prescribing for presbyopia
Fitting the Impossible Contact Lens Patient
BY N. REX GHORMLEY, OD, FAAO
I have been providing contact lens care for more than 30 years, during which time I have seen all types of patients. I have built my practice on our ability to fit difficult and "impossible" patients with contact lenses
Ten months ago, patient MR, a 53-year-old female, came to my office for contact lens care. When I entered the room she proclaimed, "You are my last chance -- I really want to wear contact lenses." She said three eye doctors in the past year all told her she couldn't wear them. "I have dry eyes and I use eye drops many times during the day," she explained. MR also stated that her primary care physician told her that she had Sjögren's Syndrome. "Hopeless," I muttered to myself.
Surveying the Situation
I carefully listened to MR and performed a comprehensive vision exam. MR's refraction was +3.25 0.50 x135 20/20 OD and +3.50 0.25 x45 20/20 OS. She needed +2.00D add power OU. Her Schirmer test results were 3mm/5minutes OD and 2mm/ 5minutes OS. Biomicroscopy showed tear break-up time of 3 OD and 2 OS, positive rose bengal staining OU and that approximately half of the corneal epithe lium in both eyes showed diffuse stippling with fluorescein stain.
I looked MR in the eye and asked her why she wanted to wear contact lenses. She replied, "I just want to wear contact lenses when I go to church and out to dinner with my husband. I don't want to always wear these thick, heavy glasses when I go out socially."
I asked, "Would you be happy wearing contact lenses three to four hours at a time, several times a week?"
MR replied, "If you can do that you're a miracle man!" With those words I knew we had to try to achieve some clinical success with this "impossible patient."
I decided to fit MR with silicone hydrogel lenses. Diagnostic fitting with Focus Night & Day (CIBA Vision) lenses resulted in 8.6/+3.25D 20/20 distance visual acuity OD; 8.6/+5.50D 20/20 near visual acuity OS. Night & Day's high Dk (140), low water content (24 percent) and plasma coating that enhances wettability would ensure that MR's compromised cornea received enough oxygen and experienced less lens-related dryness.
I placed a drop of Systane (Alcon) artificial tears in both eyes before applying the lenses. Contact lens comfort and vision stabilization occurred within a few minutes. MR was thrilled with her distance and near vision without her glasses.
I instructed MR to wear her contact lenses for several hours for a few days and to return to my office for a progress evaluation in seven to 10 days. I prescribed the Clear Care (CIBA Vision) hydrogen peroxide contact lens care system and recommended that she apply Systane artificial tears before lens application. I also inserted silicone plugs into the puncta of both lower lids.
A Lesson Worth Learning
MR returned in 10 days for her contact lens evaluation. She wore a broad smile when I entered the room and happily reported that she was wearing the lenses every day for six to eight hours with good lens comfort and excellent vision. But my big surprise came when I performed biomicroscopy and found 75 percent of the corneal stippling gone.
MR has since worn her silicone hydrogel lenses successfully for 10 months. The lesson you should learn from this case is that if you listen to your patient, establish realistic expectations and use modern contact lens technology, then many "impossible" patients can achieve successful contact lens wear.
Dr. Ghormley is in private practice in St. Louis, MO. He is a past president of the American Academy of Optometry and is a Diplomate of its Cornea & Contact Lens Section.