Do More-ia for Your Phoria: Prismatic Correction in Multifocal Scleral Lenses for a Patient with Duane Retraction Syndrome Kent Uehara, Kevin Willeford OD MS PhD FAAO, Sharon Park Keh OD FAAO Duane Retraction Syndrome (DRS) is a congenital anomaly of the abducens nucleus with aberrant innervation of the lateral rectus by the oculomotor nerve. DRS is characterized by difficulty with abduction, adduction, or both, in the affected eye 1 . In addition, because of the faulty innervation by the oculomotor nerve, patients may manifest other vertical or horizontal deviations Although refractive error in these patients is managed primarily with spectacles, vertical prism can now be incorporated into scleral lenses predictably by aligning toric peripheral curves with the astigmatic sclera. Scleral lenses are large-diameter, rigid contact lenses that vault over the cornea, allowing for comfortable, clear vision for both healthy and diseased eyes. The minimal movement and high stability that comes with a properly fitted scleral lens allows for more nuanced customizations, such as the addition of a multifocal design or prism correction. BACKGROUND CASE A 31-year-old while male with Type 1 DRS OD presented for a scleral contact lens fitting following poor success with custom soft contact lenses with prism due to discomfort and lens awareness. His current spectacles have 4 prism diopters (PD) base down (BD) ground-in to alleviate a 6 PD right hyperphoria. His binocular status is significant for convergence excess as his accommodative convergence-to- accommodation ratio is abnormally high, 9:1. Currently, the patient prefers multifocal lenses to alleviate asthenopia during prolonged nearwork. The patient’s motivation for pursuing scleral lenses was to achieve comfortable prism correction without spectacles. EXAMINATION FINDINGS AND RESULTS Initial Examination At initial presentation, his entering acuity and best-corrected visual acuity were 20/15 OD, OS. Distance vertical and horizontal phorias were measured as 2 right hyperphoria and 4 esophoria, respectively. See Figure 1 for the patient’s extraocular motility findings. He had normal, healthy anterior segments OU in slit lamp examination. Prism Distance VPhoria RSupra Range RInfra Range Pre-prism correction 6 RH 4/1 1/0 2 BD OD 4 RH 2/2 4/1 4 BD OD 4 RH 4/1 3/1 Scleral Lens Fitting A step-wise diagnostic fitting was performed using the Valley Contax Custom Stable Elite lenses. With the assistance of the consultation department, four pairs of lenses were designed: 1. Single vision lenses without prism to achieve optimal fit and vision 2. Single vision lenses with vertical prism to achieve optimal fit, vision and binocular comfort 3. Single vision lenses with increased vertical prism to achieve optimal fit, vision and increased binocular comfort 4. Center-distance multifocal lenses with vertical prism to achieve optimal fit, vision, binocular comfort, and to address convergence excess Figure 1: The patient’s eyes are aligned in primary gaze (a). Abduction of the affected right eye is limited and is accompanied by slight elevation and widening of the palpebral fissure (b, c). Adduction is accompanied by narrowing of the palpebral fissure (d). 1(a) 1(b) 1(c) 1(d) Table 1: Vertical phoria and ranges measured through scleral lenses with increasing amounts of prism. Incorporation and Assessment of Prism in Scleral Lenses The patient’s distance vertical phorias and ranges were as follows: OD OS Base Curve 7.85 7.85 Sagittal Depth 4568 microns 4670 microns Diameter 15.80 15.80 Power -1.25 -2.25 Add +0.75 +0.75 Prism 4.0 BD No prism Material Optimum Extra Optimum Extra Limbal clearance 0.50 0.00 Peripheral curves -3.00 (Steep) / +1.00 (Flat) -5.00 (Steep) / +4.00 (Flat) In our case, increasing the vertical prism in the scleral lenses did not lead to a proportional change in the patient’s phoria. After eliminating confounding factors such as decentration of the lens (and inability of the patient to access the prism), we believe that this is largely attributable the patient’s long-time wear of spectacle lenses with prism correction. Similar to horizontal phorias, it has been found that prolonged exposure to vertical binocular disparity can lead to prism adaptation 2 . Addition lenses are used to treat convergence excess caused by a high AC/A ratio 3 . With the combination of the vertical prism and multifocal design, the patient was ecstatic about the quality and comfort of his vision and felt it was superior to spectacle correction with prism. REFERENCES 1. D. Yüksel, J.J. Orban de Xivry, P. Lefèvre. Review of the major findings about Duane retraction syndrome (DRS) leading to an updated form of classification. Vision Res, 50 (23) (2010), pp. 2334-2347 2. R. Kono, S. Hasebe, H. Ohtsuki, T. Furuse, T. Tanaka. Characteristics and variability of vertical phoria adaptation in normal adults. Japanese Journal of Ophthalmology, 42 (5) (1998), pp. 363-367 3. Scheiman M, Wick B. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. Philadelphia: JB Lippincott, 2015:273-77. ACKNOWLEDGEMENTS This study was made possible by Valley Contax, who generously provided the lenses for the patient in this case study. Table 2: Final lens parameters. Figure 2: A side-by-side comparison of the patient's right (a, b) and left (c, d) scleral lenses. The portion of the lens corresponding to the inferior cornea is noticeably thicker than the lens without prism. 2(a) 2(c) 2(b) 2(d) This case demonstrates the viability of scleral lenses as an alternative to other forms of prism correction in patients with binocular disorders. Especially in cases where patients have concurrent corneal disease, scleral lenses with prism can help patients achieve optimum vision while simultaneously addressing their binocularity issues. Because a successful scleral lens fit intrinsically strives for rotational stability, the additional legwork of adding other parameters such as prism and a multifocal design into a scleral is minimal. CONCLUSION
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Do More-ia for Your Phoria: Prismatic Correction in Multifocal Scleral Lenses for a Patient with Duane Retraction Syndrome
Kent Uehara, Kevin Willeford OD MS PhD FAAO, Sharon Park Keh OD FAAO
Duane Retraction Syndrome (DRS) is a congenital anomaly of theabducens nucleus with aberrant innervation of the lateral rectus by theoculomotor nerve. DRS is characterized by difficulty with abduction,adduction, or both, in the affected eye1. In addition, because of thefaulty innervation by the oculomotor nerve, patients may manifestother vertical or horizontal deviations Although refractive error inthese patients is managed primarily with spectacles, vertical prism cannow be incorporated into scleral lenses predictably by aligning toricperipheral curves with the astigmatic sclera.
Scleral lenses are large-diameter, rigid contact lenses that vault overthe cornea, allowing for comfortable, clear vision for both healthy anddiseased eyes. The minimal movement and high stability that comeswith a properly fitted scleral lens allows for more nuancedcustomizations, such as the addition of a multifocal design or prismcorrection.
BACKGROUND
CASEA 31-year-old while male with Type 1 DRS OD presented for a scleralcontact lens fitting following poor success with custom soft contactlenses with prism due to discomfort and lens awareness. His currentspectacles have 4 prism diopters (PD) base down (BD) ground-in toalleviate a 6 PD right hyperphoria. His binocular status is significantfor convergence excess as his accommodative convergence-to-accommodation ratio is abnormally high, 9:1. Currently, the patientprefers multifocal lenses to alleviate asthenopia during prolongednearwork. The patient’s motivation for pursuing scleral lenses was toachieve comfortable prism correction without spectacles.
EXAMINATION FINDINGS AND RESULTSInitial ExaminationAt initial presentation, his entering acuity and best-corrected visualacuity were 20/15 OD, OS. Distance vertical and horizontal phoriaswere measured as 2 right hyperphoria and 4 esophoria, respectively.See Figure 1 for the patient’s extraocular motility findings. He hadnormal, healthy anterior segments OU in slit lamp examination.
Prism Distance VPhoria RSupra Range RInfra Range
Pre-prism correction 6 RH 4/1 1/0
2 BD OD 4 RH 2/2 4/1
4 BD OD 4 RH 4/1 3/1
Scleral Lens FittingA step-wise diagnostic fitting was performed using the Valley ContaxCustom Stable Elite lenses. With the assistance of the consultationdepartment, four pairs of lenses were designed:
1. Single vision lenses without prism to achieve optimal fit and vision2. Single vision lenses with vertical prism to achieve optimal fit, visionand binocular comfort3. Single vision lenses with increased vertical prism to achieve optimalfit, vision and increased binocular comfort4. Center-distance multifocal lenses with vertical prism to achieveoptimal fit, vision, binocular comfort, and to address convergenceexcess
Figure 1: The patient’s eyes are aligned in primary gaze (a). Abduction of theaffected right eye is limited and is accompanied by slight elevation and wideningof the palpebral fissure (b, c). Adduction is accompanied by narrowing of thepalpebral fissure (d).
1(a) 1(b)
1(c) 1(d)
Table 1: Vertical phoria and ranges measured through scleral lenses with increasing amounts of prism.
Incorporation and Assessment of Prism in Scleral LensesThe patient’s distance vertical phorias and ranges were as follows:
OD OS
Base Curve 7.85 7.85
Sagittal Depth 4568 microns 4670 microns
Diameter 15.80 15.80
Power -1.25 -2.25
Add +0.75 +0.75
Prism 4.0 BD No prism
Material Optimum Extra Optimum Extra
Limbal clearance 0.50 0.00
Peripheral curves -3.00 (Steep) / +1.00 (Flat) -5.00 (Steep) / +4.00 (Flat)
In our case, increasing the vertical prism in the scleral lenses did notlead to a proportional change in the patient’s phoria. After eliminatingconfounding factors such as decentration of the lens (and inability ofthe patient to access the prism), we believe that this is largelyattributable the patient’s long-time wear of spectacle lenses with prismcorrection. Similar to horizontal phorias, it has been found thatprolonged exposure to vertical binocular disparity can lead to prismadaptation2.
Addition lenses are used to treat convergence excess caused by a highAC/A ratio3. With the combination of the vertical prism and multifocaldesign, the patient was ecstatic about the quality and comfort of hisvision and felt it was superior to spectacle correction with prism.
REFERENCES1. D. Yüksel, J.J. Orban de Xivry, P. Lefèvre. Review of the major findings about Duaneretraction syndrome (DRS) leading to an updated form of classification. Vision Res, 50 (23)(2010), pp. 2334-23472. R. Kono, S. Hasebe, H. Ohtsuki, T. Furuse, T. Tanaka. Characteristics and variability ofvertical phoria adaptation in normal adults. Japanese Journal of Ophthalmology, 42 (5)(1998), pp. 363-3673. Scheiman M, Wick B. Clinical management of binocular vision: heterophoric,accommodative, and eye movement disorders. Philadelphia: JB Lippincott, 2015:273-77.
ACKNOWLEDGEMENTSThis study was made possible by Valley Contax, who generously provided the lenses for the patient in this case study.
Table 2: Final lens parameters.
Figure 2: A side-by-side comparison of the patient's right (a, b) and left (c, d) sclerallenses. The portion of the lens corresponding to the inferior cornea is noticeablythicker than the lens without prism.
2(a)
2(c)
2(b)
2(d)This case demonstrates the viability of scleral lenses as an alternativeto other forms of prism correction in patients with binocular disorders.Especially in cases where patients have concurrent corneal disease,scleral lenses with prism can help patients achieve optimum visionwhile simultaneously addressing their binocularity issues. Because asuccessful scleral lens fit intrinsically strives for rotational stability, theadditional legwork of adding other parameters such as prism and amultifocal design into a scleral is minimal.
CONCLUSION
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