A 50-YEAR-OLD FEMALE came to our office for her first visit. She wore glasses, but reported that she hated wearing them. She was wearing progressive addition lenses and disliked the way the glasses felt on her face and that she had to move her head to access the part of the lenses that provided clear vision.

Her habitual prescription was +1.50 –0.50 x 070 20/20^- OD and +1.25 –1.00 x 110 20/20^- OS with +1.50 add, resulting in 20/20 at near. Her new refraction was +1.25 –0.75 x 090 20/20^- OD, +1.50 –0.50 x 130 20/20^- OS with add of +1.50D in each eye for 20/20 at near.

She also reported that she “gets glasses every few years but my vision never really seems correct.” She had an unremarkable medical history, reported no other ocular history, and her internal ocular examination was normal.

BUT WAIT, THERE’S MORE

Upon examination of the ocular surface, we noted moderate negative staining. Fluorescein assessment with a cobalt blue light and a Wratten #12 filter was performed, and it was clear that the patient demonstrated signs consistent with early epithelial basement membrane dystrophy (EBMD).

Corneal photo documentation and an anterior segment optical coherence tomography (AS-OCT) scan were performed (Figure 1). In this patient, the regions of elevated corneal epithelium were consistent with thinned regions of epithelial thickness on AS-OCT. The condition was discussed, and three options were provided: 1) continue correction with glasses with the variable vision that she currently experienced, 2) refer for phototherapeutic keratectomy, or 3) fit with a contact lens in an attempt to renormalize the refractive surface.

We decided to initially pursue soft silicone hydrogel lenses with a higher modulus, hoping it would mask irregularities better than a lower modulus material. To address her presbyopia, a low add daily disposable design was selected, largely ignoring the astigmatism in the hope that the irregular astigmatism would be corrected with the lens.

The patient was fit with a daily disposable multifocal lens that had the following parameters: +1.25D OD and +1.50D OS; both had an 8.6mm base curve, a 14.2mm diameter, and a low add.

Although not a common practice with multifocal soft lenses, an over-refraction was performed monocularly behind the phoropter to see whether there was any undercorrected refractive error, and there was not. Interestingly, even though the patient was looking through a simultaneous design multifocal contact lens, she reported that her vision seemed better through the contact lenses as compared with glasses.

THE VERDICT

After training and dispensing, the patient returned a week later pleasantly surprised at how comfortable the lenses felt. She admitted at this visit that she was surprised contact lenses were even discussed as an option, as she had always been told that the type of contact lenses needed would make it so that she wouldn’t see quite as well as she did with her glasses.

If not offering EBMD contact lenses to patients is the new norm, then we don’t want to be normal. CLS