Pediatric and Teen CL Care

Using Contact Lenses Together With Vision Therapy

BY MARY LOU FRENCH, OD, MED, FAAO

In addition to fitting children with contact lenses, my practice also provides vision therapy. Although not frequent, there are some cases in which the two intersect.

Treating convergence insufficiency with vision therapy has a long history in eye care and was proven to be effective with office vision therapy in major studies (Serna et al, 2011; Archives of Ophthalmology, 2008). As with any treatment plan, there are times when we must provide alternatives to complete the treatment.

A Case of Convergence Insufficiency

Dominic was 9 when he began vision therapy for convergence insufficiency. On occasion, his exophoria would decompensate to an intermittent alternating exotropia, both near and far. He was a cooperative patient, and his mother was diligent in bringing him in for treatment. He made steady progress over the course of four months of therapy, and I released him from formal office therapy with convergence skills in the range of normal. Fortunately, his schoolwork was never impacted by the muscle imbalance; unfortunately, there continued to be suppression on occasions when the exotropia manifested itself. In spite of the more-than-adequate convergence abilities, he continued to exhibit the intermittent exotropia. At one point I did refer him to my pediatric ophthalmologist for a surgical consult because of the continued exotropia. The surgeon agreed with my reservations on a surgical correction.

His mother and I discussed other options, one of which was an overcorrection for myopia. Typically I have used that with a divergence excess, but Dominic responded well to a myopic correction. As long as he wore the glasses, his convergence skills were maintained and the exotropia was controlled. But because he was only mildly myopic, it was difficult to get him to consistently wear the glasses. Explaining to a 9-year-old that he should wear his glasses to maintain binocular vision when he sees fine without them can be very frustrating.

Introducing Contact Lenses

Dominic maintained his convergence skills with the glasses. He is now 12, and although he understands the reason for wearing glasses, his motivation is poor because binocular vision is a more abstract concept than an improvement in visual acuity. I thought that fitting him with the overcorrection of myopia in contact lenses would be an even better way to help him. Wearing this correction at all times would theoretically be better than having to remind him to wear his glasses.

It was a longer process than usual. The initial diagnostic lenses did not fit properly, so I tried multiple lenses. Then I had to empirically determine the best power to minimize the exophoria without compromising his accommodative system. In the end, an ovecorrection of –1.50D yielded the optimum results.

At his one-week follow-up visit, his mother reported that she did not see any signs of the intermittent exotropia, nor did Dominic report any difficulties with headaches or any form of eye-strain. Visual acuities were 20/20 OD and OS. His convergence and accommodative skills were both in the range of normal, and at this visit I saw no exotropia.

I realize the risk of increasing his myopia, but his binocular system was more at risk at this time and a surgical correction is the last stop with far more long-term attendant risks. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #204.