Patient:

PB age 57 F

Occupation:

Banker. Uses computer 3 + hrs / day.

Hobbies:

Reading, art & walking.

History:

Previously wore rigid lenses for 10 yrs. Was refitted with GP lenses 3 yrs ago. Had difficulty reading and did not want to wear reading glasses. Unable to wear contact lenses since being treated for Bells Palsy in Dec. 2000. Wants to wear bifocal contact lenses.

General Health:

Currently treated for Osteoporosis with Fosomax, Bronchial hyperactivity with Provocol and Protonix for Esophagitis.

Ocular Health:

Diagnosed with Bells Palsy. Mild ptosis in OS and marginal dry eye symptoms.

CC:

"Hates glasses, wants to wear bifocal contact lenses."

Subjective:

OD -3.75 -0.75 x 55 20/25+
OS -3.50 -0.75 x 110 20/30
Add +2.00, OU

Keratometry:

OD 45.00 /46.00 @164
OS 45.75 / 46.62 @ 030

Slit Lamp:

Lid position in left eye demonstrated a moderate amount of ptosis* as a result of the inflammatory disorder related to Bells Palsy and the left vertical aperture measured 1.5 mm smaller. TBU showed a low tear break-up time (8 sec); however, the blink was complete.

*See photo of eye on Ring Verification on Topography Map below.

Pupils:

Pupil diameters were 4 mm in normal room illumination.

Dominant Eye:

OD

Contact Lenses:

OD 7.50 BC- 4.25DS 8.80 Dia/7.50OZ .14 CT / Paraperm 02
(3/21/00) OS 7.34 - 3.25 8.80 7.50 .14 Paraperm 02

Lens Performance:

Distance vision was acceptable; however, near vision was unacceptable and left lens was unacceptable due to unstable position related to lid ptosis.
 

Diagnostic Fitting:

Spherical base curve Dx cls in Mandell Seamless, a front surface concentric translating design was found to give the best performance for distance, mid-range and near vision.

Final Design:

A spherical base curve lens utilizing a 3/4 BD prism to provide for better lens centration.

OD 7.54BC -3.50DS 9.80Dia 8.00OZ 3/4 BD +2.25 Add 3.80 Zone
OS 7.42 -2.50 9.60 7.80 3/4 +2.25 3.80
Note: both lenses utilized a 1.0mm Intermediate zone and material used was Boston ES. Optimum care regimen and Viva rewetting.

Discussion:

This patient presented with a great desire to wear multifocal lenses. She also had a very problematic situation as the result of her episode of Bells Palsy that resulted in left upper lid ptosis and a marginal dry eye condition. The reduction of the diameter in the left lens, as well as the inclusion of prism, provided the centration and stability to give good distance vision; yet it did not interfere with the need for the lens to translate for mid and near vision tasks.

This case demonstrates how a well-designed multifocal gas permeable contact lens can perform and how it can give a good range of vision as well as work for a patient with an eyelid dysfunction and marginal dry eye.

Patient:

RJ, age 54

Occupation:

Veterinarian. Uses computer, performs diagnostic and surgical procedures.

Hobbies:

Reading, swimming & exercising.

History:

Has worn various types of rigid lenses for 25 years. He is currently wearing single vision lens (GPs past 7 years).

General Health:

Mild allergies, otherwise unremarkable.

Ocular Health:

Unremarkable except for some dry eye symptoms.

CC:

Difficulty with distance vision past year. Does not wear any backup specs.

Subjective:

OD -4.00 - 0.25 X 100 20/25 Add +2.25 20/25
OS - 4.75 - 1.00 X 95 20/30 Add +2.25 20/25-

Keratometry:

OD 44.37 / 45.25 @ 148 D1
OS 44.50 / 45.00 @ 78 D1+

Slit Lamp:

Lids, lashes, conjunctiva and corneas were unremarkable.

Lid Position:

Lower lids were 1.5mm below lower limbus, and upper lids were 1.5 mm above the upper pupil margins in normal room illumination.

Pupil Size:

4+ mm in normal room illumination

Dominant Eye:

OD (also had better distance VA).

Current Lenses:

OD 7.40 - 4.50 DS 9.20 Dia 7.80 Oz .15 ct 20/50 Near 20/30
OS 7.38 --5.25 DS 9.20 Dia 7.80 Oz .14 ct 20/60 20/40

Lens Performance:

Visual acuity at distance was reduced as a result of the lens condition and the fitting relationship, which was steep. The under correction in the distance did give some effective add power for near vision tasks but causing poorer distance visual acuity. Patient also has significant problems with dry eye symptoms.
 

Diagnostic Fitting:

The patient has critical vision demands for all working distances. Avocational distance vision demands were also considered. As a result of all of the various requirements, several different lenses utilizing translating design with Tangent Streak, Mandell Seamless and Paragon ST 60 were first attempted. The results with the initial designs consistently produced relatively good distance vision but not always adequate near vision and usually unacceptable mid-range vision. The evaluation process then proceeded to the aspheric design (Simultaneous Vision).

Essentials III Aspheric High Add GP multifocal

OD 7.40 BC -5.50 DS 9.80 BC Boston EO
OS 7.40 BC -6.00 DS 9.80 BC Boston EO

Performance Notes: Distance vision problems due to riding position, which were not correctable with lens parameter changes.

Life Style Design

OD 7.60 EQ/7.44 BC -5.00 DS 9.50 Diam SGP II +2.00 Add
OS 7.50 EQ/7.33 BC -6.75 DS 9.50 Diam SGP II +2.00 Add

Note: This lens design allows good distance vision when the lens positions high in relation to the pupil.

VAs were:
            Dist: 20/25, OU
            Near 20/25+OU with good range of vision at near.

Discussion:

This case demonstrates how a patient with less than ideal lid position, dry eye problems and full range vision demands can be fitted successfully. This case represents the need to allow for a comprehensive diagnostic evaluation process and the commitment to find the appropriate lens design to provide adequate vision performance. This case also demonstrates how important lens material is when dealing with dry eye conditions.