Keratoconus, a progressive thining disorder of the cornea, often reaches a stage where corneal transplantation surgery is the only option. However before taking this step patients should be evaluated by an experienced contact lens specialist to see if other options are possible. Here is a wonderful case example.

This past week I was referred a young man (only 22 years old) from one of our associates at our practice. The patient was first examined by my associate about 4 years ago when he noticed that his vision in his left eye was getting blurry. A careful analysis revealed the presence of early keratoconus with best corrected vision in the eye of 20/25 with distortion. My associate, Dr. Darin Strako, is a pediatric specialist however he also treats adults and has significant contact lens experience. He fit the young man in “piggy back” system lenses. This is a treatment modality where we fit the patient with a thin, highly oxygen permeable soft disposable contact lens (with no effective prescription) and then we fit a rigid highly gas permeable keratoconus design lens to be worn directly over the soft lens. The advantages include improved comfort over rigid lens wear alone and the ability to center the lens over the eye more consistently because the soft lens tends to improve the regularity of the corneal surface to a mild degree. This contact lens system worked for our patient for a few years, however he stated that the vision correcting rigid lens started to move off center and dislocate frequently. Attempts by my associate to improve the fit were not successful.

Dr. Strako noted dramatic progression in the degree of keratoconus in the patient’s eye to the point that he felt that he needed corneal transplantation surgery. The patient was referred to me for consultation prior to surgery. Upon my examination I noted that the patient had true one eye (or unilateral) keratoconus. There was no evidence of the disease in the right eye at all (even with our most sophisticated and advanced testing). The keratoconic left eye however was quite advanced with the disease (moderate scaring and dramatic thinning and distortion of the cornea). For sure corneal transplantation was a distinct possibility for our patient. However I wanted to make one more attempt to put off surgery if possible. I performed a diagnostic evaluation of a scleral contact lens. We were able to fit a lens that centered over the cornea, vaulted the cornea to provide a tear layer under the lens but above the surface of the cornea. The lens rested on the less sensitive white of the eye (the sclera). Amazingly the patient was immediately very comfortable with the lens on  and to our great pleasure (as well as that of the patient and his mom!) we were able to provide him with 20/25+ visual acuity without distortion!

This is another example of the benefit of patients seeing experienced contact lens specialists when they have diseases such as keratoconus. Although surgery may still be in this patient’s future, I expect him to avoid corneal transplantation for some time to come.  With each passing year our surgical techniques become more advanced and successful – so delaying surgery is typically a positive thing to do in cases like this.

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