Contact lens for Keratoconus case study

Contact lens for Keratoconus case study

• 1.
  BY: •Noor Munirah btAwang 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:  Startwearing 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 RELE 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 RELE 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 wasinstructed 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:  Camewith 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: Whatare 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: Whatother 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: Whatother 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: Whatother 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
• 12.
  Thank you