- Email: [email protected]
SoftPerm contact lens fitting for a case of pellucid marginal degeneration
Case Report
SoftPerm Contact Lens Fitting for a Case of Pellucid Marginal Degeneration Terry
Scheid,
OD,
FAAO,
and Steven
Introduction
Refraction:
A 67 year old female patient with pellucid marginal degeneration manifesting 13.00 diopters against the rule corneal cylinder was successfully fit with a SoftPerm contact lens after all rigid lens and soft toric designs had proved unsuccessful. The SoftPerm lens corrected approximately 10.00 diopters of the cornea1 cylinder and a spectacle overcorrection provided the remainder, giving good visual acuity. Keywords: Cornea1 degeneration, toric contact lenses, SoftPerm contact lens
Case Presentation Patient D.S., a 67 year old Hispanic female, was referred for a possible contact lens fitting. She complained of decreased left eye vision for several years. An ophthalmologist had diagnosed Terrien’s marginal degeneration more advanced in the left eye. She had no allergies, no ocular trauma or surgical history, and was utilizing no ocular or systemic medications. Diagnostic data The patient was wearing a bifocal spectacle acuities as follows: OD: OS:
+2.75 +2.50 + 2.00 +2.50
with visual
-3.25 x 88 2Of25 -2 add 20/25 at 16” - 2.50 X 88 finger count at 8 ft. add 20/400 at 10”
Address reprint requests to Dr. Scheid at S.U.N.Y. Optometry, 100 East 24th St., New York, NY 10010, USA. Accepted for publication August 1990.
296
ICLC,
P. Wetcher,
Vol. 17, November/December
1990
OD,
OD: OS:
Keratometry:
FAA0
+3.50 + 2.50 +3.50 +3.00
-4.00 X 90 20/20 -2 add 20/20 at 16” -13.00 x 95 20/40 add 20/30 at 14”
OD: 43.00/46.25 @ 85 slightly irregular OS: 38.00/54.00 @ 95 irregular and distorted. A B&L keratometer with extended range technique was used.
Biomicroscopy: Inferior cornea1 thinning more advanced OS, with a 3 mm pinguecula abutting the OS nasal limbus was observed. The central corneas were clear with a midperipheral arcus-like appearance (Figure I). Tear film findings were normal with a 14 second tear break-up time in each eye. Blink rates and lid closures were also normal. Ophthalmoscopy: Dilated fundus exam revealed 0.4 C/D symmetrical in both eyes with well-defined disc margins, normal maculae and A/V findings, and no retinal abnormalities.
Treatment Plan The patient was satisfied with the spectacle correction in the right eye. It was decided to fit the left eye with a rigid lens due to the cornea1 irregularity. However, various spherical base curve and diameter rigid lens designs slipped off the cornea within minutes. Back surface toric rigid lenses also positioned inferiorly and displaced due to the vast against-the-rule cornea1 astigmatism. Toric hydrophilic lenses were fitted with the idea of providing additional cylinder in the patient’s spectacle over correction. Lenses such as the W-J Optifit ( -3.75 cyl
0 1990 Butter-worth-Heinemann
PeUucid Marginal Degeneration:
Scheid and Wercher
Figure 2B. Optifit toric.
Figure 1. Biomicroscopy
finding.
Figure 3. SoftPerm with fluoresoft.
Figure 2A. Sunsoft lens.
14.5 diameter) and Sunsoft 15.0 diameter with a -7.00 cylinder demonstrated inferior lift off and variable rotation due to the comeal irregularity and the nasal pinguecula. A Sunsoft lens of 8.3 base curve, 15.0 diameter and +2.00 - 7.00 x 90 Rx provided 20/50 acuity with a plano -5.00 x 9.5overrefraction but demonstrated severe inferior lift off (Figure 2A). Various other diagnostic hydrophilic toric lenses positioned similarly due to the comeal and conjunctival topography (Figure 2B). A diagnostic Sola/Bames Hind SoftPerm lens was in;erted. This lens holds promise not only in the treatment of :he normal eye but also for patients with corneas that are distorted and demonstrate irregular astigmatism. ’The Soft‘erm lens has a total diameter of 14.3 mm and base curves )f 7.1 mm to 8.1 mm in 0.1 mm steps. The rigid center has Ln 8.0 mm width and a 7.0 mm optic zone (Pentasilcon naterial) polymerized with a 25% water content hydrobhilic skirt.* A lens of 7. I mm base curve and - 2.75 Rx erasinserted. The lens positioned well with adequate movelent and overlayed the nasal pinguecula (Figure 3). Fluo-
resoft (fluorescein 35%) was utilized to aid in evaluating the fit as standard sodium fluorescein was contraindicated due to the staining of the hydrophilic skirt. An overrefraction of the lens revealed OS + 2.00 - 3.00 x 90 with acuity of 20/25 -2 and 20125 at 16” with a + 3.00 add. By chance, the patient’s current spectacle lens OS was + 2.00 - 2.50 X 88 giving 20/30 over the contact lens. A 7.1 mm - 2.75 SoftPerm lens was dispensed with the patient’s current spectacles. The patient was evaluated over time wearing the lens and currently wears it 12 hours daily with excellent visual, cornea1 and conjunctival physiological responses. The OS spectacle lens was later changed to + 2.50 - 3.25 x 90 with 20/25 - 2 acuity and + 3.00 add giving 20/25 at 16”.
Discussion Although the referral indicated a diagnosis of Terrien’s marginal degeneration, it was felt that this was in fact a case of pellucid marginal degeneration. Pellucid marginal comeal degeneration is a bilateral, inferior comeal thinning that leads to marked irregular against-the-rule area between the astigmatism.3 Th ere is an uninvolved
ICLC, Vol. 17, November/December
1990
297
Case Report thinned section of the cornea and the limbus, there is no vascularization or lipid deposition, and comeal sensation remains normaL The etiology is unknown, but it is sometimes associated with keratoconus. Terrien’s marginal degeneration is a thinning of the peripheral cornea occurring most often in males. It begins superionasally with the development of fine, white peripheral subepithelial opacities that spare the limbus. As the peripheral cornea thins, the entire cornea tilts forward and large amounts of astigmatism develop. Since this patient was female, and the inferior, rather than the superior cornea was thinned, it was felt the proper diagnosis was pellucid marginal degeneration rather than Terrien’s; however, the presence of arcus-like deposits in this patient somewhat confused the issue. Differential diagnosis also includes keratoconus; however, none of the characteristic signs, such as central cornea1 thinning, Vogt’s lines, and Fleischer’s ring, were present. Regardless
Clinical
of the differential diagnosis, conventional rigid and hydrophilic lenses failed to fit properly on this unusual cornea. However, a SoftPerm lens did, correcting approximately 10D of cornea1 cylinder and providing an excellent visual and physiological response. References Edwards GL: Birth of a new lens . . . SoftPenn. Contemp Optom, 1989;8( 1):13. Dubow B, Vrchota L: SoftPenn: the “quintessential” lens design for practice-building professionals. Contact Lens Forum, 1990;15(4):17-18. Kenyon KR, Fogle ]A, Grayson M: Dysgeneses, dystrophies, and degenerations of the cornea, in Tasman W (Ed): Duune’s Clinical Ophthalmology, Philadelphia, JB Lippincott Co., 1969, ~014, chap 16, p 49. Smolin G: Dystrophies and degenerations, in Smolin G, Thoft R (Eds): The Cornea, Boston, Little Brown &I Co., 1983, p 335.
Implications
This case report illustrates the tremendous potential of the SoftPerm lens for clinicians. The patient exhibited an irregular cornea with 13.00 D of against-the-rule cornea1 cylinder. Conventional contact lens options, including spherical rigid gas permeable (RGP) lenses, back toric RGP lenses, and soft toric lenses failed to provide a satisfactory fit and/or visual acuity. The SoftPerm lens, however, resulted in good centration and excellent acuity, eliminating the need for a cumbersome and expensive piggy-back lens system. In addition to unusual cases (such as that described above), I have had positive experiences with the SoftPerm in more routine situations, including toric soft lens patients with poor or fluctuating vision, those unable to tolerate RGP lenses, and contact lens patients with significant dry-eye symptoms. The SoftPerm lens is a significant improvement over its predecessor, the Saturn II lens. The diameter is larger and a peripheral curve has been added to the central rigid portion. These design features increase the ease and consistency of the fit. The main drawbacks of the SoftPerm lens are the low Dk value (14) and the limited base curve range (for keratonconus). Although reported, I have not encountered problems with lens tightening or with lens removal. In summary, this case report documents the problem-solving capability of the SoftPerm lens. I recommend that clinicians try this lens for routine, as well as unusual, clinical situations. Adam Gordon, OD, MPH School of Optometry/The Medical Center University of Alabama at Birmingham Birmingham, Alabama 35294
298
ICE,
Vol. 17, November/December
1990
Pellucid Marginal Degeneration: S&id
ad
Wet&r
Terry Scheid, OD, FAAO, received a BS from the Ohio State University and an OD from the State University of New York School of Optometry. Dr. Scheid is a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry and an assistant clinical professor at State University of New York School of Optometry. He also maintains a private practice in Merrick, NY.
I I I
Steven P. Wetcher, OD, FAAO, received a BA from the State University of New York at Stony Brook, an MS from the Pennsylvania State University, and an OD from the State University of New York School of Optometry. Dr. Wetcher is an assistant clinical professor at S.U.N.Y. School of Optometry and also maintains a private practice in Green Village, NJ.
ICLC, Vol. 17, November/December
1990
299
SoftPerm Contact Lens Fitting for a Case of Pellucid Marginal Degeneration Terry
Scheid,
OD,
FAAO,
and Steven
Introduction
Refraction:
A 67 year old female patient with pellucid marginal degeneration manifesting 13.00 diopters against the rule corneal cylinder was successfully fit with a SoftPerm contact lens after all rigid lens and soft toric designs had proved unsuccessful. The SoftPerm lens corrected approximately 10.00 diopters of the cornea1 cylinder and a spectacle overcorrection provided the remainder, giving good visual acuity. Keywords: Cornea1 degeneration, toric contact lenses, SoftPerm contact lens
Case Presentation Patient D.S., a 67 year old Hispanic female, was referred for a possible contact lens fitting. She complained of decreased left eye vision for several years. An ophthalmologist had diagnosed Terrien’s marginal degeneration more advanced in the left eye. She had no allergies, no ocular trauma or surgical history, and was utilizing no ocular or systemic medications. Diagnostic data The patient was wearing a bifocal spectacle acuities as follows: OD: OS:
+2.75 +2.50 + 2.00 +2.50
with visual
-3.25 x 88 2Of25 -2 add 20/25 at 16” - 2.50 X 88 finger count at 8 ft. add 20/400 at 10”
Address reprint requests to Dr. Scheid at S.U.N.Y. Optometry, 100 East 24th St., New York, NY 10010, USA. Accepted for publication August 1990.
296
ICLC,
P. Wetcher,
Vol. 17, November/December
1990
OD,
OD: OS:
Keratometry:
FAA0
+3.50 + 2.50 +3.50 +3.00
-4.00 X 90 20/20 -2 add 20/20 at 16” -13.00 x 95 20/40 add 20/30 at 14”
OD: 43.00/46.25 @ 85 slightly irregular OS: 38.00/54.00 @ 95 irregular and distorted. A B&L keratometer with extended range technique was used.
Biomicroscopy: Inferior cornea1 thinning more advanced OS, with a 3 mm pinguecula abutting the OS nasal limbus was observed. The central corneas were clear with a midperipheral arcus-like appearance (Figure I). Tear film findings were normal with a 14 second tear break-up time in each eye. Blink rates and lid closures were also normal. Ophthalmoscopy: Dilated fundus exam revealed 0.4 C/D symmetrical in both eyes with well-defined disc margins, normal maculae and A/V findings, and no retinal abnormalities.
Treatment Plan The patient was satisfied with the spectacle correction in the right eye. It was decided to fit the left eye with a rigid lens due to the cornea1 irregularity. However, various spherical base curve and diameter rigid lens designs slipped off the cornea within minutes. Back surface toric rigid lenses also positioned inferiorly and displaced due to the vast against-the-rule cornea1 astigmatism. Toric hydrophilic lenses were fitted with the idea of providing additional cylinder in the patient’s spectacle over correction. Lenses such as the W-J Optifit ( -3.75 cyl
0 1990 Butter-worth-Heinemann
PeUucid Marginal Degeneration:
Scheid and Wercher
Figure 2B. Optifit toric.
Figure 1. Biomicroscopy
finding.
Figure 3. SoftPerm with fluoresoft.
Figure 2A. Sunsoft lens.
14.5 diameter) and Sunsoft 15.0 diameter with a -7.00 cylinder demonstrated inferior lift off and variable rotation due to the comeal irregularity and the nasal pinguecula. A Sunsoft lens of 8.3 base curve, 15.0 diameter and +2.00 - 7.00 x 90 Rx provided 20/50 acuity with a plano -5.00 x 9.5overrefraction but demonstrated severe inferior lift off (Figure 2A). Various other diagnostic hydrophilic toric lenses positioned similarly due to the comeal and conjunctival topography (Figure 2B). A diagnostic Sola/Bames Hind SoftPerm lens was in;erted. This lens holds promise not only in the treatment of :he normal eye but also for patients with corneas that are distorted and demonstrate irregular astigmatism. ’The Soft‘erm lens has a total diameter of 14.3 mm and base curves )f 7.1 mm to 8.1 mm in 0.1 mm steps. The rigid center has Ln 8.0 mm width and a 7.0 mm optic zone (Pentasilcon naterial) polymerized with a 25% water content hydrobhilic skirt.* A lens of 7. I mm base curve and - 2.75 Rx erasinserted. The lens positioned well with adequate movelent and overlayed the nasal pinguecula (Figure 3). Fluo-
resoft (fluorescein 35%) was utilized to aid in evaluating the fit as standard sodium fluorescein was contraindicated due to the staining of the hydrophilic skirt. An overrefraction of the lens revealed OS + 2.00 - 3.00 x 90 with acuity of 20/25 -2 and 20125 at 16” with a + 3.00 add. By chance, the patient’s current spectacle lens OS was + 2.00 - 2.50 X 88 giving 20/30 over the contact lens. A 7.1 mm - 2.75 SoftPerm lens was dispensed with the patient’s current spectacles. The patient was evaluated over time wearing the lens and currently wears it 12 hours daily with excellent visual, cornea1 and conjunctival physiological responses. The OS spectacle lens was later changed to + 2.50 - 3.25 x 90 with 20/25 - 2 acuity and + 3.00 add giving 20/25 at 16”.
Discussion Although the referral indicated a diagnosis of Terrien’s marginal degeneration, it was felt that this was in fact a case of pellucid marginal degeneration. Pellucid marginal comeal degeneration is a bilateral, inferior comeal thinning that leads to marked irregular against-the-rule area between the astigmatism.3 Th ere is an uninvolved
ICLC, Vol. 17, November/December
1990
297
Case Report thinned section of the cornea and the limbus, there is no vascularization or lipid deposition, and comeal sensation remains normaL The etiology is unknown, but it is sometimes associated with keratoconus. Terrien’s marginal degeneration is a thinning of the peripheral cornea occurring most often in males. It begins superionasally with the development of fine, white peripheral subepithelial opacities that spare the limbus. As the peripheral cornea thins, the entire cornea tilts forward and large amounts of astigmatism develop. Since this patient was female, and the inferior, rather than the superior cornea was thinned, it was felt the proper diagnosis was pellucid marginal degeneration rather than Terrien’s; however, the presence of arcus-like deposits in this patient somewhat confused the issue. Differential diagnosis also includes keratoconus; however, none of the characteristic signs, such as central cornea1 thinning, Vogt’s lines, and Fleischer’s ring, were present. Regardless
Clinical
of the differential diagnosis, conventional rigid and hydrophilic lenses failed to fit properly on this unusual cornea. However, a SoftPerm lens did, correcting approximately 10D of cornea1 cylinder and providing an excellent visual and physiological response. References Edwards GL: Birth of a new lens . . . SoftPenn. Contemp Optom, 1989;8( 1):13. Dubow B, Vrchota L: SoftPenn: the “quintessential” lens design for practice-building professionals. Contact Lens Forum, 1990;15(4):17-18. Kenyon KR, Fogle ]A, Grayson M: Dysgeneses, dystrophies, and degenerations of the cornea, in Tasman W (Ed): Duune’s Clinical Ophthalmology, Philadelphia, JB Lippincott Co., 1969, ~014, chap 16, p 49. Smolin G: Dystrophies and degenerations, in Smolin G, Thoft R (Eds): The Cornea, Boston, Little Brown &I Co., 1983, p 335.
Implications
This case report illustrates the tremendous potential of the SoftPerm lens for clinicians. The patient exhibited an irregular cornea with 13.00 D of against-the-rule cornea1 cylinder. Conventional contact lens options, including spherical rigid gas permeable (RGP) lenses, back toric RGP lenses, and soft toric lenses failed to provide a satisfactory fit and/or visual acuity. The SoftPerm lens, however, resulted in good centration and excellent acuity, eliminating the need for a cumbersome and expensive piggy-back lens system. In addition to unusual cases (such as that described above), I have had positive experiences with the SoftPerm in more routine situations, including toric soft lens patients with poor or fluctuating vision, those unable to tolerate RGP lenses, and contact lens patients with significant dry-eye symptoms. The SoftPerm lens is a significant improvement over its predecessor, the Saturn II lens. The diameter is larger and a peripheral curve has been added to the central rigid portion. These design features increase the ease and consistency of the fit. The main drawbacks of the SoftPerm lens are the low Dk value (14) and the limited base curve range (for keratonconus). Although reported, I have not encountered problems with lens tightening or with lens removal. In summary, this case report documents the problem-solving capability of the SoftPerm lens. I recommend that clinicians try this lens for routine, as well as unusual, clinical situations. Adam Gordon, OD, MPH School of Optometry/The Medical Center University of Alabama at Birmingham Birmingham, Alabama 35294
298
ICE,
Vol. 17, November/December
1990
Pellucid Marginal Degeneration: S&id
ad
Wet&r
Terry Scheid, OD, FAAO, received a BS from the Ohio State University and an OD from the State University of New York School of Optometry. Dr. Scheid is a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry and an assistant clinical professor at State University of New York School of Optometry. He also maintains a private practice in Merrick, NY.
I I I
Steven P. Wetcher, OD, FAAO, received a BA from the State University of New York at Stony Brook, an MS from the Pennsylvania State University, and an OD from the State University of New York School of Optometry. Dr. Wetcher is an assistant clinical professor at S.U.N.Y. School of Optometry and also maintains a private practice in Green Village, NJ.
ICLC, Vol. 17, November/December
1990
299