By the time I saw Yisroel, a 16 year-old Yeshiva student yesterday, his mother reported that he had previously seen all kinds of specialists. His odyssey began with his entry into this world, having been born with a congenital cataract of the left eye. I had no previous records available at the time of his evaluation, but was able to capture an image of his lens through my phone camera held to the slit lamp ocular.
As you can see in this undilated view, the cataract spares enough of his visual axis in the pupillary space to afford good visual acuity. The decision was therefore made when he was an infant not to remove his lens. Through the years, his mother was told that his right eye was “perfect”, but that his left eye would need to be checked frequently to make sure that his vision was developing normally. Yisroel came for his visit wearing glasses with no power in the right lens, and a power of +1.50 -0.50 cx 080 in the left lens. There was no history of visual treatment other than his spectacle Rx. His presenting visual acuity through the right eye was 20/40 at distance and 20/20 at near. His acuity through the left eye with his Rx on was 20/30 at distance and near.
My evaluation showed that Yisroel was able to see 20/20 at distance with the right eye through -0.75 sphere, and 20/20 through the left eye with +2.25 – 0.75 cx 085. In addition, he exhibited considerable convergence insufficiency, and intermittent suppression of the left eye at near. Fusional stability was obtained, and best binocular balance at distance and near by cutting 0.25 sphere OD and OS, and incorporating 2^ base-in for the left eye.
We are often called upon to make decisions without having access to prior records a the time of our evaluation and frankly, in many cases, prior records don’t tell us much and won’t change our clinical decision making. In Yisroel’s case the many specialists that he had seen previously were initially eye specialists, but through the years involved learning specialists puzzled by the discrepancy between his intellect and learning performance. Whenever his mother inquired about his vision, she was reassured that it had no bearing on his learning. That is, until yesterday, when he finally saw the right kind of specialist.
The VisionHelp Blog 
Out of curiosity, would you consider a cyl contact lens for the left eye only.
I would, if it were apparent that image size differences or induced vertical prismatic imbalance were significant factors with spectacles. What I Rxed was a good starting point but in some cases there is additional benefit from going with a contact lens and using spectacles over that to provide the desired prism.