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“What about my contact lenses?”

“What about my contact lenses?”. Catherine Kister University Eye Center Grand Rounds 10/17/05. D.L. 60-year-old, AA female Seen at UEC Contact Lens Clinic on 10/07/05. Chief Complaint Blurred vision at distance. Pt. reports that she lost OS CL 4-5 months ago. HPI

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“What about my contact lenses?”

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  1. “What about my contact lenses?” Catherine Kister University Eye Center Grand Rounds 10/17/05

  2. D.L. • 60-year-old, AA female • Seen at UEC Contact Lens Clinic on 10/07/05. • Chief Complaint • Blurred vision at distance. • Pt. reports that she lost OS CL 4-5 months ago. • HPI • Blur is greater OD than OS. • “Cloud” present over central vision OD. • (+) flashes of light – pt. sees “bright neon lights”. • (+) pain – occasional sharp pains behind OS in the past.

  3. D.L.- OHx • Previous patient at Illinois Eye Institute affiliated with ICO. • At exam on 01/08/98, aided VA’s were 20/50+ OD and 20/70- OS secondary to high myopia. • Pt. counseled: “Pt. concerned with progression of myopia and decr. VA. Talked about condition and risk of RD- S/Sx, F/F. Told patient that condition is most likely stabilized.”

  4. D.L.- 10/10/03 U.E.C. • Refraction: OD: -21.75-3.00x152 20/70-1 OS: -17.00-2.50x150 20/200 • Concerned over loss of BCVA particularly in OS. • Pt. refused dilation at that visit and was scheduled for a CL f/u and DFE. • Pt. returned for CL f/u but refused DFE on that day due to dissatisfaction with vision through new CL’s. • Pt. no-showed for rescheduled DFE appointment.

  5. D.L. Exam 10/07/05 U.E.C. • Acuities – aided • 20/400 OD at distance • 20/800 OD at near • Acuities – unaided • FC at 1 ft OD at distance • FC at 5 ft OS at distance • 20/400 OS at near • Pupils, EOMs, and Confrontations all WNL.

  6. 10/7/05 U.E.C. • O.R. OD • +0.50D (20/400) • Subjective Rx OS • -16.75-3.00x015 (20/200)

  7. Questions • What are you thinking about possible reasons for her reduced VA? • What additional testing should be done now?

  8. SLE 10/7/05 • Lids and lashes – WNL • Conjunctiva – pinguecula nasal and temporal OU • Cornea – CLR OD, SPK at 7 o’clock OS • Tear film – oily • Anterior chamber – deep and quiet OU • Lens – 2+ cortical cataract OU • Goldman Tonometry – 20 mmHg OU

  9. OD

  10. OD

  11. OS

  12. OS

  13. DFE • Mild Staphyloma OD, OS • C/D ratios – 0.4/0.4 OD, 0.3/0.3 OS • Serous detachment OD • Elevated macula secondary to CNVM and surrounding hemorrhage approx. 2DD in size. • Atrophic scar OS • 2DD in size • Fuch’s spot (a.k.a. Forster-Fuch’s spot) • RPE Hypertrophy peripherally 1-3 o’clock OS

  14. Assessment • Serous Retinal Detachment OD • Choroidal Neovascular Membrane OD • Atrophic Macular Scar OS • Plan • Retinal consult scheduled with Barnes Retinal Institute on 10/18/05. • Educated pt. on retinal detachment. • Monitor scar OS for changes.

  15. Patient’s concerns • “What about my contact lenses?” • Pt. insisted on being fit into contact lenses at this appointment. • Question pt. comprehension that neither contact lenses or spectacles will improve her central vision. • Ordered new RGP bitoric CL’s for pt. based on last year’s contact lens Rx. • Pt. counseled at length by several clinicians that VA was unlikely to improve with CLs

  16. OD Polycon 2 Power: -20.00/-20.25 BCR: 7.58/7.26 Diameter: 9.0 OS Polycon 2 Power: -16.00/-19.50 BCR: 7.58/7.26 Diameter: 9.00 Contact Lenses Ordered for Patient

  17. CL Dispense and Follow-up • D.L. returns to clinic on 10/26/05 for CL dispensing. • She reports that she is having laser retinal surgery at Barnes Retinal Institute that coming Friday, October 28th. • Is VERY glad her new contact lenses have arrived.

  18. Acuities – aided with new Bitoric RGPs • Distance • 20/200 OD • 20/150 OS • Near • 20/200 OD • 20/100- OS • Over-refraction • Plano OU • Fit • Lid attachment fit OU. Lenses well centered OU. • Apical pooling, mid peripheral alignment, and peripheral clearance OU.

  19. D.L. reports that she is disappointed that her vision is not markedly improved with new contact lenses. • It is again explained to her that her vision decrease is due to the retinal detachment OD and will not be corrected by contact lenses alone.

  20. Patient Expectations • Patient education is crucial. • There are some instances and some patients where the information given is not completely understood. • What do you do when a patient does not comprehend their ocular condition and predicted outcomes?

  21. Report from Barnes Retina • D.L. underwent laser photodynamic therapy OD on October 28, 2005. • Procedure went well with no complications. • D.L. is scheduled to RTC for follow-up care in six weeks.

  22. Degenerative Myopia • Differs from refractive myopia in that there is an alteration of the structure of the globe that is progressive and may lead to severe vision loss. • 2 Stages • Developmental Stage • Elongation of globe, peripheral vitreoretinal degenerations, disc tilting • Degenerative Stage • Choroidal atrophy, lacquer cracks, CNVM • Associated with an increased incidence of POAG due to anterior chamber alterations.

  23. Degenerative Myopia • Symptoms • Decreased vision • Signs • Myopic crescent (scleral or choroidal) • Oblique insertion of optic disc • Macular pigment abnormalities • Optic disc pallor • Peripapillary atrophy • Subretinal hemorrhage • Peripheral retinal thinning

  24. Degenerative Myopia cont. • Signs cont. • Lacquer cracks • Lattice degeneration • CNVM • Retinal detachment • Staphyloma • Work-up • Dilated fundus exam • Scleral depression • FA if CNVM is suspected • HVF • IOP measurement

  25. Photodynamic Therapy • Verteporfin is injected into the blood stream intravenously and allowed to perfuse to the CNVM. • The CNVM is treated with a laser of either a red or blue wavelength for approximately 90 sec. • Red wavelength has deeper penetration, so it passes through blood or fibrosis that may be in front of the CNVM better. • Once activated by light, the dye forms free radicals damaging the neovascular endothelium causing vessel occlusion.

  26. FDA Studies • Retreatments • Average of 3.4 treatments in the first year. • 2.1 treatments in the second year. • Total of 5.5 treatments needed in the 1st 2 years to stabilize vision. • Stability • After 1 yr. of treatment with verteporfin approx. 60% of patients retained stable vision (45% placebo). • 15% reported improved vision (7%).

  27. Bitoric RGPs • Indicated for patients with • Residual astigmatism with spherical RGPs • High astigmatism • >2.50D corneal cylinder • 2 ways to fit bitorics • Empirical • Mandell-Moore Guide • Diagnostic • Fit 0.12-0.50 flatter than K • Add over-refraction to each meridian

  28. Bitoric RGPs • Lens materials similar to spherical RGPs • Plus/Minus lenticular • Plus lenticular – power > -6.00D • Minus lenticular – all + powers and – powers < 1.50D • Ultrathin designs

  29. References: • Alexander, Larry J. Primary Care of the Posterior Segment. New York: 2002. • Bennett, Edward S. and Henry, Vinita Allee. Clinical Manual of Contact Lenses. Philadelphia: 2000. • Kanski, Jack J. Clinical Ophthalmology A Systemic Approach. 5th Edition Edinburgh: 2003. • Rhee, Douglas J. and Pyfer, Mark F. The Wills Eye Manual. 3rd Edition Philaedelphia: 1999. • www.fda.gov. FDA studies on Verteporfin.

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