Advanced Presbyopia (Low Lower Lid): Douglas P. Benoit, OD, FAAO
Patient JH, a 59-year-old attorney, presented for a complete eye examination. He was wearing single vision GP lenses, fit elsewhere. He had been told single vision contact lenses were the best choice, and that monovision would not work for him. He stated that bifocals had not been presented as an option. He did not like having to wear glasses over his contact lenses to read.
Test Prodedures, Fitting/Refitting, Design & Ordering
OD: -3.25 – 0.75 x 171
OS: -3.00 – 1.00 x 178
Add: +2.25 OU
OD: 41.37 @ 175; 44.12 @ 085
OS: 41.75 @ 180; 43.12 @ 090
Current GP Lens Parameters:
Slit Lamp Evaluation: Slit lamp examination revealed mild meibomian plugging, but a tear meniscus of average height and width. Corneas were clear and conjunctivae showed only mild pinguecula OU.
Palpebral fissure height was 12 mm OU.
Lid Position: the upper lid overlapped the superior limbus by 2 to 3 mm, while the lower lid was approximately 1.5 mm below the inferior limbus.
Pupil Diameter: 4 mm in average room light.
Dominancy: the patient was right eye dominant.
Due the position of the lower lid relative to the limbus, this patient was a better candidate for an aspheric multifocal than a translating design. The lower lid placement would likely not allow for proper positioning of the segment in primary gaze or adequate translation on down gaze.
The following lenses were ordered empirically:
ReClaim HD (Blanchard) with plasma treatment
Add: +2.50D in a 3.0mm central zone OU
Patient Consultation and Education
At dispensing, the lenses provided good comfort upon insertion. After settling for approximately five minutes, vision was assessed and resulted in the following:
OD: 20/20 distance and near
OS: 20/20-2 distance and 20/20 near.
Each lens had a superior-central position in primary gaze, and translated up nicely on down gaze. Evaluation with fluorescein showed a slight apical clearance pattern with good peripheral clearance OU. These lenses were dispensed with Boston Simplus (Bausch & Lomb) and the patient scheduled for follow-up in two weeks.
Follow-up Care/Final Outcome
At follow-up, the patient was very happy with the vision and comfort of his GP multifocals. He was able to wear them at work without the need to resort to reading glasses over them. He could wear them for 14 hours per day and denied any spectacle blur on lens removal. He was released for six weeks and at that follow-up visit, he was just as happy as before.
Discussion/Alternative Management Options
This patient is the classic example of why multifocal lenses should be discussed with all patients. He had been told only about monovision and distance contact lenses with readers. A colleague mentioned his bifocal contact lenses and sent the patient to our office. The ability to be successful with an empirical fitting process is convenient for the patient and simplifies the process for the practitioner. As discussed before, this patient was not a good translating GP lens design candidate due to the low positioning of his lower lid. In such cases it is difficult to get a segment height that will provide good near vision. A soft toric multifocal could have been used, but vision could be less sharp and less stable as soft lenses tend to be torqued by the lids more than GP lenses.
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