Change in Visual Quality Following Surgery in a Case of Anterior Lenticonus Without Syndromic Association.

To the Editor: We describe a 28-year-old man who presented to us with complaints of progressive diminution of vision in both eyes for 2 years. The uncorrected distance visual acuity was 20/200 in both eyes, improving to 20/80 with pinhole. Near vision was N18 in both eyes. Retinoscopy was irregular with an oil-droplet reflex on distant direct ophthalmoscopy. Dilated slit-lamp examination showed anterior lenticonus in both eyes (Figures 1A-1B). Fundus examination was within normal limits. With a clinical suspicion of Alport’s syndrome, a history of renal insufficiency, hematuria, or hearing deficit was ruled out.1 Figures 1C-1D show the spectral domain anterior segment optical coherence tomography (Casia SS1000; Tomey, Nagoya, Japan) of both eyes. Ray-tracing aberrometry (iTrace; Tracey Technologies, Houston, TX) showed total higher order aberrations of 2.963 μm in the right eye and 1.689 μm in the left eye. Figures 1E-1F show that both higher and lower order aberrations of the cornea were within normal limits in both eyes. There was a significant increase in internal defocus (3.522 μm in the right eye and 3.215 μm in the left eye), which contributed to the patient’s large refractive error. Spherical aberration was also high (1.309 μm in the right eye and 1.231 μm in the left eye). Both vertical and horizontal coma was abnormal in the right eye (0.149 and 0.417 μm, respectively). A detailed assessment of preoperative visual quality metrics for the entire eye is shown in Figure 2. Modulation transfer function curve (Figure 2B) was flat preoperatively for both eyes, suggesting poor contrast sensitivity for both higher and lower spatial frequencies (area under the curve: 2.81 for the right eye and 2.88 for the left eye). Strehl’s ratio (Figure 2C) was 0.00141 in the right eye and 0.00192 in the left eye. Snellen’s simulated E charting for visual acuity of 20/30 showed gross distortions in both eyes.