contact lenses

Colors are Therapeutic

Use therapeutic specialty-tinted contact lenses to improve lives and grow your practice.

Sunny M. Sanders, O.D., F.A.A.O., Fullerton, Calif.

Imagine standing among a group of people who are marveling at a rose garden's beauty and wondering to yourself: "What's all the fuss?" or "If only I could see what they see." Now, conceptualize sitting in your backyard on an August night and squinting at the sky after hearing your next-door neighbor begging her husband to come out and view the "incredible" full moon. These scenarios illustrate that color deficiency and photophobia, respectively, can have just as much of an affect on one's quality of life as many refractive issues. Therefore, dispensing lenses that correct these issues has the potential to have just as much of an affect on your practice's revenue as the dispensing of spectacles and regular contact lenses. (See "Marketing Your Therapeutic Specialty Tinted Contact Lens Practice.")

The following two cases are examples of how therapeutic specialty-tinted contact lenses can improve patient's lives and your bottom line.

EMT candidate fails color vision test

A 25-year-old Hispanic male was referred by one of our current patients to the Eye Care Center at the Southern California College of Optometry after failing to pass a required vision test to enter an Emergency Medical Technician (EMT) program.

History: The patient's past medical history was unremarkable. His vision and ocular history was also unremarkable except for his report that he, his father and brother were colorblind. Our patient did not wear corrective lenses and never had.

Exam findings: The patient's uncorrected visual acuity was 20/15 OU with no measurable correction needed. All other binocular visual functions were unremarkable except for the color vision screening test performed using Pseudoisochromatic plates. The results of this test indicated a red-green deficiency with the patient only scoring two out of six correct answers. To standardize the color vision testing, we employed the Farnsworth Dichotomous Test for Color Blindness Panel D-15.

The D-15 is commonly used as the testing standard for color vision and is recognized and accepted by most law enforcement, military and social service agencies.

Diagnosis: I diagnosed this patient as having dichotomous Protan (Red-bluegreen) and Deutan (Green–redpurple) color deficiencies.

Discussion: Color vision deficiency is the inability to distinguish certain shades of color or in severe cases, any colors. The term "color blindness" also describes this visual condition, but very few people are completely colorblind. Color vision deficiencies affect 8% of males and .04% of females.¹

To understand color vision deficiency, we must first reacquaint ourselves with the way the eye processes color. The human retina contains two light receptors: the rod cells (active in low light) and the cone cells (active in normal daylight). The retina is composed of three kinds of cones, each containing a different pigment. These cones are activated when the pigments absorb light. The S-cones (blue cones) are sensitive to short wavelengths of light with their peak sensitivities in the color spectrum's blue area. The M-cones (green cones) are sensitive to medium wavelengths of light with their peak sensitivities in the color spectrum's yellow-green area. The L-cones (red cones) are sensitive to long wavelengths of light with their peak sensitivities in the color spectrum's yellow areas. The absorption spectra of all three systems cover much of the visible spectrum.

This monthly replacement daily wear plano custom deep-brown plum-tinted lens enabled this young man to become an EMT.

The sensitivity of normal color vision depends on the overlap between the absorption spectra of the three aforementioned cones: The retina recognizes different colors when the different types of cones are stimulated to different degrees. Red light, for example, stimulates the long wavelength cones much more than either of the others. Meanwhile, reducing the wavelength causes the other two cones' systems to become increasingly stimulated, inducing a gradual change in hue.

Most color-deficient people can see colors, but they have a difficult time differentiating between certain colors.

The most common form of color deficiency is red-green. Patients with this deficiency have a difficult time differentiating between these colors. And, the difficulty these patients have in differentiating these colors depends on how dark or light the colors are. In other words, certain shades of reds and greens are difficult for people with red-green deficiency to differentiate.

Blue-yellow is another form of color deficiency. This form is more rare (one in 13,000 people) and more severe than the red-green form, as patients with the blue-yellow deficiency frequently have red-green blindness too.¹ In both cases, it's common for these patients to see neutral or gray areas instead of a particular color.

The final form of color deficiency: achromatopsia is complete color blindness. These patients can only see in black and white or shades of gray. Color deficiency results from genetic inheritance, disease or injury. It is usually an inherited bilateral condition caused by a common x-linked recessive gene passed from mother to son. This makes color deficiency more common in males than in females. As a result, the patient and his brother inherited the condition due to their mother's X-chromosome contribution and not from their colorblind father.

The specific diseases that can cause color deficiency as a result of damage to the optic nerve or retina are diabetes, glaucoma, age-related macular degeneration, Alzheimer's disease, Parkinson's disease, multiple sclerosis, chronic alcoholism, leukemia and sickle cell anemia. Depending on the area of the optic nerve and/or retina affected, the color deficiency can be unilateral rather than bilateral.²

Color deficiency is generally diagnosed through a comprehensive eye examination. Pseudoisochromatic plates are commonly used to screen for color deficiencies and specify the colors involved. That being said, additional testing may be needed to determine the exact nature, degree of the color deficiency and effectiveness of any functional treatment considered. This is the reason we administered the Farnsworth Dichotomous Test for Color Blindness Panel D-15 to this patient.

No cure exists for inherited color deficiency. So, treatment in these cases consists of the use of special-tinted spectacles or a therapeutic specialty-tinted contact lens worn on one eye to increase the patient's ability to differentiate between colors. The tinted lens is trialed on each eye to determine the preferred eye for the tint lens based on the patient's response and test performance.

If the patient has injury disease-induced color deficiency, comanagement with the patient's physician(s) may be in order. If the underlying cause can be addressed, the condition may improve. Should the patient not recover his color vision, however, special tinted spectacles or therapeutic specialty-tinted contact lenses may help these patients improve their vision.

Management: As a result of the patient's bilateral dichotomous Protan (Red-bluegreen) and Deutan (Green–redpurple) deficiencies, I prescribed a monthly replacement daily wear piano custom deep brown-plum-tinted contact lens with a 12.0mm diameter iris mask OS. (Colored contact lenses for color deficient patients are usually placed in the non-dominant eye.) The lens was tinted in-office while the patient waited. (We've found that the profits from tinting 10 to 15 lenses covered the cost of this equipment purchase.) (See "Tinting Options," below.)

Financial rewards: This case included the initial consultation and determination of the color deficiency diagnosis. The tint assessment consultation and fabrication of the lenses were separate visits and fees. The patient paid out of pocket for this care program and materials. The overall fees for similar services range from $899 to $1,400 based on the type of lenses used (replacement schedule), the number of lenses tinted and the cost of tinting the lenses (e.g. in-house vs. outside tinting lab — relative to each individual practice).

The financial rewards are ongoing, as we receive referrals from other professionals and patients we have helped previously.

Outcome: After inserting the lens, the patient passed the D-15 color test as well as the Pseudoisochromatic plates test with 100% accuracy. He successfully became an EMT and continues to wear this therapeutic contact lens design as prescribed.

Tween unable to enjoy water sports

A 10 year-old Caucasian male with bilateral aniridia and nystagmus was initially referred from another practitioner who was evaluating him as a low vision patient. At that time, the patient was fit with annual replacement therapeutic pinhole prosthetic hydrophilic lenses to minimize his photophobia complaint for his daily activities and was very successful wearing these contact lenses for some years.

Recently, this patient returned to the Center complaining of intense photophobia when participating in water sports, such as water polo and various beach activities. He did not wear the prosthetic soft lenses originally prescribed while participating in water activities due to the risk factors of the contact lenses being exposed to ocean and pool water. Additionally, his parents expressed concern about the excessive UV exposure of the beach environment to their son's eye health.

History: The patient's medical history revealed congenital nystagmus, aniridia and possible macular hypoplasia (fovea hypoplasia). The cause of these congenital conditions was not linked to any particular event or cause. The patient's current medical history was unremarkable.

Exam findings: The exam findings were isolated to the contact lens-related procedures, as the patient was seen for his routine care by the referring doctor. Our baseline findings revealed 20/280 OU acuity with glasses, and we were able to improve the acuity to 20/250 with −7.00 OU contact lenses. The nystagmus was small-to-moderate in all fields with a right gaze.

Diagnosis: As a result, of the patient's current complaints, past ocular history and latest exam findings, I supported his diagnosis of extreme photophobia.

Discussion: Photophobia can be a common complaint. It is known as excessive sensitivity or pain to the eyes due to light exposure. The condition occurs when too much light enters the eye, causing over stimulation of the photoreceptors in the retina and subsequent excessive electric impulses to the optic nerve.

Too much light can enter the eye if the eye is damaged, such as with a corneal abrasion or retinal damage, or if a pupil(s) is unable to normally constrict (as seen with oculomotor nerve damage). Patients who have photophobia will avoid contact with or protect their eyes from direct light (sunlight and room lights). In addition, they may seek a dark room or wear dark sunglasses and hats or visors to protect their eyes from intense light.

Photophobia can occur as a result of several different medical conditions related to the eye or the nervous system. These include achromatopsia, aniridia, aphakia, buphthalmos, cataracts, cone dystrophy, corneal dystrophy, pigment dispersion syndrome, albinism, chronic fatigue syndrome, migraine, pupillary dilation naturally or chemically induced, scarring of the cornea or sciera, and anticholinergic drugs may cause photophobia by paralyzing the iris sphincter muscle.³

Thanks to these gray-tinted contact lenses, this severely photophobic patient was able to excel at water sports and enjoy the beach.

Management: As a result of this patient's intense photophobia, his desire to enjoy water sports and his parent's concern regarding UV-exposure to their son's eyes, I decided to fit him with corrective-powered, daily disposable UV-absorbing medium dark gray-tinted contact lenses worn only while participating in water-related activities. I determined the tint's exact intensity by creating in-office, gray-tinted lenses of different darknesses and having the patient wear them in various light conditions to determine the most comfortable combination of color and iris mask size. The trial process was initially performed in-office, and then a few pair of daily lenses were "test driven" during his normal water sports activities before the final color combination was chosen. The patient orders a 90 pack of lenses at a time, and the lenses are tinted in-office.

Financial rewards: Cases like this result in a multi-faceted care program. The initial task was to fit the patient bilaterally with prosthetic-effect hydrophilic lenses, which resulted in fees for services and materials in the range of $900 to $1,500. The next project was the tinted one-day soft lenses. The services and materials for this range from $1,000.00 to $1,500.00. The patient's mother has since referred several patients to the center for similar services.

Outcome: This young man is now participating in a junior lifeguard program and can perform his training without discomfort. He has also excelled in his water polo sport and has scored goals since he started wearing the tinted lenses. Because color deficiency and photophobia can have just as much of an affect on one's quality of life as many refractive issues, dispensing therapeutic specialty-tinted contact lenses has the potential to have just as much of an affect on your practice's revenue as the dispensing of spectacles and regular contact lenses. As result, it's time you consider adding this unique and profitable service to your practice. OM

Dr. Sanders is an associate professor at the Southern California College of Optometry. Her clinical teaching responsibilities are in the Contact Lens Service and Ocular Prosthetic Service of the College's Eye Care Center in Fullerton, Calif. E-mail her at ssanders@scco.edu.