GP Lens Case Grand Rounds Troubleshooting Guide – 48

Young Progressive Myopic Patient: John Rinehart, OD

Background

A 13-year-old white female presented with her mother who exhibited concern about the progression of her myopia. At age 6 years she was emmetropic, at age 8 she was 1.00 D myopic, by age 13 she was 4.00 D myopic. After discussion of the options it was decided to begin a plan of orthokeratology.

Test Procedures, Fitting/Refitting, Design & Ordering

Best Corrected Acuity (Spectacles):

OD: 20/20
OS: 20/20

Unaided Distance Acuity:

OD: 20/250
OS: 20/250

Subjective Refraction:

OD -4.00 sphere
OS -4.25 sphere

K-readings:

OU 41.75/42.50 @ o90 0 distortion
Prefit topography OD only

Diagnostic fitting was performed using the R & R Lens Design inventory fabricated by Danker Labs of Sarasota, Florida. On the open eye it was determined that the best combination of centration and movement was achieved with an alignment curve radius of 8.08 for the right eye and 8.04 for the left. The patient was instructed in placement, removal and care of the lenses. She was told to put the lenses on 15 minutes prior to going to bed and upon waking to lubricate the lenses with reconditioning solution. She was scheduled to be seen, with the lenses on, early the next morning.

Follow-Up Care/Final Outcome

At the day one visit the lenses centered well and fluorescein pattern showed a “bull’s eye” with only a small amount of movement. Upon removal of the lenses her unaided acuity was OD 20/40 and OS 20/20.

Subjective Refraction:

OD: -2.00 sphere
OS: -1.25 sphere

K-readings:

OD: 39.00/40.50@ 090
OS: 39.75/40.50 @ 090 0 distortion OU

Day one topography, below, shows a treatment zone that is very slightly decentered superiorly.

She was instructed to continue to wear the lenses overnight and to return in one week. At the one week visit she had been wearing the lenses an average of 9 hours per night. On this day the lenses had been off for 6 hours.

Unaided DVA:

OD: 20/40
OS: 20/50

Retinoscopy:

OD: -1.00 sphere
OS: -0.75 sphere

K-readings:

OD: 39.25/39.50 @ 090
OS: 39.50/39.50 @ 090

One week topography, below, shows the OD treatment zone to be decentered nasally. In order to get better centration the overall diameter of the right lens was increased from 10.6mm to 11.0 mm. To achieve more refractive change the base curve of each lens was flattened by 0.12 mm.

One Week Topography OD:

Two week after the new lenses were dispensed the patient’s unaided DVA OD 20/20 OS 20/20.

Subjective Refraction:

OD: +0.75 -0.50 150 20/20
OS: Pl sphere 20/20
K-reading OD 39.00/39.75 @ 090 OS 39.25/39.75 @ 090 0 distortion OU

Topography, below, shows a much better centered treatment zone.

Discussion/Alternative Management Options

At the time of the examination, with the patient’s mother present, the advantages and disadvantages of other options were discussed. The patient and parents were concerned with her increase in myopia. While spectacle lenses and soft contact lenses provide crisp clear vision they would do nothing to slow the progression of the myopia.

Traditionally fit gas permeable lenses could be expected to provide the desired clear vision and may slow the progression of myopia and might even slightly decrease the myopia but not to the extent that orthokeratology would decrease the correction.

Due to the patient’s age refractive surgery is not an option. For these reasons the patient, the patient’s parents and myself felt that orthokeratology was the best option for this young lady.

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