Contact Lenses for Grandma?

[palfi]

This has been puzzling me = == =when is too old for contact lenses - too old? Is there a cut off point: so after the age of 60, or 70 or 80 or 90 do you hang up your last pair of contact lenses and call it a day? Also - when are you too old to start contacts? Would you start a swinging 70 year old in contact lenses - and if you did , when lenses are best? Anyone know ? does it matter?
We have had 3 cases of corneal infections since February (that I personally know about) and all of them were over 60 years old , is this a trend ?
Palfi

[chip anderson]

Too old:

1) When patient is too senile to handle them.
2) Corneal health is no longer sufficent (rumatoid arthritus for example).

I have patients (usually coventional aphakes) well into thier nineties wearing PMMA (which I actually think is highly superi0r to soft or HGP contacts for conventional aphakes) contacts.

Chip

The hard part with elderly and very young patients is convinceing them that they are capable of handling them. Both groups will never learn to insert or remove them if they can find a sucker in the family that will do it for them. If not, they do just fine.

[harry888]

There is no "too old" when extended wear is involved.

Remember before IOLs were out? Patients either had very high plus specs or +14.00 permalens.

I was a contact lens tech in a practice in the early 80's, every Saturday the same elderly would come in and we would remove the permalens, ultrasonic, then put back in.

Harry

[vitalogy44]

harry888 said:
There is no "too old" when extended wear is involved.

Harry,

I tend to disagree with you--many factors must be investigated. The elderly's increased susceptibility to infections/disease, decreased dexterity (they have to be able to remove the lenses sometime!?!?), etc.

What is the center thickness on a +10 to +16 contact lens? What are you going to fit them in for this "extreme" extended wear? What kind of follow schedule are you going to initiate (on this feable 80 year old who rarely leaves the house)--q3months, q6months??

I agree that a contact lens would be optically superior and I realize the trouble that an aphake will have removing the lens, but I feel a central corneal ulcer is not worth the risk.

What about having Medicare pay for PCIOL insertion??

Just playing devil's advocate..........

[palfi]

I am grateful for the replies. I hae now looked at or 3 cases in greater detail. All are very similar in age, total lens wear (30 years plus of all types), and wearing span (all day 6 days out of 7). The youngest was Female 65, Female 70 and Male 71.

All are about +5.00 and wore hydrogel monthly lenses.

One had put up with the increasing discomfort until she got her infection. The other lady had gross chronic sudden onsetting corneal oedema (corneal decompensation)and then got an ulcer
on the top.

The gentleman had suffered a mild stroke and not noticed that he had reduced corneal sensitivity and got an infection from handling problems.

All were difficult to make compliant. None would listen to me and all were stubborn.

All oldies have reduced tear volume and reduced endothelial populations and they all have less efficient immune systems. They also have thinner and less sensitie corneae due to contact lens wear in the past. I have another lady who got her doctor (who knows little about contacts) to tell me that she could continue her contact lens wear inspite of her Sjogrens and chronic dry eye. And another who suffers recurring infections due to her very dry eye from Lupus, got her eye surgeon to write to me to stop fussing and give her the lenses! Are lenses an addiction?

I am thinking of trying to find a simple rule to monitor safety

[vitalogy44]

chip anderson said:
Too old:

1) When patient is too senile to handle them.
2) Corneal health is no longer sufficent (rumatoid arthritus for example).

I have patients (usually coventional aphakes) well into thier nineties wearing PMMA (which I actually think is highly superi0r to soft or HGP contacts for conventional aphakes) contacts.

Chip

The hard part with elderly and very young patients is convinceing them that they are capable of handling them. Both groups will never learn to insert or remove them if they can find a sucker in the family that will do it for them. If not, they do just fine.

Hey, Chip, why do you feel PMMA is superior for conventional aphakes??? Remember, the Dk/L is 0--meaning that the oxygen transmissibility is zero. Do you think that the benefits of comfort (maybe?) and optics of PMMA outweigh the fact that they allow basically no oxygen to pass through.

[chip anderson]

Vitalogy44:

Fitted thousands of them in the days before HGP's and soft. Got fantastic results with same. Problems with protein depsosts, poor vision, etc. are virtually non-existant. Vision fantasticly better than HGP's and so much better than soft there is no comparison. No residual astigmatism, much more durable lens, lasts for decades, no broken flanges unless you make them too thin on flange. No eye I couldn't fit, damn few I couldn't get better than spectacle vision.

Oxygen permeablity is virtually non-existant on lenses this thick anyway, no matter what the various manufacturers tell you. It's an execellent lens if you can fit and modify lenses, but not for amaturers and what passes for training today.

Chip

[vitalogy44]

Oxygen permeability (Dk/T) is not as good a measure as oxygen transmissibility (Dk/L) and there is a huge difference between PMMA and other contact lenses. Your statement about lens thickness in high + powers giving no oxygen to the cornea is incorrect. A PMMA lens will have Dk/L of 0, but Silsoft from B&L is an aphakic lens available to +20DS with a Dk/L of 71, so even though lens thickness must be taken into account, there is no way that it is the only factor.
PMMA might be an optically superior material, but it a terrible choice when corneal health is concerned, especially in a high plus lens.........
"Polymegathism: The cornea is only about 500 to 600 microns in thickness (25,400 microns equals 1 inch), the innermost layer being only 1 cell layer thick and known as the endothelium. This single layer of cells is responsible for maintaining the proper amount of water in the cornea. These cells are unique in that we are born with a certain number and they are never replaced. As we age, the number of cells decreases, so the remaining cells must take on irregular shapes to fill in any gaps in the endothelium. The first contact lens designs in the '50s and '60s were made out of a plastic known as PMMA and only allowed minimal amounts of oxygen to pass through to the cornea. Lack of oxygen promotes corneal edema and endothelial cell death thus PMMA is no longer recommended for long term use. This is another reason for the importance placed on the ability of a contact lens to permit oxygen to pass through onto the cornea. A high oxygen transmission contact lens allows the cornea to maintain proper long term health."
One of the reasons this occurs is that after long term use the hard/RGP lens wearer has lost most, if not all of his/her corneal sensitivity and is obliovious to any symptoms. Also, with endothelial swelling you will have a certain amount of stromal swelling giving corneal warpage, etc. Plus with decreased dexterity in the elderly there is a higher probability of a corneal abrasion with these lenses.
Just because a patient says vision is good and lenses are comfortable--there is no reason to compromise corneal health especially in the elderly who tend to be more susceptible to infection, etc.
When you fit these patient (w/PMMA)--how often did you follow-up or chack their lenses?

[chip anderson]

V:


Checked at two weeks, six-weeks and every six-months and if and when there was a problem. Followed most of them to the grave or am still following. Not as many problems as we experience with HGP lenses. R

Remember more O2 is exchanged by tear circulation than is obtained from through the lens in a rigid lens no matter how gas permeable the material is. Also remember that most of the stuff you hear and read in meetings is paid for my the people making the stuff.

It's one of those things where "you hadda be there." History that you read seldom presents all points of view. I am not going to go much further with this, but trust me the results were and are good but your fitting skills had to be probably ten times what they are in HGP and probably a hundred times what they are in soft.

And the main argument I heard during the sales/introduction/and promotion for HGP lenses on the subject of polymegathism was: "ophthalmologist feel there may be complications on these patients during cataract surgery." Well the patient has already had his cataract surgery.

Chip

[Diane]

vitalogy44 said:
Oxygen permeability (Dk/T) is not as good a measure as oxygen transmissibility (Dk/L) and there is a huge difference between PMMA and other contact lenses. Your statement about lens thickness in high + powers giving no oxygen to the cornea is incorrect. A PMMA lens will have Dk/L of 0, but Silsoft from B&L is an aphakic lens available to +20DS with a Dk/L of 71, so even though lens thickness must be taken into account, there is no way that it is the only factor.
PMMA might be an optically superior material, but it a terrible choice when corneal health is concerned, especially in a high plus lens.........
"Polymegathism: The cornea is only about 500 to 600 microns in thickness (25,400 microns equals 1 inch), the innermost layer being only 1 cell layer thick and known as the endothelium. This single layer of cells is responsible for maintaining the proper amount of water in the cornea. These cells are unique in that we are born with a certain number and they are never replaced. As we age, the number of cells decreases, so the remaining cells must take on irregular shapes to fill in any gaps in the endothelium. The first contact lens designs in the '50s and '60s were made out of a plastic known as PMMA and only allowed minimal amounts of oxygen to pass through to the cornea. Lack of oxygen promotes corneal edema and endothelial cell death thus PMMA is no longer recommended for long term use. This is another reason for the importance placed on the ability of a contact lens to permit oxygen to pass through onto the cornea. A high oxygen transmission contact lens allows the cornea to maintain proper long term health."
One of the reasons this occurs is that after long term use the hard/RGP lens wearer has lost most, if not all of his/her corneal sensitivity and is obliovious to any symptoms. Also, with endothelial swelling you will have a certain amount of stromal swelling giving corneal warpage, etc. Plus with decreased dexterity in the elderly there is a higher probability of a corneal abrasion with these lenses.
Just because a patient says vision is good and lenses are comfortable--there is no reason to compromise corneal health especially in the elderly who tend to be more susceptible to infection, etc.
When you fit these patient (w/PMMA)--how often did you follow-up or chack their lenses?

vitalogy44,

Glad to see your responses to this particular thread.

Diane

[vitalogy44]

chip anderson said:
V:


Checked at two weeks, six-weeks and every six-months and if and when there was a problem. Followed most of them to the grave or am still following. Not as many problems as we experience with HGP lenses. R

Remember more O2 is exchanged by tear circulation than is obtained from through the lens in a rigid lens no matter how gas permeable the material is. Also remember that most of the stuff you hear and read in meetings is paid for my the people making the stuff.

It's one of those things where "you hadda be there." History that you read seldom presents all points of view. I am not going to go much further with this, but trust me the results were and are good but your fitting skills had to be probably ten times what they are in HGP and probably a hundred times what they are in soft.

And the main argument I heard during the sales/introduction/and promotion for HGP lenses on the subject of polymegathism was: "ophthalmologist feel there may be complications on these patients during cataract surgery." Well the patient has already had his cataract surgery.

Chip

If this was long ago and it had to be because no one uses PMMA anymore, then the cataract surgeries going on were much more invasive and prone to complications--because of this weren't the corneas that were being fit much more compromised than they are today?? And if PMMA was so wonderful, well, why is it virtually non-existent today. Did all of this come about because of the high number of aphakes and the virtual rarity of HEMA lenses?? Chip, I'm not trying to be abrasive--just trying to figure out there weren't more complications with PMMA. Just playing devil's advocate.......once again.........

[chip anderson]

44:

Why do disposable companies excel in sales even when in some cases the product is inferior? Why does "antibacterial soap" sell.
If you do enough advertising, and Hire enough experts to testify for your product, you can sell it. With enough experts (who may or may not be competent contact lens techs) and enough pretty girls in mini-skirts you can sell anything. When was the last time you saw an ugly man as a drug or frame rep?

PMMA died due to the fact that the number of competent fitters was very small. Prescribers had little time to apply such time and effort even if they had the skills most were busy with things like surgery, examination, medicine, stuff like that. Unfortuantely, some idiot let precribers find out contact lenses were profitable, so they started doing thier own fitting. Contact lens fitting was no longer referred to experts who did nothing else (except forthe most diffcult cases. Another factor was the FDA who likes for all things to be uniform, the FDA would prefer for all products to be uniform as opposed to some excellence and some less than good. The HGP and silicone lenses required little and sometimes no fitting skills. Now When I fit a small child/aphake, I use silsoft. When I fit a young person with a rigid lens I usually use HGP. Not because I believe it to be better for long term health, but I don't want to be defending stuff like I am doing now all my life. But still I have followed and maintained thousands of aphakes for over four decades and over all I would say that their corneal health, vision, and absence of "contact lens side effects" has been considerably superior to that of any of the HGP or soft material. I would even say that if one were to follow soft and HGP lens wearers for one decade and compare to aphakic PMMA lens wearers followed for four or more decades, the PMMA wearers (provideded they were well maintained, and well fitted) would have better corneal health and vision. Also remember it the eye functions, sees optimally until the patients death, who cares what the pacometer said? Signs of "suspected potential damage" do not matter if the actual damage does not occur or does not manifest itself before death (Unless you are concerned with harvesting corneas for transplantation).

Chip

PS: I also think the crescent fused PMMA bifocal contact lens is the best available bifocal contact. Strange ain't I?

[palfi]

I find the posts very interesting. I can not help thinking that cl use in any form, but used for cosmesis, is a bit like cigarettes - everyone has met someone who smoked 40 a day and lived until they were 90. But really - as we know - that ignores (or hides) the many that ciggies did for. Yep - I have met oldies with some very grubby hi water contact lens they extended for 3 months at a time - and got away with it. But I do know that our local eye casualty takes in 2 to 3 people a day with corneal ulcers from contacts. And does it matter? at the end of the day - what is the point in risking their vision. The tear volume goes down markedly after 60 (especially for ladies) to about 1/3. The tear composition changes and can be greasy or sticky and the incidence of lid problem increases. My wife says I care too much - but I did phone the husband of the lady with the corneal ulcer and he thanked me - he said he had been trying for five years to get her to pack in contact lens wear. Now the infection had done it for him! There is two sides of every coin. Its abit like wearing high heals if you has osteo parosis - second childhood - dodgy! palfi

[chip anderson]

Palfi:

Aphakic contact lenses are not for cosmesis. In spectacles aphakic patients see doors curved, see everything 15-22% larger than it is. Have what is called a ring scotoma (a round blind spot in the entire field of vision, try to imagine a wall with a two windows, two lamps and a door, you don't see the two lamps in the mid range. In addittion aphakes have a rather limited range side to side. All of these things go away in contact lenses.

Further note: I have never had an aphakic patient whom we could pursuade to wear the lenses for over a week that did not think they were the best thing that ever happened in thier lives after catarac surgery (at least in rigid lenses, in soft lenses they don't seem to be that impressed.).

Chip

[palfi]

yea - I agree with you Chip - in my cranky way I was trying to say that its hard to justify long wearing schedules with cosmetic contact lens in oldies. As you say, if there is a medical requirement - then its another matter. And I also agree that there is nothing really terrible in hard cls as they are too old to be troubled by corneal changes anyway. We had a bloke here who had aphakic cls for years until technology came along and the docs gae him an implant. Never looked back after that! regards palfi

[vitalogy44]

chip anderson said:
44:

Why do disposable companies excel in sales even when in some cases the product is inferior? Why does "antibacterial soap" sell.
If you do enough advertising, and Hire enough experts to testify for your product, you can sell it. With enough experts (who may or may not be competent contact lens techs) and enough pretty girls in mini-skirts you can sell anything. When was the last time you saw an ugly man as a drug or frame rep?

PMMA died due to the fact that the number of competent fitters was very small. Prescribers had little time to apply such time and effort even if they had the skills most were busy with things like surgery, examination, medicine, stuff like that. Unfortuantely, some idiot let precribers find out contact lenses were profitable, so they started doing thier own fitting. Contact lens fitting was no longer referred to experts who did nothing else (except forthe most diffcult cases. Another factor was the FDA who likes for all things to be uniform, the FDA would prefer for all products to be uniform as opposed to some excellence and some less than good. The HGP and silicone lenses required little and sometimes no fitting skills. Now When I fit a small child/aphake, I use silsoft. When I fit a young person with a rigid lens I usually use HGP. Not because I believe it to be better for long term health, but I don't want to be defending stuff like I am doing now all my life. But still I have followed and maintained thousands of aphakes for over four decades and over all I would say that their corneal health, vision, and absence of "contact lens side effects" has been considerably superior to that of any of the HGP or soft material. I would even say that if one were to follow soft and HGP lens wearers for one decade and compare to aphakic PMMA lens wearers followed for four or more decades, the PMMA wearers (provideded they were well maintained, and well fitted) would have better corneal health and vision. Also remember it the eye functions, sees optimally until the patients death, who cares what the pacometer said? Signs of "suspected potential damage" do not matter if the actual damage does not occur or does not manifest itself before death (Unless you are concerned with harvesting corneas for transplantation).

Chip

PS: I also think the crescent fused PMMA bifocal contact lens is the best available bifocal contact. Strange ain't I?

Chip, do you want to be the first person to have to defend yourself when someone permanently loses vision?? I really beleive the reason that PMMA fell from grace was because it let no O2 to the eye. There is no way that corneal health of a PMMA wearer for 40 years would be better than that of an RGP after 10 years. You make some valid points, but after that comment and the whole mini-skirt debacle, well, those statements just don't make sense.

[vitalogy44]

chip anderson said:
Palfi:

Aphakic contact lenses are not for cosmesis. In spectacles aphakic patients see doors curved, see everything 15-22% larger than it is. Have what is called a ring scotoma (a round blind spot in the entire field of vision, try to imagine a wall with a two windows, two lamps and a door, you don't see the two lamps in the mid range. In addittion aphakes have a rather limited range side to side. All of these things go away in contact lenses.

Further note: I have never had an aphakic patient whom we could pursuade to wear the lenses for over a week that did not think they were the best thing that ever happened in thier lives after catarac surgery (at least in rigid lenses, in soft lenses they don't seem to be that impressed.).

Chip

This answer I will agree with--:p !!!!!