April 17, 2023
By Ashley Wallace-Tucker, OD, FAAO, FSLS
Subjective:
A 12-year-old African American male presented to our clinic for his first comprehensive eye examination. The patient reported no vision-related complaints and had no prior history of vision correction. His mother reported that he had not passed his most recent school vision screening but had no other concerns. Upon questioning, she reported his academic performance was average for his age, but he particularly struggled with reading when he was younger. After two years of tutoring from the ages of 6 to 8, his reading performance improved significantly. On average, he spends about two hours on near work per day outside of school. He likes playing basketball.
He was born at 38 weeks gestation with no complications. His medical and ocular history were both unremarkable. Both his mother and father are moderate myopes with no other remarkable ocular history.
Objective:
The patient’s preliminary testing was within normal limits with the exception of the following:
Stereopsis
Local: none
Global: 500 arc seconds
Binocular Vision Assessment
15pd constant exotropia OS (distance and near)
Uncorrected visual acuity
Distance
OD: 20/20-2
OS: Hand Motion @ 2 ft
Near
OD: 20/20
OS: Hand Motion @ 2ft
Refraction with corrected visual acuity:
OD +0.75-1.25 x 180 20/20+
OS -19.00 -4.50 x 165 20/400
Axial Length (obtained from Topcon MYAH Fig. 1)
OD: 22.94 mm
OS: 29.69 mm
It is important to note that keratoconus — a common cause of high myopia, high astigmatism, and reduced visual acuity — was ruled out by a normal corneal topography OU provided by the MYAH. (Fig. 1)
Fig. 1: Topcon MYAH report, including refraction, keratometry, and cornea data.
His anterior segment assessment with slit lamp was normal. His dilated fundus exam was unremarkable OD, but viewing the posterior chamber OS with auxiliary lenses and slit lamp, BIO, and fundus photography was challenging due to its extreme depth. A referral was made to a local retinal specialist for further assessment and evaluation.
Assessment:
A report from the retinal specialist shortly after my examination confirmed unilateral pathological myopia with lattice degeneration and atrophic retinal holes 360 and optic nerve staphyloma OS.
Plan:
Due to the complexity of this case, many vision correction options were presented to the family:
- Full-time correction OU with soft toric contact lenses in hopes of improving visual acuity OS
- Myopia management, including soft multifocal toric contact lenses and/or atropine 0.05% OS
- Low-dose atropine OD for myopia prevention
- Spectacle correction OD with balance OS for safety purposes
- Combination of spectacles and soft contact lens OS
Unfortunately, all interventions were denied due to financial concerns. In addition, the patient could not confirm better vision with a trial frame. A follow-up exam was scheduled to revisit vision and myopia interventions in six months.
Education:
Because the visual prognosis of patients with pathologic myopia is often poor, the common thought for correction is to balance the prescriptions to allow for a better optical and cosmetic experience. However, there is recent evidence in support of amblyopia therapy to improve the visual outcome for these patients, including full-time correction either with spectacles and/or contact lenses, patching of the non-myopic eye, atropine penalization, and vision therapy.1 Due to the aniseikonia effects that will occur with spectacles, contact lenses would provide the patient with a better visual experience and likely compliance.
Whether or not myopia management should be initiated for patients with unilateral pathologic myopia is debatable. As we know, controlling myopia progression by any amount lowers the chance of ocular pathology. However, in cases such as this one, where myopia has already progressed, and visual acuity is poor, it may make more clinical sense to focus all myopia management efforts on the normal eye if the refractive error progresses to myopia.
For this patient, I stressed the importance of protecting the unaffected eye and preventing myopia onset with all of the following:
- Sunglasses or safety glasses during sports
- A minimum of two hours outdoors each day
- Limited screen time outside of school
The parents were receptive to incorporating lifestyle changes into their daily routines.
References
- Weiss AH. Unilateral high myopia: optical components, associated factors, and visual outcomes. Br J Ophthalmol. 2003 Aug;87(8):1025-31.
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Dr. Ashley Tucker graduated from the University of Houston College of Optometry in 2010 and completed a Cornea and Contact Lens Residency at UHCO in 2011. Dr. Tucker is a partner at Bellaire Family Eye Care, a private practice in the Houston, Texas, area where she primarily manages patients in need of specialty contact lenses and myopia management. She is also a Visiting Assistant Professor at UHCO and is the course master for the Ophthalmic Optics laboratories. In addition, Dr. Tucker is a member of the Speaker’s Bureau for the Specialty Division of Bausch + Lomb, a consultant for CooperVision, and a lecturer for the STAPLE (Soft Toric and Presbyopic Lens Experience) program. |
