Pseudomyopia with paradoxical accommodation: a case report.

BACKGROUND: Pseudomyopia is caused by increased refractive power by ciliary muscle spasm. Most patients cannot overcome pseudomyopia spontaneously; therefore, treatment of pseudomyopia is fastidious and needs a multidisciplinary approach. We report a case of unusual pseudomyopia with paradoxical accommodation, straining eyes to induce emmetropia at far distance and relaxing eyes to focus at near objects, contrary to physiological accommodation. CASE PRESENTATION: A 33-year-old woman experienced intermittent distant vision discomfort. This occurred at least a few hundred times daily. She could see near objects clearly; however, distant objects could be seen clearly only when she strained her eyes. Uncorrected distance visual acuity was 20/20 and manifest refraction (MR) in both eyes in the relaxed state was approximately - 2.5 D. MR changed to approximately - 0.5 D when she grimaced and strained her eyes when attempting to focus on distant letters. Her response was contrary to the physiological accommodative response. Cycloplegic refraction was approximately 0.0 D. Binocular autorefractor/keratometer was used to objectively evaluate her refractive response and pupil reaction according to accommodative stimulation. The IOL Master was used to evaluate the anterior chamber depth (ACD), lens thickness (LT), and pupil diameter with relaxed and strained eyes. For stepwise static accommodative stimuli (1-5 D), the refractive responses were correspondingly stepwise, similar to those elicited by healthy individuals. However, contrary to physiological accommodation, she strained her eyes to see distant objects and relaxed them to see near objects. There was no change in pupil diameter despite the accommodative stimuli being maximum. Biometry results showed that ACD deepened and LT flattened with eye strain, which were contrary to those during physiological accommodation. CONCLUSIONS: We report a rare case with reverse of physiological accommodative response. When patients complain of unusual distant visual discomfort, pseudomyopia with paradoxical accommodation should be considered.

Comparison of Objective and Subjective Changes Induced by Multiple-Pinhole Glasses and Single-Pinhole Glasses.

Multiple-pinhole (MPH) glasses are currently sold in many countries with unproven advertisements; however, their objective and subjective effects have not been investigated. Therefore, to investigate the effects of MPH glasses excluding the single-pinhole (SPH) effect, we compared the visual functional changes, reading speed, and ocular discomfort after reading caused by MPH and SPH glasses. Healthy 36 participants with a mean age of 33.1 years underwent examinations of pupil size, visual acuity (VA), depth of focus (DOF), and near point accommodation (NPA); tests for visual field (VF), contrast sensitivity (CS), stereopsis, and reading speed; and a survey of ocular discomfort after reading. Both types of pinhole glasses enlarged pupil diameter and improved VA, DOF, and NPA. However, CS, stereopsis, and VF parameters deteriorated. In comparison with SPH glasses, MPH glasses induced smaller pupil dilation (5.3 and 5.9 mm, P < 0.001) and showed better VF parameters with preserved peripheral VF. However, no significant difference was observed for VA, DOF, NPA, stereopsis, and CS. Reading speed using pinhole glasses was significantly slower than baseline; SPH glasses showed the slowest reading speed. Both types of glasses caused significant ocular discomfort after reading compared with baseline, and symptoms were worst with MPH glasses. In conclusion, both types of pinhole glasses had positive effects due to the pinhole effect; however, they had negative effects on VF, CS, stereopsis, reading speed, and ocular discomfort. In spite of the increased luminance and preserved peripheral VF with MPHs, these glasses caused more severe ocular discomfort than SPH glasses.

Anterior stromal puncture for treatment of contact lens-intolerant keratoconus patients.

PURPOSE: To report the results and effectiveness of anterior stromal puncture for contact lens-intolerant keratoconus patients with subepithelial fibrotic nodules. METHODS: Nine eyes of nine keratoconus patients who were rigid gas-permeable contact lenses (RGP)-intolerant due to subepithelial nodular scars were included in this study. The nine patients were enrolled in the study between March 2008 and December 2008. After confirming nodular elevation from slit-lamp biomicroscopy, the area where the epithelium of nodular scars had sloughed was punctured by anterior stromal puncture using a 26-gauge needle attached to a 1-ml syringe under slit-lamp biomicroscopy. The RGPs of all patients were refitted around 4 weeks after the puncture. RESULTS: Five of the nine patients were male, and the average patient age was 29.6 years (SD ± 5.22 years). Mean follow-up time was 13.7 months (SD ± 4.8 months), and the epithelial defect healed in 1.4 days on average. After the puncture, four of nine patients presented with a recurrent erosion of the nodule during follow-up and needed a second puncture. All the patients showed good contact lens tolerance and satisfactory contact lens fit. No complications such as corneal perforation or keratitis developed. CONCLUSIONS: Anterior stromal puncture using a 26-gauge needle can be a successful and effective method to induce corneal epithelium and Bowman's layer reattachment. It can be used as an outpatient procedure to improve RGP tolerance in patients with keratoconus with elevated subepithelial nodules.

The effect of the YK lens in keratoconus.

PURPOSE: To report the clinical results of the use of the YK contact lens (Lucid Co., Seoul, Korea) for keratoconus. METHODS: One hundred and twenty nine keratoconic eyes were fitted with a YK lens which has one base curve and three peripheral curves. A light feather touch fluorescein pattern was obtained based on topographic indices. Visual acuity, comfort, mean wearing time, and ocular tissue changes were evaluated. Mean follow up was 17.5 +/- 13.8 months (range 6-75). RESULTS: One hundred and twenty six (97.6%) eyes tolerated the contact lenses. A total of 94.5% of the eyes achieved a visual acuity of 20/40 or better (average 0.79 +/- 0.21), and flatter base curve radius (BCR) was related to better visual acuity. One hundred and seventeen (90.7%) eyes reported that the lenses were comfortable. Mean wearing time was 12.1 h per day (range 4-18). Changes in keratometric values were not significant between baseline and final follow-up visit. CONCLUSIONS: The YK lens can provide successful visual outcome, with comfort, and no significant influence on the progression of keratoconus.

Fitting miniscleral contact lenses in Korean patients with keratoconus.

BACKGROUND: The aim was to evaluate the clinical results of fitting MSD miniscleral contact lenses (MSD; Happy Vision Corp, Anyang, Korea) in Korean patients with keratoconus. METHODS: This report presents a retrospective case review of 38 keratoconic patients fitted with MSD lenses. Visual acuity, comfort, mean wear time, final lens parameters, relationships between sagittal depth and topographic indices, success rate with the first lens ordered and adverse events were documented. RESULTS: The mean logMAR visual acuity was improved from 0.85 ± 0.78 with glasses and 0.28 ± 0.29 with corneal rigid gas-permeable lenses to 0.10 ± 0.11 with miniscleral contact lenses. Ninety-seven per cent of patients found the miniscleral contact lenses to be comfortable and the mean daily wear time was 10.1 ± 2.3 hours. The mean sagittal depth was 4.70 ± 0.35 mm and there was no correlation between sagittal depth and topographic indices. An average of 3.4 trial lenses was needed to decide the ordered lens and 1.3 ordered lenses to achieve the optimal fitting. One patient discontinued the wear of the lenses after three months due to discomfort. CONCLUSION: The use of MSD miniscleral contact lenses is a good alternative for patients with keratoconus and for those who failed to respond to other types of lens rehabilitation that results in both successful visual outcome and comfort.

Effect of orthokeratology in patients with myopic regression after refractive surgery.

PURPOSE: To evaluate the clinical effect of orthokeratology (ortho-K) lenses and to introduce the fitting steps of ortho-K lens for myopic regression after keratorefractive surgery. METHODS: Twenty-one eyes from 12 patients with myopic regression after keratorefractive surgery were fitted with ortho-K lenses and followed up for 12.11±3.68 months. The mean K value of the peripheral cornea was used to speculate preoperative central corneal K value, estimated K. After dispensing the lenses according to estimated K, biomicroscopic examination including fluorescein staining and over-refraction were performed to determine the final K and final lens power. RESULTS: LogMAR uncorrected visual acuity was 0.48±0.39 before and 0.00±0.00 after wearing ortho-K lenses (p<0.001). Pre-fitted refractive error was -1.87±1.05 diopters (D) in myopia, 0.54±0.42 D in astigmatism, and spherical equivalent of -2.14±1.01 D. At the final visit myopia level and spherical equivalent significantly decreased to -0.73±0.84 D (p<0.001) and -1.01±0.87 D (p<0.001), respectively. Estimated K was 8.07±0.36 mm, and final K used for ortho-K prescription was 8.19±0.30 mm. Final K significantly correlated with K value of pre-fitted peripheral cornea (r=0.737, p<0.001) and estimated K (r=0.721, p<0.001), respectively. There was no correlation between pre-fitted degree of myopia and the Final lens power (r=0.429, p=0.053). CONCLUSIONS: Ortho-K lenses may be an effective solution for patients with myopic regression following keratorefractive surgery. Estimated K value can be used as reference value in ortho-K prescription.