Uncommon Uses for Colored Lenses

Cosmetic contact lenses aren’t just for kids and costumes. For injured patients, they can restore cosmesis and even confidence.

BY SCOTT A. EDMONDS, O.D., F.A.A.O.

Cosmetic contact lens use falls into three broad categories. The first, and by far most common, is the use of contact lenses to correct ametropia in lieu of spectacles. This category covers most cosmetic contact lenses prescribed in the United States, but isn’t the focus of this overview. The second is the use of contact lenses to change the natural color of the iris. The final category of cosmetic contact lenses is the use of specialty or custom lenses to correct blind or disfigured eyes. Here, we’ll review the latter two uses of cosmetic contact lenses.

Iris-color contact lenses

The use of contact lenses to change the color of the iris dates back to the late 1950s. The initial application in the film industry lead to several attempts to change the eye color of the general public with the use of colored polymethylmethacrylate (PMMA) lenses. In patients with very light irises, the use of a green, bright blue, grey or brown lens caused a notable effect. In patients with darker iris colors, however, the application was disappointing. Painted, opaque iris lenses were available, but they required a laminate process to keep the paint sealed away from the ocular tissues. These lenses were used for television and movies but were quite expensive and weren’t tolerable for any significant length of time due to the low oxygen supply of non-gas-permeable (GP) lenses when fit large and tight enough to achieve the cosmetic effect.

An off-the-shelf colored lens restored cosmesis for this post-cataract surgery patient.

With the advent of soft contact lenses in the 1970s, the idea of iris color change was reborn. Straight tints of soft contact lenses were more dramatic. Once again, however, the best effects were limited to patients who had lighter iris color.

The advent of opaque-dot-colorization in the 1980s finally opened the possibility of changing the color of a dark iris to blue, green or other light color options. The availability of these lenses in a “stock” series of colors led to a large market for many patients who had virtually no refractive error, but a strong desire to change their iris to a lighter color. Many ophthalmic practices resisted fitting these “plano” contact lenses, as the risk/benefit ratio didn’t seem appropriate.

Practitioner resistance and the cost of a professional fitting and supply of colored lenses prompt-ed a bootleg industry. The Internet also opened the door to direct foreign imports that could circumvent the Food and Drug Administration (FDA) and other U.S. agencies.

Unfortunately, the over-the-counter (OTC) supply of these lenses without proper fitting or any patient education on the basics of lens care resulted in inappropriate use of the lenses.

Today, there is continued growth in the cosmetic contact lenses category.

Injured and disfigured eyes

For the contact lens practitioner, the term “cosmetic contacts” is often reserved for this application. Few contact lens applications are more rewarding than the one that restores a disfigured eye. Many injuries lead to this problem. One of the first clinical decision points is the issue of remaining vision in the disfigured eye. In some cases, useful vision is obtainable. This is particularly true when the affected eye is aphakic. In other cases, the eye is blind or has minimal vision that the patient can ignore. In yet other cases, the eye has a glare or distortion that actually detracts from the vision in the normal eye. In these cases, the contact lens must also serve as an occluder.

Slit lamp view shows this patient’s blown pupil, O.S.

The same eye with colored lens in place.

In my experience, air-bag injury is quickly becoming the most common injury that requires a cosmetic lens. The discharge of an airbag into the face can result in a blown pupil. I’ve found that this is a monocular event. The patient then presents with two problems: the cosmetic problem of unequal pupils and the glare from constant dilation on the affected side. It’s critical to ascertain which of these problems is most troublesome. Many practitioners just assume that glare is the major issue when in fact, it’s more often the cosmetics. For patients with cosmetic issues, the first choice in management is the disposable iris changing lenses. You can fit this lens in the affected eye or in both eyes depending on iris color and patient preference. Although these lenses don’t provide much in the way of light control, the cosmetic effect is quite good.

Another common injury: a paintball accident. In spite of eye protection requirements, if paint obscures your goggles, you must remove them to find your way off the course. This is exactly when the paintball finds its target. These eyes often present as aphakic with a blown pupil. In some cases, the patient can obtain good vision, but unfortunately in most, there is also a retinal detachment, often accompanied by macular edema or pucker. In these cases, occlusion of the “dead” eye is required.

The long-standing candidate for the reconstructive cosmetic contact lens application is your diabetic patient. With a host of complications from diabetic eye disease, these patients often are in need of refractive correction, light control and cosmetic improvement due to whitened or opaque corneas. On initial examination, it’s critical for you to determine for each patient, which problem is most important and the order of concern for other problems. Your contact lens management must then be tailored to meet these individual needs.

Custom colors

In eyes for which light control is the primary issue, you can obtain occlusion or artificial pupils with an opaque soft lens. If both occlusion and cosmetic matching are required, or when the color match is essential, you’ll need to order specialized color lenses. If your patient requires a very specific custom match, several companies can make a custom color lens. (See Custom-Made Contacts, page 42.)

Many of these companies require a color photo of the good eye and often require special lighting of the photo to achieve the best result. These companies can produce these lenses with a color-matched sclera ring to improve the match, and these lenses can even correct low degrees of eso- or exotropia. The time required to produce these lenses and the cost involved make this option difficult for the average contact-lens practitioner or patient. But for specialty cases, this is a great option.

Chair time

Cosmetics are a primary concern for most contact-lens wearers. You must be aware of this concern and work to meet it along with all the patient’s visual goals. Colored lenses are widely available and should be part of the spectrum of contact-lens care. You can compensate for the extra chair time required to address the patient’s cosmetic concerns by delegating color selection and options to the technician or assistant who will provide the insertion and removal instructions and other contact lens education.

With the ready availability of so many colored and specialty soft contact lenses, patients are very aware of this option. You can manage many of the patient’s cosmetic issues, even those that appear complex, with creative, yet “off-the-self” contact lens solutions. A careful history and listening to the patient’s exact concerns may allow you to meet most of the cosmetic needs of your patients.

DR. Edmonds owns and manages Edmonds Eye Associates, a group practice based at Wills Eye Hospital in Philadelphia. He is president and lead consultant for the Edmonds Group, a consulting firm that specializes in managed eye care. Dr. Edmonds and his wife, Dr. Susan Edmonds, serve as co-directors of the Contact Lens and Low Vision Service, also at Wills Eye Hospital.