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GP Problem Solving

With Dr. Edward Bennett and Dr. Robert Grohe

Links to Case Studies:

Case 1

By: Dr. Edward Bennett

Patient AM, a 25 year old graduate student, came to the clinic complaining of gradual increase in dryness and redness, resulting in an inability to wear the lenses all day. Her friends have also been commenting that her eyes look red. She also indicated that her vision tended to be blurred with the lenses when she is driving at night. She has been wearing a medium Dk silicone/acrylate lens material for the past 11 years.

TEST PROCEDURES, FITTING/REFITTING, DESIGN AND ORDERING

Evaluation of Current Lenses:
Visual Acuity (with contact lenses):

OD: 20/20-1 (fluctuates with blink)
OS: 20/20-2 (fluctuate with blink)

Over-Refraction:
OD: +0.25DS 20/20-1
OS: +0.50 – 0.25 x 171 20/20

Slit Lamp Examination (with contact lenses):
Both lenses decentered inferiorly and are not picked up adequately with the blink. Excessive edge clearance is present 360° OU. Some muco-protein filming was evident after the blink OU.

Evaluation without Lenses:
Slit Lamp Examination (after lens removal):
OD: Grade 2+ corneal desiccation temporally and Grade 2 nasally.
OS: Grade 2 corneal desiccation nasally and temporally.

Grade 2 bulbar conjunctival injection OU and Grade 1 papillary hypertrophy of the superior palpebral conjunctiva OU. Tear Break-Up-Time was 8 seconds OD and 7 seconds OS.

Manifest Refraction:
OD: -5.75 – 1.50 x 178 20/20+2
OS: -5.25 – 1.75 x 005 20/20+1

Keratometry:
OD: 43.25@180;44.50@090 (mires clear)
OS: 43.50@180;45.00@090 (mires clear)

Anatomical Measurements:
Pupil Diameter (photopic): 6mm
Horizontal Visible Iris Diameter: 12mm
Upper Lid Position: Overlaps superior limbus by approx. 1mm
Vertical Fissure Size: 10.5mm

Her lenses verified as:

HOW TO MANAGE??

Case 2

By: Dr. Robert Grohe

BACKGROUND:

Patient DL is a 38 year old bank manager. He arrived at the office wearing a pair of three year old gas perms that were fit elsewhere. Chief complaints, primarily in the right eye, were blurred vision, difficulty removing the lens and lingering eye ache for several hours after lens removal. While no clinical records were available, DL has been wearing rigid contact lenses for 20 years. Both the right and left contact lenses have been intermittently difficult to remove in the last six years. Medical history is significant for hayfever and seasonal allergies. Work history is significant for daily computer use of 4-6 hours per day. Lens care consists of soaking the lenses overnight and cleaning in the morning prior to insertion.

TESTING PROCEDURES:

Visual Acuity (with GPs)

OD: 20/30 (with monocular vertical diplopia)
OS: 20/20 -1

Over-Refraction:

OD: - 1.00 -50 x 170 = 20/20 -2 ( with trace monocular vertical diplopia)
OS: - 0.25 = 20/15

Slit Lamp (with GPs):

Surface quality/lens deposits:
RCL: 2 + protein hazing and central retro lens debris
LCL: trace protein hazing and retro lens debris

Right GP lens with anterior lens surface hazing and retro lens debris

Slit Lamp ( without GPs)

OD:

• Inferior 2+ SPK with epithelial tissue bunching adjacent to arcuate rim of compression ring imprint.
• 2 + upper marginal papillary hyperemia and hypertrophy
• 1 + lower lid marginal papillary hyperemia and hypertrophy
• Tear BUT 10 seconds superiorly and spontaneous inferiorly

OS:

• Faint compression ring with trace SPK along rim of compression imprint.
• Trace superior and inferior marginal papillary hyperemia and hypertrophy
• Tear BUT is ~ 14 seconds

Keratometry:
OD: 42.25 X 40.00 @ 80 (moderate mire overlap & distortion)
OS: 42.50 X 43.00 @ 90 (trace distortion)

Corneal topography:
OD: noticeable inferior compression ring imprint
OS: normal

Inferior arcuate compression imprint on OD

Refraction:

OD: -4.00 - 1.50 x 170 = 20/25+2 (monocular vertical diplopia)
OS: -3.50 - 1.00 x 180 = 20/20

Anatomical measurements (both eyes):

• Pupil diameter (Photopic): 4mm
• HVID: 12mm
• Upper lid position: no ptosis with 1mm superior corneal overlap
• Vertical fissure size: 10.5mm

Current lens verification:

MANAGEMENT:

The right eye was experiencing a compression ring and corneal imprint due to lens adhesion. Compression rings may linger on the cornea for 2-6 hours prior to resolving. The retro lens debris, common among allergy and GPC patients who wear GPs, was exacerbating the adhesion by creating a glue-like binding of the posterior surface to the cornea. Secondary monocular diplopia from the accompanying corneal distortion usually resolves in 1-4 months with a new lens design that no longer binds to the eye.

NEW LENS DESIGN:

Material: Boston XO2
Design: Lenticular
Surface: PLASMA treatment

The patient was also asked:

• To use rewetting drops during the day and prior to lens removal,
• Clean the lenses every evening before storing in soaking solution,
• Supraclens enzyme every night,
• Pataday OU qd,
• Try blinking more frequently to offset blink reduction while using the computer and
• Consider replacing lenses every year to minimize protein buildup.

FUTURE EXPECTATIONS:

Successful treatment will be characterized by the regression of any eye ache along with easier lens removal. There should be a zero tolerance for eye ache accompanying lens adhesion as this indicates an advanced condition predisposing a cornea to corneal warpage, abrasions or ulcers. There may be relapses of lens adhesion. Sometimes it persists despite changes in lens design, lens care and lifestyle. Oddly, adhesion may persist for one eye more than the other. However, by maintaining a clinical vigilance, adhesion can be controlled by stressing the importance of yearly exams to the patient. Any allergy history in a GP wearer may require a combo antihistamine/mast cell stabilizer for GPC itching and mucous control.

Links to Case Studies: