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Unusual Contact Unusual Contact Lens CasesLens Cases

JimHanniganJimHannigan ODOD

Case # 1Case # 1

Simple PKP fitSimple PKP fit………………....

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Patient CJPatient CJ

Referred by corneal specialist for Referred by corneal specialist for evaluation of contact lensevaluation of contact lensShe had fit CJ with She had fit CJ with RGPRGP’’ss, but CJ unable , but CJ unable to wear due to comfortto wear due to comfortCJ is postCJ is post--op PRKop PRKCJ is 80 CJ is 80 y/oy/o, but sharp, but sharp

Options:Options:

Refit Refit RGPRGP’’ssPiggyback Piggyback RGPRGP’’ssSee what See what sclscl’’ss can docan doOther?Other?

Patient CJPatient CJ

Referral included Rx:Referral included Rx:OD: OD: --2.50 2.50 --1.25 x 172 20/501.25 x 172 20/50--22OS: OS: --2.00 2.00 --1.75 x 116 20/601.75 x 116 20/60--22Discovered CJ was postDiscovered CJ was post--op PKP, postop PKP, post--op op lasiklasik (performed after PKP), and post(performed after PKP), and post--op op cataract extraction with IOL (performed cataract extraction with IOL (performed before PKP)before PKP)

Patient CJPatient CJ

Tried OD Tried OD sclscl trial (trial (BiofinityBiofinity) ) --3.003.00OR OR --2.752.75……..good! why?..good! why?Tried OD Tried OD sclscl trial (trial (BiofinityBiofinity) ) --5.75 20/255.75 20/25CJ thrilled with comfortCJ thrilled with comfortOD doneOD done…………..

Patient CJPatient CJ

Tried OS Tried OS sclscl trial (trial (BiofinityBiofinity) ) --5.505.50OR +3.00 OR +3.00 --4.75 x 113 20/204.75 x 113 20/20--33Tried OS Tried OS sclscl trial (trial (BiofinityBiofinity torictoric) ) --3.50 3.50 --1.75 x 110 ( no rotation)1.75 x 110 ( no rotation)OR +1.00 OR +1.00 --3.00 x 125 20/203.00 x 125 20/20--22Ordered trial Ordered trial BiofBiof T T --3.25 3.25 --2.25 x 120 2.25 x 120 What next??What next??

Patient CJPatient CJ

Patient needs near Rx Patient needs near Rx Has worn bifocals for many yearsHas worn bifocals for many yearsSoSo…………She wears bifocals over She wears bifocals over sclscl OD and OD and sclscltorictoric OSOSRX: OD: Plano 20/25RX: OD: Plano 20/25

OS: +.75 OS: +.75 --2.00 x 120 20/25+22.00 x 120 20/25+2Note: I lowered Note: I lowered cylcyl by .50 (+2.25 add)by .50 (+2.25 add)

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Case # 2Case # 2

Can you do Can you do orthoortho--kk with a soft contact with a soft contact lens???lens???

WellWell……..yes, after RK..yes, after RK

RK patients have corneas that are greatly RK patients have corneas that are greatly affected by oxygen permeabilityaffected by oxygen permeabilityRK patients have corneas that are greatly RK patients have corneas that are greatly affected by tear tonicityaffected by tear tonicityTypically they have different Typically they have different rxrx’’ss am vs. pmam vs. pm(note) (note) muromuro 128 5% prevents this128 5% prevents thisThe greater the number of incisions, the The greater the number of incisions, the greater the effectgreater the effect

Patient SSPatient SS…………RK 19 y/agoRK 19 y/ago

Early Early presbyopiapresbyopiaRx OD Rx OD --1.00 1.00 --.25 x 36.25 x 36RX OS RX OS --1.25 1.25 sphsphPast Past sclscl wearerwearerDoesnDoesn’’t prefer glassest prefer glassesFavorite hobbyFavorite hobby……..waterskiing..waterskiing

Options??????Options??????

SCL with readers?SCL with readers?Distance RX, remove to read? Distance RX, remove to read? MonovisionMonovision? Good choice, but what ? Good choice, but what about waterskiingabout waterskiingOrthoOrtho--k with k with sclscl? What?? What?

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Patient SSPatient SS

Wears Wears sclscl on OD for distanceon OD for distanceAny nonAny non--silicone silicone hydrogelhydrogel would workwould workShe has 8 radialsShe has 8 radials……..perfect..perfectLemmeLemme explain the aboveexplain the above…………

Patient SSPatient SS

After several weeksAfter several weeksRefractionRefraction…….OD .OD --.25 .25 sphsphNote Note clcl was was --1.50, why?1.50, why?She can now remove her She can now remove her clcl for for waterskiing etc and see wellwaterskiing etc and see well

Case # 3Case # 3

RGP as valuable diagnosticRGP as valuable diagnostic

Patient RH Patient RH

1 week post op cataract extraction with 1 week post op cataract extraction with IOL, ODIOL, ODPatient is 20/40 best corrected ODPatient is 20/40 best corrected ODSurgeon is concernedSurgeon is concernedRefers patient to me for refraction checkRefers patient to me for refraction checkSays Says ““if you canif you can’’t get better than 20/40, t get better than 20/40, send him to Dr. send him to Dr. xxxxxxxxxx for a retinal check.for a retinal check.””

Patient RHPatient RH

Refraction shows best corrected vision as Refraction shows best corrected vision as 20/4020/40I notice the patient has had a I notice the patient has had a limballimbal relaxing relaxing incisionincisionThis was performed during the cataract surgery This was performed during the cataract surgery to correct astigmatismto correct astigmatismIt gives the spherical equivalentIt gives the spherical equivalentWorks well if spherical equivalent is Works well if spherical equivalent is planoplano, not , not just post opjust post op

Patient RHPatient RH

Could the blur be secondary to the LRI?Could the blur be secondary to the LRI?Or is it retinal?Or is it retinal?Retina looked OK to me (and to the Retina looked OK to me (and to the surgeon)surgeon)HmmmHmmm……..how do you tell?..how do you tell?

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Patient RHPatient RH

I instilled I instilled proparacaineproparacaine……..I put an RGP on the ODI put an RGP on the OD……. . OverrefractionOverrefraction……....Vision? Clear 20/20Vision? Clear 20/20I tell the surgeonI tell the surgeon…….not retinal (he.not retinal (he’’s s confused)confused)RGP great for evaluating corneal RGP great for evaluating corneal warpagewarpage

Case # 4Case # 4

Corneal surface irregularityCorneal surface irregularity

Patient DNPatient DN

50 50 y/oy/o male with Reiss Bucklers Corneal male with Reiss Bucklers Corneal DystrophyDystrophyOS has had PTKOS has had PTKBest corrected vision with glasses is good Best corrected vision with glasses is good OSOS……20/2520/25OS refraction: OS refraction: --3.25 3.25 sphsphBest corrected vision with glasses is poor Best corrected vision with glasses is poor ODOD……20/10020/100OD refraction: +3.75 OD refraction: +3.75 –– 6.00 x 986.00 x 98

Patient DNPatient DN

What do you do?What do you do?PTK OD? Patient says hePTK OD? Patient says he’’s not ready for s not ready for that, what else can I do?that, what else can I do?RGP, with or without piggybackRGP, with or without piggyback…….poor .poor comfort, but 20/30 vision.comfort, but 20/30 vision.HeHe’’s tries to s tries to ““get used to itget used to it””Not working for himNot working for him

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Patient DNPatient DN

I put a high power I put a high power sclscl ((BiomedicsBiomedics) on ) on OD, +6.00OD, +6.00I I overrefractoverrefract……..--3.00 3.00 --300 x 100300 x 10020/2520/25--33Why did I overcorrect his Why did I overcorrect his hyperopiahyperopia??

Patient DNPatient DN

Reason # 1: to reduce the Reason # 1: to reduce the anisometropiaanisometropiaReason # 2: it masked cylinder as well as Reason # 2: it masked cylinder as well as corneal surface irregularitycorneal surface irregularity

Case # 4 1/2Case # 4 1/2

DNDN’’ss son BNson BN

Patient Patient DNDN’’ss Son, BNSon, BN

28 28 y/oy/o malemaleReiss BucklerReiss Buckler’’s Corneal Dystrophys Corneal DystrophyRefraction OD: +.75 Refraction OD: +.75 -- 1.75 x 115 20/301.75 x 115 20/30Refraction OS: +1.75 Refraction OS: +1.75 –– 1.00 x 136 20/301.00 x 136 20/30

Patient BNPatient BN

Fit with Fit with torictoric sclscl’’ssOD: +1.25 OD: +1.25 -- 1.25 x 120 20/201.25 x 120 20/20OS: +2.00 OS: +2.00 -- .75 x 130 20/20.75 x 130 20/20

Case # 5Case # 5

Contacts for Color DeficiencyContacts for Color Deficiency

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Patient RVPatient RV

25 25 y/oy/o male with history of male with history of ““color color blindnessblindness””Unable to get position at work Unable to get position at work Ishihara color plates show red/green Ishihara color plates show red/green color deficiency color deficiency 4 out of 14 plates identified correctly4 out of 14 plates identified correctly(note) he has red hair and a red car!(note) he has red hair and a red car!

Patient RVPatient RV

He has compound myopic astigmatismHe has compound myopic astigmatismSo I fit him with an XSo I fit him with an X--chrome rigid chrome rigid contact lenscontact lensHe runs around the office all excited by He runs around the office all excited by his his ““newnew”” vision (the fire extinguisher was vision (the fire extinguisher was fascinating to him)fascinating to him)

Patient RVPatient RV

Vision clear, but dim, as I put the Vision clear, but dim, as I put the ““redred””lens on his dominant eyelens on his dominant eyeI tried another set with the nonI tried another set with the non--dominant dominant eye wearing the red lenseye wearing the red lens…….he said it was .he said it was much bettermuch betterIshihara platesIshihara plates……..10 out of 14 correct!..10 out of 14 correct!

Patient RVPatient RV

Other optionsOther options…………..If no astigmatismIf no astigmatism……....ChromagenChromagen (Y,M,G,P,A,O,V)(Y,M,G,P,A,O,V)Color Vision (by United Contact Color Vision (by United Contact lens)lens)…….they charge $15 above your lens .they charge $15 above your lens cost of an cost of an ocufilconocufilcon A lensA lens

Case # 6Case # 6

Photophobia resolvedPhotophobia resolved

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Patient SGPatient SG

18 18 y/oy/o female recently diagnosed with female recently diagnosed with CrohnCrohn’’ss Disease (chronic inflammatory Disease (chronic inflammatory bowel disease)bowel disease)She wears She wears AcuvueAcuvue 2 2 sclscl’’ssVery photophobicVery photophobic

Patient SGPatient SG

Slit lamp difficult because of photophobiaSlit lamp difficult because of photophobiaNo cells or flareNo cells or flareNo fixed pupilNo fixed pupil+ lancet+ lancet’’s signs signDxDx: sub: sub--clinical clinical iritisiritis secondary to secondary to CrohnCrohn’’ss DiseaseDiseaseTreatment??Treatment??

Patient SGPatient SG

HomatropineHomatropine gives some reliefgives some reliefSteroids were withheldSteroids were withheldPatient says photophobia Patient says photophobia ““always therealways there””I tried Nike I tried Nike MaxsightsMaxsights to see if any help to see if any help She says they helped, but did have effect on She says they helped, but did have effect on color vision, mostly with amber, less with greycolor vision, mostly with amber, less with greyShe decided to use them for any outdoor She decided to use them for any outdoor activities, as well as sunglassesactivities, as well as sunglassesVery happyVery happy……

Case # 7Case # 7

Fitting a scary corneaFitting a scary cornea

Patient RWPatient RW

38 38 y/oy/o male referred by local OD to see if male referred by local OD to see if any any clcl could help reduce OS vision blur could help reduce OS vision blur as well as as well as anisometropiaanisometropiaWhat???What???

Patient RWPatient RW

Patient had Patient had ““IntacsIntacs”” inserted into OU inserted into OU corneas for the correction of simple corneas for the correction of simple myopiamyopiaRefraction OD: +.75 20/20Refraction OD: +.75 20/20Refraction OS: Refraction OS: --.25 .25 –– 6.50 x 36 20/806.50 x 36 20/80

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Patient RWPatient RW

Slit lamp reveals reasonSlit lamp reveals reason……....

Patient RWPatient RW

TopoTopo very irregular, unreliablevery irregular, unreliableUnable to wear glassesUnable to wear glassesTried trial RGP after Tried trial RGP after proparacaineproparacaineBC 45.00BC 45.00……..my usual if no other info ..my usual if no other info helpshelpsPower Power --2.50 (it2.50 (it’’s what I had!)s what I had!)

Patient RWPatient RW

OverrefractOverrefract: : --2.25 2.25 -- 2.75 x 40 20/402.75 x 40 20/40Terrible fitTerrible fit…….bubble superiorly, lens moves .bubble superiorly, lens moves excessivelyexcessively…….but good info.but good infoThe The overrefractoverrefract sphere indicates a flat BC of sphere indicates a flat BC of 43.00 ( BC of 43.00 ( BC of clcl was 45.00 and seems to be 2 was 45.00 and seems to be 2 dioptersdiopters steep as evidenced by the steep as evidenced by the overrefractionoverrefraction))I donI don’’t trust the steep BC using the same t trust the steep BC using the same methodmethod

Patient RWPatient RW

I order a biI order a bi--curve bicurve bi--torictoricBC 44.00/46.50BC 44.00/46.50Power Power --1.25/1.25/--3.753.75

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Patient RWPatient RW

Easy if taken one axis at a timeEasy if taken one axis at a timeFlat kFlat k……..43.00..43.00Rx Rx --.25.25CLCL……..44.00 (1 D steep)..44.00 (1 D steep)CL power CL power --1.251.25

Patient RWPatient RW

Steep axis kSteep axis k……..49.50 (or close to that!!)..49.50 (or close to that!!)Steep RX Steep RX --6.756.75CL steep axisCL steep axis…….46.50 ( 3 D flat).46.50 ( 3 D flat)Steep axis power Steep axis power --3.753.75Note: diameter 9.6Note: diameter 9.6

Patient RWPatient RW

CL orderedCL orderedAt dispense timeAt dispense time…….I used .I used proparacaineproparacaineLens showed some bearing across the Lens showed some bearing across the 40 degree meridian40 degree meridianVision 20/20Vision 20/20--33Patient happy with visionPatient happy with vision…….not so much .not so much with comfortwith comfort

Patient RWPatient RW

1 week follow up1 week follow up…… still poor comfort, but still poor comfort, but patient patient ““determineddetermined”” as his vision was as his vision was much improvedmuch improvedCL looked centeredCL looked centeredOverrefractionOverrefraction showed plshowed pl--.50 x 126 .50 x 126 20/2020/20……..cylinder was overcorrected, but ..cylinder was overcorrected, but acceptableacceptable

Patient RWPatient RW

2 week follow up2 week follow up……..unable to wear more ..unable to wear more than 5 hoursthan 5 hoursTime for piggybackTime for piggyback……....AVOAVO…….any power ( I used a .any power ( I used a --2.00)2.00)Comfort much improved immediatelyComfort much improved immediatelyLens also showed less Lens also showed less ““rockingrocking””

Patient RWPatient RW

4 week follow up4 week follow upPatient wears Patient wears clscls 88--10 hours/day10 hours/day……..very ..very happy, although some occasional blur happy, although some occasional blur corrected by blinkingcorrected by blinking

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Patient RWPatient RW

DkDk not much of a problemnot much of a problemLess mechanical trauma with piggybackLess mechanical trauma with piggyback