BACKGROUND
LS, a 62 year old female was referred to possibly be fit with GP contact lenses. She has Fuch's dystrophy. Four years ago she had a
cataract removed OS, and at the same time a corneal transplant was performed. The patient reports being fit with a GP lens 4-6 months
after surgery, and "seeing better, but the lens repeatedly blinked out of the eye," and after 4-5 lost lenses, she was fit with an
aphakic soft contact lens with spectacles worn over it. According to her account, she only wore this lens "a few months," before being
informed that the induced corneal hypoxia had caused neovascularization into and very nearly throughout the entire graft.
She was discontinued for contact lens wear, and the resultant corneal irregularity from the extensive neovascularization caused very poor
best corrected spectacle acuity. Therefore, she had been uncorrected in the left eye for over three years.
TEST PROCEDURES
Entering spectacles: Entering VA with spectacles:
OD +1.25 - .75 x 105
20/40-
OS Balance lens
Hand Motion
Manifest Refraction:
OD +1.50 – 1.00 x 105
20/40-
OS +12.00 – 6.00 x 70
20/200-
Keratometry:
OS 39.75
@ 165 / 46.75 @ 75 (distorted mires)
PATIENT CONSULTATION AND EDUCATION
LS was advised that a GP lens would provide a more uniform surface to the left eye, with the tears filling in some of the corneal
irregularity behind the contact lens. Because of the large amount of corneal astigmatism, a toric back surface would be
required. Due to the ghost vessels throughout the cornea, the patient was advised that the expected acuity level was unknown but in
fact may not be very good. A GP lens was offered as her only viable corrective option for the left eye, however, and she desired to proceed.
No trial lenses were available anywhere close to her requirements, so a bitoric lens was designed utilizing the Mandell-Moore Bitoric Lens Guide.
The calculations were as follows:
Flattest
K
Steepest K
3. Enter K
39.75
46.75
4. Spectacle Power +12.00
+6.00
5.
Vertex Adjusted line +14.00
+6.50
6.
Insert Fit Factor
-0.25 +0.25
-0.75 +0.75
Add all lines
7. Final CL Rx
39.50 +14.25 46.00 +7.25
The lens ordered was thus 39.50 / 46.00, powers +14.25 / +7.25, 9.2mm diameter. The only way the lens can meet these specifications
is to add cylinder power on the front surface, which then makes it a bitoric (both surface are toric). The difference between
the base curves (6.50 diopters) and the difference between the power meridians (7.00 diopters) are not the same. Therefore, this
particular bitoric lens will have the effect of a cylinder lens on the eye (i.e. it is not a "spherical-power effect" bitoric).
FOLLOW-UP CARE / FINAL OUTCOME
Upon dispensing of the left GP lens, it was noted to center a little low, move and fit reasonably well, and the acuity was 20/25.
The lens was dispensed, and when LS returned in one week, she was very pleased with her vision. Over-refraction of +1.00 sphere
brought her vision to 20/20-. A second lens of the same base curves was ordered, but with powers of +15.25 / +8.25 (i.e. +1.00 was
added to each meridian).
When LS reported to be dispensed the new lens, she was in fact 20/20-. What had been her "useless eye" was now her good eye, and she was very
appreciative. As an interesting post-script, one month later LS won the highest prize in the Indiana lottery. She felt it was
indeed a lucky time for her- first getting improved vision, then the lottery. She promptly retired from her job and moved to
Florida, but not before ordering a back-up GP lens.
DISCUSSION/ALTERNATIVE MANAGEMENT OPTIONS
LS is a dramatic case of the great benefit GP lenses can be in cases of corneal irregularity. She had poor vision with any
spectacle lens for her left eye, due to the extensive irregularity caused by the neovascularization. The network of ghost vessels
was so extensive, there was good debate if fitting a lens was worth the effort.
When she was previously fit a GP lens, it was probably a spherical base curve. With her 7D of corneal
astigmatism, this lens had a difficult time staying on the eye. Utilizing a back toric design allows the lens to much better find
it's place. The design of the lens was very simple and straightforward using the Mandell-Moore Guide.
In this particular patient, spectacle acuities were poor, and the refraction was difficult at best. Keratometry was also less precise than
normal. These combined to cause the power to be off a little in the calculated lens, but this was easily adjusted for in the second lens.
While certainly a specialty lens, there really were no special skills or knowledge needed to be able to manage this
patient. By simply being able to fill in the blanks on the Mandell-Moore Guide, the life of this patient was significantly improved.
Refer to the Mandell-Moore Bitoric Guide.
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