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| CASE REPORT |
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| Year : 2022 | Volume
: 2
| Issue : 3 | Page : 736-738 |
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Intervention of Adie's tonic pupil with iris tinted contact lenses with clear pupil - Case report
Hiral J Korani1, Karishma Bhate2, Disha Bhalakia3
1 Department of Optometry, Lotus College of Optometry, Mumbai, Maharashtra, India
2 Department of Glaucoma, Lotus Eye Hospital, Mumbai, Maharashtra, India
3 School of Optometry, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
| Date of Submission | 14-Oct-2021 |
| Date of Acceptance | 18-Feb-2022 |
| Date of Web Publication | 16-Jul-2022 |
Correspondence Address:
Dr. Hiral J Korani
Lotus College of Optometry, 13th NS Road, Vithalnagar Society, JVPD, Juhu - 400 049 Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_2602_21
We report the optometric management of a 27-year-old female diagnosed with Adie's tonic pupil who was otherwise systemically stable. This case report is an effort to understand how tonic pupil management with iris tinted clear pupil contact lenses helps to resolve quantitative and qualitative visual disturbances similar to pharmacological treatment (diluted pilocarpine). The case report shows that it is an effective alternative management to overcome visual symptoms for patients with Adie's tonic pupil compared to pilocarpine (0.1%).
Keywords: Accommodation, Adies tonic pupil, diluted pilocarpine, Glare sensitivity, Iris tinted clear pupil contact
How to cite this article:
Korani HJ, Bhate K, Bhalakia D. Intervention of Adie's tonic pupil with iris tinted contact lenses with clear pupil - Case report. Indian J Ophthalmol Case Rep 2022;2:736-8 |
How to cite this URL:
Korani HJ, Bhate K, Bhalakia D. Intervention of Adie's tonic pupil with iris tinted contact lenses with clear pupil - Case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Apr 2];2:736-8. Available from: https://www.ijoreports.in/text.asp?2022/2/3/736/351143 |
Adie tonic pupil is a neurological disorder in which there is parasympathetic denervation of the affected pupil, leading to dilated unilateral or bilateral pupils with light-near dissociation, photophobia, and blurry near vision.[1],[2] It is common in females between 20 and 40 years of age.[1] The low-concentration pilocarpine (0.01%) test helps to demonstrate the cholinergic denervation in the affected eye.[1],[2]
Management for Adie's tonic pupil includes prescription of bifocal spectacles or low-dose pilocarpine. Long-term use of pilocarpine can lead to ciliary spasm, brow ache, worsen anisocoria, or induce nearsightedness.[3] Use of tinted contact lenses with clear pupils has proven beneficial in conditions such as albinism to reduce photosensitivity.[4],[5] Use of contact lenses has been limited in the management of Adie's tonic pupil. This case report describes the management of a patient with Adie's tonic pupil with poor visual function by using an iris-tinted contact lens with a 4-mm clear pupil and compared with diluted pilocarpine administration.
| Case Report | |  |
A 27-year-old female presented to Lotus Eye Hospital for a second opinion on June 17, 2021 with complaints of irregular pupil size in the last 2–3 months and photophobia. She was prescribed pilocar 2% in the left eye twice a day (for 1 week) elsewhere but did not use it. The patient had no history of ocular surgery, trauma, or any systemic disease in the past. Her best-corrected visual acuity in each eye was 0.0 logMAR for distance and 0.4 M for near at 40 cm. Her extraocular motility was normal. The anterior segment examination revealed anisocoria, with the left eye (affected eye) pupil being larger (7 mm) and not responsive to direct and indirect light stimulus as compared to the right eye [Figure 1] and poor response to near reflex. No abnormality was detected in the posterior segment. | Figure 1: A 27-year-old female was diagnosed with Adie's tonic pupil as the left eye pupil was dilated and there was no response to light
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Pharmacological testing was undertaken by instilling diluted pilocarpine (0.1%) in both eyes. After 30 min, the pupils were observed showing left eye pupil constriction, while the right eye pupil remained unaffected confirming the diagnosis of Adie's tonic pupil [Figure 2]. | Figure 2: The image was taken post instillation of diluted pilocarpine in both eyes, right eye (top) and left eye (bottom)
Click here to view |
Our patient had Adie's pupil without any systemic autonomic involvement. She did not have any clinical findings to support predisposing systemic illness and was evaluated by a neurologist to rule out other potentially serious disorders.
She was referred to the contact lens department of Lotus College of Optometry for qualitative and quantitative tests comparison, such as contrast sensitivity with glare tester, distance and near visual acuity, and amplitude of accommodation between iris tinted with clear-pupil contact lens and pilocarpine versus without intervention. She visited on June 18, 2021, prior to the contact lens fitting and pilocarpine instillation. Written consent was obtained for identifiable health information included in this case report, and authorization for a waiver from the ethics committee of Lotus College of Optometry and Lotus Eye hospital was approved. All the tests were measured at baseline with distance spectacles, carried out by a final year optometry student under the supervision of a senior optometrist. She was fitted with lenses (Purecon Pvt. Ltd.) in her left eye having median base curve, 14-mm diameter, 4-mm clear pupil diameter, Plano power, and dark brown “C” type iris color [Figure 3]. Measurements were repeated post 30 min of obtaining the optimal fitting. Similarly, tests were repeated post 30 min of 2% pilocarpine diluted to 1/10th. No difference was found in the visual functions such as near vision and amplitude of accommodation under three conditions (distance spectacles, with contact lens, and diluted pilocarpine). Contrast sensitivity with glare source was found to be better with contact lens than the other two conditions [Table 1]. | Table 1: Comparison of measurements with spectacles, contact lens, and pilocarpine
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 | Figure 3: Image of the patient with a trial prosthetic lens in the left eye. The available trial lens was used to see the improvement in photophobia symptoms.
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| Discussion | | |
Two major goals achieved in this patient with the use of contact lenses included (1) a decrease in glare and (2) cosmetic improvement of anisocoric pupils.
The use of tinted soft lenses for aniridia, albinism, and Adie's tonic pupil has been reported in the literature.[5],[6],[7] Studies have shown that the use of tinted soft contact lenses/spectacles decrease photophobia in various types of patients.[7],[8] The present case report demonstrates that the use of a tinted-iris contact lens with a 4-mm clear pupil reduces glare sensitivity and delivers an advantage on the visual function. Philips et al.[9] observed that when a severe albino patient was fitted with a soft prosthetic contact lens, photophobic symptoms reduced and facial cosmesis was enhanced. Studies on reduced pupil diameter and accommodation have reported no induced accommodative effect,[10] which was also noted in this case study.
Studies have reported pilocarpine eye drops being successful and the most acceptable treatment for Adie's tonic pupil. However, 1%–4% pilocarpine is poorly tolerated due to significant ocular side effects.[5] Dilute formulation of pilocarpine 0.1% is considered, but this formulation is not commercially available and has to be specially compounded, which may be expensive; moreover, its sterility is questionable. Though the patient's functional vision with pilocarpine and contact lens was the same, because of expense and sterility issues, contact lens was considered to be an ideal management plan.
Therefore, clinicians encountering a symptomatic patient with Adie's pupil should prescribe/consider iris-tinted clear-pupil contact lens to overcome the symptoms of photophobia and cosmesis.
| Conclusion | | |
Contact lenses with tinted iris and clear pupil can be prescribed to patients with Adie's tonic pupil for reducing the amount of light entering the dilated pupil, thereby decreasing the symptoms of glare and sensitivity to light and not affecting accommodation. However, appropriate care and maintenance are needed to fulfill the rehabilitative role in patients with Adie's tonic pupil.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Leavitt JA, Wayman LL, Hodge DO, Brubaker R. Pupillary response to four concentrations of pilocarpine in normal subjects: Application to testing for Adie tonic pupil. Am J Ophthalmol 2002;133:333-6.  |
| 2. | National Institute of Neurological Disorders and Stroke. Holmes Adie Syndrome Information Page. Last updated on 27/03/2019. |
| 3. | Thompson HS. Adie's syndrome: Some new observations. Trans Am Ophthalmol Soc 1977;75:587-626. |
| 4. | Omar R, Idris SS, Meng CK, Knight VF. Management of visual disturbances in albinism: A case report. J Med Case Rep 2012;6:316. |
| 5. | Vincent SJ. The use of contact lenses in low vision rehabilitation: Optical and therapeutic applications. Clin Exp Optom 2017;100:513-21. |
| 6. | Spinell MR, Haransky E. The use of the new Wesley lessen opaque lens for a congenital aniridia patient. International contact lens clinic 1987;14:489-91. |
| 7. | Zack MN. The cosmetic treatment of Adie's tonic pupil using selectively tinted hydrophilic soft contact lenses. Cont Lens Anterior Eye 1984;12:14-5. |
| 8. | Connor CG, Williams S, Ebbers R. A New Method to Relieve Photophobia and Glare Problems in Your Patients. CL Spectrum1992;3:41:2. |
| 9. | Philips AJ. A prosthetic contact lens in the treatment of ocular manifestations of albinism. Clin Exp Opt 1989;72:32-4. |
| 10. | Charman WN, Radhakrishnan H. Accommodation, pupil diameter and myopia. Ophthalmic Physiol Opt 2009;29:72-9. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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