Q: What cosmetic lenses are available for a patient with a large traumatic iris defect? He also has a large radial tear and full exposure temporally, and he’s very sensitive to light.
A: Initially, the decision has to be made to fit soft or gas-permeable lenses. Soft lenses are more common and more easily obtainable, says Christine Sindt, O.D., director of Contact Lens Service at the University of Iowa and co-chief clinical editor of Review.
So, when it comes to soft contact lenses, says Dr. Sindt, there are three choices:
• Tinted lenses. A wide variety of tints are available, says Dr. Sindt. “These are the least expensive and have good functionality. Generally, a brown tint works best for glare control, and you can order a lens in any power that a soft lens is available in.” And, many labs will help you order and fine-tune tinted lenses for patients, she adds.
• Stock designs. “These opaque lenses are not hand painted; rather, a design is stamped onto the lens,” says Dr. Sindt. “Stock lenses offer a variety of iris patterns. All stock lenses that are available are listed in Tyler’s Quarterly.” They are also listed in Jobson’s Annual Contact Lenses and Lens Care Guide.
When fitting prosthetic lenses, know that you face an uphill battle. “Patients tend to have this idea that the eye will look exactly like it did, so I like to show them a lens early on so they have a clear concept,” Dr. Sindt says. “I always start with a stock design so that patients will see what they can get. It requires long discussions with the patient—the more information and tools I can give them in the beginning, the better off it turns out. The doctor has to set the patient’s expectations early on—stock and especially custom lenses can be expensive.”
Prosthetic lenses can be custom painted to match a patient’s fellow eye and disguise the aftereffects of corneal trauma.
• Painted lenses. The most expensive option, a painted lens involves matching a photograph of the fellow eye with an artist’s rendering on the lens. “These lenses tend to cost from $750 to $1,000 per lens. We send the artist a lens and photograph, and a color match is sent back. When the patient approves the color match, the artist paints the final lens. This process can take up to six months,” says Dr. Sindt. And the patient must understand that once the final lens is ordered, it can’t be changed.
Fit a lens as soon as possible to retain as much vision in the eye. Also, the sooner the eye’s vision is restored, the less chance there is of sensory exotropia. “I’ll fit a lens as soon as the cornea is epithelialized,” says Dr. Sindt. “After the trauma, I’ll wait a couple weeks but get a lens on the eye as soon as possible. If there are still sutures, I’ll fit a GP over the sutures and recommend sunglasses.”
In an eye that still retains some vision, fit the soft lens just like you would any lens, and then piggyback a gas-permeable lens on top for visual capability. But, first ensure that the patient can tolerate lens wear. “Fit a plain, non-tinted lens and have the patient wear it to make sure he or she can tolerate the lens before ordering any tinted, stock or painted lens,” says Dr. Sindt. “Post-trauma eyes are very sensitive.”
The process of fine-tuning a prosthetic lens can be long and complex, so make sure that you build a relationship with your lab. “These lenses have a large emotional component due to the trauma involved; very frequently, patients are not happy with the results right away, so it’s good to work with a lab that will help with the process.”
Prosthetic Fitting Goals
When it comes to fitting goals, you need to take a cue from the patient, says Dr. Sindt. “Sometimes, for the patient, cosmesis is more important than vision. Your fitting goals depend on the patient and what’s wrong with the eye. If the patient wants functionality, for example, go with a tinted lens.”
Other factors can play a role after trauma, such as sensory exotropia. When the eye is turned in such cases, the image on the lens can be decentered, says Dr. Sindt. Simply fit the lens and then place a dot where the pupil should be. But remember, she says, use a prism-ballasted lens to prevent rotation.
“Possible complications are about the same as any with a normal contact lens,” says Dr. Sindt. “Also, rarely, the cornea under the pupil opening of a prosthetic lens can get some edema in it. Just remember that these are low-Dk lenses."
