Practitioner Interview: Restoring 20/20 After a Rare Complication
Dr. Stephanie Pisano and Dr. Maddie Fortman at the Ohio State University Wexner Medical Center presented a case at the Global Specialty Lens Symposium on a young keratoconus patient who developed extensive corneal scarring after cross-linking surgery. By combining BostonSight SCLERAL lenses with topical losartan therapy, they were able to restore her vision to 20/20 and reduce her scarring over time. Watch the highlights above, or read the full interview below.
BostonSight SCLERAL: Please tell us your names and what you do.
Dr. Stephanie Pisano: My name is Stephanie Pisano. I am an optometrist at the Ohio State University Medical Center in the Department of Ophthalmology. We fit a lot of scleral lens patients that need more complex designs and fits due to their underlying ocular conditions.
Dr. Maddie Fortman: My name is Maddie Fortman. I’m the current Cornea and Contact Lens Resident at the Ohio State Department of Ophthalmology. I work with Dr. Pisano to assist in fitting these patients with specialty lenses.
BostonSight SCLERAL: Can you tell us a bit about the research that you presented in your poster and why you wished to share it with your colleagues?
Dr. Fortman: I presented a case of a young woman who has keratoconus and underwent corneal cross-linking surgery to prevent the worsening of her condition. She unfortunately developed a corneal ulcer after the cross-linking procedure and was left with extensive corneal scarring and corneal neovascularization, which caused reduced visual acuity. We were able to fit her with a scleral lens, which did improve her vision. But we also had an additional therapy where we utilized topical losartan, which is an angiotensin II receptor blocker that has been shown, when topically administered, to reduce corneal scarring over time. We utilized both the topical losartan therapy and the scleral lens to provide better vision for the patient and reduce her corneal scarring, leading to better visual outcomes.
BostonSight SCLERAL: Why did you choose to use BostonSight SCLERAL for this particular case?
Dr. Fortman: BostonSight allows us to use additional features that other scleral lenses do not provide, such as Smart Channels. This patient had a lot of corneal neovascularization, so it was really important to optimize how much oxygen is getting to the cornea while the patient is wearing the lens. We were able to utilize Smart Channels to try and minimize how much corneal neovascularization this patient was developing. We’re also always very happy with the consultation services with BostonSight. In complicated cases like this, we can always rely on them to help make sure we’re optimizing the fit the best that we can for the patient.
Dr. Pisano: This patient also benefited from front surface eccentricity for her vision, because we realized that with the regular eccentricity scleral lens, she wasn’t getting to the best vision we could achieve. So that was another design feature we utilized for her.
BostonSight SCLERAL: From the patient’s perspective, can you tell us about the quality-of-life impact of this condition and how your approach addressed it?
Dr. Fortman: From a quality-of-life perspective, it’s important to remember that without her scleral lenses, this patient really has very poor vision — not functional vision to do the daily activities she needs to do. She’s constantly relying on her scleral lenses to provide functional vision to be successful in her life. We have to make sure the lens is fitting her properly so it’s going to be healthy for her to wear long term — for the rest of her life. And we have to make sure it’s comfortable, because she’s relying on these lenses all day to do her daily activities. Although we’re immediately improving her vision, it has to be a long-term solution for her to be successful and do the things she needs to do in life.
Dr. Pisano: She’s an interesting case because we fit her pre-cross-linking a few years ago and she went from about 20/400 to 20/20 with the scleral lens. Everybody was excited. Then she had the cross-linking done and her vision reduced again because of the corneal scar. She knew what 20/20 vision was and she really wanted to get back to that. Being able to refit her into a new lens after that scar developed was really helpful to her. Also, our cornea team — as soon as they knew she developed a scar — said, “OK, let’s get you back into a scleral lens.” That co-management back and forth with our ophthalmology team and us was really paramount in her success.
BostonSight SCLERAL: Tell us about the customization process. Did you use FitConnect? Did you interact with a consultant?
Dr. Fortman: We were able to fit this patient from the diagnostic fitting set that BostonSight provides, and that gave us a pretty good initial fit. But we used FitConnect to make more customized changes for the patient. FitConnect has been great for making efficient changes. And we can also make notes for the consultation team or call them if needed to discuss more complicated changes.
BostonSight SCLERAL: What would you say are the most significant outcomes from this case?
Dr. Fortman: The most important outcome was restoring this patient’s vision back to 20/20. She underwent an unfortunate and rare complication of cross-linking, and it definitely wasn’t expected. Luckily, we were able to provide a solution and get her back to 20/20. It was also nice to be able to offer additional treatment with the topical losartan and give this patient some hope that her corneal scarring could improve — which it did over time. We were able to provide a solution in a rare and unfortunate event.
BostonSight SCLERAL: Any insights or advice for other practitioners who might find themselves tackling a similar case?
Dr. Fortman: It’s always great to collaborate with other scleral lens providers. Dr. Pisano has seen similar cases, and chatting with her about her ideas and what has been successful in the past has been super valuable. That’s why I did a residency — so I could really learn from experts who have already managed similar cases. And always relying on consultation is helpful as well. Just knowing you have someone as backup when you don’t know exactly what change to make — they do this all day, every day. They have great suggestions when you aren’t sure what the next move should be.
Dr. Pisano: I’ll add one more thing. When you see the picture of this patient’s corneal scar, it does not look like you could get this level of vision improvement. In our world, we always put on a scleral lens when we see a scar on the cornea, because you never know how much vision improvement you can get. As soon as we put the lens on and got her to 20/20, the patient was ecstatic. Her cornea specialist was ecstatic. No one thought she was going to get that good a vision with how dense that scar is. My advice is always put a lens in to try. You never know how much you can improve these patients’ quality of life and their vision.
BostonSight SCLERAL: Looking back, how did this case reinforce the value of BostonSight SCLERAL within your practice?
Dr. Fortman: This case really showed what we can do with scleral lenses and how much we can customize them to make sure the patient is able to wear them long term, throughout the whole day. Knowing that we’re able to customize these lenses to a really high level to help even in very complicated cases has been really great to see.
BostonSight SCLERAL: Thank you so much for your time, Dr. Pisano and Dr. Fortman.
Dr. Pisano: Thanks.
Dr. Fortman: Thank you.
About BostonSight®
BostonSight is a nonprofit eye healthcare organization that advances the treatment of irregular corneas and ocular surface disease through specialty lenses. Our ongoing commitment to research and achieving optimal patient outcomes via innovative specialty lens designs, education, and technology has saved the sight of thousands of people around the world. Learn more at www.bostonsight.org
