When vision is possible – and still not enough in everyday life

“We don’t want to accept limits.
We want to know all the options
we can offer our customers.”

— Lars Teubler

Fitted – yet clearly restricted in everyday life

This in-between situation is precisely what makes the case clinically interesting: the fitting worked optically to some extent, but it was not stable enough for everyday life. The patient herself assumed that nothing more was possible.

“It somehow worked.
But she also thought:
this is the only fitting option.”

— Lars Teubler

An ophthalmologist recognises the limit – and opens the next door

For Lars, this is exactly the right approach: the ophthalmologist does not lose importance. Rather, optometric contact lens fitting complements medical care with time, handling support, follow-up checks and detailed work on lens fit.

“The ophthalmologist should not
lose their role. We want to work
as a complement and take the time
that a fitting like this requires.”

— Lars Teubler

________________________

THE CASE AT A GLANCE

Patient born 1973; works in education

Diagnosis bilateral pellucid marginal corneal degeneration (PMD)

History status post corneal crosslinking in 2013 and 2014

Visual requirements high irregular astigmatism, hyperopia and presbyopia

Previous fitting corneal rigid Rose K lenses

Everyday problems instability, foreign bodies under the lens, repeated removal and marked squinting

The tangential topographies show markedly distorted Placido rings and pronounced asymmetric curvature patterns in both eyes. The changes are inferiorly accentuated; central steepening is also present. The fitting decision was therefore based not only on the diagnosis, but also on the clearly different baseline situation of the two eyes.

Why a scleral lens in this case?

The combination of pronounced bilateral corneal irregularity, recurrent displacement of the previous lenses, foreign-body problems and reduced wearing comfort favoured a scleral lens. The aim was a fitting that optically vaults the irregular cornea, rests stably on the sclera and provides reliable vision during movement and long days.

The conversation came before the first diagnostic lens

Lars deliberately separated getting to know the new visual aid from the actual fitting. The first appointment focused on the history, previous experiences and expectations. Only at the second appointment did they begin working with the scleral lens.

This was particularly important in this case. The patient had great respect for the diameter of the scleral lens and wondered how she would ever be able to apply such a large lens herself. Lars initially removed this step from the equation: he showed her the lens, explained the process and applied it himself during the early phase. This allowed her first to experience how the lens felt and what level of vision was possible. Handling was then introduced step by step.

“The psychological aspect
is very important in fittings
like these. Many people come
from previous fittings that
did not work well.”

— Lars Teubler

“Black run”: The first diagnostic lens was too flat – and still pointed in the right direction

The fitting started with a standard diagnostic lens from the fitting set. Immediately after application it became clear that the sagittal height was insufficient. Lars therefore switched to the steeper variant. His concise comment: “Black run.”

“Even though the lens was not
yet fitting correctly, the patient
could immediately experience
that something was possible.”

— Lars Teubler

From diagnostic lens to individual i-MATRIX

After the first individual pair of lenses, sagittal height was increased once more to reduce the remaining bearing. At the subsequent check, the overall situation was clearly more harmonious, without relevant temporal blanching. The right lens was later changed optically because of an over-refraction; the geometry remained unchanged.

Overall, the fitting was completed in approximately four to four-and-a-half appointments. Binocular visual acuity of 1.0 remained stable with the final fitting.

Fitting course at a glance

Final fit: geometrically stable, with only an optical adjustment on the right afterwards

The fluorescein images from 9 April document the fit after geometric optimisation. According to Lars’ assessment, there was no longer any relevant blanching and the landing was harmonious overall. On the right, only the subsequent optical change due to the over-refraction followed.

The result was visible beyond the visual acuity chart

With the final fitting, the patient achieved stable binocular visual acuity of 1.0. What mattered even more was what happened outside the examination room: she was able to keep her eyes noticeably more open throughout the day, bicycle rides were possible again without repeatedly removing the lenses because of foreign bodies or instability, and her face appeared visibly more relaxed.

One family photograph remained particularly memorable. The patient reported that it was the first time in a long while that she had her eyes open in a photograph. The change was also noticed at work: colleagues asked whether she had had something done to her face because she suddenly looked so much more open.

“For the first time in a long
while, a family photo showed
me with her eyes open.”

— Patient feedback

After the fitting was completed, the patient wrote Lars a personal letter and brought flowers. For Lars, that moment was the real confirmation that the fitting had changed more than a measured value.

“That is exactly why you do this.”

— Lars Teubler

What Lars would do differently next time

The case was successful – and still not without learning moments. The right lens was changed once more optically because of a conspicuous over-refraction. In retrospect, Lars would first recheck this value at a later point before ordering another lens.

“We probably could have saved
ourselves the last right lens.
But that’s how you grow with
experience.”

— Lars Teubler

This detail is precisely what makes the case valuable: it does not show a perfect textbook course, but real fitting practice. Even with a very good result, it is worth critically reviewing decisions in retrospect.

Three learnings from this case

1.

Good visual acuity is not yet a good everyday fitting Assessment should include not only visual acuity, but also stability, wearing comfort, eye opening, handling and whether the lens works reliably at work, during movement and in leisure time.

2.

The conversation can be a fitting step in its own right With a long history and considerable apprehension about a scleral lens, not everything has to happen at the first appointment. First understand, explain and let the patient experience it – handling can then be built up systematically.

3.

An imperfect diagnostic lens can already show the right direction Optical potential, sagittal height, landing and blanching provide important information. What matters is structured documentation and step-by-step refinement – in this case together with the Appenzeller Professional Service.

Conclusion: shifting limits works best together

The result was stable binocular visual acuity of 1.0. More importantly, the patient was able to open her eyes comfortably again and experience everyday life without the previous interruptions.

Shifting fitting limits does not mean ignoring them. It means recognising them, knowing the available options and working together at the right moment.

____________________________________