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HomemicontactA Keratoconus Kaleidoscope

A Keratoconus Kaleidoscope

One of the best ways to eradicate career boredom and frustration – and to expand one’s scope – is to take on a speciality niche like advanced contact lens care, writes Alan Saks.

I recently stumbled upon a Facebook post referencing a Tasmania-based artist who suffers from keratoconus. She ascribed her unique art in part to her low vision and altered visual perception. People with conditions like astigmatism, aphakia, macular degeneration, cataracts, colour vision deficiency etc. also experience altered visual perception.

The artist’s post reminded me of the challenges and rewards that come with caring for patients who live with complex ocular conditions. It also reinforced that managing patients like her ensures your career doesn’t become consumed with the mundanity of day-in day-out refractions.

When we expand our repertoire of skills and scope of practice, we can take on speciality niches; keratoconus management being just one.

Behavioural optometry is another area that can be most rewarding, as is working with patients who have low vision etc. With the increasing prevalence of age-related macular degeneration, low vision care has plenty of potential.

Advanced contact lens care has been my passion since my student days, and I’ve been fortunate to have had great teachers and mentors, who I’ve written about in the past.


During my practising years, I derived great satisfaction fitting and managing patients with high myopia and astigmatism, along with aphakia and keratoconus, providing life changing eye care. I don’t use that term loosely. You can literally see, on a regular basis, how restoring functional vision to people enables them to perform so much better in life and emotionally, achieving things they could not otherwise have managed.

One memorable patient – who was not always easy to deal with – was referred to me wearing way-too-flat rigid gas permeable (RGP) contact lenses. His RGPs had caused severe, chronic apical abrasion/scarring, extreme pain, photophobia, and reduced vision. He’d lost his job and suffered ongoing mental health issues.

I refitted his lenses, changing one of them from a very flat-fitting 6.70 BC to a ‘just apical clearance’ 4.95 BC, -27.50 D. I had to do this empirically as he was in such a bad way, he could barely open his eyes to do K readings or insert trial lenses. I assessed his existing lenses on eye with sodium fluorescein (NaFl) and a Burton lamp, and measured what the old lenses were on my radiuscope and vert etc. I translated this into a custom tertracurve design, tweaking the power based on the over-refraction and the calculated alteration of the tear lens power. This turned out to be a game changer.

His visual acuity improved, and he could wear contact lenses for longer hours, with improved comfort. The reduced apical abrasion meant his photophobia reduced dramatically. With careful co-management of his severe atopia, floppy lids, mucous fishing, psychotropic medication side effects, and environmental issues, we managed to keep him on a relatively even keel. Every few years he would suffer aggravated mental health issues, resulting in him being incarcerated in mental health facilities. On occasion I had to intervene as they would take his contact lenses away and he would spiral downwards, as he could not see to read or function.

He once sent me a letter explaining how important my care had been to him. In his eyes, it was in the realm of being miraculous.


Keratoconus may be a challenging field, but the rewards are immense. We face a veritable kaleidoscope of patients, signs, symptoms, severity, topographical variation, complex lens designs, tolerance, compliance, complications, and personalities.

Providing expert care in keratoconus is critically needed as there are few practitioners – even in the biggest cities – who are skilled in the field. There’s great demand for those who are! It’s a skill set that can never be taken away and most potential competitors are unable to deal with these cases.

It’s not something you can suddenly do overnight, but small steps are the way to go. Seek a mentor, join a practice that does this kind of work, or seek one that allows for expansion into advanced areas of practice. Start with simple cases. Get on board with myopia controlling soft lenses and entry level contact lenses, develop orthokeratology expertise, and so on. In time, the super complex cases will also become part of your repertoire.

There’s no better place to start than a valuefor-money Cornea and Contact Lens Society membership and to attend the fantastic International Cornea and Contact Lens Congress on the Gold Coast from 23–25 August.

CCLSA: www.cclsa.org.au

ICCLC 2024: www.icclc2024.com.au

Alan Saks is a retired optometrist. He is the Chief Executive Officer of the Cornea and Contact Lens Society of Australia, and a regular contributor to mivision.