CONTACT LENS MANAGEMENT OF THE CORNEAL SURGERY PATIENT
AMERICAN ACADEMY OF OPTOMETRY 2011
Michael DePaolis, OD, FAAO
Visionary Eye Associates
University of Rochester Medical Center mgadep@aol.com
FINANCIAL DISCLOSURE STATEMENT
Clinical Investigator: Alcon, Allergan, AMO, B&L, Ciba, CooperVision, Paragon, SynergEyes, J&J, VMax
Optometric Editor, Primary Care Optometry News
Independent Director, RevitalVision
CONTACT LENSES & REFRACTIVE SURGERY CLINICAL CONSIDERATIONS
INDICATIONS
RADIAL KERATOTOMY
EXCIMER LASER PRK & LASEK
EXCIMER LASER LASIK
PENETRATING KERATOPLASTY
DEEP ANTERIOR LAMELLAR KERATOPLASTY (DALK)
CORNEAL COLLAGEN CROSS-LINKING
RATIONALE
PERIOPERATIVE ADJUNCT
LONG-TERM VISUAL RESTORATION
POST SURGERY SPECIAL CONSIDERATIONS

PHYSIOLOGIC ALTERATIONS
 EPITHELIAL, STROMAL & ENDOTHELIAL INTEGRITY
 OCULAR SURFACE DRYNESS
CORNEAL TOPOGRAPHY
 ‘REFRACTIVE ZONE’ REGULARITY & CENTRATION
REFRACTIVE CONSIDERATIONS
 INTRODUCTION OF HIGHER ORDER ABERRATIONS?
POST SURGICAL CONTACT LENSES CLINICAL CONSIDERATIONS
RIGID GAS PERMEABLE - TOPOGRAPHY BASED FITTING GUIDELINES
BASE EVALUATIONS ON ‘AXIAL’ MAPS
BASE CURVE BETWEEN PRE-OPERATIVE AND POST-OPERATIVE CENTRAL K’s
‘REVERSE GEOMETRY’ 2nd PC AVERAGE OF 4 MID-PERIPHERAL POINTS
CONFIRM WITH NaFL EVALUATION !!
CASE STUDY - KC 47 YOF
OCULAR HISTORY
LASIK OU 4 YEARS AGO, 2 ENHANCEMENTS OU, POST SURGICAL ECTASIA, C/O BLURRED VA AND
DRYNESS
SYSTEMIC HISTORY: FIBROMYALGIA
MEDS: AMYTRIPTYLINE NKDA FAM HX NEGATIVE
EXTERNAL EXAMINATION: VA Rx OD 20/80 & OS 20/60
PERRLA (4mm) EOM F&S CF - FULL TO FC OU
BIOMICROSCOPY: WELL HEALED LASIK OU, INFERIOR THINNING OU , EPITHELIAL PIGMENT OU
OPHTHALMOSCOPY: 0.3 x 0.3 HNRR / NRML VASC, MAC, PP, PERIPH OU

TOPOGRAPHY: PELLUCID’S OD & OS. KERATOMETRY: OD 48.00x56.00 OS 42.50x49.75
REFRACTION: OD +2.00-7.50x92 = 20/100 OS +2.00-6.50x88 = 20/60
PACHYMETRY: OD NA & OS NA
CONTACT LENSES
OD SynergEyes KC 6.90 14.5 -8.50 C/OPT 20/30+
OS SynergEyes KC 7.60 14.5 -3.50 C/OPT 20/25
WT ~ 14 HR qd OF Express qhs
EXCIMER LASIK POTENTIAL COMPLICATIONS
EPITHELIAL FLAP DEFECTS
INFILTRATIVE KERATITIS
DIFFUSE LAMELLAR KERATITIS
REFRACTIVE SHIFTS
LASIK CLINICAL PEARLS
POST OPERATIVE ECTASIA IS THE ‘DEMON’ IN THE CLOSET
LISTEN TO PATIENT’S PRE OPERATIVE CL HISTORY
PRESCRIBE WITH A ‘KERATOCONUS’ MENTALITY
MINIMIZE CONTACT LENS RELATED ‘TRAUMA’
USE THERAPEUTIC ADJUNCTS AGGRESSIVELY
WITH SYNERGEYES, START WITH THE SIMPLEST DESIGN
CASE STUDY - GH 55 YOM
SURGICAL HISTORY : RADIAL KERATOTOMY OU / ENHANCED OD PILOCARPINE 0.5% OU PRN

PREOPERATIVE RX: OD -1125 -050 x 175 / +175 = 20/30+ OS -950 -050 x 110 / +175 = 20/30+
BIOMICROSCOPY: WELL HEALED 16 INCISION RK OD & 8 INCISION RK OS, NO KCS OR INCISION GAPING
OU
KERATOMETRY: OD 3325@150 & 3475@100 OS 3525@100 & 3625@180
REFRACTION*: OD -275 -100 x 114 / +200 = 20/40- & OS -300 -050 x 27 / +200 = 20/40-
*Diurnal variations & monocular diplopia
TX: GPCL OD BEO REVERSE GEOMETRY 910 -700 98/80 810(2nd)/1000(pc)
GOOD CTR & OPT MVMT VA = 20/30
TX: GPCL OS BEO REVERSE GEOMETRY 910 -550 98/80 810(2nd)
SL DCR & OPT MVMT VA = 20/30+
WT 10 HRS qd & BOSTON LENS CARE
RADIAL KERATOTOMY POTENTIAL COMPLICATIONS
EPITHELIAL EROSION
INCISION LINE KERATITIS
CORNEAL NEOVASCULARIZATION
REFRACTIVE ERROR REGRESSION
RADIAL KERATOTOMY CLINICAL PEARLS
DIURNAL FLUCTUATIONS -> RIGID OPTICS
ORIENTATION OF OZ DECENTRATION IS MORE IMPORTANT THAN NUMBER OF INCISIONS
ELIMINATE TRADITIONAL PC MENTALITY
CASE STUDY - JS 36 YOM
OCULAR HX: CONTACT LENS INTOLERANCE SECONDARY TO KERATITIS SICCA

SYSTEMIC HX: DEPRESSION & SEASONAL ALLERGY MEDS: NONE
BILATERAL PRK CC: DRY EYES & ASTHENOPIA
EXTERNAL EXAMINATION : OD sc 20/40 / OS sc 20/70 PUPILS - PERRLA (6mm / 8mm) EOM - F & S / CF
- FULL OU
TONOMETRY: 15 mm Hg OD / 15 mm Hg OS
OPHTHALMOSCOPY: DFE - 0.4x0.4 HNRR / MYOPIC CONUS / PP NRMLOU
BIOMICROSCOPY: MILD KCS OU, ARCUATE HAZE OD,,CENTRAL HAZE OS, LENS CLR OU
PACHYMETRY: OD NA & OS NA
PREOPERATIVE Rx: OD -7.50 -0.50 x 165 = 20/15 OS -7.00 -0.75 x 180 = 20/15
FINAL Rx: OD +1.50 -1.25 x 21 = 20/25+ OS -1.25 -0.75 x 142 = 20/25+
KERATOMETRY: OD 37.78 x 39.32 D and OS 39.87 x 40.95 D
DX: KCS OU / PRK INDUCED ANISOMETROPIA
TREATMENT: LID HYGIENE / THERATEARS qid / GEN TEAL GEL qhs / LOWER LID PUNCTAL PLUGS
OD FREQUENCY 55 8.7 +1.50 -1.25 x 20 = 20/25
OS FREQUENCY 55 8.7 -1.25 -0.75 x 140 = 20/25
AMO COMPLETE MPS qhs / BLINK gtt prn
POST-PRK HAZE PREVENTION
Stojanovic, etal J Ref Surg 19(3):2003
N = 314 Eyes Tx w/o Vitamin C
N = 204 Eyes Tx w Vitamin C (500mg po bid x 3 wks)
Haze was significantly less at 1 week &
1, 3, & 6 month visits in the Vitamin C group
Late presenting haze in 11 eyes in the group w/o Vitamin C & in 0 eyes in the Vitamin C group

EXCIMER PRK RIGID CONTACT LENS “PEARLS”
Shipper I, Businger U, Psarrer R: CLAO 21(4):1995.
POST PRK GP FITTING FOR Rx: STANDARD ASPHERIC DESIGN, FINAL GP BC ~ 0.065 mm FLATTER
THAN PRE-OPERATIVE RGP BC
EXCIMER PRK & ASA POTENTIAL COMPLICATIONS
EPITHELIAL EDEMA
INFILTRATIVE KERATITIS
STROMAL HAZE (LATE PRESENTING)
REFRACTIVE REGRESSION
POST PRK CLINICAL “PEARLS”
 AGGRESSIVELY TREAT OSD BEFORE SURGERY
 AGGRESSIVELY MANAGE OSD AFTER SURGERY
 IF TEAR EVAPORATIVE DRY EYE -> GO SOFT
 IF GPCL, SELECT DESIGN SIMILAR TO PRE-OPERATIVE DESIGN
CASE STUDY - HS 33 YOM
OCULAR HX: CONTACT LENS INTOLERANCE SECONDARY TO KERATITIS SICCA
SYSTEMIC HX: ALLERGIES & ASTHMA MEDS: SINGULAIR
BILATERAL LASIK CC: VARIABLE VISION
EXTERNAL EXAMINATION : OD sc 20/40 / OS sc 20/30 PUPILS - PERRLA (4mm / 6mm)
EOM - F & S / CF - FULL OU

TONOMETRY: 14 mm Hg OD / 14 mm Hg OS
OPHTHALMOSCOPY: DFE - 0.4x0.4 HNRR / MYOPIC CONUS / PVD OU
PREOPERATIVE RX: OD -15.25-2.75X165 = 20/30 OS -13.50-3.00X179 = 20/30
PRE-ENHANCEMENT RX: OD -2.75 SPH = 20/30- OS -0.50 -1.25 x 165 = 20/25-
FINAL RX: OD -0.75 -0.50 x 172 = 20/25+ OS -0.50 -0.50 x 23 = 20/25+
BIOMICROSCOPY: MILD KCS OU, CENTRAL BASAL EPITHELIAL PIGMENT OU, LENS CLR OU
PACHYMETRY: OD 393 u and OS 412 u
TOPOGRAPHY: CENTRAL FLATTENING, MILD DECENTRATION
KERATOMETRY: OD 34.07 x 33.40 D & OS 34.70 x 35.50 D
DX: POST LASIK TEAR STAGNATION DRY EYE
TREATMENT:
KCS MANAGEMENT - LID HYGIENE / SYSTANE gtt prn / PUNCTAL PLUGS
OD 1-DAY ACUVUE 9.0/14.2 -1.25 = 20/25 & OS 1-DAY ACUVUE 9.0/14.2 -0.50 = 20/25
POST LASIK CLINICAL PEARLS
THE ENEMY OF GOOD IS PERFECT
DON’T UNDERSTATE THE IMPORTANCE OF THE POTF IN VISION
ALWAYS INVESTIGATE THE SIMPLE SOLUTIONS FIRST
CASE JV – 34 YOF
OC HISTORY : Previous EWSCL OU, Bilateral acanthamoeba keratitis 2001
SYSTEMIC HISTORY : Excellent. No med. No nkda
CC:Blurred Vision with spectacles OU. Intolerant to GPCL OU.

OCULAR MEDS: Pred forte OS qid & Zovirax ung OS bid
VISUAL ACUITY cc : OD 20/40+ & OS 20/400
BIOMICROSCOPY: Corneal leukoma and neovascularization OS > OD, No activeherpetic lesion OS
REFRACTION: OD -6.25-0.75x45 = 20/20 OS -4.50-5.50x91 = 20/50
TOPOGRAPHY: Irregular astigmatism OU KERATOMETRY: OD 43.62 x 45.00 OS 41.12 x 54.12
CONTACT LENSES
 OD Boston EO 7.60 9.3/7.8 -6.00 Central position, apical clearance, optimal movement, 20/20
 OS SynergEyes 7.30 14.5 -8.00 8.6sc Inferior position, apical clearance, minimal movement ,
20/25
CASE STUDY - RH 48 YOM
OCULAR HX: ELECTIVE LASIK 18 MTHS PRIOR. OD ABORTED DUE TO ‘SHORT’ FLAP
OD LASIK 3 MTHS LATER -> OVERCORRECTION. OS LASIK WITHOUT COMPLICATIONS
SYSTEMIC HX: EXCELLENT MEDS: NONE
EXTERNAL EXAMINATION: OD sc 20/100 / OS sc 20/25+
PUPILS - PERRLA EOM - F & S / CF - FULL OU
TONOMETRY: 15 mm Hg OD / 15 mm Hg OS
BIOMICROSCOPY: ARCUATE HAZE OD , CLEAR CORNEA OS
PREOPERATIVE RX: OD -5.50 - 0.75 x 180 = 20/20 OS -5.25 - 0.50 x 180 = 20/20
FINAL RX: OD +3.50 - 0.50 x 150 = 20/20- OS PLANO SPH = 20/20-
KERATOMETRY: OD 34.87 x 36.50 @113 OS 39.50 x 40.37 @ 97
DX: Lasik Overcorrection OD
TREATMENT: LENS DYNAMICS POST LASIK DESIGN BOSTON EO 8.33 10.0/8.0 Plano ‘C’

BOSTON SIMPLUS qhs SYSTANE prn SLE - CENT /OPT MVMT / MAC VA = 20/20
FOLLOW UP VISIT: WT 16 HRS qd BOSTON SOLNS Qhs “VISION IMPROVING WITHOUT CL!!”
SLE - CENT / OPT MVMT VA = 20/20 OD 36.88 x 38.08 @130 OD +2.50-0.50 x 25 = 20/20
REORDER ?
LENS DYNAMICS INTRALIMBAL DESIGN BOSTON EO 8.10 11.2/9.4 -1.25
WT 16 HRS qd / SIMPLUS Qhs SYSTANE gtts qprn SLE - CENT / OPT MVMT / MAC VA = 20/15-
POST LASIK CLINICAL PEARLS
RETREATMENTS ARE ANYTHING, BUT ROUTINE
GPCL’s CAN ALTER REFRACTIVE STATUS
IF SIGNIFICANT OBLATE CORNEA, THINK REVERSE GEOMETRY AND/OR LARGE DIAMETER
DISCONTINUATION OF GPCL PRIOR TO ADDITIONAL SURGERY ?
Gemoules Eye Contact Lens 31(1): 2005.
N = 5 eyes post refractive surgery
corneal topography & wavefront analysis with & without GPCL’s
Mean visual acuity sc 20/40, spectacle Rx 20/26, GPCL Rx 20/20
GPCL wear ….
improved corneal topography (regularity & symmetry)
reduced higher order aberrations
provided a molding effect which last hours to days
CASE STUDY - SC 34 YOM
OCULAR HISTORY: BILATERAL LASIK 18 MONTHS PRIOR, C/O ‘FUZZY’ VISION IN LOW LEVELS OF LIGHTING

ALPHAGAN 1gtt ou qd HELPS
SYSTEMIC HISTORY: EXCELLENT / NO MEDS / NKDA
EXTERNAL EXAMINATION: UCVA OD 20/40+ & OS 20/30+ PERRLA (5mm) / EOM F&S / CF - FULL OU
GOLDMANN IOP’s OD 15 & OS 15
BIOMICROSCOPY: WELL HEALED LASIK OU
OPHTHALMOSCOPY: 0.3 x 0.3 HNRR / NRML VASC, MAC, PP, PERIPH OU
TOPOGRAPHY: SUPERIOR TEMPORAL ABLATION OD / SUPERIOR ABLATION OS
KERATOMETRY: OD 41.83x42.31@140 OS 41.46x42.26@60
REFRACTION: OD -0.50-0.50x120 = 20/20 OS -0.50 sph = 20/20
PACHYMETRY: OD 478u OS 509u
TREATMENT PLAN:
OD B&L PUREVISION 8.6 -0.50 C/OPT 20/25+ & OS B&L PUREVISION 8.6 -0.50 C/OPT 20/20
OPTIFREE REPLENISH qhs, ALPHAGAN –P 1 gtt ou qd prn
LONG TERM STRATEGY : WAVEFRONT GUIDED ABLATION
POST LASIK CINICAL PEARLS
SYMPTOMS OF GHOSTING AND SHADOWING CAN INDICATE HIGHER ORDER ABERRATIONS
‘POOR MAN’S ABERROMETER’
CONSIDER ABERRATION BLOCKING SCL’s OR GPCL’s
CONSIDER ALPHAGAN-P prn
Gegnoules & Morris Eye & Cont Lens 33(6):2007.
N = 20 eyes s/p refractive surgery with visual symptoms
iTrace aberrometry w/o & with Macrolens

Mean visual acuity: Sc 20/30 Spectacles 20/25 GPCL 20/20
GPCL reduced …. Total HOA 30 – 77% (m = 65%), Coma 39 – 93% (m = 71%), SA 41– 100% (m = 82%)
Increased HOA fx of pre-operative Rx and pupil size
CASE WF – 56 YOM
OCULAR HISTORY: Keratoconus OU x 35 yrs, Bilateral PK x 30 yrs, Bilateral RK x 25 yrs, Bilateral IOL x 5
yrs, Bilateral Graft Failure
BCVA (SCL + Rx): OD 20/200 OS 20/150
S/P DSAEK OS - BCVA 20/30 with PureVision 86 140 -050. AMO Complete qhs & Blink gtt prn
CASE STUDY - WT 59 YOM
OCULAR HISTORY: BILATERAL LASIK 33 MONTHS PRIOR, ENHANCEMENT OU / FLAP LIFTED x 3 OD
C/O BLURRED VISION OD >> OS
SYSTEMIC HISTORY: EXCELLENT / NO MEDS / NKDA
EXTERNAL EXAMINATION: UCVA OD 20/80- & OS 20/30+
PERRLA (4mm) EOM F&S CF - FULL TO FC OU
BIOMICROSCOPY: WELL HEALED LASIK OU, MACROSTRIAE OD , EPITHELIAL PIGMENT OU
OPHTHALMOSCOPY: 0.3 x 0.3 HNRR / NRML VASC, MAC, PP, PERIPH OU
TOPOGRAPHY: CENTERED OD & OS. KERATOMETRY: OD 39.7x42.5@8 OS 41.8x42.1@25
REFRACTION: OD +2.75-2.75x105 = 20/25 OS +1.25-1.00x80 = 20/20
PACHYMETRY: OD 342u & OS 512u
B&L SOFLENS 66 8.5 14.5 +2.75 - 2.25 x 100 OPTIMAL FIT & NO ROTATION VA cc 20/25-1
RENU MPS qhs
CASE RB - 53 YOM

OC HISTORY : CONGENITAL CATARACT & AMBLYOPIA OS, FUCH’S DYSTROPHY OU / CATARACT OU
SYSTEMIC HISTORY: EXCELLENT / NO MEDS / NKDA
SURGICAL HISTORY: CATARACT EXTRACTION + IOL + PK OD
VISUAL ACUITIES: OD Rx 20/80 and OS Rx CF@2ft
BIOMICROSCOPY: OD - CLEAR PK & PC IOL, OS - FUCH’S DYSTROPHY & CATARACT
KERATOMETRY: 41.50 x 52.00 @ 157
REFRACTION: OD Rx -5.75 -5.00 x 75 = 20/80
PIGGYBACK CONTACT LENS: PUREVISION 8.6/14.0 +0.50 SCL with BOSTON EO 7.00 9.5/8.1 -9.50
CENT POS / OPT MVMT VA = 20/20
PENETRATING KERATOPLASTY POTENTIAL COMPLICATIONS
NEOVASCULARIZATION CONTACT LENS ADHERENCE
GRAFT REJECTION MICROBIAL KERATITIS
CONTACT LENS MANAGEMENT OF THE CORNEAL SURGERY PATIENT
Thank you for attending!
Michael DePaolis, OD, FAAO
DePaolis & Ryan, OD, PC
University of Rochester Medical Center
mgadep@aol.com