Case Report: What Are We Doing For Our "20/20 Unhappy" Scleral Lens Patients?

SIGNIFICANCE: Scleral lenses (SLs) partially mask higher-order aberrations (HOAs) in highly aberrated eyes. Although visual acuity (VA) may show satisfactory quantitative clinical outcomes during SL wear, residual (uncorrected) HOAs can leave subjective visual quality goals unmet.PURPOSE: The purpose of this study was to report a case where a "20/20 unhappy" patient with SLs was able to meet visual goals with wavefront-guided SLs.CASE REPORT: A 40-year-old male with bilateral keratoconus, whose Snellen VA with SLs was 20/20+2 right eye (OD) 20/16+2 left eye (OS), reported halos and glare at night and perceptual smearing. When viewing a point of light, a "Ferris wheel" shadowing was observed OD and a U-shaped shadowing OS. Residual higher-order root mean square wavefront error was 0.49 mu m OD and 0.39 mu m OS; visual image quality measured by visual Strehl ratio was 0.067 OD and 0.092 OS (pupil size, 4.00mm). Wavefront-guided SLs reduced residual higher-order root mean square to 0.19 mu m OD and 0.25 mu m OS, VA improved to 20/10 OD and 20/13 OS, and visual Strehl improved to 0.150 OD and 0.121 OS. The patient reported reduced smearing, shadowing, and night vision concerns, meeting his visual expectations and goals.CONCLUSIONS: Wavefront sensing quantifies both lower and HOAs, which can cause visual dissatisfaction in individuals with highly aberrated eyes, despite sometimes reaching typical levels of VA. As wavefront-guided SLs targeting these residual aberrations to improve visual image quality becomemore available, they should be considered for 20/20 unhappy patients when conventional clinical options are unsatisfactory.