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Creative Cures Using Contact Lenses
BY SUSAN G. RODGIN, OD, FAAO
A 23-year-old male presented for a comprehensive eye examination, complaining of difficulty reading. He reported that print blurred after variable amounts of time, the onset of which began when he was in college. Additionally, when he was in the military, night goggles would cause him to have blurred vision when viewing at distance.
He also had a number of complaints that have persisted since sustaining two injuries (described below). The complaints included severe dry eyes with chronic foreign body sensation, which were not relieved with use of artificial tears 14-to-16 times a day (which stung his eyes), gel, ointment and punctal plugs.
Other complaints included extreme sensitivity to bright lights and an inability to follow objects coming toward him — especially baseballs or soccer balls, but also motor vehicles — which was worse in bright light. Following the injuries, systemic complaints included intermittent vertigo when lying supine and intermittent headaches.
Figure 1. Patient's normal eye color.
Ten months preceding his examination, this patient was injured in Iraq by the explosion of an improvised explosive device (IED). He incurred a closed head trauma with two minutes of loss of consciousness and two weeks of loss of vision. The injury was managed in the field by a medic with minimal equipment, using bilateral patching and cold compresses. The patient reported that he was unable to open his eyes for two weeks and was highly sensitive to light following the accident.
Three weeks after the initial injury, the patient was seen in the hospital. The only records available from this examination showed an uncorrected VA of 20/200 OD and OS, a 3mm abrasion on the left cornea and cells (ungraded) OD and OS in the anterior chambers (without flare). A diagnosis of "traumatic iritis OU" was made, and the patient was treated/taper-ed over the course of one month on Pred-G (Allergan) hourly, bacitracin ointment twice a day and atropine three times a day.
Five months later, in a mine blast, the patient was thrown from his vehicle and skidded down a 200ft path on his back, suffering a concussion, blurred vision and nausea/vomiting. A recent neurology work-up showed a normal head MRI and rare punctate calcifications in the left cerebellar hemisphere on a C.T. scan. (There was no record of thyroid/aparathyroid labs.)
At presentation, uncorrected VA was 20/20-2 OD and OS. Entrance tests were unremarkable, and color vision was normal in each eye. Saccadic movements and pursuits were also normal. Static retinoscopy was +0.25DS OD, plano OS. Refraction with binocular balance was –0.50 –0.25 × 135 OD and –0.50DS OS, yielding 20/20 in each eye. Accommodative testing showed significant accommodative insufficiency OD and OS. An add of +1.25D over the refraction yielded immediate comfort and increased clarity with reading.
Slit lamp examination revealed 2+ generalized injection OD and OS with trace meibomian capping OD and OS. There was mild inferior superficial punctate keratitis, OS greater than OD. Tear breakup time (TBUT) was four seconds OD and one second OS. Applanation tonometry was 16mmHg OD and 17mmHg OS at 10:15 am. Dilated examination of the retina was unremarkable OD and OS except for a 0.5 DD area of chorioretinal atrophy with vitreal adhesion in the superotemporal periphery OS.
I diagnosed this patient with severe dry eye, significant accommodative insufficiency and extreme photosensitivity, which I presumed was exacerbated by or secondary to the initial injury and prolonged atropinization during the course of treatment.
Figure 2. Tinted contact lens on right eye. The patient tried variations of brown, grey, yellow and pink tints and found that the pink tint most comfortably blocked glare.
Figure 3. Tinted contact lenses on both eyes.
Initial treatment included preservative-free ocular lubricant ointment t.i.d.-to-q.i.d. OD and OS, which provided significant symptomatic relief and did not sting upon instillation. This decreased the redness in his eyes and increased his TBUT to 10-to-12 seconds OD and OS.
Next, because he requested contact lenses to improve distance vision, we fitted him with low-water disposable bifocal lenses (–0.50DS with +1.25D add OD and OS) to give him clear, comfortable distance and near vision and to relieve his symptomatic accommodative insufficiency. (He was traveling abroad for a year and not available for vision therapy.) We added a custom tint to each lens, the color of which was subjectively selected by the patient to best block indoor and outdoor glare (Figures 1 through 3).
This patient was very symptomatic upon presentation. Preservative-free ocular lubricant drops relieved his dry eyes. Creatively using custom-tinted soft bifocal contact lenses relieved both his glare sensitivity and accommodative insufficiency.
It is important to approach ocular problems with a cadre of treatments, creatively finding the best combination to fit each patient's needs. In this case, combined use of correct lubrication, bifocal contact lenses and custom tinting solved this patient's eye symptoms. CLS
Dr. Rodgin is in private practice in Wayland, MA and is on staff at the Boston V.A. Medical Center. She is an Adjunct Faculty member at the New England College of Optometry.