The cutest six-year-old young man arrives for his first eye exam. He failed his school vision screening. The vision report that his mom brought in had the check mark in the visual acuity box with the notation that the left eye only had failed.

Mom is surprised because of the lack of a family history of any significant vision problems, just the usual, grandparents needing reading glasses, the occasional aunt or uncle wearing contacts or glasses for driving.

Ho hum, no big deal, the run of the mill case history. Lovely young man and mom is charming, too. So I suspect that there is just the customary child maybe wanting glasses.

Oops, so much for my predictive powers, what do we have here? Plano OD, and a -6.00 diopter autorefract OS, with visual acuities of 20/20 OD and no patient response to any visual acuity, OS.

All of a sudden, the usual becomes very much more interesting.

There is not any history of an eye turn, or trauma, and he has never failed a vision screening before, so much for routine screenings, that is another story. He is a healthy young man, all developmental milestones have been met and he does very well in school.

The refraction is as advertised Plano OD yields 20/20 with a -6.00 sphere OS, the visual acuity is possibly 20/400. Both eyes are healthy; there is not a sign of any strabismus at distance or near.

Okay, now what to recommend? Glasses vs. contact lenses? Most of the time, when I begin to recommend a contact lens for this type of case, the parents are less than thrilled with the idea.

Realizing the amount of responsibility they will ultimately have for the contacts can be scary for parents who do not wear contact lenses themselves. Most of these parents are not ready for that so they will settle for glasses, but something about Ian and his Mom gave me hope that they will be receptive to this optimum treatment plan, and I was correct.

After a few questions that were easily answered we decided to go ahead with a contact lens for his left eye. However, I decided to recommend the Ciba Night and Day for extended wear (I have no financial interest in the Ciba products).

What I hope to accomplish .....is to encourage you to think outside the box.

My theory was that this patient would always have a lens on his left eye, so that would maximize the optimum visual acuity for that eye. There would not be a time, either on the weekends, or if he woke up late for school and did not have enough time to insert the lens, where he would be without contact lens on his eye. In addition, there was the added benefit that the parents would not have any extensive care of the lens other than once per month to remove a lens and reinsert a new one.

The initial diagnostic evaluation lens selection performed well, and the trial lens that I ordered for him, B.C. 8.6 -6.00 sphere, became the lens he took home that day.

Both parents participated in the contact lens instruction. Ian, himself, learned how to take the lens out, always a good skill for a young patient to accomplish. The 1-week progress was uneventful. Parents and child were comfortable with the overnight wear of the lens. One incident occurred with the lens coming out of his eye, but it was reinserted without any problem.

His cornea was clear without any sign of insult or edema. Visual acuity of that eye was still only 20/100 on that visit, but that is all I expected. Based on the age of the patient and the significant amount of anisometropia, I do not expect much improvement in his visual acuity. With an anisometropia of greater than 5.00 diopters of myopia, there is a greater than 75% risk of amblyopia. However, even with this guarded prognosis, I expect Ian to have improvements in his depth perception and binocular vision skills.

At his 1-month progress evaluation, occlusion therapy was initiated. With this deep amount of amblyopia, I recommended 6hours per day of occlusion therapy for Ian. The 2 hours per day regimen, published recently, is for milder amount of amblyopia.

At his 2 month evaluation visual acuity is 20/80 with single letter. Ian is doing fine with the lens. He is a great kid and I hope to have his acuity improve to at least 20/40. That is always a goal, because then he could have a life without restrictions should anything happen to his better seeing eye.

About the same time as I saw Ian, I saw another patient the same age with the same issues, although she was a hyperopic as he was myopic. This young lady was wearing glasses and receiving occlusion therapy already. Her mother was concerned that more could be done to improve her daughter?s vision. I decided to fit her with a standard 2-week disposable lens because both parents wear contact lenses and were comfortable with the routine of daily wear. She has worn her lens for about the same period but it keeps "falling out". I suspect that she fiddles with it during school, and then it comes out.

Last week, based on the successful results with Ian I decided to order her a 30 day EW lens as well, just on a trial basis to see if the lens is more comfortable for her. I am curious but this young patient appears to be less compliant with contact lens wear, in spite of her having parents who do.

What I hope to accomplish with these cases is to encourage you to think outside of the box in your treatment of these young refractive anisometropic amblyopes. We all know that contact lenses are the best option, but with close monitoring the newer extended wear lenses will help the parents by minimizing the amount of time they would need to spend on the care of the lens.