Article Date: 8/1/2016 Print Friendly Page

POST-OP FITTINGS
Postoperative Contact Lens Fittings
The specifics of fitting contact lenses post-corneal collagen
cross-linking and intrastromal corneal ring segment
implantation.
BY MELANIE FROGOZO, OD, FAAO

Keratoconus, pellucid marginal degeneration, and iatrogenic corneal ectasia secondary to laser
refractive surgery are all characterized by progressive corneal steepening. In these non-
inflammatory ectasias, the cornea assumes an asymmetrical contour, which leads to high
irregular astigmatism and decreased visual acuity. For such conditions, corneal collagen cross-
linking (CXL) and intrastromal corneal ring segment (ICRS) implantation are both well-accepted
and widely performed treatment options.

Although CXL and ICRS implantation—both U.S. Food and Drug Administration (FDA)-approved
procedures—are both effective in treating corneal ectasias, most patients who have undergone
these surgeries need to wear contact lenses to reach their full visual potential. Therefore, it is
important to become familiar with how these procedures change the corneal contour and, thus,
the approach to fitting contact lenses postoperatively. This article will review contact lens fitting
after CXL and ICRS implantation.

Procedures and Corneal Shape Changes

In patients who have primary and secondary ectasias, CXL and ICRSs help normalize the corneal
contour and make it more optically regular. Nonetheless, the corneal shape is affected differently
after each procedure. Understanding both procedures and the consequential postoperative
corneal shape is therefore key to successful contact lens fitting in this population.

Corneal Cross-Linking CXL is a technique that uses ultraviolet light and a photosensitizer to
strengthen the corneal stroma. The primary objective of CXL is to stop the progression of ectasia
by enhancing the mechanical stability of the corneal tissue. Therefore, the best candidates for
CXL are those who have documented progressive ectasia.

CXL is accomplished through a polymerization reaction as a result of combining riboflavin and

ultraviolet A (UVA) irradiation. Riboflavin acts a photosensitizer and, when combined with UVA,
increases the crosslinks between and within the corneal collagen fibers (Spörl et al, 1997; Ziaei
et al, 2015). This interaction between riboflavin and UVA creates reactive oxygen species that
promote the formation of covalent bonds between collagen fibers, increasing corneal rigidity,
collagen fiber thickness, and resistance to enzymatic degradation. Additionally, the increase in
overall strength of the cornea decreases stromal swelling and permeability in the anterior stroma
(Spoerl et al, 1998; Wollensak, Spoerl, Seiler et al, 2003).
Interestingly, CXL is being investigated for other applications, such as treatment of non-
responding infective keratitis (Alio et al, 2013), bullous keratopathy (Ghanem et al, 2010), and
prevention of ectasia in refractive surgeries (Nguyen and Chuck, 2013). Figure 1 shows a
patient undergoing the CXL procedure.

Figure 1. Patient undergoing a CXL procedure. Photo courtesy of Gregory Parkhurst,

MD.

The basic CXL treatment protocol starts with de-epithelialization of the corneal surface followed
by the stromal application of 0.1% isotonic riboflavin solution in 20% dextran. The riboflavin
increases UVA absorption and prevents the corneal endothelium, lens, and retina from being
damaged by UVA light. Note: to avoid UVA endothelial damage, the cornea must be at least 400
microns thick. Finally, UVA light at the wavelength of 360nm to 370nm with an accumulated
irradiance of 5.4 J/cm2 is applied to the corneal surface for 30 minutes (Spoerl et al, 2003;
Wollensak, Spoerl, Seiler et al, 2003).

Currently, attempts at bettering the basic protocol are being investigated. This research includes
improving the stromal penetration of riboflavin while preserving the integrity of epithelium
(Bikbova and Bikbov, 2014) and decreasing the amount of time that the patient is exposed to
UV irradiation (Waszczykowska and Jurowski, 2015).

CXL changes the corneal shape by decreasing keratometric values. In patients who have
progressive keratoconus, reduction in maximum keratometric values range from 1.45D to
6.16D, with an average of about 2.00D (Wollensak, Spoerl, and Seiler, 2003; Vinciguerra et al,
2009; Wittig-Silva et al, 2008). In comparison, those who have iatrogenic corneal ectasia after
laser-assisted in situ keratomileusis (LASIK) only showed a reduction of 1.00D in their maximum
keratometric value after CXL.
The variation in treatment response effectiveness may be due to the difference in riboflavin
diffusion rates or the intrinsic pathophysiology of each individual disease (Hersh et al, 2011).
Although there is mild flattening of the keratometric values from CXL, the overall shape change
is not dramatically affected after the procedure. Thus, contact lenses can be fitted in a regular
fashion post-CXL.

Intrastromal Corneal Ring Segments ICRS implantation is a surgical technique in which

polymethyl methacrylate (PMMA) semi rings are implanted into the stroma to create central
corneal flattening, which consequently reduces refractive error. Originally used for treatment of
low myopia, ICRSs are currently used to improve vision in corneal thinning disorders, such as
keratoconus and LASIK-induced corneal ectasia. ICRSs can also be offered as an alternative to
corneal transplantation (Rabinowitz, 2010; Rabinowitz, 2013).

The ICRS procedure is reversible, and the segments can be removed. Once removed, the cornea
appears to return to its pre-operative shape (Nosè et al, 1993). Figure 2 shows a patient after
ICRS implantation in the left eye.

Figure 2. Keratoconic left eye after ICRS implantation.

The basic procedure of ICRS implantation starts with creation of a tunnel for the segments either
via femtosecond laser or with a mechanical spreader provided by the manufacturer. The tunnel
incision is usually 70% of the corneal thickness. After the tunnel is created, the plastic segments
are placed within the stroma, and a suture is inserted to close the wound site.

Ideal candidates for ICRSs are patients who have mild-to-moderate ectasia and are contact lens-
intolerant. Those considering ICRS must have a clear visual axis, a steepest keratometry value
of ≤58D, and a corneal thickness at the insertion zone for the segment of at least 450 microns
(Rabinowitz, 2010; Rabinowitz, 2013).

Placement location and combination of ICRSs used can vary depending on the type of ectasia
being treated. Usually, implantation of smaller arc segments and greater width sizes leads to
greater reduction in myopia. Customarily, an oval central cone is treated by implanting
asymmetric segments: a wider segment inferiorly and a smaller width superiorly. In milder cases
of keratoconus (in which the cone does not cross the horizontal meridian) and in cases of post-
LASIK ectasia, a single inferior segment is used for treatment (Rabinowitz, 2010; Rabinowitz,
2013).

On average, ICRSs flatten the cornea by 2.0D to 3.0D, which is accompanied by two to three
lines of gained best-corrected vision. Interestingly, improvement in best-corrected vision is
thought to be due to a decrease in higher-order aberrations resulting from ICRSs (Rabinowitz,
2010; Rabinowitz, 2013).

Figure 3A shows a sagittal (axial) curvature map of a patient pre-ICRS implantation and post-
implantation in the right eye. In this case, the max K decreased by 2.3D within an eight-month
follow-up period (Figure 3B).

Figure 3. Axial curvature map OD of a patient who has keratoconus before ICRS
implantation (A) and eight months after implantation (B).
Note the decrease in corneal irregularity after the procedure.

Using Both Procedures Together Although segment implantation flattens the central cornea,
consequential shape changes in the periphery can pose obstacles in contact lens fitting. The
challenge is created due to the increase in elevation above the segment and drastic depression
adjacent to it. This change in elevation throughout the cornea will vary depending on the arc and
width sizes used as well as the location and number of segments implanted. These irregularities
in elevation may cause difficulties with centering a lens and may trap application bubbles in the
areas of depression (Hladun and Harris, 2004; Uçakhan et al, 2006).

It is common to have both CXL and ICRS procedures performed on affected patients.
Nevertheless, the combination treatment efficacy of these surgeries is still unclear. Several
studies have reported that combined CXL and ICRS implantation—compared to each treatment
alone—improved uncorrected and best-corrected acuity as well as keratometry readings
(Saelens et al, 2011; Kiliç et al, 2012; Coskunseven et al, 2009). However, another study
showed no difference in topographical and visual outcome in combined procedures (Cakir et al,
2013).

Contact Lens Fitting After Surgery

After surgery, it is important that the cornea is completely healed and topographic indices are
stable before fitting a patient with contact lenses. Current literature states that corneal GP fitting
can be initiated at three months (Louie et al, 2014; Tran and Edrington, 2007; McCandless,
2008). In my experience, a fitting can be completed as early as one month after CXL and/or
ICRS implantation. Nonetheless, in most cases, three months is an ideal time to start contact
lens fitting after each of these procedures.

With patients who have elected CXL and ICRS treatment, several factors should be met during
the fitting process. First, the lens should provide adequate coverage of the cornea. Contact
lenses, GP more so than soft, will center over the steepest part of the cornea. In post-ICRS
implantation, the lens will decenter toward the peripheral segments. So, consider a larger-
diameter lens to attain satisfactory corneal coverage.

Second, maintain a sufficient oxygen supply to the cornea to avoid hypoxic changes, including
edema and neovascularization. To maximize oxygen transmissibility, it is important to prescribe
lenses made from high-oxygen-permeable (high-Dk) materials.

Third, contact lenses should have a healthy mechanical fit with the ocular surface. In post-ICRS
implantation, corneas will have an area of localized uneven elevation at the segment. It is
important to confirm that the lens has a good mechanical fit and is not rubbing this area. Erosion
of the overlying cornea may cause anterior displacement of the segment (Nosè et al, 1993).

Soft Contact Lenses In many cases, standard soft lenses can be fitted on patients in a
conventional way and still provide adequate quality of vision. This is particularly true for patients
who have mild ectasia and low power corrections. Any of the available daily or frequent
replacement lens modalities are possible for fitting post-CXL or -ICRS implantation.

The material modulus and thickness will affect the way that a standard lens will fit. High-
modulus (stiffer) lenses may result in fluting of the edges, while lower-modulus (softer) lenses
may lay flat and drape over the entire cornea. Even with a low modulus, if the lens has an
increased center thickness, this will create a stiffer profile and will make the lens more
susceptible to fluting. For example, a high-powered soft lens that is thicker in the middle will
tend to flute in comparison to a low-powered lens.

Nevertheless, traditional soft lens designs often provide less-than-optimal vision. In such cases,
consider specialty soft contact lenses designed for irregular and surgically altered corneas.
Specialty soft lenses provide sharper optics by having an increased center thickness to mask
irregular astigmatism. Additionally, these lenses are available in higher sphere and cylindrical
powers, and they have steeper central and peripheral curves to accommodate larger amounts of
corneal irregularity.

Figures 4 and 5 show a patient who has post-LASIK ectasia and who underwent CXL in both
eyes and ICRS implantation in the left eye. The patient is wearing a standard soft toric design in
the right eye (Figure 4A) and a soft lens for irregular corneas in the left eye (Figure 5A). An
optical coherence tomography (OCT) cross-section of each lens is shown for the right (Figure
4B) and left (Figure 5B) eyes; notice the thickness difference between the two designs.
Figure 4. LASIK-induced iatrogenic corneal ectasia fitted with regular soft toric lens in
the right eye (A). OCT cross-section over this lens (B).
Figure 5. LASIK-induced iatrogenic corneal ectasia with ICRSs in the left eye fitted
with specialty soft lens for irregular astigmatism (A). OCT cross-section over this lens
(B). Note differences in lens thickness between the two lenses shown in
Figures 4B and 5B.

Corneal GP Lenses Rigid contact lenses may be the only option to fully correct vision in ectatic
patients who have undergone CXL and ICRS implantation. The differences in shape present
between the surgically treated areas of the cornea and the areas that have not been altered
make GP lenses challenging to fit. Often, corneal GPs do not exhibit a classic alignment pattern
on a surgically altered cornea. Nonetheless, this may be acceptable as long as there is adequate
lens movement, room for a healthy tear pump behind the lens, and the lens does not cause any
harsh areas of punctate erosion.

Although there is mild corneal flattening after CXL, the overall corneal contour does not change
dramatically. Thus, depending on the severity of the ectasia, you can fit corneal GP lenses in a
conventional way. Keratoconus patients who have undergone CXL can be fitted into any of the
available keratoconus lens designs.
In LASIK-induced iatrogenic corneal ectasia, the topography will have a combination of steeper
areas at the site of the ectasia and in the untreated periphery, and it will be flatter in the non‐
ectatic ablated areas. In post-LASIK ectatic patients who have undergone CXL, consider large-
diameter lenses (i.e., greater than 10mm) for centration over the areas of ablation and ectasia
(Steele and Davidson, 2007).

ICRS implantation creates a unique challenge in fitting corneal GP lenses due to the elevation
over the segment and large areas of depression adjacent to it. Corneal insult over the segment
from mechanical irritation must be avoided when fitting a corneal GP contact lens.

Larger-diameter corneal GP lenses center better over this broad area of irregularity and provide
more sagittal depth to achieve light touch to vault over the segment. Figure 6 shows a patient
in a large-diameter corneal GP that vaults over the ICRSs and centers adequately over the left
eye.

Figure 6. Large-diameter corneal GP fitted over ICRSs implanted for treatment of

keratoconus in the left eye. Note the area of clearance over the ICRSs.

A reverse geometry design can also be used to fit patients post-ICRS implantation. In reverse
geometry GP lenses, the peripheral curve adjacent to the optic zone is steeper in comparison to
the optic zone radius.

A reverse geometry lens can be utilized after ICRS implantation if the back optic zone diameter
approximates the size of the segment arc treatment zone (Louie et al, 2014) and the adjacent
peripheral curve is wide and steep enough to either vault or align with the segment. The width of
the optic zone created by ICRSs can range from 4.5mm to 7.0mm, and the segment width can
range from 0.25mm to 0.45mm (Rabinowitz, 2010).

Piggyback Systems Many patients report corneal sensitivity over the segment after ICRS
implantation. When fitting a corneal GP lens, a soft lens with a low power can be fitted
underneath it to increase patient comfort. Additionally, the soft lens can aid in preventing
mechanical irritation over the implanted ICRS. To minimize corneal hypoxia, fit a soft lens with a
high Dk (Nosè et al, 1993; Louie et al, 2014; Smith and Carrell, 2008). Figure 7 illustrates a
piggyback system over ICRSs in the left eye.

Figure 7. Soft lens piggyback system with corneal GP fitted over ICRSs for keratoconus
in the left eye.

Hybrid Lenses Hybrid lenses may also be utilized in fitting those who have undergone CXL and
ICRS procedures. Hybrids have a corneal GP center fused with a soft peripheral skirt. Newer
hybrid lenses are made from high-Dk materials that allow assessment of fit using regular
fluorescein.

Just as with corneal GP lenses, strive for an alignment fit with hybrid designs; however, this is
typically very difficult to accomplish in ectatic and post-surgically altered corneas. Again, the
lens fit is acceptable as long as it allows for healthy tear exchange and is not causing corneal
irritation.

As a reminder, extra precaution must be taken over ICRS implants so as not to cause corneal
erosion over the segments. This can be accomplished with a hybrid lens by making sure the GP
center either aligns with, or vaults over, the ICRSs. Both regular and reverse geometry designs
are available in hybrid lenses. Figure 8 shows a hybrid lens vaulting over ICRSs in the right eye.
Figure 8. A hybrid lens vaulting over ICRSs in the right eye.

Scleral Lenses In contrast to fitting corneal GP lenses in which corneal topography is crucial to
lens design, scleral lenses have the advantage of being able to vault the cornea and rest on the
scleral‐conjunctival anatomy. This makes scleral lenses ideal for fitting over highly irregular
corneas after CXL and ICRS.

These large lenses center well and offer stable vision and good comfort; additionally, their fluid‐
filled reservoir offers therapeutic applications in the case of post-LASIK ectasia patients suffering
from dry eyes (Parminder and Jacobs, 2015). Of additional benefit for patients who have ectatic
disease, the large scleral lens diameter protects the cornea from eye rubbing and thus from
inducing mechanical insult and potentially progressing their disease state.

Scleral lenses are available in both regular and reverse geometry designs.Figure 9 shows two
patients who were successfully fitted with scleral lenses after ICRS implantation. The first patient
had keratoconus and a pinguecula in the right eye, and so the periphery of the lens was notched
(Figure 9A). The second patient developed dry eyes and ectasia after LASIK, and a scleral lens
was used to rehabilitate his vision and treat the dry eye symptoms in his left eye (Figure 9B).
Figure 9. Scleral lens with notched peripheral haptic fitted over ICRSs for keratoconus
in the right eye (A). Scleral lens fitted over left eye with LASIK-induced iatrogenic
corneal ectasia implanted with ICRSs (B).

Summary

CXL and ICRS implantation are both commonly performed surgical treatment options for non-
inflammatory corneal ectasias. Nonetheless, most patients who undergo these surgeries will still
need to be fitted into a contact lens to reach their full visual potential. Knowledge of the various
contact lens designs and the ability to interpret the corneal shape after CXL and ICRS
implantation is key to helping this population succeed in contact lens wear. CLS

For references, please visit www.clspectrum.com/references and click on document #249.

Dr. Frogozo specializes in adult and pediatric specialty contact lenses. She is the
director of the Contact Lens Institute of San Antonio and the owner of Alamo Eye
Care in San Antonio, Texas. She also is a consultant to CooperVision. You can
contact her atcontactlensinstitutesa@gmail.com.
Contact Lens Spectrum, Volume: 31 , Issue: August 2016, page(s): 22-27