Piggyback Success in a
Contact Lens-Intolerant Patient

BY TED M. SMILEY, O.D.
MAY 1996

A 35-year-old female, Pamela, complained of blurred vision and significant discomfort while wearing her rigid gas permeable lenses. She had worn PMMA lenses for 14 years and RGP lenses for five. She had also tried soft lenses, but the vision was unacceptable. Her medical history was positive for juvenile rheumatoid arthritis and Sjögren's Syndrome. Her ocular history was positive for bilateral spontaneous retinal detachment and scleral buckle repair six years ago in the left eye and one year ago in the right eye. She was taking Plaquinil and Feldene and, occasionally, Prednisone.

DIAGNOSIS & MANAGEMENT

Examination revealed the following refraction:

O.D. -13.50 -2.00 X 025, 20/25

O.S. -16.00 -2.25 X 030, 20/60-2

Pamela complained of monocular diplopia in the left eye. Biomicroscopic examination revealed significant neovascularization and scarring at the 4 and 8 o'clock positions of both corneas. There was a 1+ post-erior subcapsular cataract in the right eye and a 3+ posterior subcapsular cataract in the left eye. Pamela's retinas appeared normal. The bulbar conjunctiva stained with fluorescein and rose bengal as did the cornea. Pamela's tear breakup time was two seconds and we observed no tear prism. The Schirmer Test resulted in 2.5mm wetting.

TRIAL & ERROR

We referred Pamela for cataract extraction and posterior chamber lens implant in the left eye, which resulted in 20/15 acuity with a -0.50 -3.25 x 171. However, the resultant 13.00 diopter anisometropia required a correction, ideally with a contact lens. Since a previous attempt to wear RGP lenses was unsuccessful, we prescribed a Sunsoft custom soft toric lens for Pamela's right eye. Although the comfort was satisfactory, the visual acuity was unacceptable and the lens had to be replaced frequently due to the significant mucous production caused by Sjögren's Syndrome. The cost became prohibitive.

A RESOURCEFUL APPROACH TO TREATMENT

Since a Softperm lens was not available in her prescription, we prescribed a piggyback lens arrangement in hopes that it would provide sharp vision and acceptable comfort.

We placed an 8.8 base curve, -2.00 Acuvue lens in Pamela's eye and allowed it to settle for 10 minutes until a stable keratometric reading was possible, resulting in 42.50/46.50 x 10. We placed an 8.0 base curve, 9.0 diameter, -5.00 Polycon II lens over the soft lens and overrefracted to -3.25 sphere. The resultant piggyback combination was an 8.8, -2.00 Acuvue with a -8.25, 8.0, 9.0 Polycon II.

SPECIAL NEEDS
FOR SPECIAL PATIENTS

Pamela's Sjögren's Syndrome requires the use of a daily disposable soft lens. She cleans the Polycon lens nightly with Miraflow Daily Cleaner and soaks it in Allergan's Profree Enzyme for 30 minutes before placing it in Boston Conditioner overnight to maintain wearability. She removes and rinses her piggyback lens combination with saline twice daily. We chose a low Dk material to provide the stability and durability required by frequent handling and cleaning during the day. We also provided overwear spectacles to correct Pamela's residual pseudophakic and presbyopic needs in her left eye.

Pamela has been successful in this piggyback arrangement for nearly three years. This unique combination of contact lenses and spectacles has continued to satisfy Pamela's visual needs and, we hope, will continue to do so until the PSC in her right eye requires surgery. A clear lensectomy could be justified if her present correction becomes intolerable. CLS

Dr. Smiley is in group practice in Columbus, Ohio. He specializes in contact lenses and family vision. He has been published in various ophthalmic journals.