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Consider issues beyond cosmesis when fitting prosthetic contact lenses
The patient's ocular health and personal goals are additional factors.
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A 43-year-old white female had a chief complaint of photophobia with headache on the left side of her head. She also described “funny” vision and a sense of being “off balance” as well as minimal cosmetic concerns.
Her ocular history included blunt trauma in the left eye 5 to 6 years ago resulting in anisocoria. An examination at the time of the incident ruled out all other traumatic sequelae. Her uncorrected visual acuities were OD: 20/25-2 with pinhole 20/20 and OS: 20/30+2 with pinhole 20/20-2 OS, with all other chair skills normal.
The patient’s refraction was OD: -0.50 D -0.75 D x 045 20/20 and OS: -0.25 D -1.00 D x 160 20/20. Her pupils had appropriate reaction to direct light in the right eye and minimal reaction to direct light in the left eye. There was no afferent pupillary defect in either eye.
In the light, her right pupil was 3.5 mm and her left pupil was 7.5 mm. In the dark, her right pupil was 5.0 mm and her left pupil was 8.0 mm. There were no tears in the iris and no pupillary margin abnormalities. The iris color was light blue with a dark limbal ring.
Fitting the lens
I fit her with a plano BioColors (Orion Vison Group, Marietta, Ga.) soft contact lens with a base curve of 8.8 and a diameter of 14.3 mm. The lens was 42 (blue enhancer) in the V series with a U3 (stormy) underlay, a 4.2 mm clear pupil and limbal ring added.
Images: Tompkins AM
The initial fit was acceptable with good coverage, centration and movement. Comfort was excellent, and appearance was natural.
In the office under normal room illumination, the patient noted less glare on the computer screen. Outdoors, she reported immediate relief from sunlight on her left side and, overall, described more “balance” between her eyes.
The patient was instructed to use hydrogen peroxide solution if she was not using the solution that came with the kit. The micropigmentation technology in BioColors allows the use of hydrogen peroxide without damaging the color.
I did not attempt tinted disposable lenses in this patient because she wanted to achieve more than just a cosmetic effect. She was most concerned about photophobia and the funny feeling, which I attributed to the larger pupil size. Probable differences in higher-order aberrations with different aperture sizes between the eyes likely contributed to the vague off-balance sensation. Because of her symptoms, I chose a lens that would provide an opaque backing to gain a more symmetric aperture size between the two eyes as well as cosmetic symmetry.
When to consider a prosthesis
The obvious reason to consider a prosthetic lens is cosmetic purposes. Patients coping with conditions such as anisocoria, iris disorders, heterochromia, trauma and chemical burns benefit from prosthetic contact lenses. In addition to vision therapy and surgical options, prosthetic contact lenses change the appearance of the inward or outward turned eye in strabismus cases.
Prosthetics not only offer cosmetic benefit but also have therapeutic applications, including symptomatic anisocoria, occlusion (minimizes diplopia and replaces eye patch in amblyopia therapy), increasing contrast in patients with contrast sensitivity loss (glaucoma, retinitis pigmentosa), enhancing color vision and reduction of migraine symptoms.
Additional considerations
Once you have identified your patient’s need for a prosthetic, you must consider several other issues.
Does your patient’s ocular health support full-time contact lens wear?
Does the ocular condition you are correcting require additional special consideration? Many different prosthetic designs are available, ranging from soft to hand-painted scleral lens designs.
Your patient’s specific needs and goals should be considered when choosing the appropriate lens design. Is the goal cosmetic, therapeutic or both? Are his or her goals realistic?
Never forget that this is a potentially life-changing experience for your patient. Assess the patient’s psychological and emotional state. Is he or she well-adjusted to the situation? Be sure to communicate realistic outcomes. Successfully delivering the patient’s expectations results in patient satisfaction and loyalty.
It is imperative to remain sensitive to the patient’s symptoms, psychological state and visual impairment as well as his or her cosmetic insecurities. With these in balance, we can have a profound impact on quality of life.
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- Amanda M. Tompkins, OD, is an instructor at the Southern College of Optometry in Memphis. She can be reached at atompkins@sco.edu.
Disclosure: Tompkins reports no relevant financial disclosures.