BY:•Noor Munirah bt Awang Abu Bakar•Optometrist (Moc No: O-869)

CASE STUDY :KERATOCONUS

58 years old /MaleOccupation: Office workerNature 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

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

NO EXAMINATION RE LE1 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

NO EXAMINATION RE LE3 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 Limit5 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

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 LE1 Corneal

astigmatism3.4D 2.6D

2 Sim K •6.61mm @ 155 •9.95mm @ 95

•6.46mm @ 13•6.83mm @ 103

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

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

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

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.

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

Thank you