Download Jamie Kuhn ,OD, FAAO, FSLS Arizona College of Optometry

MIDWESTERN UNIVERSITY
Adventures in Prosthetics – A Contact Lens Approach to Improving Cosmesis
Jamie Kuhn ,OD, FAAO, FSLS
Arizona College of Optometry
Introduction
Conclusions
Figure 7
Figure 3
Patients with corneal abnormalities resulting in obvious cosmetic impairment struggle with
appearing normal in their day-to-day lives. While these patients retain the globe of the
eye, in many cases the vision is significantly reduced or absent, resulting in reduced
confidence in maneuvering in their environments. Contact lenses exist which can improve
the overall cosmetic appearance of the eye(s), in turn allowing patients to feel more normal
to the public eye.
The fitting of ocular prosthetic devices has historically fallen into the hands of highly skilled ocularists.
These craftsmen painstakingly duplicate the natural appearance of a patient’s fellow “good” eye onto the
surface of a rigid ocular prosthetic device. Although the most common type of ocular prosthetic device is a
plastic reform eye which provides bulk to an anophthalmic socket, there exists the need for ocular prosthetic
devices which fit similarly to a contact lens for patients with a remaining globe.
In some cases, the patient may be blind or have significantly reduced vision in one eye due to a physical or
medical ocular condition. These patients can have reduced cosmetic appearance of the affected eye, varying
from having obvious ocular deformities such as scars or aniridia to a notable strabismic appearance. In cases
where the globe remains, patients must be fit with an ocular prosthetic device more similar to a contact lens
in order to maintain good health and comfort with the device.
Some ocular prosthetic contact lens options include:
- Tinted soft lenses
- Can be a solid mask or a pinhole lens with pigment only in the periphery
- Including black-out and clear pupils
- Typically ordered from manufacturers or produced in house
- Can be overlaid by a corneal GP contact lens to provide vision
- Stamped-design soft lenses
- Providing iris detail in a pixelated pattern
- Looks more natural than solid-tinted soft lenses
- Available with black-out or clear pupils
- Can be overlaid by a corneal GP contact lens to provide vision
- Hand-painted soft lenses
- Painted by highly skilled artists to mimic the “good” eye
- Provide color to the lens edge, marring scleral abnormalities or eye turns
- Can be overlaid by a corneal GP contact lens to provide vision
- Rigid scleral lens with a stamped-on design
- Available with black-out or clear pupils
- No current options for scleral color matching
- Pigment stamped to the front surface of the lens
- Hand-Painted PMMA Rigid lenses
- PMMA will accept pigment and can be matched to the “good” eye
- Provide color to the lens edge, marring scleral abnormalities or eye turns
- Available with black-out or clear pupils
- Available with prescription for sighted individuals
In the two cases described, both patients initially expressed concerns of cosmesis of their
blind eye, attributing their psychological distress to anxiety with their appearance in
public. Although fit with two different contact lens modalities, each patient showed an
improvement of cosmesis as well as personal confidence following dispense of a
personalized ocular prosthetic contact lens. These two cases represent the nature of
cosmetic ocular prosthetic contact lenses as being more than just skin deep, and highlight
the practitioner's duty to treat the patient as a whole, not just as a sum of their parts.
A
A
Figure 4
B
A
C
B
Case #1:
Comparison of without (A) and with (B) the ocular prosthetic scleral contact lens.
C. Patient wearing habitual glasses over ocular prosthetic lens.
Comparison of without (A) and with (B) the ocular prosthetic tinted soft contact lens for Case #1
B
Appearance of the Left Eye for patient in Case #2
A. Without placido disc, note the calcifications and opacities present on the cornea
B. With the placido disc reflections, note the obvious irregularity of the cornea
Figure 5
Case #2
Case #1
Figure 1
Case Presentation:
A 45 year-old Indian female presented to the clinic with a chief complaint of overall poor cosmesis of the right
eye following a failed corneal graft. The patient’s main concern is to improve cosmetic appearance so she
could attend several upcoming social events without feeling as though her deformity is on display.
Ocular history (OD only, no pertinent history OS):
- Corneal graft and IOL exchange 2’ to MVA x 15 years prior to consult for prosthetic lens
- Second corneal graft surgery 2’ to graft failure and IOL dislocation from a fall x 3 years prior to consult
- Vision loss 2’ corneal opacification and increased scleral injection x 3 years
- Increased IOP with concurrent pain and treatment with Diamox x 3 years
- Enucleation of blind eye declined by patient
Medical history:
Unremarkable per patient
Appearance of the Right Eye for the patient in Case #1
Note the irregularity of the placido disc mires, the deposits on and opacities within the cornea, and
the scleral injection concentrated inferior nasal.
Figure 2
Examination Findings:
OD: Corneal opacification resulting in blindness OD – cornea shows similar appearance to keratoconic ectasia
with severe central steepening, as well as calcium deposits along the corneal epithelial surface (see Figure 1, at
left). Opacities exist in the peripheral cornea at the graft-host junction, as well as other areas of stromal
scarring following graft failure. Additionally, large and full scleral vessels are present throughout the front
surface and concentrated in the inferior and nasal quadrant.
Ocular history (OS only, no pertinent history OD):
- Retinal detachment with subsequent scleral buckle repair x “several years ago”
- Corneal graft and IOL exchange following complications of retinal detachment surgery
- Vision loss 2’ corneal opacification and increased scleral injection x 5 years
- Increased IOP with concurrent pain and treatment with topical steroids (PF 1% 1 gtt OS PRN) x 5 years
- Currently on Combigan (0.2%/0.5%) 1gtt OS BID for IOP maintenance
Medical History
Medications
-
-
Hypothyroidism
Non-Insulin Dependent Diabetes Mellitus
Essential Hypertension
Generalized Myalgia
Generalized Depression Disorder
Levothyroxine 0.05mg 1 T PO qd
Metformin 1000mg, 1 T PO qd
Lisinopril 10mg, 1T PO qd
Gabapentin 600mg, 1 T PO daily
Oxycodone 20mg, 1 T PO PRN
Oxycontin-ER 15mg, 1 T PO BID
Cymbalta 60mg, 1 T PO qd
Fish Oil, OTC 1-2 T PO qd
Multivitamin, OTC 1 T PO qd
Fit of clear scleral contact lens on the ocular surface for Case #2
Good overall clearance in the central, graft-host junction, and limbal zones.
Acceptable scleral alignment without blanching or impingement.
Figure 6
OS: All findings consistent with normal ocular health and function.
Plan: Fit the patient into a cosmetic ocular prosthetic device OD only to meet the patient’s goals. After
discussing the options available and trialing several lens types, patient opted for soft contact lens option only
(the patient was unable to tolerate application of a large-diameter soft lens or scleral lens for an improved fit).
As the patient was intolerable to rigid and large-diameter soft lens modalities and expresses a strong desire for
some cosmetic correction, a hydrogel soft contact lens was trialed for possible in-house tinting. The fit of the
lens shows fluting at the inferior nasal edge, along with superior temporal decentration (see Figure 2, at right),
and spontaneous ejection in the absence of ocular lubrication. The occurrence of spontaneous ejection of the
contact lens was greatly reduced over a 4 hour trial of the clear lens and copious lubrication.
Ultimately, the patient was finalized into an in-office tinted soft toric hydrogel contact lens for part time wear
and in the presence of copious ocular lubrication. The final lens prescribed was omafilcon B material, with a
base curve of 8.4mm, diameter of 14.4mm, and power of plano – 0.75 x 100 (toric lens design stabilized the
lens to prevent from rotation). The lens tinting was performed in- house, and the pigment was decentered by
hand in order to provide the best match in ocular alignment to the fellow eye.
Fit of soft hydrogel contact lens on the ocular surface for Case #1
Note the fluting of the lens inferior nasal, and the decentration of the lens superior temporal.
Case Presentation:
A 48 year-old African-American female presented to the clinic with a chief complaint of overall poor cosmesis
and fluctuating pain and discomfort of the left eye following a failed corneal graft. The patient’s main concern
is to improve cosmesis while maintaining comfort of a contact lens; the patient is a singer and has found it
difficult to return to the stage and work in general with the obvious corneal deformity.
See photos above in Figure 3 for the appearance of the patient’s eye with and without ocular prosthetic contact
lens wear.
Examination Findings:
OD: All findings consistent with normal ocular health and function.
OS: Corneal opacification and neovascularization resulting in significant reduction of vision OS (reduced to
HM and light perception peripherally). Cornea shows similar appearance to a keratoconic ectasia with severe
central steepening, as well as calcium deposits along the corneal epithelial surface (see Figure 4, at right). No
current phthisis bulbi, but instead the eye appears to bulge out more so than the fellow “good” eye. The
patient reports considerable corneal sensitivity and will not tolerate a ocular prosthetic scleral shell.
Plan: Fit the patient with a trial scleral contact lens made from PMMA material, provide color matching
samples for artist to match to the “good” eye, and order ocular prosthetic device for habitual patient wear.
Ordered and trialed clear scleral lens for stability of fit and maintenance of ocular health with scleral lens wear
(see fit of clear lens in Figure 5, at right). Ultimately prescribed the following lens parameters, and ordered
hand-painted artistry onto the ocular prosthetic device: 18.0mm OAD, BC 6.00mm, CLP: plano (see fit of
prosthetic lens with artistry in Figure 6, at right). After 3 months of wear with the lens, the patient began to
note lens awareness, so increased diameter to 20.0mm, while keeping all other parameters the same. The
patient has not yet returned to have the new lens dispensed at the time of this writing.
Fit of hand-painted scleral contact lens on the ocular surface for Case #2
Note the mild superior decentration, but overall good scleral color match.
See photos A and B above in Figure 7 for the appearance of the patient’s eye with and without cosmetic
contact wear. Additionally, improved cosmetic appearance can be seen with the ocular prosthetic device while
wearing habitual refractive corrective spectacle lenses in photo 7C.
A special thank you to:
- Dr. Brett Larson, OD, FAAO, FSLS, for the beautiful work on the scleral lens artistry for Case #2
(and many other rigid ocular prosthetic devices used in our clinic).
- Truform Optics for allowing PMMA materials to be used in conjuction with their lens design
Acknowledgements