GP Lens Case Grand Rounds Troubleshooting Guide

Young Progressive Low Myopic Patient: Robert L. Davis, OD, FAAO

Background

KH came to the office with his parents for an annual examination because of difficulty seeing at distance. KH is a ten year-old male who enjoys sports and plays on a traveling baseball team. During the winter months he plays basketball at the park district and his glasses either become foggy or displaced. During the case history KH inquired about contact lenses. His mother and father wear soft disposable bifocal contact lenses with a replacement schedule of once per month. His father asked if KH was too young to wear disposable lenses. I told his father that age was not a requirement but if KH wanted to wear contact lenses he would have to be responsible for proper hygiene and care. KH seemed excited about the prospect of being fit with contact lenses. I told him and his parents that before we discussed the options of contact lens wear we need to find out if he is a good candidate.    

KH is not currently taking any medications and does not have any allergies. He has no family history of hypertension, diabetes, glaucoma or macular degeneration. He has been wearing a spectacle prescription for the last year:  OD -1.00DS and OS: -1.25DS.

Test Procedures/Fitting and Refitting/Lens Design and Ordering

Manifest Refraction:

OD:  -1.50DS
OS:  -1.75DS

Keratometry:                                                                                                       

OD:  42.25 @ 180; 43.00 @ 180
OS:  42.00 @ 180; 43.12 @ 180

Intraocular Pressure: OD: 10 mmHg; OS: 12mmHg

Slit Lamp Evaluation: All ocular structures were within normal limits. The tear film was adequate to support contact lens wear. No evidence of anterior or posterior blepharitis was present.  The cornea was negative for any abnormalities.

At the conclusion of the examination the results and contact lens options were discussed with KH and his parents. Soft contact lenses and an orthokeratology (corneal reshaping) program are the best available options to meet their expectations.  KH increased his myopia during the last year and if their goal in wearing contact lenses was to limit the progression of myopia one of the only available options would be the application of an orthokeratology program.  Spherical soft contact lenses would achieve the goal of eliminating the glasses during sport activities although the current research shows it does not limit the progression of myopia. The orthokeratology program would eliminate the wearing of contact lenses and glasses during the day and these lenses are only worn at night.

The orthokeratology lens gently flattens the cornea in the amount of the prescription so that when the lenses are taken off in the morning no prescription exists. This procedure does not permanently eliminate the prescription although as long as KH wears these lenses at night when he wakes up in the morning, the prescription is removed. The cornea will go back to its original shape if the lenses are not worn each night and the prescription will present itself again. My goal with the orthokeratology program is to limit the progression of myopia although my patients like the idea of not wearing any contact lenses or glasses during the day. The fee schedule was presented to KH and his parents and the decision was made to move forward with the orthokeratology program. An appointment was made for one week for a dispensing visit.

The manifest refraction and keratometry readings were sent to Euclid Systems for fabrication according to their Emerald orthokeratology lens design. The following lenses were designed by the manufacturer:

Dispensing visit:

KH returned for the dispensing visit in one week and the lenses were placed on his eyes without anesthetic.

Slit Lamp Evaluation: Slit lamp evaluation was performed with fluorescein and exhibited an optimal bulls-eye shaped pattern compressing the cornea centrally and a bright ring of fluorescein circling the central area. The lenses moved with the blink without any air bubbles throughout the lens.

KH was not comfortable with the lenses when the eyelids were open although when I asked him to close his eyes no discomfort was experienced. I asked KH if he thought he could fall asleep with the eyes closed and he commented that it should not be a problem. I told him the good news is that he would only wear the lenses with his eyes closed and that most patients over time experienced an improvement of comfort with the eyes open.

KH demonstrated he could apply and remove the lenses. A sample of the Boston Advance Conditioning (Bausch + Lomb) solution was given and proper lens care and storage were discussed. The patient was also instructed to fill the concave side with Optive prior to lens application. The application of the wetting solution removed all the air bubbles that at times becomes trapped underneath the lens. KH was instructed to wear the lenses overnight and return to the office in the morning for a follow-up appointment the next day. He was also educated on the use of rewetting drops. Prior to leaving the office KH demonstrated the proper cleaning and disinfection of the lenses. A follow-up appointment was made the following morning to check the progression of the program.

Follow-Up Care/Final Outcome

One Day Follow-Up Visit:

KH returned to the office for his one-day follow-up evaluation without wearing glasses or contact lenses and was amazed that his vision became clear. He had no problems falling asleep with the contact lenses on and when he woke KH had some difficulty removing the lenses for the first time. KH had slept with his contact lenses for eight hours. Contact lenses were removed approximately three hours before the visit. KH was brought to the patient education room to refine his technique on removal of the contact lenses. He was also asked to verbalize his cleaning and disinfection regime. KH was again educated about the placement of Optive in the center of the lens without rinsing for proper contact lens application.

Manifest Refraction/Visual Acuity:

OD: PL – 0.50 x 180   20/20
OS:  PL – 0.75 x 180   20/20

Sim K Readings:

OD:  40.87 @ 180;  41.00 @ 090
OS:  40.62 @ 165 ;  41.50 @ 075

Slit Lamp Evaluation: No hyperemia or corneal staining was exhibited. Corneal compression was centered and the full correction was removed after one day. All other findings were the same as the dispensing visit. The bulls-eye fluorescein pattern is shown below.

A follow-up appointment was scheduled for two weeks. KH and his parents were told if he had any problems to call the office.

Two Week Follow-Up Appointment:

KH returned to the office for his two-week follow-up appointment without a complaint. Lens application and removal became easier over time. His vision appeared to be consistent and he commented that, at times, he fell asleep without putting the lenses on and his vision remained consistent the following day. We decided that his wearing schedule would follow a Monday, Wednesday, Friday, and Sunday format.

Manifest Refraction/Visual Acuity:

OD: PL – 0.50 x 180   20/20
OS: PL – 0.75 x 180   20/20

Sim K Readings:

OD:  40.62 @ 006 ; 41.50 @ 096
OS:  41.12 @ 180 ; 41.87 @ 090

Slit Lamp Evaluation: Corneal compression was centered. The typical bulls-eye pattern was illustrated. The reverse curve exhibited a bright ring of fluorescein around the compression zone. No hyperemia or staining was exhibited. All other findings remained normal. A follow-up appointment was scheduled for six months.

Six Month Follow-Up Visit

KH returned to the office for his six-month visit commenting that it was like having normal vision again. Occasionally when he applied the lenses they did not feel comfortable and he had to remove the lenses and reapply. KH also commented that during sport activities the distractions of glasses no longer interfered with his effectiveness. His parents wondered if this would be a good procedure for them. I told his parents because of their near vision requirements their soft disposable bifocals represented the best option. They also wondered why patients would want the option of refractive surgery when this modality was available. I told them it was all about the expectations of the patient and some patients do not want to wear contact lenses at all.

Manifest Refraction/Visual Acuity:

OD: PL – 0.75 x 180  20/20
OS:  PL – 0.25 x 180  20/20

Sim K Readings:

OD:  40.87 @ 178 ; 42.25 @ 088
OS:  40.75 @ 178  x 42.00 @ 088

Slit Lamp Evaluation: A bulls-eye pattern was exhibited when fluorescein was instilled. After the lenses were removed a very mild superficial punctate keratitis was observed. The lenses were brought into the laboratory for inspection. Scratches were found on the lens and were polished to return the surface of the lens to their original smooth surface. The base curve radius and power were verified. All other findings remained normal. A follow-up appointment was scheduled for a one-year annual visit.

Discussion/Alternative Management Options

Myopia is the most common eye disorder worldwide. In some regions of the world it is classified as an epidemic. Previous studies such as the LORIC study and CRAYON study showed that orthokeratology can have both a corrective and preventive/control effect in childhood myopia.(1,2) The Stabilizing Myopia by Accelerating Reshaping Technique (SMART) multi-center study found that 80.5% of eyes can achieved first-fit success with empirical fitting with another 15% of the eyes requiring only one additional change to achieve success.(3,4)

Orthokeratology fitting is a viable option for young patients in the growth years to meet their expectations of no daily wear contact lenses and the possibility of halting the progression of myopia. Daily wear contact lenses and spectacle wear are associated with complication during sports and daily life activities. These include limiting field of view, environmental fogging during temperature change, displacement, dryness, and soiled lens deposits. Wearing lenses during a controlled environment while sleeping with the eyelids closed is associated with different complications although not subject to environmental contaminants.

This case demonstrates an improvement in the quality of life by the use of an orthokeratology program for this patient. KH’s expectations were satisfied by this lens design and no other procedure could have been used as an alternative to reach his goals for contact lens wear. As the writing of this case, no increase in myopia was experienced during the first year. Only the future will demonstrate if the progression of myopia has been deterred.  

References

1.  Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong; a pilot study on refractive changes and myopic control. Curr Eye Res 2005;30:71-80.

2.  Walline JJ. Slowing myopia progression with lenses. Contact Lens Spectrum 2007;22(6):

3. Eiden SB, Davis RL, Bennett ES, DeKinder JO. Stabilizing Myopia by Accelerating Reshaping Technique (SMART) study: background, rationale, and baseline results. Contact Lens Spectrum  2009;24(10):

4.  Davis RI, Eiden SB, Bennett ES, et al.  Stabilizing myopia by accelerating reshaping technique (SMART) study three year outcomes and overview.  Advances in Ophthalmology & Visual System 2015;2(3).

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