CONTACT LENS CASE FILES: COLOR AND OCCLUSION

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For patients with disfigured eyes, cosmetic/prosthetic lenses can alleviate visual symptoms and improve self-esteem.

CASE 1: ANIRIDIA
A 63-year-old white female presented with a history of a penetrating injury to her left eye, resulting in a traumatic aniridia. This patient needed a prosthetic lens to relieve her extreme light sensitivity and improve the appearance of her left eye. Her natural iris is a hazel-blue color with several pigment spots—an appearance that can be challenging to duplicate.

Hand-painted lenses allowed us to match the patient’sinjured eye to her healthy one.

We opted for a custom, hand-painted lens for this patient for several reasons. First, she desired her contact lens to match her natural iris as closely as possible. Second, we needed good light control, and a hand-painted lens can have a very dark base color to allow light only through the open pupil.

To begin a hand-painted prosthetic lens fitting, take several photos of the patient’s natural eye color with a good quality camera in several lighting conditions, like natural light, bright and average room lighting. These images will be sent to the lab, where the photos will be analyzed and the lens will be designed. This lens was ordered from Adventures in Color, and the patient was satisfied with the overall result after a small pupil size adjustment.

Discussion: Patient education is essential to ensure realistic expectations on how their eyes will appear in most settings. During this discussion, discover what is the most important aspect of your patient’s lens wearing experience. Is it function, appearance, out-of-pocket costs, or turnaround time from the lab? This patient was highly motivated for best cosmesis, and she was willing to pay extra, and wait longer, for this custom product.

Additional tips: When creating an artificial iris for patients such as this one, the main focus often falls on lens appearance and if it’s blocking enough light. Be sure to encourage your patient to wear the lens in different lighting conditions, including dim situations, to ensure that the lens does not block too much light.

CASE 2: PUPIL OCCLUSION
A 22-year-old white male presented to our office with a chief complaint of diplopia. His medical history included a recently diagnosed brain tumor, leaving him with extraocular muscle restrictions of the left eye in several gazes. In order to alleviate his diplopia, the goal was to occlude his left eye.

A first-line approach to this case would be to utilize a lens that covers his pupil only. It would simply include selecting a pupil diameter to match most lighting situations and would not require matching the contact lens coloring to his natural iris.

Before and after: Another patient, a truck driver with an injury to his eye, complained of glare.
This lens gave him a controlled pupil.

His pupil size was measured at 4mm in average room lighting, so a prosthetic tinted contact lens with a lens with a clear iris and 4.5mm pupil was ordered to ensure the vision in his left eye was fully occluded. After a couple lens adjustments, it was found that the occluding pupil needed to be 7mm in diameter to fully occlude his left eye. Given his blue eye color, the large and dark pupil of the prosthetic lens was cosmetically unacceptable.

We transitioned the patient into a prosthetic tinted lens from Orion Vision Group’s BioColors fitting set. This set contains varying shades of brown, green and blue iris colors, as well as limbal and pupil enhancement rings. The set comes with a stand that allows you to layer the iris colors and enhancement rings to build a custom look. For corneas that are scarred and white in appearance, there are dark underprints for a base color, and the iris tints can be layered on top. For this patient, I used a dark underprint with a black pupil to make sure his vision was fully occluded, and then layers blue colors over top. This resulted in a beautiful match to his natural iris and provided the full occlusion we desired.

Discussion: Pupil size is an important consideration in a case like this. Obviously, there will be times when the pupil size of the contact lens does not match the pupil size of the natural iris. Accurately determining the pupil size is an important task, so it’s critical to ask about where the patient spends most of their time and when it’s most important for good cosmesis.

Additional tips: Because these lenses are custom made, there can be a varying range of lens diameters and base curves. In addition to pupil size, keratometry and horizontal visible iris diameter measurements are important. A desired lens fit would be one that moves enough to allow some tear exchange but snug enough that it doesn’t move significantly as the patient moves the eye or during blinks.

CASE 3: CATARACT COVER-UP
A 27-year-old white male presented with an ocular history of retinopathy of prematurity that resulted in a total retinal detachment of the left eye and no light perception. Subsequently, a cataract developed, giving his pupil a white appearance—a stark contrast to his dark eyes and hair.

Given this was a non-seeing eye with the dark iris, we were successful in the simple occlusion approach for this eye. He was fit in a pupil-occluding lens with a clear iris from Alden Optical. His natural pupil was about 3.5mm, so a clear lens with a 4mm dark pupil was ordered. Ultimately, the final pupil size ended up at 4.5mm to fully occlude the white pupil. Thankfully, this patient has a dark brown iris, so the 1mm difference between the natural and prosthetic pupil is barely noticeable when conversing with the patient outside the exam room.

Discussion: This case was one of my first prosthetic lens fits, and while it was less challenging than the previous two cases, it was extremely rewarding. Being able to offer a tool to improve self-confidence is an amazing experience.

Additional tips: The final lens parameter had a slightly larger pupil size and more snug fit than the first lens ordered to limit movement with blinks. Since his cornea was normal, we were able to obtain reliable keratometric data via topography measurements of the left eye. We did this by providing an alternative fixation target for his right eye during testing.

Brooke Messer, OD, FAAO, graduated from Southern California College of Optometry, where she also completed her cornea and contact lens residency. She works in private practice, focusing on specialty contact lenses, and lectures on cornea and contact lens topics.

WHERE TO FIND IT
Adventure in Colors
800.537.2485 | TechColors.com

Alden Optical, Inc.
800.253.3669 | AldenOptical.com

Orion Vision Group
866.289.773 | OrionVisionGroup.com

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