Pediatric and Teen CL Care

Managing High Refractive Error and a Corneal Dystrophy

BY MARY LOU FRENCH, OD, MED, FAAO

When Benjamin first came to my office, he was a rambunctious 5-year-old young man who refused to wear his glasses. Not an uncommon behavior for many young patients, but he arrived with a prescription for +5.00 -3.00 × 020 OD and +4.50 -2.75 × 180 OS. At that age, with that prescription, most of my patients are compliant. Generally, they conclude that they can see better with their glasses.

Benjamin proved to be an assessment challenge. This was a very bright young man who was in no mood to cooperate. With a lot of patience and cajoling, I did arrive at approximately the same recommended prescription.

A Complicating Factor

This young man’s case was particularly interesting in that he also had an unknown corneal dystrophy. According to his mother, the condition has a strong inheritable pattern. Adding to the difficult refraction, it was challenging to get Benjamin near a slit lamp. However, a Burton lamp sufficed to reveal his corneal stromal issues. Now I better understood his reluctance to wear his glasses—it most likely did not improve the visual acuity as much as it would in another child who did not have a complicating eye health issue. Nonetheless, it was critical to the overall development of his visual system to convince him to wear his glasses.

Over time, his visual acuity improved to 20/40 OD and OS. This level of visual acuity was surprising to me considering the appearance of his corneas. He did become more cooperative as he grew, but still insisted that he could see fine without any glasses. However, his unaided visual acuity didn’t agree at 20/60 OU.

Switching to Contact Lenses

Fast forward to age 9. I typically recommend fitting my noncompliant glasses-wearing patients with contact lenses, provided that the parents and children understand the importance of the hygiene required and are able to manage lens application and removal. Benjamin’s mother understood the importance of her son wearing a vision correction all the time, and was willing to work with him with contact lenses.

The selection of lenses in this prescription range is limited. After a few diagnostic attempts, I prescribed a monthly lens. His familial corneal dystrophy is fortunately not degenerative, and it impacts the stroma more than the epithelial layer. Both of these factors worked in Ben’s favor to help him become a successful contact lens wearer.

However, he continues to be a rambunctious young man. The good news over the last two years is that his visual acuity improved to 20/30 OD and 20/25 OS. Consistent vision correction, even in the absence of any type of amblyopia intervention, improved his visual function. The less happy news is the additional cost of replacing his monthly lenses more often than monthly because of lens loss, tearing, etc.

A Move to Daily Disposables

At Benjamin’s most recent comprehensive eye health examination, his corneas and prescription were stable. I discussed with his mother the option of refitting him with a single-use lens for astigmatism. The drawback is that the current lens available does not fully correct his astigmatism.

Balancing the economics of replacing his current lenses more frequently than once per month against the cost of the single-use lenses and the mild reduction in correction, we decided to make the switch. He gains other eye health benefits with a lens that is replaced daily. CLS

Dr. French is a graduate of Illinois College of Optometry. After her doctorate, she completed post-doctoral programs in learning disabilities, early childhood development, and business management. She is a lecturer, author, and industry consultant specializing in children’s vision. She is also a consultant or advisor to Vistakon. You can reach her at mlfrenchod@childrenseyes.com.