Primary care ODs are ‘uniquely poised’ to manage patients with ocular prosthetics

SAN ANTONIO – Primary care optometrists can help patients with a prosthetic eye establish a better plan for lens care, Jaime Kuhn, OD, said at a hot topics in comprehensive eye care symposium here at the American Academy of Optometry meeting.

“I am truly appreciative to have this patient population, as it’s really a delicate thing,” Kuhn said. “There are not a lot of people doing work in ocular prosthetics. Ocularists are kind of falling off the map, and we need someone to step in.”

Kuhn explained how her mentor, Sunny M. Sanders, OD, FAAO, sparked her interest in doing ocular prosthetics.

“We are uniquely poised to help serve these patients,” Kuhn said, quoting Sanders. “We know about the health of the eye. We are able to implement treatment. We know how the eyes are supposed to work and we can actually give patients who need this service full scope of care.”

Ocularists are highly skilled artists who specialize in fabricating prosthetic eyes, but the problem, Kuhn said, is that, “they aren’t trained in looking at the socket tissues.”

They often neglect to inform the patient about follow-up visits, care and removal, she said.

About 50,000 Americans lose an eye yearly, she said, due to injury, during war time from blast injuries, melanomas, aging disorders or other cancers.

For patients with sighted eyes, the prosthetic contact lens is intended primarily to increase the patient’s comfort in the case of diplopia, light sensitivity, migraines or a color deficiency, Kuhn said.

“You can put them in a rigid ocular device, but it tends to be more complicated because of the thickness,” she said.

In nonsighted eyes, prosthetic eyes are primarily more for cosmetic purposes, but they also serve as support to the socket structure of the eye to prevent tissue retraction. They also can help with pain and discomfort.

With soft, prosthetic contact lenses for those with diplopia and amblyopia, “Doctors tend to do a high plus as a patching device, which you can do with a center black-out design,” she said. “It can be cosmetic; if you have an opaque cornea, it can help with that.”

Center-tinted lenses are typically filtered for those who have light sensitivity and need to limit the wavelengths of certain lights. Kuhn said she fits many migraine sufferers with blue lenses, which decreases their trigger and helps reduce the frequency and severity of migraines.

Patients with color deficiencies can be fit to help improve their occupational or lifestyle, “but they shouldn’t be fit to help them pass any sort of tests,” she added.

Custom enhancing tints are also available for athletes.

Pinhole lenses work well for patients who can still see but are experiencing photophobia or diplopia due to an iris abnormality, she said.

“Soft lens designs are by far the most common type you’ll see because we can get the pigments to actually sit in the contact lens without leaching out and causing a toxic problem,” Kuhn said.

PAGE BREAK

“Gas-permeable contact lenses don’t hold pigment very well,” she said. “It’s not a good device for patients to use long-term. Previously, we used PMMA [polymethyl methacrylate], which comes with many issues, like hypoxia. Typically, if you have a patient who is sighted and needs a GP, you’ll usually fit a soft lens option and cover it with a GP, so the patient can see.”

Kuhn described three types of soft lens prosthetics:

Hand-painted designs have the highest level of artistry and beauty. They can be painted so it appears a patient with exotropia is looking straight;

Color transfers or color stamps are analogous, in a way, to an iron-on T-shirt design; and

Solid tinted lenses can be ordered through various manufacturers to help with migraine and other issues.

Kuhn expects primary care optometrists to see fewer rigid oculoplastics because they are not made of acrylic.

Kuhn stressed the importance of examining the eye socket for possible infection.

“If you open up a socket and it looks squishy and wet and red or white, you’re fine,” Kuhn said, “as long as it’s not dripping blood and there’s no mucus. You don’t need to know what a normal socket looks like, as long as you know what a bad socket looks like. You can treat that. If they are having discharge, mucus, if you see the implant waving back at you, those are things you send off for a referral.”

The more a prosthetic moves in the socket tissue, the more mechanical irritation can occur, she said. She recommended applying Maxitrol (neomycin, polymyxin B sulfate, dexamethasone ophthalmic suspension, Alcon) on the back of the prosthetic.

“If you do nothing at all, ask the patient to take the prosthetic out; we don’t want them getting an infection,” she said.

In her practice, Kuhn said she records a lot of patient history.

“How many surgeries have they had? Who fit the original eye? How do they like the appearance of the eye? Do they clean it?” she said.

Optometrists can help patients to develop a better plan for care, she said.

She also recommends looking at the prosthetic.

“You can do a light polish and a clean on the prosthetic, and you can refer for a heavier polishing and cleaning,” she said. “You can also send them off for a new fabrication.”

Does the prosthetic have motility? Are there gaps in the lid? Are there any discharge or deposits on the lid? These are all things to consider when looking at the device, she said.

Baking soda, hydrogen peroxide or a nonabrasive GP solution work well for cleaning, Kuhn said. “You never put something dry into an orifice,” she added.

Medicare covers a replacement every 5 years, and providers are usually reimbursed what they charge, she said.

“Unless the patient has some other co-insurance, some state health plans do the same,” Kuhn said.

Some private insurers require prior authorization, she added. – by Abigail Sutton

Reference:

Kuhn J. Comprehensive eye care section symposium: Hot topics in comprehensive eye care. Presented at: American Academy of Optometry annual meeting; San Antonio; November 7-10, 2018.

Disclosure: Kuhn reports no relevant financial disclosures.