See

discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/281243346

Piggyback Lens Systems for Keratoconus

ARTICLE SEPTEMBER 2006

READ

2 AUTHORS, INCLUDING:
RE Gundel
State University of New York College of Opto
29 PUBLICATIONS 162 CITATIONS
SEE PROFILE

Available from: RE Gundel

Retrieved on: 11 October 2015

Article Date: 9/1/2006

MANAGING KERATOCONUS

Piggyback Lens Systems for Keratoconus

Fitting a silicone hydrogel/GP lens combination may improve comfort and vision
for keratoconic patients.
By Jill J. Rodio-Vivadelli, OD, FAAO, & Ralph Gundel, OD, FAAO
Keratoconus is a corneal ectasia characterized by progressive corneal thinning, steepening and
apical scarring. Presenting with variable amounts of irregular astigmatism, practitioners most
often correct the resultant corneal distortion with GP lenses. Despite the success with GP lens
wear in many keratoconic patients, problems with decreased comfort and wearing time may
lead to lens intolerance as the condition progresses.
Alternative contact lens options for keratoconic patients include soft toric lenses, specialty soft
keratoconic lenses, hybrid lens designs and piggyback lens systems. In early, mild keratoconic
patients, glasses or soft toric lenses may prove to be the best option.
As keratoconus worsens, specialty soft keratoconic lenses, such as the Flexlens Tri-curve
Keratoconus lens (X-Cel), are an option. Limited success with these lenses often results from
low oxygen permeability (Dk), resulting in hypoxia and corneal neovascularization. Some hybrid lens
designs, such as the SoftPerm lens (CIBA Vision), improve comfort and lens positioning, but these tightfitting lenses often lead to similar complications associated with hypoxia.
Piggyback Systems
Piggyback lens systems date back to the early 1970s. First reported attempts at this combination lens
fitting technique occurred in 1964 by Westerhout with results published in 1973, in which successful fitting
of five dual-lens systems in keratoconic patients resulted in 14 to 16 hours of wearing time with good
comfort and vision.
Consisting of a GP lens fit on top of a soft lens, older piggyback lens systems often resulted in corneal
edema and neovascularization due to hypoxia. With improved GP and soft lens materials that offer higher
Dk, piggyback lens systems have resurfaced as a viable option for keratoconic patients. Research shows
that we can achieve the physiological corneal oxygen requirements necessary to reduce and prevent
edema with these higher-Dk combination lenses.
This clinical study examines the comfort and visual quality outcomes of fitting a piggyback contact lens
system utilizing an 8.3mm base curve silicone hydrogel soft lens (Acuvue Advance, Vistakon) on
keratoconic patients who were current successful GP contact lens wearers.
TABLE 1
GP Materials Used in Successful
Piggyback Fittings
SUCCESSFUL
PIGGYBACK
FITTINGS

SUCCESSFUL PIGGYBACK
DROPOUTS

Material

Dk Material

Paraperm
02

16

Paraperm
02

16

Unknown
Unknown

Dk

Fluoroperm
30

30

Unknown

Fluoroperm
Unknown
60
60
Boston
EO

58

Paraperm
16
02

Boston
EO

58

Paraperm
16
02

Boston EO

58

Boston ES

18

Boston ES

18

Fluoroperm
30

30

Fluoroperm
30

30

Unknown
Unknown
Fluoroperm
30

30

Fluoroperm
30

30

Fluoroperm
60
60
Fluoroperm
60
60
Unknown

Patients and Methods

We enrolled 16 mild-to-advanced keratoconic patients (30 eyes)
at SUNY College of Optometry who were current GP wearers
and had no additional ocular pathology in this study and followed
them for a minimum of four weeks after a successful piggyback
fitting. In the two patients who had only one eye each enrolled in
the study, we excluded the fellow eyes because they didn't wear
a GP lens on those eyes. Eligible patients must have worn a
successful piggyback lens system for at least four consecutive
weeks with acceptable visual acuity and absence of corneal
compromise.
The mean age of eight females (15 eyes) and eight males (15
eyes) was 44.5 years 13.33 SD (range 18 to 73 years). In this
study, the average age for the initial keratoconus diagnosis was
29.13 years 13.34 SD (range 14 to 68 years) and the average
age when these patients first started wearing GP lenses was
27.8 years 9.64 SD (range 14 to 45 years).
We performed a comprehensive pre-fitting evaluation on all
patients, including case history, pre-fitting questionnaire
(Appendix A, available in the online version of this article at
www.clspectrum.com), verification of current GP lens
parameters, fitting evaluation of current GP lenses, keratometry,
subjective refraction, corneal topography (Alcon Eyemap) and
biomicroscopy.

Unknown

Once we determined that patients were candidates, we fit each

eligible eye with an 8.3mm base curve silicone hydrogel lens
30
(Acuvue Advance, Vistakon). After evaluating the fit of this soft
lens, we applied each patient's own GP lens on top. To achieve
Fluoroperm
30
30
a successful piggyback fitting relationship between the GP lens
and the soft lens, the first variable that we adjusted, if necessary,
Bolded material=new gas permeable
lenses ordered for the study.
was the power of the soft lens. Our goal was to achieve an
acceptable piggyback fit utilizing each patient's own GP lenses.
Fluoroperm
30

Plus power soft lenses create a steeper anterior surface and minus power soft lenses create a flatter
anterior surface. Thus, we could potentially achieve a successful fit by altering soft lens power. A fit is
successful when a well-centered GP lens moves independently of the soft lens with each blink with
acceptable visual acuity and absence of corneal compromise. Ideally, the GP lens should achieve threequarters to 1 millimeter of movement over the soft lens surface with each blink. If the GP lens is too tight
and moves less, the potential for central corneal edema increases. The soft contact lens should move
one-quarter to one-half of a millimeter with each blink. Additionally, stationary air bubbles trapped
between the soft and GP lens that can't be removed indicating an exceedingly steep GP lens fitting
relationship are unacceptable.
In this study, we determined the optimal soft lens fit by trial and error. If we couldn't achieve a successful
fit (as detailed above) by altering soft contact lens power, then we selected a new GP lens. To determine
the ideal base curvature of the new GP lens, we performed keratometry over the soft lens. We then used
the flat keratometry measurement as the initial base curvature of a diagnostic GP lens. After we
determined the base curve through fitting relationship evaluation and calculated the power through overrefraction, we ordered a new GP lens. Table 1 lists the variety of GP materials worn in the study.

The cleaning protocol for the GP lenses included a GP lens cleaning solution (Boston Advance, Bausch
& Lomb) and rinsing/storage with a soft lens multi-purpose solution (Opti-Free Express, Alcon). A
separate cleaning protocol for the silicone hydrogel soft lenses included Opti-Free Express for
disinfecting, rinsing and storage. We instructed patients to use rewetting drops (Blink Contacts, AMO) as
needed.
We instructed patients to return for follow up at one
week, wearing the piggyback system for at least three
hours before the visit. We evaluated vision,
piggyback lens fit and corneal health; if these were
acceptable, we scheduled a final evaluation at a
minimum of four weeks following the successful
fitting. At this last evaluation, we performed visual
acuity testing and a slit lamp examination, including a
lens fitting evaluation. Additionally, we asked patients
to complete a post-fitting questionnaire (Appendix B,
available in the online version of the article) to assess
wearing time, visual quality and comfort levels with
the new piggyback lens system.

Figure 1. Pre-fitting keratoconus severity.

We used a paired t-test for with-in group comparisons to assess statistically significant changes in
wearing time and visual acuity. To analyze visual acuity data, we converted decimal values to logMAR
equivalents.
Results
Piggyback Lens System Fitting Of the 30 eyes of 16 patients included in this study, we achieved
successful piggyback fits in 26 eyes of 14 patients (87 percent). We excluded two eyes of the 14
successful patients because one eye wore soft contact lenses alone and the other eye did not wear any
contact lens due to a history of corneal hydrops with secondary advanced scarring. Of the 26 successful
piggyback fits, we achieved 20 using the patients' own GP lenses (77 percent).
Despite good comfort and fit with the piggyback lens system, three of the successfully fit patients (six
eyes) dropped out of the study before the one-month follow up due to loss of interest. Of the 30 eyes
included in this study, we couldn't achieve a successful piggyback fit in four eyes (13 percent) of two
patients. In one of these patients who had advanced keratoconus, the silicone hydrogel base curve
(8.3mm) wasn't steep enough to fit the cornea properly. In the other unsuccessful patient, despite
numerous attempts with a variety of GP parameters, persistent stationary central air bubbles remained
between the soft silicone hydrogel lens and GP lens.

Figure 2. Comfort with piggyback lens system vs. GP

lens alone.

Corneal Health We conducted a thorough slit lamp

examination of the anterior segment and more
specifically the cornea before the piggyback fitting to
assess baseline corneal health. The distribution of
clinical findings in keratoconic eyes in this study
included seven subclinical eyes (23 percent), nine
eyes with Fleischer's rings and absence of
striae/scarring (30 percent), one eye with striae, a
Fleischer's ring and absence of scarring (3 percent),
and 13 eyes with striae, Fleischer's rings and various
degrees of scarring (43 percent). Subclinical
keratoconic eyes exhibited classic topographical
patterns in the absence of visible corneal findings.

To compare severity, Heyman (1967) categorized keratoconic eyes using keratometry readings, with
moderate eyes ranging from 48D to 52D, advanced eyes from 52D to 56D and severe eyes from 56D to
60D. Based on this classification system, Figure 1 shows the severity of keratoconus in eyes included in
this study: Three eyes with sub-moderate keratometric readings, 14 eyes with moderate keratometric
readings (47 percent), six eyes with advanced keratometric readings (20 percent) and seven with severe
keratometric readings (23 percent).
All 30 eligible eyes exhibited an absence of significant corneal compromise and complications throughout
the piggyback fitting process and one-month follow-up period. Additionally, we found no evidence of
hypoxia throughout the study. We noted sodium fluorescein staining in 28 of 30 (93 percent) eyes prior to
the piggyback lens fitting. A large concentration of staining in eyes wearing only GP lenses was located in
the typical 3 o'clock and 9 o'clock positions, with grade 3 staining in one eye (3 percent), grade 2 staining
in three eyes and grade 1 staining in 18 eyes. Prior to the piggyback fitting, central sodium fluorescein
staining appeared in 11 eyes (37 percent) with grade 1 staining in nine eyes and grade 2 staining in two
eyes.
Before the piggyback lens fitting, 18 of the 20 eyes successfully fit in piggyback systems demonstrated 3
o'clock and 9 o'clock staining with an average grading of 1 and six of the 20 eyes (30 percent) showed
central staining with an average grading of 1. One month after the successful piggyback fittings, only two
of these 20 eyes showed 3 o'clock and 9 o'clock staining with an average grading of 1, and we noted no
central staining.
Comfort Figure 2 compares subjective comfort after wearing the piggyback lens system for one month
vs. prior GP lens wear alone. Eighteen of the 20 (90 percent) eyes successfully fit with a piggyback lens
system had the same or improved comfort compared to previous GP lens wear alone. Using a scale of 1
to 10 on the patient questionnaires, the mean subjective comfort rating improved to 8.95 one month after
the piggyback fitting from the 8.00 mean rating prior
to piggyback fitting.
Wearing Time All 20 eyes successfully fit with a
piggyback system had the same or increased
wearing time vs. the GP lens worn alone. The mean
wearing time reported before the piggyback fitting
was 13.1 hours vs. a mean wearing time of 13.4
hours one month after the piggyback fitting, which is
not statistically significant (p=0.21).
Visual Outcomes Seventeen (85 percent) of these
eyes fit with piggyback lens systems experienced the
same or better Snellen visual acuity. Figure 3
compares subjective visual satisfaction one month
3. Subjective visual quality outcomes with
after successfully wearing the piggyback lens system. Figure
piggyback lens system vs. GP lens alone.
Seventeen of 20 eyes (85 percent) had improved
visual quality with the piggyback lens system vs. their previous GP lens alone. Using a scale of 1 to 10 on
the patient questionnaires, the mean pre-fitting subjective visual quality rating was 8.05, which improved
to a 9.00 mean visual quality rating one month after the piggyback fitting.
Handling and Care While 12 of 20 (60 percent) eyes reported more difficulty and inconvenience with
handling a piggyback lens system, six of these 12 eyes reported that other benefits associated with the
piggyback lens system outweighed this potential disadvantage. Using a scale of 1 to 5 on the patient
questionnaires, the mean convenience rating decreased from 4.05 before the piggyback fitting to 3.65
one month after the piggyback fitting.

Overall Patient Satisfaction Figure 4 compares overall patient satisfaction with the piggyback lens
system vs. prior GP lens wear alone. Only one of the 20 successful piggyback fits that completed the
one-month follow-up felt that the piggyback lens system was worse than wearing the GP lens alone. After
the one-month follow up, 17 of 20 (85 percent) eyes continued with full-time piggyback lens wear. Two
eyes of one patient continued with part-time piggyback lens wear after the study. One patient continued
with GP lenses alone in one eye and full-time piggyback lens wear in the other eye.
Discussion
With limited vision correction alternatives for
keratoconus, piggyback lens systems have evolved
into a viable option for a wide range of keratoconic
patients. Using the methods described, it's possible
for practitioners to improve vision and comfort for
many problematic keratoconic patients by simply
introducing a soft silicone hydrogel lens beneath their
existing GP lens.
One of the most important outcomes of the
successful piggyback lens system fittings was the
resolution of many previous complications, including
central and peripheral superficial punctate keratitis. Improved corneal health with a significant reduction of
sodium fluorescein staining occurs because the soft contact lens provides a cushioning or bandage effect
from the overlying GP lens. The soft lens covers the entire cornea, minimizing abrasions of the fragile
cone apex and peripheral corneal tissue.
Figure 4. Overall patient satisfaction with piggyback
lens system.

In this study, it appears that a variety of GP lens materials in combination with a higher-Dk silicone
hydrogel contact lens sufficiently eliminated hypoxic complications. Researchers must attempt longerterm follow up and more material combinations to confirm this finding.
Between 10 percent and 25 percent of keratoconic patients undergo a penetrating keratoplasty because
of lens intolerance, reduced vision and/or corneal compromise. By increasing comfort, wearing time and
vision while decreasing corneal compromise, a piggyback system may delay or prevent the need for a
penetrating keratoplasty.
We can attribute improved comfort and increased wearing time with the piggyback system to a lack of
significant GP decentration or excessive GP lens movement. Kok et al (1993) found that in 80 percent of
eyes, patients wore piggyback systems longer than 12 hours per day without discomfort. Decreased
mechanical irritation and pressure on the weakened corneal apex allows keratoconic piggyback lens
wearers longer wearing times without comfort difficulties.
Improved subjective visual quality and objective visual acuity with a piggyback lens system is yet another
advantage for keratoconic patients. The soft contact lens effectively masks some of the irregularity of the
corneal surface. This enables the GP lens to more effectively correct the remaining irregular astigmatism
common in keratoconic eyes.
Despite the advantages this study found with piggyback lens systems, many patients found the care and
handling necessary to maintain the lenses inconvenient. In addition to the need for handling two different
types of lenses for each eye, patients must use two different care systems to optimally disinfect each lens
type. Because of this time-consuming care process, several patients successfully fit with piggyback lens
systems dropped out of this study. One commonality among all of these patients was an absence of
comfort and vision problems associated with wearing their habitual GP lenses alone. Symptomatic
patients may be more receptive to the potential increased comfort and visual quality of the piggyback lens
system.

Promising Option for Problematic Patients

As reported in this study, it's often possible to achieve a successful piggyback lens fitting utilizing a
patient's own GP lens. The relative ease of completing this piggyback fitting allows you more corrective
options in managing keratoconic patients. With proper patient selection, the advantages of increased
comfort, wearing time and visual quality can outweigh the inconvenience associated with handling and
caring for two sets of lenses. Tsubota et al (1994) reported that 10 of 11 patients who had keratoconus
and weren't able to tolerate hard lenses were successful in avoiding surgical intervention by switching to a
piggyback system. By fitting piggyback systems using new higher-Dk GP and soft lens materials, you may
help symptomatic keratoconic patients delay or avoid the long recovery period and other complications
often associated with a penetrating keratoplasty.
For references, please visit www.clspectrum.com/references.asp and click on document #130.
Dr. Rodio-Vivadelli graduated from State University of New York College of Optometry in 2004, then
completed a fellowship program in cornea and contact lenses in New York City, which provided advanced
training in specialty contact lens fitting and refractive surgery. She currently lives in Hammonton, NJ, and
practices in the area.
Dr. Gundel is an associate clinical professor and director of the Cornea and Contact Lens Fellowship
Program at SUNY State College of Optometry, New York, NY.

Contact Lens Spectrum, Issue: September 2006