Lecture: Optometry to the Extreme: How We Manage Our Extreme Cases

During this live webinar, we will discuss how we manage our extreme cases in optometry from severe hyperopia, pathologic myopia, keratoconus, and anisometropia. Using examples from our clinic, we will discuss the work-up and management of challenging refractions with patients. Our objectives will highlight how to maximize the patients’ visual potential and follow them long-term to prevent vision loss. (Level: Intermediate)

Dr. Neelam Patadia, Optometrist, Loyola University Stritch School of Medicine, USA
Dr. Megan Hunter, Optometrist, Loyola University Stritch School of Medicine, USA


DR HUNTER: Okay. Hello. Good morning. Welcome. I’m Dr. Megan Hunter, and I’m here with Dr. Neelam Patadia, and we are going to talk about some of our more difficult refractive cases that we’ve seen in our clinic recently.

Okay. Sorry. We have no financial disclosures.

So as I mentioned, I’m Dr. Megan Hunter. I practice in the Chicago, Illinois, area, at Loyola University Medical Center in the Department of Ophthalmology.

DR PATADIA: Hi, everyone. Thanks for joining us today. I’m excited to be here. My name is Neelam Patadia. I am an optometrist. I work with Dr. Hunter at Loyola University Medical Center.

We work in their ophthalmology department. And so we’re in more of an academic institution, and we are excited to share some of our exciting refractive cases that we’ve seen over the years.

DR HUNTER: Okay. So we’ll get started. So this is a case I saw this past spring. Cataract surgery that did not go as planned. So a 77-year-old male, who presented to one of our surgeons with a visually significant cataract in his right eye, he had cataract in both eyes, worse in the right than the left, and this case is a little unique, because this patient is actually a physician in our institution.

Not in the Department of Ophthalmology. But in our institution. And still practicing. And had a lot of visual requirements. So wanted to have surgery and immediately get back to work. So on April 10th, he had cataract surgery in his right eye.

But the surgery was complicated, because of severe zonular dysfunction during the surgery. And unfortunately, our surgeon was unable to put in intraocular lens, and left the patient aphakic.

So that is where I came in. This patient was in a rush to have functional vision, because he had an upcoming conference that he was leading.

So the first day that I saw him, he was count fingers at 4 feet in his right eye. That was uncorrected vision. He was 20/40 with his current spectacle correction in his left eye. His EOMs and confrontation visual fields were normal. His pupil examination was normal.

His ocular health was normal. You know, lid, lashes, conjunctiva, cornea, clear anterior chamber, deep and quiet, iris was clear, aphakic in the right eye, and he did have a cataract in the left that was starting to approach visual significance.

His posterior segment was fairly healthy. His cup to disc ratio was a little large. But his rim was — his disc was pink and healthy, and he had an intact neuroretinal rim.

So first step is a refraction. So with a +9 manifest refraction, he was 20/25 in his right eye. And in his left eye, with an updated refraction, his vision did improve to 20/25. But you can see here that he was myopic.

And had significant astigmatism in his left eye. So this was just a very complicated situation for spectacle correction. Because of significant anisometropia. Considering the spherical equivalent, which is half of the cylinder added to the sphere, he had a roughly 12 diopter refractive difference between the two eyes.

So I knew that this would not be tolerated in a spectacle correction.

So we discussed his options, and really contact lenses was the best and quickest — soft contact lens was the best and quickest option to get this patient with functional vision for his upcoming conference.

So my initial contact lens choices were a Cooper Biofinity. +10 in the right eye. And that is because his spectacle correction was a +9, but with contact lens corrections, we have to take into consideration the effective power.

So whenever the refraction is 4 diopters or more in any meridian, the power has to be adjusted. So a plus lens is actually more effective as a spectacle. So to have an equivalent power, the contact lens power has to be higher.

And a minus lens is actually more effective as a contact lens. So the contact lens prescription will be lower than the spectacle correction.

And there is an equation that can be used, but as a general rule of them, if the spectacle correction is 4 diopters, you just adjust for the contact lens in either direction, based on hyperopia or myopia, by a quarter.

When you get to about 6 diopters, it’s half a diopter. And then 8 diopters, 0.75, at 10, you’re adjusting by a whole diopter.

So unfortunately, the contact lens for his left eye was backordered. And this is a general problem with high astigmatic soft contact lenses.

These are more rare prescriptions. So we do not get these contact lens orders very fast, unfortunately.

So I tried this first lens, and he did have a significant overrefraction. Luckily, I was able to get him a lens for his left eye pretty quickly, with a +11.50. He was 20/30 in that right eye. But I could not get a left lens for him in time.

So what he decided to do — he was very, very motivated, and he found a place that would be able to make him a pair of glasses, updated glasses, in the same day.

So he wore the contact lens in the right eye, and then wore glasses over, with a plano lens in the right eye, and his full correction in the left eye. And he was able to tolerate that difference between the two eyes.

So he was ready for his surgery. The only problem was that this patient was unable to insert and remove contact lenses himself. Despite several training sessions with me and my — and our team of technicians.

So his wife had to insert and remove for him. We trained her to do it for him. But that is not an ideal situation, when the patient is unable to care for their contact lenses themselves. And he had another upcoming conference that this time was out of town.

And he was not going to be able to bring his wife with him. So he was… He kind of sought out surgical options. And on May 31, he did have a secondary IOL surgery, with an intrascleral fixated intraocular lens, because he was aphakic and without capsular support.

So I saw him one last time. Because now he still needed some new glasses. And this was just a couple weeks after his surgery. So I did educate him that the prescription could still fluctuate some.

But he was pretty happy. 20/40 in the right, 20/30 in the left. He is planning to have cataract surgery in his left eye at some point in the near future. And I haven’t seen him since, so that makes me think that he’s pretty happy with this solution right now.

So this case was unique, because of the significant anisometropia. Anisometropia is any difference in the spherical equivalent between the two eyes of really more than a diopter.

What this can cause is aniseikonia, which is a difference in size of the retinal image. We typically assume that patients can tolerate up to 3 diopters of anisometropia, but anything greater than that typically cannot be tolerated in a spectacle correction.

There are some things that can be done to try to help, like changing the vertex distance, changing the front surface of the lens, of the spectacle lens, and changing the thickness of the lens. But those do not have a significant impact in large anisometropia.

So this difference in size of the retinal image can cause amblyopia in young children. And in adults, it causes eye strain, headache, double vision, imbalance, spectacle intolerance, distorted space perception. So these are really the patients that come back to unable to tolerate their spectacle lenses.

They put the lenses on and are immediately very uncomfortable.

The other thing that can happen with anisometropia is the difference in the prism, induced prism. So Prentice’s rule tell us that all lenses act as prisms when one looks anywhere but the optical center. And with spectacles, when we’re moving our eyes around, we’re often looking through something besides the optical center.

So this induced prism is the power of the spectacle correction multiplied by the decentration in centimeters. And a plus lens we think of as two lenses base to base. Whereas a minus lens we can think of two lenses — two prisms, apex to apex.

So when a patient is looking down, that is when this will be the biggest problem, especially in bifocal corrections. When they’re looking down to see at near the more plus lens will give them a base up prism effect, and the more minus lens will give them a base down prism effect.

So contact lenses of unequal powers still have retinal images that are almost the same size. And the contact lens moves with the eyes. So there’s very little induced prismatic effect. So contact lenses are a great option for patients, except of course with my patient that I just presented.

The patient does have to be able to insert and remove the lenses. Unilateral aphakia is the most extreme case of anisometropia. The aphakic eye is much more hyperopic than the fellow eye. And aphakic spectacle lens magnifies the retinal image by about 25% larger than it would be in an emmetropic eye of the same length.

Whereas the aphakic contact lens only magnifies the retinal image by 7%.

So that’s why it’s a better option.

So here is our first polling question.

Very good. So the audience has done very well. The correct answer is the first answer. Because the spherical equivalent in this case is greater than 6 diopters between the two eyes. Whereas all the other options, the difference in the two eyes was less than 3 diopters.

Thank you, and now Dr. Patadia is gonna present a similar case, but much more complicated.

DR PATADIA: Great case, Dr. Hunter. It really highlights a lot of things that, as optometrists, we can maximize our optical background to take care of our patients and their visual needs.

So my first case here is titled: When a routine exam is not so routine. So I had a patient come in, 68-year-old male, he presented with his wife for a comprehensive exam, just had complaints of blurred vision, gradual — he just wanted to come in for new glasses and to get a full ocular health exam.

Of note, he mentioned he had trauma in his right eye. He had a chainsaw injury. And he had eyelid surgery. And ever since then, he had decreased vision in his right eye.

He was also — he mentioned he had been told of high eye pressure once in the past, but there was no real follow-up that he mentioned. Or he didn’t go back for any testing or repeat intraocular pressure measurements.

So when he came in, his entering visual acuity in his right eye was 20/150 and in his left eye was 20/20. He was wearing spectacles full-time. And he mentioned that’s how he had been seeing for the last 20 years. He wasn’t complaining that his right eye was changing at all.

His entrance test showed that his EOMs and confrontation visual fields were normal. Of note, his right eye — there was an afferent pupillary defect. Which was indicative that there could be something going on in the retina, especially any sort of damage to the optic nerve.

In the left eye, the pupils were normal. Refraction did not show any change in visual acuity. He had a high astigmatic correction in his left eye. But he still corrected to 20/20. And his right eye was stable at 20/150, in Snellen acuity.

So when we checked his tonometry with applanation, he was entering with an eye pressure of 49 in his right eye and 23 in his left eye. So both ocular hypertension, in both eyes. Much more significant in the right eye.

He wasn’t complaining of any pain. When I asked him of any symptoms of angle closure, he had denied that. And so what we did is we instilled eye drops to lower his eye pressure in-office. There were no signs of angle closure on gonioscopy. And so we instilled one drop of brimonidine, one drop of dorzolamide, and one drop of timolol in office.

And his pressure did come down significantly, to 23 in the right eye. And of note, he did have thicker than average central corneal thickness, as noted on pachymetry. We did a retinal nerve fiber layer OCT, as you see here. And there was significant thinning in his right eye and his left eye was within normal ranges there.

So his ocular health assessment in the right eye — on anterior segment, his iris had irregular margins. And he had rosette-like changes on his lens, which was subluxed. Which I suspected was due to the history of the trauma. And in his left eye, he had age-appropriate nuclear sclerosis.

I did not dilate the patient in his right eye due to the high eye pressure. But in the left eye, the dilated exam was normal. Undilated, in the right eye, he had — it was a hazy view, but we could tell that the optic nerve was — there was diffuse cupping. There was no DH, but it was very hazy. There was a lot of thinning of the neuroretinal rim. In the left eye, the cup to disc ratio was larger than average.

There was moderate cupping, but the rims looked intact and healthy. So he was assessed with ocular hypertension with probable traumatic glaucoma in his left eye. I started him on medications in his — sorry. He was diagnosed with ocular hypertension with probable glaucoma in his right eye. And started on medications.

And he was sent to follow-up with our glaucoma service for evaluation of the glaucoma. And of the traumatic cataract. And I also prescribed a spectacle prescription for him to wear full-time. As he was functionally monocular. And I had very guarded prognosis of his best corrected vision in his right eye. Due to him saying he hadn’t seen better than what he presented with.

And so we talked about making sure he was wearing glasses full-time, in impact-resistant material. He presented with our glaucoma service, and a week later, his eye pressure was significantly improved.

So he was kept on the same medication. The glaucoma specialist also noted the traumatic cataract. But due to his trauma, they noted that there was missing zonules, and he would need a sutured intraocular lens implant.

And so in those cases, they’re typically referred to our retina service for surgical evaluation, as these surgeries can be more complicated and need a scleral fixated IOL.

So then the patient presented with our retina specialist. And they noted the cataract and the subluxed cataract in his right eye. And they noted that given the minimal zonular support, he would need a sutureless sclerally fixated IOL. And so before cataract surgery, they do measurements to decide on what power implant to put in.

And so they did two different tests. An A-scan and IOL biometry. And there was a big difference between the test results. So the retina specialist didn’t want to proceed with putting an IOL in, because it could be the wrong power for the patient.

So they decided to take the cataract out and leave the patient without a lens and then repeat testing in the future. And then go back and put a lens in.

Also, so that is called aphakia, when we take out the lens. And when this happens, a patient becomes extremely hyperopic. And causes anisometropia, which is obviously — we’ve highlighted in the past case — is very uncomfortable for the patients to function.

So the patient followed up with retina surgery. Or with the retina specialist after surgery. And they did start the patient on oral acetazolamide or Diamox, to help prevent increased IOPs. However, the pressure was still spiking. He was up to 34, even with topical medications and oral medications for glaucoma.

So then the patient followed up with the glaucoma service, and his pressure wasn’t getting better. So now this patient had to undergo glaucoma surgery. And so he had an Ahmed glaucoma valve placed.

Prior to going in to have an IOL placed. So this man’s been through a lot. Within six months, he’s been through… He came in for a routine exam, and now he’s had… He’s on his second surgery.

So the patient has now had cataract surgery to get the lens out. He’s had glaucoma surgery with an Ahmed valve to lower his pressure. And then he comes back to me for a refraction to find out what his best corrected visual acuity was.

And a temporary contact lens. And so he entered with count fingers vision in his right eye. With a significant hyperopic refraction. He did improve to 20/40, which is incredible, given he had started at 20/150, when I had seen him initially. So that was really great.

We had trialed an extended range power soft contact lens. And he was seeing 20/60. He was very happy with how he was seeing. And this was going to be a temporary contact lens, because the retina surgeon was gonna go in and put an IOL in.

But the patient was not motivated to learn insertion and removal for a temporary basis. And he had also expressed some frustration at this point. As he had just been pretty much living here in the eye clinic.

So he just wanted a pair of glasses. Which clearly we couldn’t give him at that point. And then also one other thing is: When discussing things with our glaucoma specialist, she also didn’t want him in a contact lens, because that contact lens can cause erosion of the thin tissue that’s above the Ahmed valve.

So we decided, based on that, and the lack of patient motivation for insertion and removal learning, that we would not do a contact lens. So the patient goes back to retina surgery, gets an IOL, and then comes back to see me.

And after he gets his scleral fixated IOL, he comes back and he refracted with a little bit of astigmatism to 20/40. And he has been really happy with his glasses. And he’s got functional vision.

He’s seeing clearer than he has in 20 years. And so it was a long journey, but he is very happy, and I just saw his wife last week. And she was just mentioning how great he is, and functioning. And doing great overall.

So things to consider here are: You know, when we’re talking about contact lenses, there’s different options for soft versus rigid, and what is your patient’s motivation.

Also what are the risks of other ocular complications. In general, there’s a lot of risk of complications with contacts, just from wear. And from misuse of contacts. But in this case, there was also an added layer of complication after he got his Ahmed glaucoma valve.

And then this case just highlights the importance of co-managing with the patient’s whole eyecare team. So here’s our second polling question.

Okay. Great. Another very accurate polling question here.

So the answer is all of the above. These are just things to think about, with patients who are treated for glaucoma with significant amount of topical medications, any sort of glaucoma surgery, and the patient’s motivation and comfort with insertion and removal.

DR HUNTER: Very interesting case. A successful conclusion, which is what we all want to see.

Here we go. So our third case was a patient that came to me. A 25-year-old healthy male. I thought this would be really easy. He wanted to wear some contact lenses. He came to me for a soft contact lens fit. Because he had just started wearing glasses one year prior.

And he was… You know, as most people do, struggling with his spectacle correction, when he was playing sports and being active. And exercising. So he was looking for contact lenses, not for full-time wear, but mostly because he played tennis, recreationally.

So he did say that he felt like his glasses prescription was changing. He wasn’t happy with his vision, with his current spectacle correction. He worked in business. And he was completely healthy. No known health problems.

So he comes in with the glasses that had been prescribed by an outside institution one year prior. And he was 20/30 in his right eye and 20/20 in his left. So he was correct that things probably had changed a little bit. EOMs and confrontation visual fields were within normal limits. His pupillary exam was normal. His anterior segment examination, completely normal.

As was his posterior segment. This was a very, very healthy patient. So refraction is here. He did have some astigmatism. And then whenever we’re going to fit a contact lens, we get the keratometry readings, because that gives us a clue as to what base curve to use for the contact lenses.

Also pachymetry was done on this patient. So there’s a few notable findings with all of this data here. One, visual acuity — he was not reading the 20/20 line very quickly in his right eye. He was struggling with it.

And in a young, healthy patient, that is not expected. We expect those patients to just quickly and easily read 20/20 or even 20/15. His K readings, his keratometry readings in the right eye, was showing more astigmatism than he was accepting or taking on his subjective refraction.

In the right eye. And his pachymetry, his corneal thickness, was thin. Thinner than average. So those were a few things to note. I proceeded with his contact lens fitting. I went with an Acuvue Oasys one day lens. And the purpose for choosing the one day lens — this is a lens that is worn for one day and then thrown away. And it’s a very good option for a patient who does not want to wear contact lenses all the time.

Because if we went with a two-week lens or a monthly lens, which is really the most popular modality, then the patient’s lens would be sitting in solution for a very long time in between time that he was wearing the lens.

So he was happy with this option. We went with this. But he came in for the dispensing, and his vision was not great in the right eye. And with the overrefraction attempt, I could not correct him to 20/20.

So whenever a young person cannot correct to 20/20, with a healthy examination, it is important to try to answer the question as to why. So at this point, I felt like further testing was indicated. And I got a corneal topography.

And this here gives us the answer as to why this patient was not correcting. So he is showing signs here of early keratoconus on this topography. He has an asymmetric bow tie appearance in the right eye here.

And you can see that the steepening is at an oblique angle. It is not with the rule, which would be vertical. Or against the rule, which would be horizontal. And in the left eye, he is showing some inferior steepening.

So this is not fun, to have to tell the patient that they have a corneal disorder, when they just came in for routine soft contact lenses to play tennis.

But I had to educate him on that. This was in June of 2022. And then I did send him to our cornea specialist, just to kind of confirm that diagnosis. And it was confirmed.

And he was followed until May of 2023, and at that point, on the topography, there was some progression noted. So at this point, options were discussed with him, and he was referred out of our institution for corneal crosslinking.

Which I will discuss in a minute. We did decide to just stick with the soft contact lenses for him. I discussed his contact lens options. But he felt like the vision was good enough for what he was using the contact lenses for.

Which was just exercise and tennis. So we stuck with that for now. So keratoconus is a bilateral, progressive corneal ectatic disorder. Typically asymmetric.

In the patient that I just presented, it was definitely progressing in the right eye or causing symptoms in the right eye. It causes irregular astigmatism. The central or paracentral cornea thins. And you will see progressive steepening on keratometry readings.

So here in this picture, this normal, uniform cornea, and in keratoconus, it starts to thin and stretch and become ectatic, and typically we see inferior steepening.

So the earliest signs of keratoconus are this mildly blurred vision, the patient might complain of glare, so a patient who is young with no cataracts, who is complaining of problems when they’re driving, with glare, something we would expect more in an older patient with some lens changes.

Their vision might be slightly distorted. One of the earliest signs is just when you cannot correct a young healthy patient to 20/20 or 20/15. Later signs — they’re going to continue to become more nearsighted.

And show more astigmatism on their spectacle corrections. Their vision will be blurry and distorted. They will have very inconsistent responses on their refraction. These are patients where one day the refraction will look one way, and the next time you check, which could be three weeks later, it will be very, very different.

They will eventually struggle wearing soft lenses, because the contact lens will not fit well on their eye. They will have poor vision with both spectacles and soft contact lenses. Because the soft lens just conforms to the cornea.

So it does not help with that irregular astigmatism at all. Munson sign is a sign when the patient looks down, the lower eyelid will kind of make a V. And that is because that cone, the inferior steepening, will be pushing on the lid. Pushing the lid out.

A Fleischer ring is iron deposits that form in the deep epithelium, and it can form around the cone. Corneal hydrops happen when there is stromal edema, because of a break in Descemet’s membrane.

The patient will present with pain, photophobia, and decreased vision. If they are suffering from hydrops. And unfortunately hydrops can lead to corneal scarring.

These are all later and advanced signs of keratoconus. So here is our third polling question.

Very good. So that is correct. Any time the patient cannot correct and there’s no explanation for it, you can ask yourself if the patient might have keratoconus. It’s a good idea to look at topography if that is available to you.

Okay. So one of the first line treatments for keratoconus is specialty contact lenses. And that is where Dr. Patadia and I come in handy, in our institution. We work with several cornea specialists.

So there are three options for patients. Corneal gas permeable lens, which is a very small lens that sits on the cornea. These lenses are typically 9 to 10 millimeters in diameter. A hybrid lens, which has the benefits of that hard, gas permeable central lens. But it is surrounded by a soft skirt.

Which makes the lens much more comfortable for the patient. And a scleral lens. Scleral lenses have become very, very popular. These are typically 15 to 18 millimeters in diameter. And they sit on the sclera.

So they vault over the entire cornea, and that makes them very beneficial in keratoconus. You can see here is a scleral lens with an ideal fit in a keratoconus patient. We can see this increased steepening here in the cornea.

And the scleral lens — we see the tear reservoir here. We want to make sure that there is no corneal contact. That even in the steepest area, the lens is clearing the cornea. And we want to make sure that there is limbal clearance as well.

And then the lens sits on the sclera. And this makes it very, very comfortable for the patient. But all these lenses have pros and cons. And a scleral lens is most difficult to insert, and it has to be inserted precisely.

So that is sometimes why it will not work for a patient. Intacs were a surgical procedure that was approved for keratoconus in the United States in 2004. And they are these arc shaped corneal inserts that are surgically positioned in the peripheral cornea.

And they serve to reshape the cornea. So they can help control the astigmatism, making it easier for the patient to be corrected with spectacles or soft contact lenses, or even make it easier for them to wear a corneal gas permeable lens.

Corneal crosslinking was first reported in 2003, and has gained in popularity significantly. It strengthens the collagen bonds within the corneal stroma. So the stromal tissue is saturated with the vitamin riboflavin, and then the cornea is exposed to UVA irradiation.

And this will just strengthen the collagen bonds and significantly slow down the progression of keratoconus. So this is very beneficial to the patient early on in their disease. Because it could prevent all of those complications of advanced keratoconus.

And our patient did end up getting corneal crosslinking, at an outside institution, in the summer of — this past summer.

When all the other options have been exhausted, then a patient may end up with a penetrating keratoplasty. Otherwise called a corneal transplant or corneal graft. And there’s just a surgical removal of the piece of cornea that is not working, and replaced with a donor cornea.

This is sutured on. Those sutures remain for months to years. So significant recovery, because while the sutures are in place, and while they are being removed, there will be significant irregular astigmatism.

Typically, a patient will still need glasses, at least. Often contacts. Because there is still some irregular astigmatism after corneal transplant. Moving on to our last case.

DR PATADIA: All right. Wonderful. So the last case is called a case for a contact lens.

I had a 12-year-old female present to my clinic, referred by her pediatric ophthalmologist for a contact lens fitting in her left eye only.

She was complaining of blurred vision and headaches. She had lost her contact lens for six months, and had been prescribed patching by our ophthalmologist, which she had not been doing.

So she wears the contact in her left eye only, with spectacles, with a bifocal correction in her left eye. Given she had a significant ocular history, that we’ll talk about. We can talk about it now, actually.

So she had a history of trauma to her left eye, when she was 4 years old. So 8 years ago. She had been hit by a plastic toy rake to her left eye by her little brother, with subsequent — a ruptured globe, due to a corneal laceration, which was repaired after she had presented to the emergency room.

Here at Loyola. After the globe repair, due to her trauma, she actually developed a traumatic cataract pretty quickly. Which was removed. And all of this happened within a month of her initial trauma.

And so since her natural lens had been removed, she was no longer able to accommodate, and that’s why she was wearing a bifocal correction, to help her see up close. And the contact lens was for her… Due to her irregular cornea. So we’ll talk a little bit about that.

So when she presented to me, her entering acuity was 20/20 in her right eye. And then 20/50 in her left. Exam-wise, relatively within normal limits.

She had an irregular dilated pupil in her left eye, due to her history of her trauma. On refraction, right eye — very minimal refractive error. Left eye, she had significant irregular astigmatism.

Which correlates with her topography here. And so we decided to order another updated contact lens for her. She was wearing a rigid gas permeable corneal lens.

So we decided to stay in that modality. And then updated her prescription glasses to wear over her contacts.

And so I think just… Talking about the patient’s history is important. She was seen in 2011, in the emergency room. And like I said, she had the globe repair. And then she had the traumatic cataract. That was taken out.

The reason it was taken out is she was four years old, and that could cause deprivation amblyopia, if they had kept the cataract in there. Which would have — she did have guarded prognosis, given her trauma.

But her eyecare team wanted to make sure we maximized any chance of improved visual potential in that eye. So the cataract was removed. And she healed well after her cataract surgery, and then was referred to the contact lens service for evaluation.

Here you can see after cataract surgery, her corneas are extremely flat. On topography. And so… And she didn’t refract any better with glasses, which is expected with such a flat cornea.

So one of our optometrists had fit her with a rigid contact lens. And so when she came back for her contact lens dispense, she was actually seeing 20/40, which is wonderful, with a rigid contact lens. Which is really important, to maximize any sort of visual potential, especially with a child who is still in their critical period of development.

To decrease any risk of amblyopia and maximize their chance of visual potential.

So she comes to me. And we fit her back in a rigid contact lens. And with her rigid contact lens and some astigmatic correction in glasses, she was seeing great. She was seeing 20/20.

So she was happy with her vision. And when she was younger, her parents were inserting and removing her contacts. Now that she was 12, she was starting to do it by herself. And she was able to do that.

She comes back to me one year later for her contact lens exam. She had lost her contact lens again. And she wasn’t wearing it, because she wasn’t comfortable with the contact lens.

So her entering acuity, again, right eye has always been great. So she’s really maximizing her right eye. And likely suppressing her left eye a little bit, just because she’s just not wearing her contact lens.

So she just can’t see as great out of that eye. And so… On refraction, we noticed again significant irregular astigmatism in the left eye. She corrects well. However, given the anisometropia here, and the irregular astigmatism, we wanted to put her back in a contact lens.

And so we discussed options here. And so what we decided to do was to go with a soft toric multifocal contact lens for her. Now, she saw 20/30. So not as great as she did with the rigid gas permeable lens.

But she was much more comfortable with the lens. And given newer technology with contact lenses, you know, in present day versus a decade ago, there are better options for toric, multifocal lenses, and so she was happy with that option.

So amblyopia — we’ll just quickly talk about amblyopia. It is the reduction of visual acuity in one or both eyes caused by abnormal binocular interaction during the critical period of visual development. It’s defined by two or more — a disparity of two lines in visual acuity.

That is worse than or equal to 20/30, with best optical correction. So really with these patients, between age… Anybody at risk for amblyopia… We really want to maximize any sort of visual potential we can, from birth to age 8, because that’s the critical period of visual development.

And so causes can be… We’ll talk about some of the causes of amblyopia. Refractive is the most common. Now it could be anisometropic or isometropic. So I’ve listed some guidelines — these guidelines are important when it comes to prescribing glasses for children.

Because we want to make sure we are aware of these guidelines, so that we can prescribe glasses appropriately, when we see any level of anisometropic or isometropic refractive error. So anisometropic is when there’s unilateral amblyopia caused by a distinct refractive error of each eye.

Isometropic refractive amblyopia occurs when both eyes are amblyopic from a significant refractive error that is similar between both eyes. So in anisometropic, your highest risk of amblyopia is with hyperopic anisometropia.

And with isometropic, the highest risk is with astigmatic uncorrected refractive error. You can also develop amblyopia from a strabismus. Or any sort of misalignment of the eyes can cause a strabismus amblyopia, if it’s not corrected, and often patching is used for these patients.

And also deprivation can cause amblyopia, such as cataracts, congenital ptosis, or visually significant corneal scar. So considerations: In this case, were the risk for amblyopia for the patient — since she was so little. Also safety with the contact lenses. As she was wearing them at such a young age.

And then, as she got older, patient comfort and lifestyle factors. So here is our last polling question.

Great. The answer is deprivation. Which, with her traumatic cataract, she was at risk for deprivation amblyopia without cataract surgery.

All right. And so I think in the interests of time, we’ll go ahead and open up the polling… The floor for questions.

And then this is just a guideline for refractive shifts that will be available with the webinar, on the website.

So we have a question: Would you do corneal topography for every contact lens fitting patient, if the modality is easily available?

DR HUNTER: So I would say any time I’m doing a specialty contact lens fit, I do use topography. Especially if I am fitting a corneal gas permeable lens. Because the topography is extremely important when designing the corneal contact lens.

For soft lenses, no. I do not do topography on my soft contact lens fit.

DR PATADIA: I agree with that. Any time I fit a specialty contact lens fit, I do corneal topography. Or if there’s a significant amount of astigmatism, typically over 2.5 diopters, I’ll just do a baseline topography to monitor for changes in the future. And just to see if there’s any early signs of inferior steepening.

DR HUNTER: Here’s another question. Can we prescribe contacts for mixed astigmatism with presbyopia? So we can. There are soft contact lenses available.

Dr. Patadia used one in her patient. In her child. Because the patient was aphakic. The patient needed a multifocal contact lens. So there are now several — most of the major contact lens brands do offer an astigmatic correction that also corrects presbyopia.

Honestly, these are not the easiest to fit, because patients — it depends on the patient. And it depends on the patient’s expectations. So that is asking a lot of a contact lens, a soft contact lens. It works so well in Dr. Patadia’s patient probably because she was a child, honestly.

And she was not accustomed to seeing great in her left eye. But a patient that comes and wants to see 20/20 at all distances and do everything with perfect vision is not a good candidate for a multifocal astigmatic contact lens correction.

Because there is some compromise to vision at both distance and near. And I do… So I do warn my patient of that. And if you can tell that their visual demands are very significant and they want very crisp vision, monovision might be a better option for them.

Where one eye is corrected… Their dominant eye is corrected for distance and their non-dominant eye is corrected for near. If they have a significant amount of astigmatism, that could be another reason why the contact lens — the multifocal astigmatic — the multifocal toric lens would be difficult.

But if the patient doesn’t mind being 20/30 or 20/25, and they just do not want to wear glasses at all, and they want to see everything, it’s worth a shot, I would say.

DR PATADIA: Yeah, I would agree with all of that. I think they are reserved for a special patient who is extremely motivated, and understands the compromise of vision that will occur. With a multifocal — a toric multifocal soft lens.

DR HUNTER: We should mention, though, that a corneal gas permeable lens naturally corrects astigmatism. By creating a tear layer. So that is an option for your patients.

You could go with a gas permeable multifocal contact lens. And that might work better, vision-wise. If the patient has worn soft lenses their whole entire life, it requires a little bit of a discussion. Because the gas permeable lens is not as comfortable.

So here is a question: How is the fluid within the chamber of the contact lens maintained? Air may enter the chamber if the lens is not fit properly. That is correct. So the fit is very important.

And the patient has to… I tell my patient: You have to bring yourself to the contact lens. You cannot bring the contact lens up to your eye.

Because the fluid reservoir is necessary. If that fluid is lost while the contact lens is going in their eye, there will be an insertion bubble, immediately. And the patient will not see clearly with the insertion bubble.

So as long as the lens fits properly, the fluid will mostly be maintained. It is important that they have enough fluid. So I fit my contact lenses and send the patient — as long as the fit looks good initially — and I have them come back in two weeks. And I want to see them after they have had the contact lens on for at least two hours, so that I can evaluate and make sure there’s enough fluid remaining after they’ve worn the lens for several hours.

Here’s a question. Intacs significance in keratoconus. Since we are not surgeons, I don’t know that we are the best to answer that question. I would say that… I practice… I started my career in Miami, Florida. And there was a big billboard that says: Do you have keratoconus? Get Intacs!

Of course, that was in the early 2000s, when Intacs were new in the United States. I have never seen a patient in our institution who has been treated with Intacs.

And we do work with four cornea specialists. So I do not think it is the most popular way to treat keratoconus. Corneal crosslinking and corneal transplants are.

DR PATADIA: A kid, seven years old and below, and is hyperopic and cyclorefraction is inaccessible, can I still prescribe the prescription to the kid?

I would say yes. I think… Based on your findings, trying to do… You can try to do specific things like try to fog the patient properly, and bring them down, use a red/green balance, with your phoropter, or do a binocular balance. Especially if you don’t have accessibility to cyclorefraction.

But if the child is younger than 7, and hyperopic, especially with a risk of amblyopia, or other things, like they have complaints of headaches, especially after near tasks, they’re having difficulty focusing, maybe they’re not doing well in school — I would do a real careful refraction.

And retinoscopy, to get the most accurate objective data you can, and prescribe to the child. To decrease risk of any amblyopia, and also just to maximize their visual potential. But I would also use guidelines as the case history, and what sort of symptoms the patient may be having.

To help guide you for these patients.

DR HUNTER: I agree, and I think once you prescribe, and the patient gets used to a correction, the next time you see the patient, they might accept a little bit more of their full hyperopic correction.

So yes, cycloplegia is important to know the full extent of their hyperopic correction. But… I would absolutely correct anyway. And I think once they start accepting some of it, more of the full prescription will come out in subsequent visits.

DR PATADIA: What would one do in case a patient is not comfortable with the full cylindrical spectacle correction and contact lens correction is not an available option? Typically for these patients, I will modify the cylinder amount and compensate with the spherical equivalent in the sphere.

And I will trial frame these patients to see what is the maximum amount of astigmatism they will accept in a trial frame. I’ll have them wear the trial frame, look around, walk around in the office, sit for a bit of time, to see if they are able. What is the maximum amount of astigmatic they will accept.

DR HUNTER: I agree. With a child with anisometropia, for example, -3 in one eye and the other eye is +3, which eye is more at risk for amblyopia?

It’s actually the +3 eye. So the least hyperopic eye in a child determines how much they’re going to accommodate.

So with that -3, they aren’t going to accommodate to see clearly in the +3 eye. And -3 does provide them very good vision at near. So they are going to be using that -3 eye to see everything at near.

But the +3 eye, they are not going to be accommodating enough to use that eye and to develop good vision in that eye. In contrast, if they were plano in that other eye, instead of +3, they would actually be okay. They would probably not develop amblyopia.

Because the plano eye would be doing all their distance tasks. And the -3 would be… They would be using for near.

DR PATADIA: So can we prescribe — if the right eye is plano and the left eye is -3.75, with a -0.5 axis 50? Is that okay?

In general, patients will accept a little bit more aniso with myopia. So I think that would be fine to prescribe. If there are concerns or the patient is uncomfortable, I would maybe modify the left eye, by 0.5 to 0.75, to help with comfort.

DR HUNTER: I would definitely — I think it’s always worth trying. Absolutely, this prescription, I would prescribe. I would try. Of course, you run the risk of the patient coming back and telling you they don’t like their glasses, but I think it’s worth the risk.

What do we do if the patient cannot manage using the contact, and they have large anisometropia and they don’t have a cataract?

So this is difficult. Unfortunately, sometimes… We see these patients all the time. There’s nothing you can do. So… You could try to modify. So that you’re at least kind of engaging that eye a little bit.

Because what are you trying to prevent? Amblyopia. The other thing — you could give them a pair of glasses, even if they weren’t going to wear them all the time, so they could patch the good eye for an amount of time every day, and then be using the poor seeing eye. So that they strengthen that brain-eye connection. And they do not develop deep amblyopia.

How can I manage chronic allergic conjunctivitis? Yeah. It’s almost allergy season here in Chicagoland. So it’s time for this to come. So we use topical antihistamine eye drops.

If it’s very, very severe, and the patient is at risk for corneal scarring, because of how significant their palpebral conjunctiva is affected, I will… Or they’re miserable… I will use a topical steroid for a short amount of time. And then taper them. While making sure that the intraocular pressure remains normal.

What else? I have been referring a lot of my very severe patients to allergists. And some patients are getting allergy shots, which can help as well.

DR PATADIA: We did that one.

DR HUNTER: This is a good question. Can we prescribe +1 for near vision in a 38-year-old male who is working more than 13 hours on the screen, if he doesn’t have any distance correction, but he’s having difficulty at near? Absolutely, absolutely. I do it all the time.

I feel like some patients, as they start to approach 40, need help already. Some of us, like myself, I’m in my 40s, and I’m okay at near still. But others become symptomatic. He could have latent hyperopia, actually.

And that will start showing up a little before 40, at near.

So prescribe away.

DR PATADIA: Okay. How best can you treat or get rid of a traumatic cataract? That would be just a referral to a cataract surgeon. That’s the only option.

DR HUNTER: Surgery, yeah. Why can’t we use contact lenses in the patients with Ahmed valves? I mean, you can. I think our glaucoma surgeon was just worried about infection and erosion of the skin… The tissue over the valve.

DR PATADIA: I asked a couple glaucoma specialists about that. And I think there’s varying opinions. I think it depends on… It’s case by case. But if you do prescribe them, then they have to watch for erosion of the tissue closer. But it still can be done.

DR HUNTER: Yeah. Ideal time to wait to prescribe contacts for a patient who has undergone crosslinking — so crosslinking is not going to improve anything. It is only going to stabilize their current — so there’s really not — I had a patient who went for crosslinking, and we kind of simultaneously — I was fitting him with his contact lenses.

I think we got most of the questions.

DR PATADIA: In a hyperopic 50-year-old patient, is it okay if we don’t give the universal known add — additional add of +2, in case it wasn’t accepted by the patient? Absolutely.

I will… If a patient — depending on their working distance and what their visual needs are, and the size of the text that they are trying to work with, if they’re working more at an intermediate distance, or if they’re a larger — a taller person who typically has a longer arm span and holds things further out, I will prescribe less than a +2, even though that is the universal age appropriate add.

Especially nowadays, so much of our near work is actually more at an intermediate distance, on computers. And I often will ask the patient before I prescribe their add.

DR HUNTER: I made that mistake early in my career. Very tall patients usually need a little less add. I had a couple remakes because of that. Spectacle remakes. So I think we’ve answered almost everything.

And unfortunately, we do have to run. Because we both have clinic right now.

But thank you so much for your attendance, and thank you for your great questions. It was a pleasure to start our morning with you today.

DR PATADIA: Thank you for being here.

Last Updated: March 25, 2024

7 thoughts on “Lecture: Optometry to the Extreme: How We Manage Our Extreme Cases”

  1. Very interesting in optometry and good learning experience. Thank you very much to Dr. patadia and Dr.Hunter.👌🌹♥️

  2. I have a qts can we prescribe near vision add glasses for a case of 12 yrs. unilateral post cataract pt with monofocal iol other eye normal.


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