1) A 58-year-old male office worker with keratoconus presented with irritation and dryness when wearing RGP lenses. He had a history of extended computer use in an air-conditioned environment. 2) Examination found punctate staining, neovascularization, nasal dellen, and hyperemia in both eyes. Corneal topography showed increased steepening. Fitting a new scleral lens provided better cone clearance and movement. 3) The patient continued having discomfort from dryness likely caused by his medications, work environment, mild MGD, and tight-fitting lenses. Scleral lenses or modifying the RGP lens parameters were recommended to improve comfort.

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

12. Thank you