Pardon the Objection (PTO) Contact Lens Clinical Case Debate (2 hours)

Transcription

1 Pardon the Objection (PTO) Contact Lens Clinical Case Debate (2 hours) Mile Brujic, O.D. Melissa Barnett, O.D. Glenda Secor, O.D. Jeff Sonsino, O.D. Summary The contact lens options that we have continue to evolve to provide our patients with an increasing array of opportunities to successfully wear contact lenses. But the options can sometimes be overwhelming. Through a case based approach, we will look at various clinical presentations and get the experts opinions on the best ways to optimize visual outcomes. Learning objectives 1) Understanding optimizing clinical outcomes for keratoconus and corneal irregularity patients 2) Discussion of fitting the high ametropic patients specifically high cylinder patients 3) Demonstrate proven clinical outcomes with multifocal lens wearers 4) Understanding the critical role of contact lens care in both soft and gas permeable lens wearers and strategies for success 5) Discussion of ocular surface disease and it s role in affecting comfortable lens wear 6) Discuss the strategies and opportunities for fitting post refractive surgery patients Course Outline Case Presentations With Faculty Strategies for Successful Management 1) The keratoconus patient wearing soft toric lenses a. Patient wearing a quarterly replacement soft toric lens b. Comfort is good c. Main complaint is vision d. Discuss the options i. Continue with soft toric contact lenses ii. Fit with a specialty soft lens designed for keratoconus iii. Hybrid lenses iv. Consider GP lenses v. Consider piggyback vi. Consider scleral lenses

2 2) The keratoconus patient wearing a small diameter GP lens a. Doesn t complain about comfort or vision but says that he wants to see if there is anything new available for people with keratoconus b. Upon further questioning says that his vision is a lot worse in the evening : i. Does brimonidine for pupil control have a role in this case? ii. Fit with a soft toric contact lenses iii. Fit with a specialty soft lens designed for keratoconus iv. Hybrid lenses v. Consider GP lenses vi. Consider piggyback vii. Consider scleral lenses 3) Female wearing a quarterly replacement lens with 5.00D of astigmatic correction a. Patient is doing ok with lenses b. When questioned, says that it takes about 20 minutes in the morning for her vision to settle and her vision frequently goes blurry throughout the day i. Continue with current lenses ii. Consider other soft toric lens designs iii. Gas permeable lenses iv. Hybrid lenses v. Scleral lenses 4) Presbyopic female frustrated with her glasses and wants to pursue contact lens options a. Low myope with a D add b. Frustrated with her glasses because she says that in the office she sees great without her glasses on and wears a to help her see better for the small print c. Getting tired of putting on and off the reading glasses d. Only really wears her current progressive addition eye glasses for driving critical distance viewning task i. Debate the options 1. Continue with current regimen 2. Simultaneous soft multifocal design 3. Custom soft multifocal 4. Hybrid lenses 5. Gas Permeable lenses 5) Patient is currently wearing a soft simultaneous design multifocal contact lens and is noticing her distance and near vision seems worse a. No over refraction with loose lenses improves her vision

3 b. At last exam had a 2BD right hyperphoria measured with von graefe method but didn t appreciate improvement in vision when demonstrated it in free space i. Continue with current regimen ii. Change to another simultaneous soft multifocal design iii. Custom soft multifocal introduce prism iv. Glasses with vertical prism v. Hybrid lenses vi. Gas Permeable lenses 6) Gas permeable multifocal wearing presbyope near vision is great but vision in the evening seems more difficult a. Feels like night vision has never been as good as day time vision b. Near vision is great in her current contact lenses i. Debate the options 1. Continue with current regimen 2. Simultaneous soft multifocal design 3. Brimonidine for pupil control 4. Custom soft multifocal 5. Hybrid lenses 6. Gas Permeable lenses i. Consider changing distance and near zone diameters ii. Consider segmented multifocal designs iii. Consider monovision with distance glasses over lenses for night vision 7) Twenty five year old female a broadway performer who complains over the last several years her contact lenses just aren t as comfortable a. She feels like there are significantly more deposits on her lenses and feels like it is because of all the make up they put on her eyes during her performance b. She brought in her contact lens care supplies i. Continue with current regimen with an increased emphasis on ii. Change the lens modality iii. Change the lens material/design iv. Consider daily disposable modality v. Consider orthokeratology vi. Consider gas permeable lens options 8) Emerging presbyope who is starting to wear her contact lenses less often

4 a. When questioned about the reason, she says that she feels she might be getting too old for contact b. Upon further questioning, she says that the contact lenses are not as comfortable as they used to be i. Continue with current regimen with an increased emphasis on ii. Change the lens modality iii. Change the lens material/design iv. Consider daily disposable modality v. Consider orthokeratology vi. Consider gas permeable lens options vii. Treat underlying ocular surface condition 1. Decreased TBUT, mild fluourscein staining and lissamine green staining inferior cornea, prominent lid wiper epitheliopathy 2. Discuss treatment protocols 9) Middle aged female reports that everything is okay with her current contact lenses a. Upon further questioning, she reports taking them out much earlier during the day then she used to b. Her beginning of the day comfort is a 10 out of 10 and at the end of the day is 3 out of 10 i. What are the diagnostic tests appropriate for this patient? 1. Fluorescein assessment a. TBUT b. Corneal/conjunctival staining c. Lid wiper epitheliopathy 2. Lissamine green assessment 3. Phenol red thread 4. Schirmer strip 5. InflammaDry 6. Tear osmolarity 7. Meibomian gland fluidity ii. What does the treatment protocol look like? 1. Topical agents, ocular nutrition iii. Continue with current regimen with an increased emphasis on iv. Change the lens modality v. Change the lens material/design vi. Consider daily disposable modality vii. Consider orthokeratology viii. Consider gas permeable lens options 10) Contact lens wearer who reports not sleeping in his contact lenses a. Says that over the last few days his eyes have been red and irritated

5 b. Reports that it seems to be getting worse c. Hasn t discontinued contact lens wear d. Physical examination is remarkable for diffuse infiltrative response e. Debate the options i. Diagnosis 1. How do we narrow down the differential? 2. Does adenoplus have a role? ii. Treatment 1. Artificial tears 2. Antibiotic 3. Steroid 4. Antibiotic steroid combination 5. Topical anti virals 11) Current daily disposable lens wearer a. Loves wearing daily disposable lenses b. Feels like the contacts aren t quite as comfortable as they used to be at the end of the day c. Would prefer to stay in daily disposables if possible d. Debate the options i. Assess for underlying ocular surface disease that may be compromising comfort ii. Consider orthokeratology iii. Are there differences in the various daily disposable lenses? 1. Hydrogel daily 2. Silicone hydrogel 3. Water gradient technology 12) Patient had LASIK several years ago a. Says that they had great results right after the surger b. Since then the vision has gotten quite a bit worse c. Significant issues with night time glare also feels like it is more difficult to focus signs in the evening d. Debate the options i. Brimonidine for pupil control ii. Custom soft lenses 1. Reverse geometry iii. Hybrid lenses iv. Gas Permeable lenses 1. Reverse geometry v. Scleral lenses