The Role of Contact Lenses in the Care of

Corneal Surgery Patients

University of Missouri-St. Louis

School of Optometry

Michael D. DePaolis, OD, FAAO

 Objectives of this lecture:

1.      To understand lens design and fitting for post-PK

2.      To understand and apply lens designs in the contact lens management of the post-refractive surgery patient

Undoubtedly, irregular astigmatism remains one of the greatest challenges for today’s contact lens clinician. Usually the result of disease, trauma, or contact lens wear, irregular astigmatism is becoming increasingly prevalent by virtue of the number of therapeutic and refractive corneal surgical procedures performed today. In this course we address the role of contact lenses in managing patients having undergone penetrating keratoplasty (PK), radial keratotomy (RK), excimer laser photorefractive keratectomy (PRK), and laser assisted intrastromal keratomileusis (LASIK). As there are few "rules" for managing these patients, the contact lens clinician must be competent, creative, and conservative.

  1. PENETRATING KERATOPLASTY (PK)
    1. Special Considerations

1.      Patient History

a.       Preoperative Diagnosis

b.      Has Patient Worn Contact Lenses Before?

1.      Status of the Transplant

a.       Epithelial Integrity/Stromal Clarity/Endothelial Viability

b.      Pre-existing Neovascularization

1.      Altered Corneal Topography

a.       Proud Vs Plateau Graft Profile

b.      Irregular Astigmatism

    1. Contact Lens Options

1.      Wearing Time – Will LASIK Give Us An Alternative?

2.      Soft Lenses – With or Without an Overcorrection?

3.      RGP Lenses – The Design of Choice?

4.      Hybrid Lenses – SoftPerm Vs Epicon/Ultracon?

5.      Combination (Piggyback) Lenses – When & Why?

    1. Fitting Strategies

1.      Material Selection

2.      Fitting Philosophy

a.       Soft Lenses – Are Torics Advisable?

b.      RGP Lenses

1.      Distribution of Lens Mass

2.      Standard Multicurve Vs Bicurve Vs Reverse Geometry Designs

a.       Hybrid Lenses – Should We Strive for Edge Lift?

b.      Combination Lenses – Assuring Adequate Movement

    1. Complications

1.      Persistent Edema

2.      Progressive Neovascularization

3.      Lens Adherence

4.      Infiltrative Keratitis

5.      Allograft Rejection

  1. RADIAL KERATOTOMY (RK)
    1. Special Considerations

1.      Patient History

a.       Previous Contact Lens Failure?

1.      Postoperative Corneal Status

a.       Epithelial Integrity – Wettability & Incision Stability

b.      Incision Neovascularization

1.      Altered Corneal Topography

a.       Irregular Astigmatism

b.      Plateau with Apical Decentration

c.       Diurnal Fluctuation

    1. Contact Lens Options

1.      Wearing Time – Can Additional Surgery Lessen Rx Dependence

2.      Soft Lenses – No Longer a Contraindication?

3.      RGP Lenses – The Design of Choice?

4.      Hybrid Lenses – Are SoftPerm or Ultracon Justified?

5.      Combination (Piggyback) Lenses – Are They Even Indicated?

    1. Fitting Strategies

1.      Material Selection

2.      Fitting Philosophy

a.       Soft Lenses – Are Torics Advisable?

b.      RGP Lenses

1.      Distribution of Lens Mass

2.      Standard Multicurve Vs Customized Design

a.       Hybrid Lenses – Assuring Adequate Mvmt

    1. Complications

1.      Progressive Corneal neovascularization

2.      Infiltrative Keratitis

3.      Refractive Instability

  1. EXCIMER LASER PHOTOREFRACTIVE KERATECTOMY (PRK)
    1. Special Considerations

1.      Patient History

a.       Prior Contact Lens Failure?

1.      Postoperative Corneal Status

a.       Ocular Surface Drying

b.      Epithelial Thickness

1.      Altered Corneal Topography

a.       Plateau of Optic Zone

b.      Decentration of Optic Zone – Not As Significant as RK

    1. Contact Lens Wearing Options

1.      Wearing Time – Can Additional Surgery Lessen Rx Dependence?

2.      Soft Lenses – The Design of Choice for Residual Rx?

3.      RGP Lenses – the Design of Choice for Irregular Astigmatism?

4.      Hybrid Lenses – Soft Perm Vs Ultracon – Do They Play a Role?

    1. Fitting Strategies

1.      Material Selection

2.      Fitting Philosophy

a.       Soft Lenses

1.      Adequate BC Alignment

a.       RGP Lenses

1.      Distribution of Lens Mass

2.      Standard Multicurve

a.       Hybrid Design

1.      Assuring Adequate Mvmt

    1. Complications

1.      Epithelial Edema

2.      Infiltrative Keratitis

3.      Late Presenting Haze

4.      Refractive Error Shifts

  1. LASER ASSISTED INTRASTROMAL KERATOMILEUSIS (LASIK)
    1. Special Considerations

1.      Patient History

a.       Prior Contact Lens Failure?

1.      Postoperative Corneal Status

a.       Ocular Surface Drying

b.      Flap Integrity

1.      Altered Corneal Topography

a.       Plateau of Flap/Ablation Zone

b.      Decentration of Flap/Ablation Zone

    1. Contact Lens Wearing Options

1.      Wearing Time – Can Additional Surgery Lessen Rx Dependence?

2.      Soft Lenses – The Design of Choice for Residual Rx?

3.      RGP Lenses – The Design of Choice for Irregular Astigmatism?

4.      Hybrid Lenses – SoftPerm Vs Ultracon – Do They Play a Role?

    1. Fitting Strategies

1.      Material Selection

2.      Fitting Philosophy

a.       Soft Lenses

1.      Is BC Flat Enough?

a.       RGP Lenses

1.      Distribution of Lens Mass

2.      Standard Multicurve

a.       Hybrid Design

1.      Assuring Adequate Mvmt

    1. Complications

1.      Epithelial Edema

2.      Flap Apposition

3.      Deep Neovascularization

4.      Refractive Error Shift