Case Discussion - the CL kid

[Ryan_eyeball]

I thought I would throw this case out there since I've actually seen it twice. Its a pretty easy one to figure out.

A fourteen year old presented to your clinic with a chief complaint of his left eye a little blurry compared to his right one. Whenever he would wear his glasses before this, he said that it would always be fine (his vision). He reports that he has been wearing the same CL's for the past five days without taking them out. He denys itch, redness, trauma, previous surgeries, double vision, pain, or discomfort in either eye.

He's wearing AV2's with a -2.75 OD 20/20, and -2.50 OS 20/60
His previous spectacle Rx was -2.50 -0.75 x 170 OD and -2.50 sph OS.
All entrance tests were WNL Pupils, EOM's, CF, and CT's.

So i performed an OR (over-refraction over his current CL's) OD eye and found -0.25 SPH 20/20 and his left eye was +2.75sph OS 20/20

Slex: NAP (no apparent pathology)
Fundus/posterior pole: All WNL

Any ideas?

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[Ben Chudner]

I thought I would throw this case out there since I've actually seen it twice. Its a pretty easy one to figure out.

A fourteen year old presented to your clinic with a chief complaint of his left eye a little blurry compared to his right one. Whenever he would wear his glasses before this, he said that it would always be fine (his vision). He reports that he has been wearing the same CL's for the past five days without taking them out. He denys itch, redness, trauma, previous surgeries, double vision, pain, or discomfort in either eye.

He's wearing AV2's with a -2.75 OD 20/20, and -2.50 OS 20/60
His previous spectacle Rx was -2.50 -0.75 x 170 OD and -2.50 sph OS.
All entrance tests were WNL Pupils, EOM's, CF, and CT's.

So i performed an OR (over-refraction over his current CL's) OD eye and found -0.25 SPH 20/20 and his left eye was +2.75sph OS 20/20

Slex: NAP (no apparent pathology)
Fundus/posterior pole: All WNL

Any ideas?

Ryan, Great case. I have also seen this with AV2. My patient was reading in bed in the morning (EW patient) and rubbed his right eye. He felt like something was in it still so he removed the right lens and put in a new one. As he was checking his vision to make sure the lens was in, he noticed he couldn't see anything. He didn't think he had a problem before he replaced the lens, but he really didn't check mono so he wasn't sure. He came into the office with his lenses still on and his entering VA was HM OD and 20/20 OS. I had him remove the right lens and began to refract. I started with his Rx in the phoropter which was -9.00D. He couldn't read anything. I gave him another -3.00D and it was no help. I then went the other way with a +3.00 and it made things better. Another +3.00 was better still. Finally, one more +3.00D and he was back to 20/20, even though the phoropter read PL for this 9.00D myope. He was pretty embarassed when I explained to him what happened, but I reassured him that one day he would laugh about it.

 

[rpames]

So could we call this "soft lens piggy-backing?"

You think they would notice that the lens felt a little thick.

 

[cpw]

this case (or one similar to it) was my last Friday at 4pm emergency phone-in "sudden decrease in vision OS"... after we figured out what happened she was REALLY embarassed. This happens more than you think

 

[Ryan_eyeball]

this case (or one similar to it) was my last Friday at 4pm emergency phone-in "sudden decrease in vision OS"... after we figured out what happened she was REALLY embarassed. This happens more than you think

Well I haven't presented anything yet you haven't figured out. I'm not too sure how many people on these forums benefit from these posts, but I think its a fun time posting. I couldn't believe it even happended to Ben's patient that was a -9.0 D myope. You'd believe that he would have known when the first contact lens was already inserted. I agree the two times I've seen this the patients have been really embarassed, and this kid was blushing really red in front of his girlfriend.

 

[star777]

Sounds pretty interesting. But would you guys mind explaining in "simple English" what the problem was in this case so that those of us who aren't in optometry school yet can understand....Thanks!

 

[Ryan_eyeball]

Whenever you finish your CL fit a patient should see 20/20 in both eyes (at least that's what we always shoot for).

Our fourteen year old was -2.75 OD, and -2.50 OS with contact lenses.

Without these contacts on his eyes you'd probably expect Visual acuities of 20/400 (rough estimate). The left eye was reduced to 20/60, but before in your initial fitting of this patient they saw 20/20 a week ago (or whenever). Almost all myopic younger patient you don't really expect their prescription to shift hyperopic (toward plus). So what has happened to our patient?

With a -2.50 Contact lens they are emmetropic (a normal eye that needs no prescription to see 20/20), because you've corrected their refractive error.

An over-refraction (O.R.) is just asking them to see if there are any lenses that further enhance their vision, while wearing their CL's. I always start with plus lenses in an OR because of avoiding over-minusing patients.

Ok...lets go through the right eye. He's wearing -2.50sph and he wants an additional -0.25 power to still see 20/20. So he could wear a -2.50 or -2.75 (the -2.50 and the -0.25 O.R = -2.75) and be ok, i'd still just stick with a -2.50 CL.

Ok...now the left eye. He claims he's wearing a -2.50 sph CL but sees 20/60. You do an OR over the left eye and find he wants +2.75sph to see 20/20 with. Or in other words his total power of his left CL would be +0.25 sph. That doesn't make any sense does it, since you know last week he was at -2.50 and seeing 20/20. So what gives....the answer if you've seen some of the hints...is that he's wearing two soft contact lenses over each other on the left eye. So the total power is like a -5.00 sph, but someone age 14 can accommodate a lot and clear some of that minus, so that's probably why he could still get to 20/60 visual acuity.

Two contacts should have felt a little thicker I agree.

i hope you could understand that. Your patients will laugh with ya when you tell them.

 

[Ben Chudner]

I couldn't believe it even happended to Ben's patient that was a -9.0 D myope. You'd believe that he would have known when the first contact lens was already inserted.

Actually, my patient took out a lens, threw it away, opened a new blister pack that happened to have two lenses in it, and inserted them both at the same time. Amazingly, I have had two other blister packs come with two lenses in them. I guess when a machine mass produces and packages CL's, it's bound to happen.

 

[star777]

Whenever you finish your CL fit a patient should see 20/20 in both eyes (at least that's what we always shoot for).

Our fourteen year old was -2.75 OD, and -2.50 OS with contact lenses.

Without these contacts on his eyes you'd probably expect Visual acuities of 20/400 (rough estimate). The left eye was reduced to 20/60, but before in your initial fitting of this patient they saw 20/20 a week ago (or whenever). Almost all myopic younger patient you don't really expect their prescription to shift hyperopic (toward plus). So what has happened to our patient?

With a -2.50 Contact lens they are emmetropic (a normal eye that needs no prescription to see 20/20), because you've corrected their refractive error.

An over-refraction (O.R.) is just asking them to see if there are any lenses that further enhance their vision, while wearing their CL's. I always start with plus lenses in an OR because of avoiding over-minusing patients.

Ok...lets go through the right eye. He's wearing -2.50sph and he wants an additional -0.25 power to still see 20/20. So he could wear a -2.50 or -2.75 (the -2.50 and the -0.25 O.R = -2.75) and be ok, i'd still just stick with a -2.50 CL.

Ok...now the left eye. He claims he's wearing a -2.50 sph CL but sees 20/60. You do an OR over the left eye and find he wants +2.75sph to see 20/20 with. Or in other words his total power of his left CL would be +0.25 sph. That doesn't make any sense does it, since you know last week he was at -2.50 and seeing 20/20. So what gives....the answer if you've seen some of the hints...is that he's wearing two soft contact lenses over each other on the left eye. So the total power is like a -5.00 sph, but someone age 14 can accommodate a lot and clear some of that minus, so that's probably why he could still get to 20/60 visual acuity.

Two contacts should have felt a little thicker I agree.

i hope you could understand that. Your patients will laugh with ya when you tell them.

Thank you for the explanation!! Now I understand the optometry lingo...

 

[Ryan_eyeball]

Thank you for the explanation!! Now I understand the optometry lingo...

Your welcome...hope this helped