By "Dr. Leukoma" Greg Gemoules, OD Coppell, Texas www.leukoma.com

The contact lens is the primary treatment for refractive surgery-induced visual aberrations. In most cases, some type of rigid lens will be necessary. This is due to the fact that almost all of the surgically-induced problems are artifacts from the ablation or flap complications involving the front surface of the eye, in which irregular and asymmetrical shapes are produced. Only the rigid lens possesses the requisite optical properties to resolve these irregularities. However, several mitigating factors can interfere with a good result.

First of all, patients who seek refractive surgery are often ill-disposed to wearing contact lenses for physiological or behavioral reasons, or else they would not have been motivated to seek a surgical alternative in the first place. Secondly, the complicated post-refractive eye is often tear deficient. Finally, finding a practitioner who has the expertise to fit them is often the most daunting of tasks. Therefore, patients first of all need to understand that additional surgery will probably not be able to fix their problem. Then, they need to be shown that the contact lenses can indeed produce the rather dramatic improvements sought, and that they will not be as unpleasant or as uncomfortable as imagined. This can be done in a fairly straightforward and uncomplicated process. Giving a tutorial in the fitting of these lenses is beyond the scope of this article. However, we shall present two cases illustrating what can be achieved with a successful contact lens fit.

Case 1

The first case is that of a woman who consulted me for treatment of vision problems related to LASIK, of approximately 4 years duration. The problem is such that she experienced poor visual acuity, monocular diplopia, glare and halos, especially at night. I first consulted with her in Spain in October of 2002. At that time, her best-corrected visual acuity was approximately 20/150. She had consulted many specialists within Spain, and had been told that her only recourse is to undergo bilateral corneal transplants to replace the damaged tissue. The cause of her visual disability is poor optics from the surgery, including various aberrations caused by a small optical zone, and numerous corrugations and wrinkles in the flaps of corneal tissue created by the surgery.

Some lenses were made and sent to her in the care of her physician. She experienced very good vision, but the lenses became uncomfortable after a few hours. She therefore decided to travel to Texas to refine the fit of the lenses. As a result of wearing the original lenses designed for her in October, her vision had improved to 20/40 in the right eye, and 20/25 in the left eye with only spectacles to correct a slight astigmatism. The cause of this is that the contact lenses had smoothed the surface of her corneas. Now, she is able to wear her new contact lenses comfortably all day. With the newest contacts in place, her vision is 20/30 in the right and left eyes. With a small spectacle prescription, she can see 20/20 in either eye without the lenses. However, of greater significance is the fact that this patient can see very well without the lenses for up to 6 hours after removal, making all day wear of them unnecessary.

I am happy to report that this woman is now working again in the piano conservatory after four years of disability, and can also drive once again at night. These are her comments:

“Do you imagine where I am writing this letter? In the Conservatory, two pupils have not come to class and I am taking advantage of it to do so. Imagine that two months ago they wanted to send me home in retirement! I hope that this will go on for a long time.”

Discussion

Examination of post-operative topographies revealed smallish (less than 6.0mm) ablations, slight decentration, and irregular astigmatism in both eyes. Sequential topographies taken after the patient had begun wearing the contact lenses demonstrated resolution of the irregular astigmatism, enlarged treatment zones, greater centration, and vastly improved symmetry and regularity of the corneas. This patient does not find it necessary to wear her lenses full-time.

Case 2

This next case is of a patient who underwent bilateral radial keratotomy (RK) 10 years ago. He came to me wearing contact lenses recently fitted by a local doctor. His visual acuity with the contact lenses was 20/30 in either eye. However, unaided, he was only 20/80 in either eye. With prescription spectacles he was correctable to 20/50 in the right eye, and 20/40+ in the left eye. Therefore, he was only able to function with contact lenses.

He was refitted with contact lenses, resulting in 20/20 with the lenses. Unaided vision improved to about 20/50. However, the best news was that he was now able to see 20/20, with spectacles. This patient once again had the option of seeing well with spectacles when he did not choose to wear the contact lenses.

Discussion

This patient exhibited grossly irregular and asymmetrical corneas. After one month of being refitted, dramatic improvements in regularity and symmetry were noted. The patient still suffered from dry eye, but was now able to switch successfully between contact lenses and spectacles.

Summary

The immediate corrective effect of contact lenses on the post-refractive cornea has been demonstrated. Furthermore, the contact lenses also demonstrate a secondary therapeutic effect, restoring the surface to a more regular, symmetrical shape. Now, patients with vision damaged by refractive surgery can be rehabilitated with contact lenses, and can be made to function reasonably normally, as they did before surgery.