Visual rehabilitation of a fighter pilot by utilizing a combination of contact lenses: a case report

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BACKGROUND: Penetrating keratoplasty is often necessary when corneal scars impact the visual axis. Post-surgical irregular astigmatism resulting from corneal deformity may necessitate the use of rigid gas permeable or scleral contact lenses to enhance visual quality. However, lens fitting becomes challenging when irregularity involves the peripheral cornea. Pinhole contact lenses are used to improve visual acuity and reduce glare in patients with iris transillumination defects. CASE PRESENTATION: This case report describes the successful design and fitting of a quadrant asymmetric peripheral scleral contact lens combined with a pinhole contact lens (a piggyback design) in a 50-year-old Ashkenazi Jewish male of Israeli origin, a fighter pilot with prior iatrogenic iris damage and mild intraocular lens subluxation who underwent a penetrating keratoplasty. Following the quadrant asymmetric scleral lens fitting, the patient's best-corrected visual acuity in the left eye dramatically improved. In photopic conditions, his distance visual acuity improved from 1.0 logMAR to 0.0 logMAR, and near visual acuity improved from Jaeger 13 to Jaeger 1 with +2.50 D reading spectacles worn over the scleral and pinhole contact lenses. Similar improvements were observed in mesopic conditions, with distance visual acuity improving from 1.3 logMAR to 0.04 logMAR and near visual acuity improving from Jaeger 13 to Jaeger 2.0. In addition, the patient's 10% low-contrast distance visual acuity in the left eye improved from 1.5 logMAR to 0.22 logMAR. The low-contrast visual acuity (10%) in the left eye improved from 1.5 logMAR to 0.7 logMAR, and the patient's Quality of Vision questionnaire score improved from 78 to 15. Moreover, the contrast sensitivity measurements across various spatial frequencies were better with the scleral and pinhole lens combination than with spectacles. Furthermore, the patient had mild ptosis that improved after 12 hours of contact lens wear. The lenses were well tolerated for 12 hours of daily wear, with stable visual acuity and no signs of ocular surface damage over a 1-year follow-up period. Patient data were collected after written informed consent. CONCLUSION: This case highlights the potential of using a quadrant asymmetric peripheral scleral contact lens combined with a pinhole contact lens to address complex corneal irregularities and glares associated with iris irregularities and intraocular lens dislocation to improve patient outcomes.

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