Guilty as charged. I probably am personally responsible for 'a few' cases of corneal warpage myself. But more and more it's become clear to me that if we respect the shape of the cornea better, it not only supports corneal physiology and increases comfort - it also prevents unwanted corneal changes. These unwanted corneal changes occur in any lens type (in fact, they are grossly underestimated in soft lens wear). But the effect with suboptimally fitted (R)GP lenses can be pretty severe. For instance, I think we should start moving away from the steep-fitted back-surface aspheric multifocal lenses that can cause severe corneal warpage. Apart from PMMA wearers, these lens wearers can be the most challenging when it comes to refractive surgery preparation. It can take weeks or even months for these patients to return to baseline. Let's show a little respect, also toward the cornea.

Eef van der Worp

"Quite possibly no other complication fills LASIK surgeons with as much dread as the development of a corneal ectasia." This is the first line of an article in Review of Ophthalmology regarding corneal cross-linking as a treatment option for corneal ectasia titled 'Arresting the freefall of corneal ectasia'. Cross-linking, possibly combined with Intacs, is discussed. The August issue of the Journal of Cataract and Refractive Surgery features an article about reducing the complication rate with cross-linking by setting strict inclusion criteria in Complication and failure rates after corneal crosslinking. A preoperative maximum K reading less than 58D may reduce the failure rate to less than 3%, and restricting patient age to younger than 35 years may reduce the complication rate to 1% according to the Swiss study. As an alternative, a study in Great-Britain looked at The therapeutic and optical application of semi-limbal contact lenses (abstract only for non-members) with a median diameter of 14mm as a correction method for ectasia. A median of only one diagnostic lens (range 1 from 3 lenses) was required to achieve a satisfactory fit.

A patient presented with an unsuccessful post-keratoplasty lens fit due to lens decentration. Lens options are limited in this case because of a superior bleb as part of his glaucoma treatment. As larger diameters are often employed to improve centration, large diameter lens options, such as scleral or semi-scleral and hybrid lenses, are limited for this patient in that the lens edge ideally should not make contact with the bleb. In addition to the bleb, preserved ocular medications make soft contact lens options, for example piggybacking, more difficult. As exemplified with this patient, considering the patient's profession, visual needs, ocular conditions and medications, contact lens comfort, and systemic health history are vital to success with contact lens wear. See this month's I(n)-site-the-practice by Matt Lampa from Pacific University (USA) for the full story, and outcome.