 6/12
2 Slit lamp (without lens)
•Cornea:
•Limbal &Bulbar conj:
•Lid Margin:
-Scattered punctate
staining
-Neovascularization
-Nasal dellen
-Hyperemia
-Mild MGD
-Scattered punctate
staining
-Neovascularization
-Nasal dellen
-Hyperemia
-Mild MGD
ASSESSMENT
5. NO EXAMINATION RE LE
3 Slit lamp (with lens)
•Upon blinking:
•Lens diameter:
-No movement
-Cones bearing
-Low riding
-Small diameter lens
-No movement
-Cones bearing
-Low riding
-Small diameter lens
4 IOP Within Normal Limit Within Normal Limit
5 Fundus examination -Healthy optic nerve head
-Flat retina
-Clear macula
-Healthy optic nerve head
-Flat retina
-Clear macula
6 Corneal topo Keratoconus with inferior
cone
Keratoconus with inferior
cone
ASSESSMENT
6. Patient was instructed to remove lenses over weekend and return for corneal
topography and lens fitting.
Came back after 3 days.
Assessment and result as follows;
Topography: Increased amount of corneal steepening compared to initial maps
CL fitting:
Capricornia KBA/ 10.2 mm/ Boston XO material
Fitting:
Both cones clearance
Good centration and movement
Pt was advised to come for after care in 1 week.
FOLLOW UP: 2ND
CONSULTATION
NO Topography RE LE
1 Corneal astigmatism 3.4D 2.6D
2 Sim K •6.61mm @ 155
•9.95mm @ 95
•6.46mm @ 13
•6.83mm @ 103
7. Chief complaints:
Came with complaints of discomfort , dryness and itchiness of wearing new
RGP lenses.
Only can wear for few hours each day, both in air-conditioned environment and
outdoor.
No difference in comfort between KBA and RXD lenses.
Instill preservative-free lubricant hourly but no improvement, causes
frustration.
Try to change care & maintenance technique & did warm compression, but the
discomfort remain.
Assessment:
External ocular health normal.
No signs of inflammatory reactions
No dryness or SPK
FOLLOW UP: 3RD
CONSULTATION
8. Q: What are the causes for discomfort during contact lens
wear for keratoconus patients?
In this case, 2 main causes:
Dryness
Age: 58 years old
Medication: Monopril, Paxtine, Valpro and Q-Var
Environment: Air-conditioned environment
Nature of work: VDU
Mild MGD: Fasten tear evaporation
Tight fitting CL
Immobile lens: No tear exchange
Low riding lens: Mechanical pressure
Cones bearing
QUESTION 1
Lead to:
•Corneal NV
•Dellen
9. Q: What other options should you consider for the patient and
why?
1. Change lens parameter
Increase lens diameter
Flatten lens BOZR
Reduce lens central thickness
Change to High Dk lens
2. Change to other lens type:
Scleral Lens-
Scleral lens has larger diameter
The central optical zone wont touch the cornea and preserve the tear reservoir
beneath lenses, landing on the sclera part, thus can improve patient’s comfort.
Patient might not have problem to adapt because he is a RGP wearer for
long time.
QUESTION 2
10. Q: What other options should you consider for the patient
and why?
3. Consultation on visual hygiene
Change to non air-conditioned environment
Apply good visual hygiene:
Frequent blinking while using VDU
4. Advice on lid hygiene and warm compression
Teach and demonstrate the proper way of cleaning lid using diluted
baby shampoo and cotton bud.
Advice to perform warm compression.
QUESTION 2 CONT.
11. Q: What other clinical investigation should you do for this patient?
1. Determination of near addition:
-The RGP fitting in keratoconus mainly to treat distance vision. Thus, near
addition must be determined to help patient (>40 years old) to see at near.
2. Fundus examination:
-Since patient is 58 years old and on medication, fundus must be examined
to see any changes.
3. Slit lamp examination
-Examine external ocular health before and after lens insertion.
-Examine lens fitting : To determine optimum or acceptable fitting.
4. Corneal topography
-To examine corneal status and curvature.
QUESTION 3