"Everything but the kitchen sink."
I am sure everyone has heard this phrase before. But what happens when 'everything' is failing your patients and you are forced to use the kitchen sink?
In our case report, we learn the kitchen sink happens to be RGPs for a 67 year old female struggling with complications after multiple corneal transplants.
Special thanks to USC Roski Eye Institute for providing us this interesting and educational case report.
RGPs: The Kitchen Sink
By:
Dr. Veronica Isozaki, OD, FAAO
Assistant Professor of Clinical Ophthalmology
USC Roski Eye Institute
Patient
67 year old Caucasian female presented to the USC Roski Eye Institute Cornea Service for a cornea consultation. She had a history of two corneal transplants OS, aphakia OS, and currently had a failed graft with steroid response and elevated IOP. The elevated IOP was eventually stabilized with drops and the patient was scheduled for PK and IOL insertion OS, but the IOL was not able to be inserted at time of surgery. Secondary angle closure glaucoma developed post-operatively due to PAS OS, and eight months later an Ahmed Glaucoma valve (AGV) OS was implanted. A secondary IOL was considered at the time of this surgery, but the corneal ophthalmologist recommended trialing an RGP instead due to the long history of surgical complications.
Entering VAs:
ccVA OD: 20/20-1
ccVA OS: CF @ 3ft
Refraction:
OD: +2.50 +0.25 x025 -> 20/20-1
OS: +11.00 +6.00 x155 -> 20/100+1
3 months after the AGV implant: The patient was referred for an aphakic contact lens consult OS.
Contact lens fitting:
OD: Post Graft/42.99 (7.85)/-1.00/10.50 diam/0.14 PC
OS: Post Graft/47.00 (7.18)/-5.00/10.50 diam/0.14 PC
OR:
OD: +3.75 DS -> 20/20-2
OS: +12.50 DS -> 20/40
Fit:
OD: alignment, centered, good mvmt, min/ave PC
OS: AC centrally with AT mid-peripherally, rides high, min PC with some impingement on tube
CHANGE: Decreased diameter OU and flatten PC OU
2 months later: CL dispense and A&R training
Contact lens fitting with new order:
OD: Aspheric/43.50 (7.76)/+2.25/9.8 diam/8.4 OZ/ 0.15 PC --> 20/20-1
OS: Post Graft/47.00 (7.18)/+9.75/10.3 diam/0.16 PC -> 20/30-1
@ near with OTC +3.00 --> OU VA 20/20
OR:
OD: Plano DS -> 20/20
OS: Plano DS -> 20/30-1
Fit:
OD: alignment, ave PC centered, good mvmt
OS: alignment, ave PC, centered, good mvmt - not impinging superior-temporal tube!
1 week later: CL follow-up
Average WT 12-14 hours, today WT 4.5 hours
Patient reports very good comfort OU but some difficulty with removal of lenses at the end of day
OD Aspheric/43.50 (7.76)/+2.25/9.8 diam/8.4 OZ/ 0.15 PC -> 20/20-1
OS Post Graft/47.00 (7.18)/+9.75/10.3 diam/0.16 PC -> 20/40-2
OR:
OD: +0.25 DS -> 20/20-1
OS: Plano DS -> 20/30
Fit:
OD: alignment, ave PC centered, good mvmt
OS: clearance centrally, min PC sup-temp and inf-nasal, centered, good mvmt, not impinging superior-temporal tube but causing inf conj impression from 5 to 7 o'clock
*impression ring from 5 to 7 o'clock when lens drops*
Order: flatter BC and flatten PC OS
OS: Post Graft/46.50 (7.26)/+10.25/10.3 diam/0.17 PC
Clinical pearls:
Scleral lenses are great, but not always possible! If a patient has a tube or a bleb from a prior glaucoma surgery, need to ensure it is patent and not obstructed by any type of contact lens
RGPs are a great options for patients who have an irregular cornea from a corneal transplant, and/or are aphakic
However, aphakic patients with RGPs will be heavy, thick, high plus lens, so monitor for movement and if the lens drops inferiorly due to the excess weight
Also should be high Dk material since lens is so thick