Monday, December 30, 2013

The Cadet

by Specs4ever

Lacey had been a patient of mine for a number of years. Her first prescription was around –1.25D when she was 14, and now at age 22 she was presently wearing contacts with a –3.50D power. Lacey was a very pretty young lady, tall and slim, with very attractive features, and nice short brown hair and medium brown eyes. She had called last week for an appointment, and I escorted her into the examination room.
“Well Lacey, do you need a new prescription?” I asked.
“I don’t think so Doc, but you do this Oker - okertherapudic stuff don’t you?” she asked.
“You mean okertherapy?” I replied.
“Yeah, that’s the stuff. You are some kind of expert aren’t you?” She said.
“I am not really an expert, but I have done it a lot, and I have had a fair amount of success.” I said.
“Didn’t you do Jim, that got onto the fire department a couple years ago?” she asked.
“Yes, I have done this for a fair number of police and fire department recruits. The visual requirements to obtain a job there are 20/40 uncorrected.” I replied.
“Well, I want to be a cop, and I know my eyes wouldn’t pass the test, so can you help me?” Lacey asked.
“There is no guarantee that it will bring your B.C.V.A.(best corrected visual acuity) down to 20/40 or better Lacey, but I am willing to try if you want to spend the money, and go through the routine.” I replied.

With that, I examined Lacey’s eyes, and fitted her with a pair of hard contact lenses that would be the first step in attempting to correct her myopia. When Lacey came back after 30 days of wearing these lenses all night, along with wearing a pair of –2D glasses during the day I found that her vision had indeed been corrected to –2D. Lacey was happy, very happy.

So, we went for step 2, and I fitted her with another pair of contacts for overnight wear. This time I gave her no glasses, and told her that her vision would be good enough to drive a car in familiar territory. Lacey came back in another 30 days, and I again examined her eyes. This time she was down to –1D for a prescription.

“Well Lacey, you are now better than 20/50. One more month and we should have you back to 20/20, or fairly close to it anyway.” I told her.
“Doc, I don’t have another month. I have to take the medical exam in less than 2 weeks.” Lacey replied.
“Lacey,” I reprimanded her, “I told you at the start that this could take 3 or 4 months.”
“I know Doc, but they are hiring right now, and if I pass this up I might not get another chance.” Lacey said.
“Well, I will start you on the final stage of lenses, but I can’t guarantee the results. You may still have to wear very weak glasses.” I replied.
“I don’t care what happens after I get the job, Doc. I just need good enough eyesight to get hired. Uncle Bob can’t do a thing for me if I can’t pass the medical and the physical stamina training.” Lacey said.

So, I fitted Lacey for the final stage of contacts for overnight wear. She had actually done surprisingly well. Most of my clients who had worn glasses as long as Lacey had, took anywhere from 6 months to a year to get to 20/20. I heard through the grapevine that Lacey had gotten the job as a police cadet, but I didn’t see Lacey again for about a year. One morning, I noticed her name on the appointment sheet. When it was time for her appointment my nurse escorted Lacey into my office, and I noticed that she was wearing the same glasses she had been wearing when she came to me to have the treatment.

“What has happened Lacey? Did you not keep up with wearing the contact lenses?” I asked.
“They hurt so much that I just couldn’t wear them, Doc. Then about 6 months ago, I started having problems seeing things in the distance, so I started wearing my old contact lenses again. But now things are even more blurry, so I figured that it was time for another eye exam.” Lacey told me.

I gave Lacey a very thorough examination. Her old glasses and contacts had been –3.50D, and I found that she was now requiring –4.50D, a whole diopter stronger. But, when I checked her corneal topography, I discovered that her cornea’s, which had been slightly reshaped by the lenses used in the okertherapy, were still at the same curvature that they had been reshaped to. This worried me a little, because this meant that Lacey’s myopia increase had gone from the –1D or less up to –4.50D without the curvature of her cornea’s changing back. I was puzzled, and I told Lacey what I had discovered.

“So what you are saying, Doc, is that this increase is likely all due to my eyeball elongating more.” Lacey said.
“Yes, and now what worried me is that the curvature of your cornea will start to revert to it’s original form, and you will gain even more myopia.” I told her.
“Well, I got the job I wanted Doc, and since I passed my initial exams they can’t get rid of me now. So, as long as I can see all right with contacts, no one ever needs to know.” Lacey said.
“That is all right for you to say now Lacey, but you can’t wear contacts 24/7. You will damage your eyes, and then maybe you won’t be able to wear contacts ever again.” I said.
“Well, then I guess I will just have to have one of those laser jobs.” Lacey told me.

A year went by before I saw Lacey again. Her name had been in the news a couple of times. Once was when she completed her training as a cadet and became a full-fledged police officer. Another time was when she received a commendation for bravery during a robbery. When she appeared at my office for another eye examination, I congratulated her on her progress.

“Well, I’ve been making another type of progress Doc. I don’t like it, but my eyes have been getting worse and worse for the past 6 months. I have to get a new pair of contacts right away.” Lacey said.

I examined her eyes, and she was right. She had gained another –1.50D of myopia. I again checked her corneal topography. There had been a slight change, possibly enough to account for –0.50D. However, there was at least another –2D of possible myopia hiding there. Lacey left my office with a new contact lens prescription of –5.75D, and a new prescription of –6.00D for her glasses.

I didn’t think any more about Lacey until I saw her name in the appointment book again. I checked her file, and it had only been about 9 months since her last increase.

“I thought my eyes were supposed to stop changing after I was 18, Doc. How come they keep getting worse?” Lacey asked me before she even said hello.
“Well, hello to you too young lady. What are you now, 24 almost 25?” I replied.
“I will be 25 in a few weeks, Doc.” Lacey replied.
“What glasses are you wearing now, Lacey?” I asked, wondering if the glasses that she had on were the –2D ones I had prescribed when she was undergoing treatment, and that she was wearing them over her contact lenses.
“These are the weaker ones I was using when you gave me that treatment Doc.” Lacey said.

I was right. They were the –2D glasses. This meant that her eyes had gotten much worse over the past 9 months, if she needed to wear the –2D glasses over her contacts to see. When I examined her eyes this time, I found that she had increased to –9.50D-, putting her in the category of a high myope. When I checked her topography, I saw that her cornea’s had released another –1D of myopia, but there was still another –1D left. This lady was heading for over –10D of myopia very quickly.

“Lacey, I can’t tell you why your eyes are so much worse. You have had another –1D increase because of your cornea reshaping itself back to its original shape, but that doesn’t explain the extra –2.50D increase in your spherical correction. Are you doing a lot of computer work, or a lot of reading? Should I be prescribing you bifocals or reading glasses to wear over your contacts?” I asked.
“Well, I have been doing all my reports on the computer, but it doesn’t take me a whole lot of time. And usually when I get off of my shift, I am so tired that I don’t do much reading. Mostly I just go home and crash.” Lacey replied.
“Have you been sleeping with your contacts in?” I asked, grasping at straws to find a cause for her eye’s getting worse.
“Once in a while I might fall asleep with my lenses in, Doc. But, I haven’t done that very often though.” Lacey responded.
“I don’t know what to tell you Lacey. Most of my female patients around your age have had their myopia stabilize. I would find this easier to explain if you had started out as a high myope, but your myopia at age 22 was fairly low, –3.50D is not really a high myopia. I just don’t have any explanation for what is happening to you.” I replied.

I knew that that wasn’t the answer that Lacey wanted, but I couldn’t come up with a logical reason, nor could I think of any solution. She had the job she wanted though, and as long as she could tolerate her contacts, she probably would be fine.

A couple of months later, I met Lacey in the mall, and I asked her how her eyesight was doing. She told me that she was doing well with her new contacts so far, but that she was really surprised at how thick her glasses were, and that the flat fronts seemed to make them look really strong. She also complained that when she switched to her glasses from her contacts she really noticed that she couldn’t see as well. I told her that this was a normal reaction with strong prescriptions.

It had been 2 years since I had last seen Lacey as a patient, and I was beginning to hope that her myopic progression had stopped. I saw her name again in the appointment book, and I thought that since such a long time had passed, she probably just wanted a checkup. I hoped that there were no further problems.

“Hi Lacey,” I greeted her. “You must have stopped your progression. This is the longest you have gone without an increase in a few years.”
“Well, I have been really struggling to see in the distance for the past couple of months, but I didn’t want an increase, Doc. Finally I realized that I can no longer function without the proper correction.” Lacey replied.

Sure enough, her cornea’s had finally returned to their pre treatment curvature. And her myopia had increased by another –0.50D. Her new glasses prescription was –11.00D for both eyes. This time I was determined to prescribe hard contact lenses for Lacey. Over the past few years I had been seeing a lot of evidence that soft lenses caused an increase in a patient’s myopia, and I had recently read a number of studies that seemed to confirm this.

“I want to prescribe a hard lens for you Lacey. They are called RGP’s, which stands for rigid gas permeable lenses. They will take a bit of time to become accustomed to wearing them, but I really want to see your myopia progression halted. You will start with wearing them for 3 hours a day, and then as you become accustomed to them the wearing time will increase gradually. Within a month we will have you up to about 12 hours a day, with occasional wear up to 16 hours.” I advised her.
“What, you mean I can only wear them for 3 hours a day. I can’t do that Doc. My shifts are 8 hours, and sometimes I do double shifts.” Lacey protested.
“Are you telling me that you now wear your contacts for over 16 hours a day Lacey?” I asked.
“All the time, Doc,” Lacey answered.
“How many days a week do you do this?” I asked.
“Well, generally I have 4 on and 3 off, but I only work one double shift. So, I wear them for about 18 hours that day. The other days I wear them for 15 or 16 hours a day.” Lacey told me.
“Girl, you are ruining your eyes. This much contact lens wear is going to cause you real problems in the near future.” I told her.

Lacey wouldn’t go for the RGP’s, so she left my office with a new soft lens prescription. I had to give her a contact lens prescription of –10D, as she just couldn’t get to 20/20 with the –9.75D I tried her with. Even this worried me a little, as –9.75D translated to more like –11.50 D for her glasses. She did see 20/20 with –11D for glasses, but she could also see 20/20 with –11.50D. I knew that she would not wear her glasses if she couldn’t see properly, so I matched her glasses prescription to her contact lenses.

I didn’t see Lacey again until she was 29. Again she was having trouble seeing distant objects, so she had figured she needed another increase. And, as usual, she had put her visit off until she was having real problems. I took a look at her eyes with her contacts removed, and what I saw made me very concerned of her visual health. Her cornea was showing signs of scarring, and I could tell that she had been over wearing her contacts a lot. And, her myopia had now jumped to –13.00D.

“Well, you succeeded young lady.” I told her.
“At what Doc.?” she asked puzzled at my statement.
“You have reached the point where you will no longer be able to wear contact lenses. It is glasses for you from now on.” I answered.
Lacey didn’t speak for a minute. “You have to be kidding me Doc.”
“No, I am not. You have over worn your lenses a few times too often. You also have some corneal scratching that tells me that you have worn your contacts a few times when you were having real problems. I bet they were not very comfortable those times were they?” I asked.
“Is there anything that you can do to help me? Can I have an operation? How about that laser surgery, or that new wave front stuff?” Lacey questioned.
“Well, to start with, no laser surgeon in his right mind would touch your eyes until they have stabilized for at least 2 years. You have just gained another –1.50D in your prescription.” I told her.
“What do you know about that deal where they put permanent contact lenses into your eyes Doc?” Lacey asked.
“Pretty much the same deal Lacey. They won’t touch your eyes if you are still having changes.” I told her.
“What can I do Doc? I just made detective. I will lose my job if they see how thick my glasses are. I have to be able to wear contacts, at least for another few years.” Lacey said with a tremor in her voice.
“Lacey, what part of going blind do you not understand. You are destroying your corneas if you attempt to wear contact lenses. You might, after your cornea heals properly, be able to wear contact lenses occasionally, but for you full time wear is definitely in the past tense. Now, put your glasses on and we will see about getting you a new pair of glasses with your new prescription.” I said.
Lacey looked at me sheepishly. “I haven’t got a pair of glasses, Doc.”
“You mean not with you don’t you Lacey?” I asked.
“No, I mean that I didn’t get another pair of glasses after my last big increase. My last pair of glasses were so thick and funny looking that I didn’t want to ever wear glasses again, so I didn’t get a pair.” Lacey told me.
“Lacey, what am I going to do with you? You can’t put your contacts back in, and you can’t leave here, requiring a –13.00D correction, without glasses. At any rate, it is going to take a week or so to get you new glasses in your prescription.” I said with an exasperated tone to my voice.
I called my assistant in. “Nora, did I see Melanie Jones put some of her old glasses into the recycling box last week?”
“Yes, I think I saw her put 2 or 3 pairs in there, Doc. Did you want me to see if I could dig them out?” Nora asked.
“Please Nora, and if you do find them, either neutralize them and bring me the correct script, or else bring me Melanie’s file so we can figure out the prescription.” I replied.
“Who is Melanie Jones, Doc?” Lacey asked.
“Melanie is a young lady of 18 who has progressive myopia. She has had a number of changes in the past couple of years, and she is now around –16.00D. When she was around 16 though, I seem to remember that she had a prescription of around –13D, so if her old –13D glasses are in the bin, we might be able to get you out of here under your own power. She doesn’t have any cylinder in her prescription, and fortunately for you, you don’t either.” I told Lacey.

Nora came back with Melanie’s records, and 3 pairs of glasses. “Here you go, Doc.”
I checked the glasses. One pair was –12.50D right, and –12.75L, one pair was –13.75D in both lenses, and the third pair was –14.25D in both lenses. I then measured the pupillary distance of the glasses, and found that Melanie’s pd. was 2 mm less than Lacey’s. I didn’t like that, as this would give Lacey the same effect as having base out prisms in her glasses. But, I didn’t have much choice, so I tried the –13.75D glasses on Lacey.

“These are about –0.75D too strong for you Lacey. If you wear them a bit away from the bridge of your nose, we might be able to get away with wearing these temporarily.” I told her, as I adjusted the glasses to fit a bit loosely over her ears.
“Doc, these are wonderful. I can see great.” Lacey said as she looked through the strong lenses.
“Well, I would rather not give you a new prescription today for glasses. I would rather have you wear those glasses for 24 hours, and come back in tomorrow. Wearing contact lenses sometimes throws the glasses prescription off a bit, so this way we will be able to get a better measure of your correct power.” I said.
Lacey had glanced at herself in the mirror while I was talking. “These things are thick as heck, Doc. But, I guess I have no choice but to wear them. I will see you tomorrow, same time same place.”
“I will have Nora pencil you in Lacey.” I replied.

As she walked out the door, Lacey turned to me and said: “Thanks, Doc. I realize this is my fault. I should have listened to you before.”

Lacey came back the following day as planned, and we tested her eyes. After relaxing for 24 hours without the contact lenses on her cornea, her eyes had relaxed, and I found that the –13.75D wasn’t really too strong for her. Lacey had noticed that as well, because she was wearing them tight to her nose when she came into the office. She complained about the tunnel effect, and the peripheral distortion, but I advised her that I couldn’t do anything about that. Lacey told me that she had called in to the station, and had applied for her vacation, as well as a couple of sick days to give her corneas’ time to heal.

“Maybe in a month, I might be able to wear contacts again, Doc.” Lacey pleaded.
I didn’t want to dash her hopes completely, so I just said, “We will see.”

Lacey had ordered a new pair of glasses. They were gold frames, with a small eye size, and the highest index lenses that we could get. She got anti reflective coating, and edge coating – in short all the bells and whistles. Her glasses were expensive, and were probably the first $400.00 pair we had ever dispensed. But, after wearing Melanie’s glasses for 3 weeks, and when Lacey saw, and tried on, her new glasses, she was very pleased with the results.

Lacey returned to her job wearing her new glasses. She later told me that she had received a number of comments, and that for the most part they were favorable. She also told me 2 years later, when she came in for her next eye examination that she regretted not wearing glasses to work once in a while before. Then it wouldn’t have been so hard for her to show up at work wearing such strong glasses. The police force had not fired her. She had been correct in her earlier thinking that if her eyes went bad while she was on the job she could only be placed on disability, and since she could see 20/20 with glasses she technically wasn’t disabled.

Lacey left my office without an increase in her prescription for the first time in years. We had discussed this, and I came up with the idea that possibly her vision problems had been due to the stress that she had been under. I told her that if she didn’t require an increase in her prescription the following year, I would refer her to a surgeon for the lens implants.

“I’m not sure if I want them anymore, Doc.” Lacey said with a mischievous lilt in her voice.
“Quit the games Lacey. What’s up with that?” I asked.
“I have been going out with Colin Phillips. He tells me he really finds that I turn him on with my glasses. So, I think I will play the cards I have been dealt to my best advantage.” Lacey said.
“Colin – the criminal trial lawyer?” I asked.
“That’s the one, Doc. Do you know him?” Lacey asked.
“I was his wife’s eye doctor before she had lasik. I take it they got divorced.” I said.
“It has just been finalized. He couldn’t get it up with her, after she had the surgery. But, it works really well when I am with him,” Lacey smiled.

Feb 2005

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