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Patient Management


Patient management is the process of careful investigation before a patient is fitted with contact lenses and maintaining successful wear afterwards. It is a means of informing, examining and selecting potential wearers, as well as anticipating or investigating possible causes that may prevent effective contact lens wear. Patient management is also a routine for regular aftercare, dealing with emergencies and treating problems successfully. It is all the processes by which a non–contact lens wearer is changed into and maintained as a successful lens wearer.

Patient management means focusing on the patient, ideally taking time to establish a connection with him or her before starting the formal part of the consultation, by showing empathy and using humour and laughter to improve communication. A patient-centred approach takes an interest in the patient as a person by spending a little time establishing a rapport with them and finding out about them, their families and their interests.

Establish what knowledge they have about contact lenses. For some it will be a mystery; others will have preconceived ideas having spoken to family and friends or researched using the Internet or social media. Each patient needs his or her own individual management and discussion.

The elements of patient management include:

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    initial discussion

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    examination and evaluation

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    diagnosis

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    prognosis

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    care plan

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    education.

There is a lot of overlap between the sections, and discussion and education are ongoing during the examination and once diagnosis and prognosis are established. A systematic approach will ensure that the initial examination is thorough but needs to be adapted according to each patient's requirements.

In assessing the patient's suitability for wearing contact lenses:

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    Look for areas of potential difficulty, and anticipate these with warnings of the possible limitations of contact lens performance or the need to use special lenses to overcome them.

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    Establish a system of training, instruction, indoctrination and information.

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    Have a system for dealing with potential or real emergencies should they occur.

Some Frequently Asked Questions

New lens wearers ask many questions. The following are some of the more common questions together with possible answers:

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    Will the lenses fall out?

Because soft lenses are flexible, they take up the eye's shape, fit under the eyelids and are therefore comfortable. They stay securely on the eye for most activities except possibly contact sports, where the lens may be moved off centre by an opponent's finger.

Rigid lenses may very occasionally dislodge during more extreme eye movements. A low-power disposable soft lens can be worn over a rigid lens for sports.

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    Will I feel the lenses?

It is worthwhile to prepare the patient for the first lens insertion with calming talk and a demonstration of the lenses.

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      Soft lenses

Demonstrate the softness and flexibility of the lens before inserting it. Try to insert the lens reasonably quickly rather than discussing it too much so that the patient can feel that there is very little sensation and start to relax.

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      Rigid lenses

Rigid lenses initially produce more sensation. The use of a topical anaesthetic (such as proxymetacaine hydrochloride 0.5%) will help, but corneal epithelial staining is more likely when an anaesthetic is used. Have the patient look down once the lens is in so that there is less lid sensation.

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    Does it take long to get used to lenses?

The time taken to adapt to the lenses will depend on the patient and on the type of lenses. Soft lens wearers do not need to be too restrictive in building up wearing time and can wear them for about 8 hours the first day and subsequently wear the lenses for as long as they are comfortable. Rigid lens wearers need more time and could start at about 4 hours, adding 1–2 hours daily. Those with sensitive eyes or irregular corneas may take longer to adapt.

Unless contact lenses are specifically fitted for extended or continuous wear, sleeping in lenses is not recommended. During sleep the tear constituents are altered ( ), less watery tears are produced and corneal hypoxia may result. The risk of infection is also increased if worn on a 24-hour basis.

Lubricating drops may be beneficial to extended lens wearers they may need to wait up to half an hour after waking before the lenses are mobile enough to be removed comfortably from the eye. Rigid lenses may be less comfortable to sleep in initially, although orthokeratology lens wearers do not usually have problems, possibly because the cornea recovers during the day without lenses (see Chapter 19 ).

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    Can I swim in my lenses?

Swimming in lenses has been shown to increase the risk of infection and should be discouraged altogether. Hypotonic water makes lenses fit more tightly, making them difficult to remove, whilst swimming pool disinfectants can make the water hypertonic and the lenses adhere to the eye more ( ). They are also retained in soft lens materials with potentially toxic effects. If patients insist on wearing lenses for water sports, it is safer but still potentially risky to wear swimming goggles and remove and discard lenses afterwards if viable ( and see Chapter 16 ).

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    Can I wear lenses in the shower or in the rain?

It is advisable to remove lenses for showering and bathing because the risk of infection, in particular Acanthamoeba keratitis, increases ( ). Alternatively, daily disposable soft lenses can be used for swimming, even if not exactly the correct prescription, and then discarded. Wearing them in the rain is unlikely to cause infection.

Initial Examination

Prefitting assessment is covered in Chapter 6 , but briefly:

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    Establish why the patient requires lenses:

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      sport

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      hobbies

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      full-time wear.

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    Take careful symptoms and history, including:

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      existing pathology so that potential contact lens problems can be considered

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      history of previous ocular infection; for example, Herpes simplex virus carries a risk of recurrence and extended wear should be avoided.

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    Decide whether treatment is necessary before contact lenses are to be fitted, and if so, initiate the treatment.

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    Carry out a careful refraction, including binocular balancing and amplitude of accommodation, to find the spectacle prescription that must be replicated in contact lens form.

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    Examine the anterior eye to establish the baseline ocular appearance.

Spectacle prescription

Degree of Ametropia

Contact lenses are available to correct most low to moderate degrees of ametropia. In the main, disposable lenses are the first lens of choice, but each patient must be assessed individually. For those with high prescriptions or ocular pathology, custom-made lenses are necessary (see Specialist Lens Fitting section, Chapter 19, Chapter 20, Chapter 21, Chapter 22, Chapter 23, Chapter 24, Chapter 25, Chapter 26 ).

Uncorrected Astigmatism and Presbyopia.

Toric and multifocal lenses are readily available in soft disposable form, but at times, a spectacle correction worn over a spherical contact lens prescription may produce the best acuity. For example, a presbyopic patient with moderate astigmatism may see better with spherical daily contact lenses worn with multifocal spectacles for detailed tasks, rather than attempting to incorporate the full prescription into contact lenses (see Chapter 13 ).

Binocular Vision Anomalies.

Only low degrees of vertical prism can be incorporated into most contact lenses, except for scleral lenses, which also can incorporate a low degree of horizontal prism. Uncorrected binocular problems cause discomfort if lenses are worn full time, which can only be alleviated by wearing the necessary prism in a spectacle overcorrection.

Slit-Lamp Examination

It is vital to carefully examine the eyelids, cornea and anterior eye using high- and low-power magnification and varying types of illumination (see Chapters 6 and 8 ).

Grading scales

Grading scales are better than word descriptions. They provide a consistent reference image for comparison when recording and monitoring both normal and anomalous appearances. The best known are the Brien Holden Vision Institute (BHVI) (see Appendix B and https://expertconsult.inkling.com/ ,) and the Efron grading scales. In addition, digital images can be stored alongside the patient record.

The following appearances should be graded:

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    limbal and conjunctival redness

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    palpebral conjunctival redness and roughness

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    corneal and conjunctival stain

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    endothelial cell polymorphism.

Using direct illumination, examine:

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    the eyelid margins, lashes and meibomian glands

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    the appearance of the tear film (see Chapter 5 ):

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      tear quality:

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        oily

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        frothy

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        tear thickness

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      tear break-up times with and without fluorescein

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      tear prism height.

Using direct, indirect, retro-illumination and specular reflection, examine:

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    bulbar conjunctiva

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    cornea

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    pupil diameter in average and bright light.

Evert the eyelids, and examine upper and lower palpebral conjunctiva in both white and blue light. The ease or difficulty of eyelid eversion is often a clue as to how simple inserting the first lens is going to be:

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      The lower eyelid must be pulled down to examine the inferior palpebral conjunctiva.

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      The upper eyelid must be everted by pulling the lashes down and away from the eye while at the same time, pushing behind the upper tarsal plate with a finger or a cotton bud (see and courtesy of Tony Phillips).

Also examine:

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      anterior angle

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      crystalline lens.

Further tests to be carried out include corneal topography and/or keratometry.

Existing Pathologies

These need to be considered carefully and treated if possible, before starting contact lens wear. These are covered in Chapter 5, Chapter 6, Chapter 16, Chapter 17

Evaluation

Selecting the first lens

The optimal lens for the patient should now be selected and advice given on safe wearing times and possible limitations. Fees and lens charges need to be discussed (see p. 316 ).

Considerations for lens type include:

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    which lens type to use

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    cost and availability of the preferred lens type

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    ease of handling, insertion and removal

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    the need for specialised lenses or materials.

A variety of designs, makes and sizes should be available in soft and rigid materials: spherical, toric and multifocal prescriptions. Specialist practices also are likely to have other lens types for conditions such as keratoconus or orthokeratology.

Use the spectacle refraction to arrive at an estimated power, allowing for back vertex distance and ignoring cylinders of less than 0.75 D unless the acuity is affected. Ideally, the first lens should be easy to insert, settle quickly, be comfortable and give good vision.

The large majority of soft contact lenses fitted nowadays are disposable, and the range of lenses available continues to increase, covering high minus, high plus and high astigmatism. Only a small proportion of patients cannot be fitted with disposable lenses. They require tailor-made soft lenses if their prescription, eye size or eye problem means that they fall outside the range of disposable lenses. A big advantage of disposable lenses is that they can be replaced quickly and easily if a lens is lost or damaged or if the wearer's prescription changes. Most can be worn comfortably all day or alternated with spectacle wear.

Disposable trial lenses should be used and thrown away or dispensed to the patient. Any soft, tailor-made trial lenses that are not disposed of should be cleaned carefully and disinfected in a peroxide solution (see Chapter 4 ). Rigid trial lenses should be cleaned with peroxide or sodium hypochlorite solutions, and stored dry (see UK regulations see https://guidance.college-optometrists.org/guidance-contents/safety-and-quality-domain/infection-control/the-re-use-of-contact-lenses-and-ophthalmic-devices/ ).

Rigid lenses are mostly individually made, though some stock rigid lenses are available. Rigid lenses may give better acuity, especially for irregular corneas (see Chapter 9, Chapter 20, Chapter 22, Chapter 23 ) and they can also be used to alter the shape of the cornea in orthokeratology (see Chapter 19 ).

Inserting the first lens

The need for good hygiene should be discussed with patients from the outset, and washing hands and other demonstrations of good hygiene can influence how they behave with their own lens care ( ). This is a good time to show the patient what the lens looks like.

Hand Washing

( http://www.nhs.uk/Livewell/homehygiene/Pages/how-to-wash-your-hands-properly.aspx ) includes the following steps:

  • 1.

    Wet hands under warm or cold running water.

  • 2.

    Turn off the tap.

  • 3.

    Apply enough liquid soap to completely cover both hands. Soap should not be highly scented but does not need to be antibacterial:

    • a.

      Rub hands palm to palm.

    • b.

      Rub the back of your left hand with your right palm with interlaced fingers. Repeat with the other hand.

    • c.

      Rub the backs of your fingers against your palms with fingers interlocked.

    • d.

      Clasp your left thumb with your right hand, and rub in rotation. Repeat with your left hand and right thumb.

    • e.

      Rub the tips of your fingers in the other palm in a circular motion, going backwards and forwards. Repeat with the other hand.

  • 4.

    Turn on the tap.

  • 5.

    Rinse hands well under running water.

Soft Lenses

Check that the lens is not inside out ( Fig. 15.1 and see ) and then insert the lens either straight onto the cornea ( Fig. 15.2 and see ) or onto the sclera then ask the patient to look towards the lens. Once the lens is in, give the patient a few moments until the comfort improves before asking them to look at the letter chart. If the lens does not settle, move it off the cornea, either having the patient to look up and moving the lens down or to the side (right for left eye and left for right eye) and slide the lens onto the temporal conjunctiva. The method is the same for the patient ( Fig. 15.3 and see courtesy of Tony Phillips). If this does not help, remove the lens and insert it again. Good vision is an excellent demonstration of the value of contact lens wear and can improve the motivation of a nervous patient. Quick and effective insertion of the first lens also helps patient confidence and reduces the discomfort of waiting with the eyelids held open. If the vision is satisfactory, say 0.2 logMAR or better, then final adjustments can be made at the next visit.

Fig. 15.1, Checking a soft lens profile for the correct way out and for any damage. The edges of the lens should sit up like a saucer. If the edges turn down, the lens is inside out.

Fig. 15.2, Soft lens insertion, holding both eyelids apart. This is the same way the patient inserts the lens for themselves

Fig. 15.3, Sliding the lens off-centre to improve comfort before recentring

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