The College of Optometrists

could you please outline a good fitting cl's history and symptoms for the final exams.

Possible Contact Lens Routine

You will get the relevant history during the prior eye exam.

Your aim with the history will be to try and get clues as to things that will be issues later. Example: possible compliance issues, previous infections or other problems, experience with previous lenses. Health issues (such as arthritis: dry eye; diabetes: slowed healing response; can affect wear. Medications can dry the eyes and also alter the healing response and should the noted and planned for. (a copy of the BNF will help you)

Armed with all this data - you can then examine the eyelids, inverting both looking for signs of papillae and tear film, using fluorescen; examine the cornea and record any findings. Look at the bulbar conjunctiva for folds, dry areas, Pingecula etc and record carefully.

While you are doing this you can discuss your findings as you go along and explain how they can affect out comes of contact lens wear.

Get your k readings and measure the lid aperture and dimensions of pupil and corneal size.

Now you have all your facts you can discuss your care plan with your patient.

Your care plan should include the type of lens best suited to the facts - daily good comfort and safety, but thin and not suitable for a dry eye as can tear. Silicon’s - only suitable lens for extended use - but also commonly fitted for people with long term ocular changes (such as neovascularization), hydrogel lenses - fast becoming obsolete - but handy for people needing high water content and also high prescriptions, presbyopic and astigmatic prescriptions.

Your care plan should include a proposed sustainable wearing schedule = occasional use for damaged eyes and young eyes (which being more labile can get neovascularization more easily), daily use for people with strong healthy eyes (even still a day a week rest is usually advised), etc.

This will naturally open a discussion about long term changes to the cornea from contact lens use - and infections (short term changes). You should include here telling how to manage infections and how to minimise risk to the eyes. How they go with this is called "compliance" and is a key factor in future contact lens wear. Ethically, you cannot stop anyone from using contact lenses - you can only warn them of the dangers. But, if they are non-compliant and irresponsibly endangering their eyes - then ethics would call that you stop wear (or modify it to control that risk).

The ethical situation is one of 'informed choice' - that is: the patient knows how to stay safe from a knowledge base you instill. This, of course, implies that the advice is accurate and upto date.

Trial lenses are now fitted and after a 30 minute settling in period - checked for fit, comfort and vision.

The lenses can then be removed and fluorescen re-instilled and the eyes examined for signs of poor fit - rubbing etc.

After discussing and teaching safe handling techniques and supplying a solution to clean and store the lenses (check for allergy) - then the trial lenses can be dispensed.

Aftercare is scheduled after a couple of weeks and the patient is asked to come in wearing the lenses. (And bring their glasses).

Take history and note any problems encountered. Re-assess lens type to help minimise these problems Check vision and fit.

Remove lenses and instill fluorescen

Check the eyelids, bulbar eye and cornea for staining etc and re-assess.

If all okay - issue (upto) three months prescription and order three months worth of lenses.

Then aftercare and re-issue Rx - this time upto one year. If problem - refit with more suitable lenses and restart two week trial wear.

As you can see - there is quite a few steps to take to keep the whole thing patient centered.

After I wrote this, I realised you wanted something on symptoms and history !! I will do it over the next couple of days. Anyway, there is a routine :-) Good luck in your finals.

Hi Ikhan

here it is! I am not sure if it is what you want ? Let me know if you're looking for more

Hope it helps - steve

My Contact Lens History!

The idea of taking a history is to build up a care plan to help the patient. In a way - we also use the history to modify the patients expectations about what can be achieved.

There is no point is taking any part of history without using the information!

Care Plans are: lens modality - daily disposable/ 2 weekly disposable/ monthly disposable/ traditional/ gp's , material type, type of wear from no wear at all through occasional wear to full time extended.

And take into account, safety, minimizing the risk of infections and long term ocular health sustainability. The care plan will be based on

Current wear and Current Problems,

Compliance,

General health and medications,

AGE,

Family history,

Current Spex Wear.

A Caution to using contact lenses would be

- Young age: enhanced risk of corneal neovascularization, possible compliance issues, unable to give consent if under 16 years old.

-Old age: reduced finger-tip sensitivity and reduced handling skills, chronic blepharitis and reduced lachrymal secretions, more complex prescriptions can make patients focal demands unrealistic.

- Many years of previous contact lens use: corneal neovascularization, low endothelial count, poor tear film, corneal warping etc

- Chronic Health problems Diabetes: slowed healing, tear film changes, fragile corneal epithelium, reduced corneal sensitivity, changeable corneal thickness, and increased risk of infections.

-Long term medications: heart and hypertension pills: reduced lachrymal secretions, meds like methotrexate and steroids give reduced response to infections and reduced lachrymal secretions. Best to get a BNF book and use it!

-Long term eye drop user: glaucoma etc would be a contra-indication while comfort eye drops a caution.

Arthritis: reduced lachrymal secretions and increased risk of infections

Thyroid dysfunction: reduced lachrymal secretions

Rosacea Acne, acne vulgaris, eczema etc. : chronic blepharitis and chronic ocular irritations.

Hay fever, other allergies including solution allergies - increased ocular sensitivity

So, rather than present a list of questions - I have shown what would represent a 'caution' for contact lens use. Add to this what the patient requests (for example for sports - swimming would be a ‘no’) and you can plan what to offer them.

It must also be woven in that you must show you have gained their consent to use lenses, knowing the unpredictable risk of problems - both short term and long term.

Taking that a perfectly healthy 25 year old would be able to take most types of lenses and wear them for reasonable periods.

You can contrast at the other end of the scale: someone who is 60 and has medicines for diabetes and has arthritis controlled with methotrexate maybe safer to use a monthly silicon lens (thicker - so easier to handle, daily tear easily in dry eye), and wear it part time as a treat.

Each caution listed above has a particular lens that may help - but if you feel that risks outweigh the benefits: then you must refuse to fit, and be able to explain why.

Symptoms:

Most patients will give you a glowing report on their contact lens wear, if they think you will stop them.

Equally, those hoping for improvement will make things sound worse than they are!

So you may get more accurate idea by asking qualitative questions as marks out of ten - with ten being perfect and zero is dreadful!

So how comfortable are the lenses at their best - marks out of ten?

And at their very worst after a long day - marks out of ten?

How easy are they to remove if they feel gritty?

How red do your eyes go after wearing lenses all day - marks out of ten?

-get the idea? Its a bit more searching!

How clear is the vision at its best -and at its worst? (Don’t forget most people’s vision will smear over when tired and eyes feel dry)

Are you on any medicines - any health changes?

One idea to gain from the symptoms is what to do within your aftercare -

So - if they declare that they are now taking hypertensive tablets - you remember to have a look at the fundus to check for any retinopathy.

From the flow of conversation - you can guess their overall compliance and advise them on getting it better - or change to a more benign lens if you suspect their compliance is poor. Don't forget - serious infections can occur out of the blue - even on with the most careful person - so compliance is important, as is a back up system for them.

You can then add these ideas to your aftercare findings = and work out your care plan to discuss with them.

As important as all this is careful note taking.

Good luck !!

steve

thanks Steve

It is clear form the recent examiners meeting that candidates are going to be expected to talk through their fitting and aftercare and particularly slit lamp routine during this one hour final assessment exam. This might be worth practising with your supervisor.

... and don't foget to use correct terminology: vascularisation instead of neovascularisation; Eversion of lids, instead of inversionof lids etc ...

After reading through the College guidelines I'm a little unclear on the CL fitting and aftercare required in the final assessment. Are we supposed to run through the procedure as we normally would in practice, omitting the parts where the info has been given to us (e.g history in CL fitting)? Or are we only expected to do what is given in the guidelines?

For example, will we be expected to do a full slit lamp exam of both eyes prior to inserting the CLs, or just a tear film assessment of the RGP eye?

Do we still need to over refract on the fitting, as the trial lenses used are likely to be the wrong prescription?

After removing the lenses are we expected to instill FLN again and assess for any damage?

In terms of competency 7.1 are we required to ensure the patient is capable of insertion and removal during the 1hr assessment?

With the aftercare, as the over refraction results will be given, does this mean we will not be required to assess VA??

Sorry for all the questions, this section is making me a tad nervous!

(one more - does anyone know when we are to expect our exam dates?)

You will have an hour to do the aftercare on one eye and a fitting of an RGP and soft lens i.e. half an hour for each.

It would be therefore sensible to do a slit lamp before inserting the lenses and after to make sure you haven't damaged the eyes and obviously during the fit to assess it.

You can over-refract if you have the time in the fitting exam but as you are not expected to in the aftercare I don't think it's critical. Really in the fitting we are looking to see how you choose, insert and remove and judge the fit of a lens. if overrefraction helps you with that fine.

You should always assess an eye after removing the lenses to assess for any damage.

In terms of competency 7.1 I do not think you could to ensure the patient is capable of insertion and removal during the fitting assessment, you should at least question your aftercare patient on their I&R and it might be possible to assess their physical skills in this exam ?

With the aftercare, you do not have to do over refraction (the results will be not be given), you can do VA, but not an over refraction.

Can't help you on when you will recive your exam dates.

Thank you for the prompt and concise reply Tim, much appreciated.

Konni

Tim it says on the fitting guidelines that a slit lamp exam and keratometry and st the day before has already been carried out so would we need to do slit lamp again before fitting. and you only need to assess the tears in the RGP eye

5.2.1 Practical Fitting Section The candidate is provided with a patient and should be advised that the patient is a prospective contact lens wearer and that it may be assumed that a full preliminary routine, including a slit-lamp assessment and keratometry, has been carried out. The candidate will then be required to:

5.2.1.1 Select a suitable rigid lens for one eye and soft lens type for the other eye, on the basis of the available information.

5.2.1.2 Given Keratometry readings and spectacle refraction, take any additional measurements as necessary to select a suitable rigid gas permeable lens for one eye and soft lens for the other eye.

5.2.1.3 Assess the tear film on the eye that is to be fitted with a rigid gas permeable lens (this should include tear prism assessment and tear break-up).

5.2.1.4 Insert a rigid gas permeable into one eye and a soft lens into the other eye.

No need to do slit lamp pre fit and as you say tear film on RGP eye.