ARTICLE

Contact Lens Characteristics and Contrast Sensitivity of Patients With Keratoconus

Rui Hua Wei,
M.D., M.Sc.,

Wei-Boon Khor,

F.R.C.S. (Ed),

Li Lim,

F.R.C.S. (Ed),

and Donald T.H. Tan,

F.R.C.S. (G)

Objectives: The aim was to describe the contact lens characteristics and contrast sensitivity of patients with keratoconus managed conservatively with contacts lenses at a tertiary eye center in Singapore. Methods: A prospective cross-sectional study of 116 patients with clinically evident or suspected keratoconus (on videokeratography) recruited over 11 months. Demographic and medical details, visual acuity (VA) and refraction, corneal topography and contact lens characteristics were documented. Contrast sensitivity with contact lenses was performed with the Vision Contrast Test System 6500 under standardized conditions. Results: Overall, 67% of the study patients were wearing contact lenses. Of the 129 eligible eyes analyzed, there were 108 eyes with keratoconus and 21 eyes with keratoconus suspect, and 94% were tted with rigid gas permeable (RGP) lenses. Proprietary keratoconus design lenses were tted in 74.9% of keratoconus eyes and 30.0% of suspect eyes. With contact lens wear, 83.3% of keratoconus eyes and 100% of suspect eyes achieved 0.3 vision. Mean contrast sensitivity curves of eyes with keratoconus and keratoconus suspect were found to be within normal, although contrast sensitivity in the keratoconus group was consistently lower. Conclusions: Most of our patients were managed conservatively with contact lenses, and keratoconus design RGP lenses were the most common type tted. Good VA can be achieved, but patients with keratoconus may still experience a reduction in contrast sensitivity. Key Words: KeratoconusContact lensContrast sensitivityCorneaRigid gas permeable. (Eye & Contact Lens 2011;37: 307311)

Although corneal transplantation has been successful in the surgical management of keratoconus, most of the patients with this condition are still managed with contact lenses for visual rehabilitation.2,3 With a wide variety of different lens materials and designs now available, careful tting and retting of lenses can result in good visual acuity (VA) even as the disease progresses. However, although VA may be improved, other aspects of visual function such as contrast sensitivity (CS) may still be affected.46 In this article, we describe the contact lens characteristics and contrast sensitivity of patients with keratoconus and keratoconus suspect eyes managed conservatively with contact lenses. This study was part of a larger prospective cross-sectional study looking into the demographics and clinical characteristics of Asian patients with keratoconus managed at the Singapore National Eye Centre, which is a major tertiary eye hospital in Singapore.

MATERIALS AND METHODS

This study was approved by the Ethics Committee of the Singapore Eye Research Institute. Patients who were diagnosed with clinically evident or suspected keratoconus at the Singapore National Eye Centre were considered to be eligible for this study. The patients with a history of corneal injury or ulceration, acquired pseudokeratoconus, or who were unable to perform the required tests were excluded. After informed consent was obtained, each patient was interviewed by a single investigator (R.H.W.) using a standardized questionnaire on demographic details and medical history; specic questions were asked about symptoms at rst presentation, habitual eye rubbing, medical conditions (such as asthma, atopic dermatitis, connective tissue diseases), family history of keratoconus, and details of any prior contact lens wear. Medical records were reviewed for further details, including the use of spectacles, the type of contact lenses (if any) used at the time of the study, and history of ocular surgery such as penetrating keratoplasty (PK). All the patients underwent the following examinations: VA and manifest refraction, a complete slitlamp biomicroscopy examination by 2 separate examiners, corneal topography, and contrast sensitivity. Contact lens wearers required two study visits to complete the study (one with contact lens wear and one without contact lens wear), whereas the remaining patients completed all the tests in a single day.

eratoconus is a noninammatory progressive corneal disease characterized by localized conical protrusion, apical thinning, irregular astigmatism, and central corneal scarring, which is usually bilateral but may be asymmetric.1,2 Keratoconus typically presents at puberty and may progress until late in life and thus affects young adults with high visual requirements in their daily lives.

From the Department of Cornea & External Eye Disease (R.H.W), Tianjin Medical University Eye Centre, Tianjin, P.R. China; and Department of Cornea & External Eye Disease (R.H.W., W.B.K., L.L., D.T.H.T), Singapore National Eye Centre and Singapore Eye Research Institute, Singapore. The authors have no funding or conicts of interest to disclose. Supported by the discretionary research fund of the Singapore National Eye Centre and a Singapore Eye Research Institute pilot grant. R.H. Wei and W.-B. Khor contributed equally to this work. Address correspondence and reprint requests to Li Lim, F.R.C.S. (Ed), Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751; e-mail: lim.li@snec.com.sg Accepted May 19, 2011. DOI: 10.1097/ICL.0b013e3182254e7d

Visual Acuity and Refraction

Visual acuity with and without patients existing optical correction and the best corrected VA (BCVA) were assessed for each eye with Early Treatment Diabetic Retinopathy Study charts (Lighthouse Low Vision Products, New York, NY) viewed at a 4-m 307

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R. H. Wei et al. distance in standardized illumination.7 The subjects were directed to read the letters of the 0.3 line (equivalent to 20/40 on the Snellen chart); if they were unable to correctly identify at least three letters for that line, then the subjects were directed to read the line above. This process continued until at least three letters of one line were read correctly and the VA recorded for the tested eye. If the subjects were able to correctly read the letters on the 0.3 line, they proceeded on to each successive line until they were unable to read further down the chart. If the subjects were unable to identify any letters on the chart at 4 m, they were positioned at 2 m and then at 1 m away from the chart, failing which their VA was documented as logMAR +1.7. In the patients who did not wear contact lenses, the BCVA was determined by manifest refraction alone; in contact lens wearers, both overrefraction (refraction over their contact lenses) and manifest refraction were performed and the better vision documented as BCVA.

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Study Denitions
Based on the clinical examination and corneal topography, subjects eyes were diagnosed with keratoconus, keratoconus suspects, or unilateral keratoconus.

Keratoconus
Eyes with keratoconus demonstrated one or more of the following clinical features: stromal thinning, conical protrusion, Fleischer ring, Vogt striae, and/or anterior stromal scar. Also included were eyes that underwent a corneal grafting procedure for keratoconus.

Keratoconus Suspect
This was diagnosed when the clinical signs of keratoconus were absent, but evaluation by corneal topography showed an area of central, inferior, or superior steepening combined with any of the following: oblique cylinder .1.5 D; steep keratometric curvature greater than 47 D, and/or central corneal thickness less than 500 mm. Contralateral eyes of subjects with keratoconus were also labeled as keratoconus suspects if a localized steepening or an asymmetric color-coded videokeratographic pattern in the axial power map was present but not sufcient to fulll the preceding criteria.

Corneal Topography and Keratometry

Corneal topography was performed using the Tomey KC screening system (Topographic Modeling System, software version 2.4.2J, Tomey Corp, Nagoya, Japan; Tomey TMS-2N) and the Orbscan II corneal topography system (Bausch & Lomb Surgical, Orbtek Inc., Salt Lake City, UT). The specic protocols used in this study and the detailed ndings of the corneal topography have been published.8

Contrast Sensitivity
Contrast sensitivity was recorded only in the patients with existing contact lens use and before pupil dilation (if any). Contrast was tested with the Vision Contrast Test System 6500 (Vistech Consultants Inc., Dayton, OH) contrast sensitivity chart in 6 spatial frequencies according to the manufacturers guidelines. The chart was placed under normal room lighting (3070 ftL), and the testing distance was 10 ft (3 m). The subject was instructed to begin with row A and to look across from the left to the right so as to identify the last visible patch on that row. If the direction of the lines within that patch were correctly identied, then this was marked on the recording form; otherwise, the subject was asked to describe the preceding patches, until a patch could be correctly identied. This process was repeated for rows B to E so that the contrast sensitivity curve for the subjects eye could be plotted. To compare the overall contrast sensitivity curves of keratoconus eyes with those of the keratoconus suspect eyes, the mean scores of test rows A, B, C, D, and E were calculated for the two groups of eyes and plotted on the VCTS 6500 recording form. The mean contrast sensitivity curves of these two groups were also compared with the normal population range reected on the recording form.

Unilateral Keratoconus
This was present if the subject demonstrated keratoconus in one eye but did not have any clinical signs of keratoconus in the contralateral eye, nor topographical features to fulll the criteria for a keratoconus suspect.

Statistical Methods
Demographic data and medical and family history were described by patient, whereas clinical ndings were described by groups of eyes; thus, it was not possible to compare the keratoconus group with keratoconus suspect group with regard to demographic data. Visual acuity, keratometry, and contrast sensitivity scores for keratoconus eyes and keratoconus suspect eyes were tested for normal distribution (one-sample KolmogorovSmirov test). Data were presented as mean6SD. Two samples independent T-test was performed for mean VA, overall mean keratometry, and contrast sensitivity to determine the differences between keratoconus and keratoconus suspect eyes. A probability less than 5% (P,0.05) was considered statistically signicant. Statistical analyses were conducted using SPSS version 11.5.

Contact Lens Fitting Evaluation

The type and characteristics of the any contact lenses worn were recorded. For new patients or patients for retting of contact lenses, study parameters were obtained using the latest tted lens. Initial contact lenses tting was based on automated keratometry reading from the Auto Ref-Keratometer RK-5 (Canon, Japan); three consecutive readings of the attest and steepest meridians of both eyes were taken and then averaged. Clinically, the t of the contact lens was assessed on a slitlamp with the use of a ourescein dye, and the contact lens t was judged to be good if there was apical clearance or mild apical touch, good centration, and adequate edge lift. 308

RESULTS
A total of 116 patients were enrolled between August 1, 2003, and June 29, 2004. Of these, 65 demonstrated keratoconus in both eyes, whereas 41 demonstrated keratoconus in one eye and were suspect in the fellow eye. Five (4.3%) showed unilateral keratoconus, and ve patients were dened as keratoconus suspects in both eyes. There were 73 men (62.9%), and the mean age of the patients at the time of the study was 29.5 years (range 9.355.0 years). Fourteen patients had undergone PK for one eye before recruitment into the study. Of the 102 patients without previous PK, most were wearing contact lenses (70.6%), spectacles (24.5%), Eye & Contact Lens  Volume 37, Number 5, September 2011

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Eye & Contact Lens  Volume 37, Number 5, September 2011 or a mix of both (2.0%), and only three patients (2.9%) were not using any form of refractive correction on enrollment.
TABLE 2.

Contact Lens Characteristics in Keratoconus

Type of Contact Lenses Fitted in Keratoconus or Keratoconus Suspect Eyes
Number of Eyes 46 19 16 14 8 6 4 3 2 2 120 Percentage 38.3 15.8 13.3 11.7 6.7 5.0 3.3 2.5 1.7 1.7 100

Contact Lens Wear

In total, 80 of the 116 (67%) patients were wearing contact lenses on enrollment. Sixty-three of these patients were wearing contact lenses in both eyes, and the rest wore a contact lens in only one eye, giving a total of 143 eyes with contact lenses wear. Contact lens data on 10 eyes of 6 patients (4 bilateral and 2 unilateral) were missing, and another 2 post-PK eyes and 2 normal fellow eyes were excluded. As such, the contact lens data from only 129 eyes were analyzed, comprising 108 keratoconus eyes and 21 keratoconus suspect eyes.

Contact Lens Rose-K Menicon EX spherical KBA keratoconus Eycon spherical Hydron keratoconus Eycon keratoconus Oculus spherical Pure vision Eycon toric Others Total

Characteristics of Contact Lenses Fitted

One hundred and twenty-one eyes (94%) were tted with rigid gas permeable (RGP) contact lenses and eight eyes with soft contact lenses. The various lens designs available at our center for the management of keratoconus is detailed in Table 1 and include keratoconus design RGP lenses, spherical design RGP lenses, and soft contact lenses. The specic type of contact lens tted in these patients was documented in 120 eyes and is summarized in Table 2. Keratometry could be recorded in 101 eyes, and Table 3 illustrates the mean keratometry reading of eyes tted with each type of contact lens. As expected, keratoconus eyes demonstrated a signicantly higher mean keratometry reading overall (53.62 D) compared with keratoconus suspect eyes (P,0.001), and the majority (74.9%) were tted with keratoconus design lenses. Keratoconus suspect eyes showed a lower mean keratometry reading (45.60 D), with 65% of eyes tted with spherical design RGP lenses and 15% of eyes tted with soft lenses.

TABLE 3.

Mean Keratometry Readings of 101 Eyes According to the Types of Contact Lenses Fitted
Keratoconus Eyes Keratoconus Suspect Eyes Number 5 6 1 5 2 1 20 Mean (D) 6 SD 46.5263.51 45.4860.98 45.70 44.6661.11 47.0563.04 43.40 45.6062.13

Contact Lens Type Rose-K Menicon Ex spherical KBA keratoconus EyCon spherical Hydron keratoconus EyCon keratoconus Pure vision EyCon toric Others Overall

Number 35 12 13 6 6 5 1 1 2 81

Mean (D) 6 SD 53.7364.29 53.9565.94 51.6264.72 47.5862.25 60.8063.61 56.3068.30 58 51.8 51.864.24 53.6265.38

Visual Acuity and Contrast Sensitivity With Contact Lens

Visual acuity with contact lens wear is summarized in Table 4. Ninety eyes (83.3%) with keratoconus achieved a VA of 0.3 or better, and forty-six (42.6%) demonstrated a VA of 0.1 or better with contact lens wear. In contrast, all keratoconus suspect eyes had vision corrected to 0.3 or better with contact lens, and 17 eyes (81.0%) achieved a VA of 0.1 or better. Unsurprisingly, the mean best-corrected logMAR VA of keratoconus eyes was signicantly poorer compared with that of keratoconus suspect eyes (0.11760.13 vs. 0.01960.06, P=0.002). The mean contrast sensitivity curves of keratoconus and suspect eyes with contact lens wear is shown in Table 5 and Figure 1. The
TABLE 1. Contact Lens Designs Available for the Management of Keratoconus
Rigid Gas Permeable Lens Keratoconus design Eycon keratoconus Hydron keratoconus KBA keratoconus Menicon K Rose-K Spherical design Eycon spherical Menicon EX spherical Ocular spherical Soft Lens Pure vision Eycon toric

mean contrast sensitivity curves of keratoconus and keratoconus suspect eyes were found to be within the normal range, although the contrast sensitivity in the keratoconus group was consistently lower than that of the keratoconus suspect group at all spatial frequencies (P,0.05). Clinically, the curves of the two groups differed by approximately one contrast value (patch) at spatial frequencies 1.5(A), 3(B), and 6(C) and approximately 1.5 contrast values (patches) at spatial frequency 12(D) and 18(E).

Characteristics of Contact Lens Fit

Contact lens t was evaluated in all the eyes. The uorescein patterns of the 121 eyes with RGP lens wear were evaluated by slitlamp examination with cobalt blue light. Excellent (51.6%) and fair (46.9%) lens centration was obtained in 119 eyes. Ninety-ve percent of RGP lenses demonstrated adequate movement. The uorescein patterns showed apical clearance or minimal conical touch in 79 eyes (65.6%) and moderate conical touch in 40 eyes (33%). The majority of the lenses (78.1%) showed desirable edge lift; 18 eyes (14.8%) showed a minimal
TABLE 4. Visual Acuity of Keratoconus Eyes Vs. Keratoconus Suspect Eyes With Contact Lens Wear
Keratoconus Eyes Visual Acuity 20/25 or better ,20/25 to 20/30 ,20/30 to 20/40 ,20/40 or worse Total Number (%) 46 (42.6) 27 (25.0) 17 (15.7) 18 (16.7) 108 (100) Keratoconus Suspect Eyes Number (%) 17 (81.0) 2 (9.5) 2 (9.5) 21 (100)

Manufacturers and distributors (as of June 2004)EyCon lenses (Ciba Vision, Atlanta, GA), Hydron Keratoconus (Hydron Pte Ltd., Adelaide, Australia), KBA Keratoconus (Capricornia, Queensland, Australia), Menicon lenses (Menicon Co. Ltd., Nagoya, Japan), Rose-K (Rose K International, Hamilton, New Zealand), Oculus spherical (Oculus Ltd., Singapore) Pure Vision (Bausch & Lomb, Rochester, NY).

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R. H. Wei et al.
TABLE 5.

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Mean CS Scores of Keratoconus Eyes and Keratoconus Suspect Eyes With Contact Lens Wear
Keratoconus Suspect Eyes (n=21) Maximum 7 8 7 7 8 Mean 6 SD 5.2660.65 6.3760.90 5.5361.07 4.8461.39 4.0561.51 Minimum 4 5 4 2 1 Maximum 7 8 7 7 8 P value 0.044 0.018 0.003 0.000 0.000

Keratoconus Eyes (n=108) CS A B C D E Mean 6 SD 4.8860.78 5.7461.07 4.5961.25 3.3661.51 2.4161.80 Minimum 2 2 2 0 0

CS, contrast sensitivity.

edge lift. The 8 eyes with soft contact lens wear exhibited excellent centration with adequate movement.

DISCUSSION
There are few studies from Asia describing the characteristics of keratoconus in the Asian population, apart from a few recent articles from India.911 Our study adds to this growing body of literature by reporting on the use of contact lens in the management of patients with keratoconus in a large tertiary eye hospital in Singapore and

also documents the contrast sensitivity function in this group of patients. Contact lenses were the main mode of treatment for the majority (70.6%) of the patients who had not undergone surgery. This is similar to other tertiary eye care centers in India (65%)9 and in the United States (74% in both eyes),12 but lower than the 90.6% in Dundee13 and 97% in London14; multiple factors contribute to these varying gures, including the severity of the disease being managed in these practices (ours included keratoconus suspects as well) and the cost and availability of these lenses. As expected, our keratoconus group exhibited signicantly higher astigmatism and

FIG. 1. Mean contrast sensitivity function of keratoconus eyes and keratoconus suspect eyes with contact lens use. The mean contrast sensitivity curves of eyes with keratoconus (solid line) and keratoconus suspect (dashed line) were found to be within the normal population range (gray area). However, the contrast sensitivity in the keratoconus group was consistently lower than that of the keratoconus suspect group at all spatial frequencies.

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Eye & Contact Lens  Volume 37, Number 5, September 2011 lower mean BCVA than did those of the keratoconus suspect group, although 83.3% of eyes with clinically evident keratoconus could still achieve a BCVA of at least 0.3 or better. In tting contact lenses for keratoconus, various lens designs should ideally be available for practitioners because no single design will work for every patient. Keratoconus design lenses were tted in 74.9% of keratoconus eyes, of which 45% found the Rose-K lens the most suitable. The Rose-K lens, as with other proprietary RGP lens designs, are multicurve lenses designed to provide a better t for the cones in moderate-to-severe keratoconus.3 Nonetheless, a good 22% (n=18) of keratoconus eyes were tted with spherical design RGP lenses such as the Menicon Ex and EyCon Spherical, despite having mean K readings that were similar to those eyes tted with keratoconus design lenses. Conversely, although keratoconus suspect eyes by denition showed no overt clinical features of keratoconus, 30% (n=6) of these eyes wore keratoconus design lenses to correct their vision. Although we generally begin contact lens tting based on automated keratometry readings, it is the assessment of the patients corneal characteristics, the uorescein pattern of the RGP lens on the eye, coupled with the patients feedback, which ultimately determines the type of lens most suitable for each individual eye. Although both groups demonstrated mean contrast sensitivities that were within the normal range, the keratoconus group demonstrated an overall lower contrast sensitivity compared with that of the keratoconus suspect group. This is consistent with the ndings of other studies,46 which have shown lower contrast sensitivity in patients with keratoconus despite apparently normal VA from contact lens wear. We found that higher order aberrations (HOAs) were larger in this same cohort of keratoconus and keratoconus suspect eyes compared with those in normal eyes,15 and there may also be an association between contrast sensitivity and HOAs.16 Our ndings reinforce the opinion of some researchers that the measurement of high-contrast VA alone does not adequately describe visual function17 and that factors such as contrast sensitivity and HOAs may explain why patients in clinical practice seem to experience functional difculties disproportionate to their documented VA. The Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study, for example, found that their patients were experiencing decits in vision-related quality of life on par with the patients with age-related macular degeneration, despite the fact that the majority (94%) of their study patients demonstrated binocular, high-contrast VA of 20/40 or better.18 There are some limitations to this study: The bias in patient recruitment should also be noted, because the patients in this study were only those who presented or were referred to the study investigators, and not all eligible patients were keen to participate in the study. Also, a hospital-based cohort of patients would be

Contact Lens Characteristics in Keratoconus expected to have a higher proportion of more advanced disease, and our ndings cannot be extrapolated to the general population. In conclusion, our study presents a review of the contact lens prole and contrast sensitivity of a group of keratoconus and suspect patients managed conservatively in a large tertiary eye hospital. Rigid gas permeable contact lenses remain the treatment for most of our patients, and good VA can be achieved. Nonetheless, patients may still experience a reduction in contrast sensitivity, which may be important in the vision-related function and quality of life in keratoconus patients, and deserves further study.

REFERENCES
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