Female, age 30. Teenage onset keratoconus

1aA corneal lens had been worn successfully in the early stages after diagnosis, but gave increasing discomfort as it aggravated a proud epithelial nebula, seen here at the apex of the cornea. A corneal transplant was offered, but the patient declined, preferring to try further contact lens options.

A sealed RGP scleral lens was an uncomplicated fitting exercise. The final lens had full corneal clearance, totally relieving the discomfort. After three years of alternating between corneal and scleral lenses, the patient has switched entirely to use of the scleral lens only.

1b

 

Female age 55. Teenage onset keratoconus

1aCorneal lens fitting was impossible with such a protrusive profile. A scleral lenses offered an opportunity for a conservative management option irrespective of the highly protrusive corneal topography. A large donor for a transplant would have been required, bringing the junction into proximity to the limbal arcades, thereby increasing the risk of rejection.

Sealed RGP scleral lens leaving a glancing contact zone was a straightforward process, giving a satisfactory 6/18 VA with comfortable full day wear.

1b

Female age 55. Exposure Keratitis

3aThis patient suffered an acoustic neuroma at age 52. The tumour was successfully excised, but leaving a residual facial nerve palsy with consequent poor lid closure on the right side.

The continuous exposure led to gross scarring and vacularisation, and unaided vision of counting fingers. A sealed RGP scleral lens was fitted, retaining a full and constant pre-corneal fluid reservoir. The visual acuity improved to 6/36 and the progress of the veovascularisation was held in status quo.

3b

Female, age 50. Acute Stevens Johnson sensitivity to routinely prescribed sulphonamides at age 25.

4aClinical History

Spectacle VA: <6/60

Rigid lens potential VA: 6/24

Fellow eye: nil L/P, wears cosmetic shell.

4bContact lens history

1981. An impression PMMA scleral lens was issued after recovery from the acute phase. This was worn successfully for 23 years.

1998. Tolerance to the PMMA lens began to be more difficult, so a preformed RGP sealed scleral lens, fitted with corneal clearance, was issued. Her tolerance improved, but the VA was inferior.A second lens with central corneal contact gave a significant improvement in VA and, surprisingly, was more comfortable.

2000. The RGP scleal lens has been worn for 24 months with improved tolerance compared to the PMMA lens. The patient also reported an improvement in clarity of vision. The recorded VA was much the same as before, at 6/24, although 6/18 has been recorded on some occasions.

4c

Male, age 55. Late onset keratoconus diagnosed age 45.

5aThere was a rapid development of a very protrusive globic type corneal profile lead to significant visual loss over a four year period leaving no worthwhile improvement with spectacles. Rigid corneal lens fitting was unsuccessful due to discomfort and instability of the lens in situ. The other eye had developed hydrops, which had more or less resolved, but refitting with contact lenses had been postponed. The profile was much the same as the right eye, having a similar outcome with corneal lenses prior to the hydrops episode. A scleral lens was suggested as a final option before a transplant. The idea was immediately taken up by the patient who did not want an eye operation if there was a feasible alternative. A sealed RGP scleral lens was fitted clear of the cornea at the visual axis and a glancing contact at the cone apex. Following issue, he built up to all day wear within one week. Visual acuity was 6/9. To date, the lens has been worn trouble free for 24 months.

5b

Female age 15. Congential cataract and ptosis.

6aThe congenital cataract was removed but following post surgical complications, the eye was left with counting fingers only. Approaching her mid teens, she became more appearance conscious and asked if any non surgical option was available to improve the appearance. A sealed RGP scleral lens was a starightforward fitting exercise and made a significant raise in the level of the upper lid from just at the upper pupil margin by a further 2 to 3mm.

 

6b

Other Examples

7aAdvanced keratoconus which was unfittable with a corneal, but an RGP non ventilated scleral retained a fluid reservoir without corneal contact.

 

7b

 

 

 

 

8a

Moderate keratoconus with a corneal erosion caused by the edge of an RGP corneal lens. A non-ventilated RGP scleral provided an opportunity for recovery while retaining useful vision.

 

8b

 

 

 

 

9aSalzmann's type corneal changes causing severe visual degradation and discomfort fitted with a non-ventilated RGP scleral lens



9b

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