CASE 2-7
Cloudy Vision
Figure 2-7
History
A 45-year-old Caucasian female presents with complaints of cloudy vision with her rigid gas-permeable (RGP) contact lenses (CL). Her current lenses are 2 years old. She has noticed a gradual clouding of her vision but has no other complaints. The lenses are comfortable, and she denies redness, irritation, or pain. She uses the Boston Simplicity care system and wears her lenses 16 hours per day. Her ocular and medical histories are unremarkable. She takes no medications and has no allergies.
Symptoms
Cloudy vision with RGP lenses
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80 Clinical Cases in Contact Lenses
Clinical Data
• Entering visual acuity with CL:
OD 20/30
OS 20/40
• Over-refraction:
OD Plano –0.50 × 170, 20/30 OS Plano sphere, 20/40
• CL Specifications:
OD 7.70 / –4.50 / 9.6 / Boston 7 Envision OS 7.70 / –5.75 / 9.6 / Boston 7 Envision
• Keratometry:
OD 44.25 / 45.25 @ 080
OS 44.50 / 45.00 @ 100
• Subjective refraction:
OD –5.00 –0.75 × 165, 20/20
OS –6.50 –0.50 × 010, 20/20
•Gross external exam: Eyes appear white and quiet OU
•Biomicroscopy: Moderate meibomian gland dysfunction, thick eyeliner along lid margins, all other structures appear clear and healthy OU
•Fit assessment: OU Superior central, blink movement 2 mm, apical touch, mid-peripheral clearance, moderate peripheral clearance, greasy surface deposits (see Figure 2-7)
Develop your list of differential diagnoses. Then, based on the clinical data, determine your final diagnosis. Based on your diagnosis, develop your treatment plan.
Differential Diagnoses
•Protein deposit
•Surface contamination
•Meibomian gland dysfunction
•Corneal edema
•Posterior segment complication
Diagnosis
Surface contamination with makeup and hair spray
Cloudy Vision 81
Management
New lenses in a lower Dk fluorosilicone acrylate material (Boston ES) were ordered. The patient’s care system was changed to the Boston Advance Comfort Formula with weekly liquid enzyme. Nightly lid hygiene with warm compresses, lid massage, and lid scrubs was prescribed. She was advised to modify her makeup application habits so as not to apply anything behind the lash line and to close her eyes when applying hair spray. She now enjoys clear vision with her lenses.
Discussion
Fluorosilicone acrylate materials have been of great benefit to rigid contact lens wearers. They have greater oxygen permeability and protein resistance than silicone acrylate materials. However, the fluorine makes these materials more lipophilic, which often causes oily, greasy deposits to build up on the lens surface.1 This is exacerbated by patients who use lotions and makeup around the eyes. It is further aggravated by abnormal tears, specifically, abnormal meibomian gland secretions and dry eye. The result is a lens surface layered with a greasy film that is hydrophobic. The lens does not wet properly, resulting in cloudy, blurry vision.2
An in-depth case history is the first step in determining the source of the contamination. The patient should be questioned about her makeup application habits, the type of makeup and lotions or hair sprays used, and any other solutions or chemicals applied to or near the eyelids. In addition, a description of the patient’s daily routine of facial hygiene and contact lens application and removal should be obtained. Is the patient wearing her lenses when makeup is applied, or does she apply the lenses after her makeup? Is she wearing her lenses while using hair spray? Does she use hand lotion prior to lens handling? If so, these behaviors should be changed. Finally, does the patient clean her eyelids at night? If her makeup is not removed, it is more likely to contaminate her lenses the next day.2,3
Management is based on the clinical findings. A careful assessment of the lid margins and tear film structure and function should be made. Makeup applied inside the lash line can spill into the tear prism and contaminate the lens. Clogged or inflamed meibomian glands signify poor or abnormal production of the tear film’s lipid layer. Express the glands to examine the quality of the meibum. If it is anything other than clear, warm compresses, lid massage, and lid scrubs should be prescribed. Examine tear breakup time, use Schirmer’s
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or phenol red-thread test, and look for corneal and conjunctival staining with fluorescein and lissamine green dyes to determine if the patient has dry eyes. Dry eye is more likely to cause deposits to form on the lens surface. Finally, assess the patient’s blink habits. If the blinks are infrequent or incomplete, the lens surface may be drying out and increasing the likelihood of deposit formation.
The next component in effective management is the care system. A multipurpose system like Simplicity is not as effective as a two-step system in removing surface deposits like protein and lipids. Changing to a care system with a separate daily cleaner allows the patient to better clean his or her lenses. Addition of a liquid enzyme also may help, by keeping lipophilic protein from coating the lens.
Finally, lens material selection should be considered. A highDk fluorosilicone acrylate material, like Boston 7, may not be the best choice for a person with lipid deposition problems. Consider a lipophilic material or even a silicone acrylate to minimize lipid deposition.
Clinical Pearls
•Makeup, lotions, and hair spray may create a greasy film that causes cloudy vision.
•Multipurpose solutions may not be effective enough to prevent buildup of makeup.
•Effective management of lipid buildup may include extensive patient education, care system modification, and lens material selection.
References
1.Bontempo AR, Rapp J. Lipid deposits on hydrophilic and rigid gas-permeable contact lenses. CLAO J. 1994;20(4):242–245.
2.Tlachac CA. Cosmetics and contact lenses. Optom Clin. 1994;4(1):35–45.
3.Baldwin JS. Cosmetics: Too long concealed as culprit in eye problems. Contact Lens Forum. 1986;11(6):38–41.