Treatment of Horizontal Binocular Diplopia With Prismatic Contact Lenses

Clinical Correspondence Section Editors: Robert Avery, DO Karl C. Golnik, MD Treatment of Horizontal Binocular Diplopia With Prismatic Contact Lenses Samuel K. Lee, Cheryl Zabrowski, OD, Collin M. McClelland, MD, Michael S. Lee, MD Downloaded from http://journals.lww.com/jneuro-ophthalmology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/04/2022 B inocular diplopia often requires treatment including monocular occlusion, strabismus surgery, and prismatic spectacles. We report a patient with horizontal diplopia who used ground-in-prisms (GIPs) in scleral contact lenses. A 39-year-old woman noted constant, stable, horizontal, binocular diplopia for 6 months in the distance only in all gazes. She denied ptosis, diurnal variation, proptosis, pain, history of patching, or amblyopia. Brain MRI was unremarkable. Medical history included anxiety treated with citalopram. Ocular history included LASIK surgery. Examination demonstrated visual acuities of 20/20 in the right eye (RE) and in the left eye (LE). She demonstrated full extraocular motility and a comitant 8 prism diopter (PD) esotropia at distance and near. The rest of her examination was unremarkable. She received a diagnosis of decompensated esotropia and was given plano glasses with an 8 PD BO Fresnel prism to wear over her contact lenses. She returned 2 months later with stable findings. The patient did not want to wear prism glasses or strabismus surgery. Impressions of the eyes were sent for custom three-dimensional (3D) printed scleral lenses from Eyeprint Pro (Lakewood, CO). There was 4 PD BO GIP in each lens, for a total of 8 PD BO overall. Two months later, she denied double vision with the scleral lenses. Her acuities were 20/20, and cover testing revealed orthophoria in all directions. The patient enjoyed good comfort, but the lens thickness and weight caused lens movement with blink and clouding of the postlens tear film (Fig. 1). She underwent several adjustments to minimize lens thickness to limit clouding from tear film debris. Refresh Celluvisc (Allergan, Dublin, Ireland) was recommended to fill the bowl of the lens as a more viscous option to reduce the amount of postlens tear exchange. FIG. 1. Anterior segment optical coherence tomography of scleral lenses without (A) and with prisms (B). The anterior (dotted arrow) and posterior (dashed arrow) surfaces of the lens and tear film (solid arrow) are shown. Note the relative difference in tear film clarity between (A, B). Department of Ophthalmology and Visual Neuroscience, University of Minnesota, Minneapolis, Minnesota. The authors report no conflicts of interest. Address correspondence to Michael S. Lee, MD, Department of Ophthalmology and Visual Neuroscience, University of Minnesota, 420 Delaware St SE, MMC 493, Minneapolis, MN 55455; E-mail: [e-mail]. Lee et al: J Neuro-Ophthalmol 2021; 41: e81-e82 Traditionally, prisms within contact lenses have been limited to base-down (BD) treatment of vertical diplopia because of the difficulty in maintaining correct prism orientation (1). The EyePrintPro lens uses custom 3D printing from eye impressions to ensure custom fit and rotational stability, allowing for incorporation of horizontal prisms. However, lens thickness limits the amount of e81 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence TABLE 1. Patients with binocular diplopia treated with scleral contact lenses integrated with prisms Authors (Year) Age Gender Ocular Misalignment Frogozo (3) (2016) 73 Male Esotropia Parker (2015) (5) 55 Male Right hyperphoria Our case (2020) 39 Female Comitant esotropia Bragg and Sindt (4) (2015) 48 Female Comitant right hypertropia Prisms Used 4.00 BO OD, 2.00 BO OS 2.25 BD OD, 1.50 BU OS 4.00 BO OD, 4.00 BO OS 3.50 BU OS Diagnosis Traumatic Decompensated deviation Decompensated deviation None listed BO, base out. BD, base down. BU, base up. OD, right eye. OS, left eye. functional prism for these lenses to about 4–5 PD per eye. Scleral lenses must maintain a minimal thickness to avoid lens warpage/flexure, but thicker lenses can cause complications including corneal hypoxia, neovascularization, poor lens fit, and comfort. Poor fit can exacerbate tear stagnation and lens fogging. The patient requires careful monitoring during and after fitting to ensure no ocular surface complications (2). However, no significant complications have been reported in other cases of Eyeprint Pro lenses for treatment of other ocular conditions (3,4). Because contact lenses move with fixation, one theoretical advantage of GIP is that the corresponding prism “strength” should remain constant through all gaze positions. By contrast, eccentric viewing through spectacles with GIP would result in variable prism “strength” as the eye deviates from the optical center. We found 3 published meeting abstracts of patients treated with GIP in scleral contact lenses and only one used horizontal prism (Table 1). In one case, a 73-year-old man was given 4 PD BO prism RE and 2 PD BO prism LE to manage constant horizontal diplopia (3). Parker described a 55-year old man with intermittent vertical diplopia, and he was given 2.25 PD BD prism RE and 1.50 PD base up (BU) prism LE (5). Another abstract described a 48-year-old woman with constant vertical diplopia secondary to right hypertropia. She received 3.5 PD BU prism LE only (4). In all 3 abstracts, patients reported excellent comfort and restored binocular single vision because of the scleral contact lenses. The case herein demonstrates that prisms incorporated into scleral contact lenses may represent a novel, viable e82 treatment of binocular horizontal diplopia. To the best of our knowledge, this has not been previously reported in the peer-reviewed literature. Further study of scleral lenses may improve treatment options for binocular diplopia as an alternative to spectacles or strabismus surgery. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: M. Lee and S. K. Lee; b. Acquisition of data: C. Zabrowski. c. Analysis and interpretation of data: C. M. McClelland. Category 2: a. Drafting the manuscript: S. K. Lee; b. Revising it for intellectual content: C. M. McClelland, C. Zabrowski, and M. Lee. Category 3: a. Final approval of the completed manuscript: S. K. Lee, C. M. McClelland, C. Zabrowski, and M. Lee. REFERENCES 1. Vincent SJ, Fadel D. Optical considerations for scleral contact lenses: a review. Cont Lens Anterior Eye. 2019;42:598–613. 2. Nguyen MTB, Thakrar V, Chan CC. EyePrintPRO therapeutic scleral contact lens: indications and outcomes. Can J Ophthalmol. 2018;53:66–70. 3. Frogozo M. Treatment of horizontal diplopia with prism correction in scleral gas permeable prosthetic device. Poster presented at: 2016 Global Specialty Lens Symposium; January 21–24, 2016; Las Vegas, NV. 4. Bragg TL, Sindt CW. Correction of binocular diplopia with novel contact lens technology. J AAPOS. 2015;19:38. 5. Parker K. Case report: EyePrintPRO prismatic lenses for diplopia. Amsterdam, Netherlands: I-Site, 2015. Available at: http://netherlens.com/december_2015. Accessed May 31, 2019. Lee et al: J Neuro-Ophthalmol 2021; 41: e81-e82 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.