Scleral lenses are helpful in managing some of our most challenging corneal cases. However, there are instances in which scleral lenses are not the answer. The following case describes such a patient who initially seemed like a good scleral lens candidate.

An Eye-Popping Case

A 42-year-old African American male presented with a chief complaint of blurry vision and light sensitivity. He had keratoconus and had never worn contact lenses before. He had a relatively small aperture size due to lower-set upper lids and bulbar hyperemia (Figure 1). His entering uncorrected acuities were counting fingers at three feet OD and at six feet OS. Corneal tomography revealed steep anterior curvature, central thinning, and significant anterior/posterior elevation consistent with advanced keratoconus, right worse than left.

Figure 1. (Left) The patient’s relatively small palpebral aperture size and bulbar hyperemia. (Right) The right eye in profile showing significant corneal ectasia.

We decided to attempt a scleral lens fitting. During routine diagnostic lens application, the globe unfortunately subluxated when the patient pulled down his lower lid. He did not initially appear to have notable proptosis; however, this was revealed with minor lid manipulation (Figure 2).

Figure 2. (Left) The patient’s left eye in profile without lid manipulation. (Right) Proptosis with upper lid manipulation.

The patient was unaware that the subluxation had occurred, and the lids were used to gently manipulate the globe back into the orbit. We were able to reapply the diagnostic lenses by handling the lids ourselves. The best-corrected acuity with over-refraction was 20/50 in each eye. We removed the diagnostic lenses without incident.

After discussing the risks and benefits of proceeding with sclerals, the patient opted to try applying a lens on his own. While watching him handle his lids in a face-down position, he nearly subluxated his globe again. We discontinued the scleral lens fit and advised the patient of alternative options, including attempting a corneal GP lens fitting or a referral for corneal transplant surgery.

We recommended that he visit his primary care provider to test for underlying thyroid conditions, which ultimately came back normal. A posterior segment evaluation did not indicate optic nerve findings that would suggest a retrobulbar space-occupying lesion. We determined that this patient likely has shallow orbits causing mild proptosis, and the action of lid eversion caused the subluxation to occur.

Proptosis: A Case for Caution

Remember to proceed cautiously when fitting sclerals on patients who have proptosis, and observe their lens application and removal to ensure proper technique. Many patients use a suction cup to remove their lenses, and this pulling force in combination with lid manipulation can lead to subluxation. If this cannot be avoided, it may be prudent to choose an alternative treatment option. CLS