Post-LASIK, malignant myopia and irregular cornea – solved with our i-Map progressive lens with negative addition
A case for creative minds
There are cases where you quickly realize:
standard approaches won’t get you any further.
Together with optometrist Alex Biefel, we managed exactly such a case – with an initial situation that combined several challenges at once.
Post-LASIK, malignant myopia and irregular cornea – solved with an individual i-Map progressive lens with negative addition
Initial situation – clearly challenging
A 45-year-old patient was referred by an ophthalmologist for contact lens fitting. The diagnosis: malignant myopia – with continued progression even in adulthood. In addition, the patient had undergone LASIK in 2012 (originally around −8 dpt), the effect of which had increasingly diminished over time. At the initial presentation, the following was observed:
- visual acuity with current glasses approx. 0.4
- best-corrected visual acuity higher, but not stable in daily life
- clearly irregular cornea
It quickly became clear: conventional correction approaches would not provide a reliable solution here.
Turning point: rethinking instead of further optimizing
The first conventional lens approaches confirmed Alex Biefel’s initial instinct: no stable visual quality, no satisfying solution. So we reopened and re-evaluated the case together – this time focusing on the actual optical situation of the cornea, not just numerical values. Our expectation of success was deliberately honest:
“We see a chance – but we cannot guarantee anything.”
The fitting process: an atypical approach
The decision was made in favor of a customized iMap Progress-F lens with negative addition. The starting point was a reverse iMap test lens, which already provided very good optical neutralization of the irregular cornea in the right eye. However, over-refraction revealed a residual cylinder of -0.50 dpt at 90°, which was still visually relevant, on top of a spherical base correction of -4.25 dpt.
In principle, this astigmatism could have been corrected using a front toric design (iMap VPT). However, this would have required prism stabilization. Since the rigid lens was already slightly noticeable, there was a risk that a prism-stabilized design, due to increased edge thickness, would further reduce wearing comfort.
Therefore, a different approach was chosen:Instead of a front toric correction, an iMap Progress-F with a centrally positioned distance zone was used.
The spherical base correction was set to -4.25 dpt.
The measured cylinder of -0.50 dpt was implemented as a negative addition.
As a result, one principal meridian has a power of -4.25 dpt, while the perpendicular meridian has a power of -4.75 dpt.
The progressive front surface creates a continuous transition between these two powers and maps the previously measured astigmatism across the entire optical zone in a simplified way.
The advantage of this approach:
additional prism stabilization could be avoided.
This kept the lens thinner, more comfortable, and at the same time optically highly effective.
A particularly interesting aspect was the comparison with the left eye.
There, with the same reverse iMap geometry, no measurable residual cylinder was detected.
Accordingly, a purely spherical correction achieved maximum visual acuity.
This direct comparison clearly demonstrated that a front toric solution with prism stabilization would likely have resulted in reduced comfort in the right eye compared to the chosen Progress-F approach.
Right and left eye:
Centered iMap Progress-F lens with a homogeneous central alignment zone and a uniformly defined paracentral pooling ring of the reverse geometry.
Overall balanced edge alignment with physiological tear exchange; slightly increased peripheral fluorescence temporally in the right eye.
Contact lenses:
R: i-MAP Progress-F
Dia: 11.0 BC: 8.6 pwr: -4.25 Add: -0.5
L: i-MAP Progress-F
Dia: 11.0 BC: 8.7 pwr: -3.00 Add: -1.0
Distance visual acuity binocular: 0.8
Near visual acuity binocular: 0.7
Consultation beyond standard approaches
This treatment approach was developed in close collaboration with the fitting consultancy and Bernd Brückner. The concept of mapping an internal astigmatism across the principal meridians using a negative addition within the lens geometry is not a standard approach.
It requires experience, a deep technical understanding, and the willingness to deliberately rethink established solution pathways.
Negative addition – what is different here
In the classical sense, an addition is used to provide different visual zones for distance and near.
In this case, however, the negative addition was used for a completely different purpose.
Through the reverse iMap geometry, the irregular cornea could already be optically neutralized very effectively.
However, a small but visually relevant residual astigmatism of -0.50 dpt remained in the right eye.
Instead of correcting this astigmatism with a front toric lens requiring prism stabilization, the negative addition of the iMap Progress-F was used to represent the different refractive powers in the principal meridians.
This resulted in an optical solution that reduced the residual astigmatism effectively, without introducing the disadvantages of a prism-stabilized lens.
The outcome:
improved visual acuity combined with high wearing comfort – and that is exactly what made this approach so successful in this case.
The path to success – this was not a quick fix, but precise, detailed work:
- multiple fitting steps
- close collaboration
- careful evaluation of fit and image quality
Result: binocular visual acuity of approx. 0.8 and significantly more stable vision in everyday life.
Conclusion of the case
Cases like this are not the easiest – neither for the practitioner nor for us as a manufacturer. And yet, these are exactly the cases that drive us forward. They challenge us to look more closely, think more openly, and allow solutions beyond standard approaches. We consciously take the time to develop these fittings together with our clients. Because this is how experience is built. And this experience ultimately benefits not only complex cases – but also makes standard fittings safer and more efficient.
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Key takeaways from this case
Alexander Biefel, B.Sc. Optometry, Alexander Biefel supports patients daily at Optik Mattern in Sandhausen and Wiesloch with a wide range of visual challenges – with individualized contact lenses playing a central role. His professional path is closely connected to ours: Through their shared academic background, he and Bernd Brückner maintain an open and trusting exchange to this day. Thank you, Alexander Biefel, for the collaboration and this exceptional case.
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1. Negative addition – revisited
Classically, addition supports near vision.
In this case, it fulfilled a completely different role.
Due to the irregular cornea, the optical system was unstable. The goal was not to correct “more”, but to create a calmer image. That is exactly where negative addition comes into play: it was used to reduce certain optical components and simplify the system as a whole. The result was not a theoretically perfect image – but a significantly more stable one. And that made all the difference.
2. Communication – when better is not enough
Visual acuity improved significantly – from approx. 0.4 to 0.8. Objectively a clear success. Subjectively not automatically. Especially patients with a LASIK history often have a very precise expectation of what “good vision” should feel like. In such situations, it helps to stay measurable: “Further improvement is not technically possible – we have achieved the maximum feasible result.” Showing development, explaining differences and clearly defining limits. That is exactly what Alexander Biefel did: not further optimizing – but contextualizing.
3. Proactivity – for the patient
After the first attempts, it became clear: the standard approach would not work here. At that point, there are two options: to struggle – or to collaborate. Alexander Biefel chose to open the case and actively seek support. Through this collaborative exchange, the case was successfully solved –
and the patient now benefits from a level of vision that allows confident everyday functioning.
