CASE STUDIES
Scleral lens case studies
Three fittings written up properly — the reasoning, the designs that failed, and what the follow-up actually involved.
Why these are written the way they are
Most published fittings read as a straight line from problem to solution. Real ones rarely are. Each of these includes the step that went backwards, the design that made things worse, or the compromise we settled for — because that is the part another clinician can use, and because a case report with no difficulty in it is not describing a difficult case.
All three are patients of this practice, written up with identifying details removed. They are individual courses, not typical results.
A refraction that would not repeat
Keratoconus · corneal warpage · Salzmann’s nodule
A man in his seventies, forty years in small-diameter rigid lenses, referred for spectacles rather than for lenses. His subjective refraction would not repeat from one presentation to the next — which is not what keratoconus does. The lenses correcting his cornea had been moulding it, and a nodule sat exactly where the lens bore down.
Fitting was deliberately deferred for a five-week washout before any measurement was taken. Includes an honest account of why five weeks was probably too short, and of midday fogging that arrived twice and was managed in opposite directions.
Past the last drop
Sjögren’s syndrome · refractory ocular surface disease · conjunctivochalasis
A woman in her sixties who had worked through serum tears, punctal plugs, amniotic membrane, ciclosporin and a secretagogue, and was still symptomatic. The case for a scleral lens here is mechanical rather than pharmacological: continuous, where every item on that list is intermittent.
Conjunctivochalasis led us to tighten the landing zone deliberately, against the usual instinct — including what the published literature says about that reasoning, which is not a clean endorsement.
A clear graft reading 20/50
Penetrating keratoplasty · high irregular astigmatism · zoster lid sequelae
A man in his seventies, eight years post-transplant, with 7.25 dioptres of astigmatism and a graft that was perfectly clear. Five haptic designs, one of which made the fit worse, and a lid position that displaced every lens from the first to the last.
Also includes a handling incident that changed how we counsel every plunger user.
For referring physicians
Every patient referred to us generates a written report: the imaging with the relevant findings called out, whether the disease looks stable or progressing and on what evidence, the lens design and why that one, the acuity achieved and what limits it, ocular surface findings, and the follow-up interval. Then they come back to you for their primary eye care.
See referring physicians, when to refer a keratoconus patient, or what happens after you refer.
If one of these sounds like your eyes
Specialty lenses are all we do. If you have been told there is nothing more to try, that is usually the point at which this practice is worth a call.