If I’m being honest, I almost always cringe when I see our pediatric surgeon calling my cell phone. He’s the nicest guy in the world. However, it typically means he’s sending someone my way. Odds are it’s almost always a train wreck even by his standards. You can almost bet your mortgage that he’s just finished sewing a cornea back together. Once healing is complete it is time to begin healing the refractive system. At best caring for these patients is an adrenaline rush. At best it can be overwhelming.

Fact is it used to be overwhelming.

A while back I concluded that there was no foolproof way of dealing with each of these cases. While daunting in that there is not a standard of care to follow (outside of “first do no harm”) I found it liberating to have complete freedom to attempt whatever had a reasonable chance of success in the name of improving a child’s life.

Below are three diverse cases with equally diverse prescriptions. What correction would you have chosen for each case? Leave your comments below and let’s make this interactive. Optometry owns the refractive realm of eye care – even though sometimes we may wish we didn’t!

Case 1

A 12-year-old female suffers a penetrating eye injury from a hot dog skewer following a family cookout. The surgeon removes the damaged lens, places an IOL, and sutures the cornea after repositioning the iris. Best corrected vision after a proper time for healing is 20/70. Corneal RGPs fail to center and standard scleral lenses fail to clear the elevated sutures while maintaining proper corneal physiology. After utilizing the EyePrint Prosthetic device the patient is able to obtain 20/15 vision.

Case 2

A 4-month-old is referred by his pediatrician due to the presence of congenital cataracts.  The child’s father also had congenital cataracts and was mostly responsible for the early intervention. The father is also quite adept at handling corneal RGPs as he has worn them for the past forty years.

The handheld keratometer malfunctioned so I managed to convince the pediatric surgeon to allow me to perform a trial lens fitting while the child was still under anesthesia. It was the easiest fitting in the history of mankind! The child continues to do remarkably well a year later while wearing bilateral +25.50 Pediasite corneal RGPs. It is expected that he will require rapid changes to his lenses as the eye matures.

Case 3

A 2-year-old suffers a penetrating corneal injury from a spike left behind by construction crews. It takes the surgeon nearly four hours to piece the cornea back together. Two weeks after surgery the child’s refraction was measured at +12.50 DS. It is assumed that the central cornea is exceptionally flat due to the large number of sutures required. There was concern that a corneal RGP may increase irritation and the potential for sutural issues.  The child was instead fit with a +12.50 DS Biofinity XR soft lens. 

Why was the lens power not vertexed? The refraction in the fellow eye is a +3.00 DS – thus, polycarbonate spectacles have been prescribed with +3.00 DS OU in an attempt to minimize the potential for amblyopia. The lens has doubled as a bandage and the child has now stopped rubbing the eye.