History Taking

Introduction

History and symptoms is critical to determining whether an individual is suitable for contact lens wear, to aid selection and to inform management. The aim is to comprehensively elicit relevant information in as concise a manner as possible, as time is limited in a clinical setting, but missing information can result in suboptimal clinical decisions. Clinical records have been found to underestimate actual care provided, suggesting that record keeping is not always as comprehensive as it should be ( ). The BCLA Contact Lens Evidence-based Academic Reports, which involved collating the available peer-reviewed evidence and a consensus of approximately 100 experts in the field, informed the recommendations in this chapter ( ).

The objectives for a new patient include:

• to determine the suitability for contact lens wear based on:

  • an analysis of patient-specific indications and contraindications

  • a detailed examination of their eye health

  • a risk benefit analysis for the individual patient

• to guide the patient as to the most suitable lens modality and type based on:

  • their lifestyle (including occupation)

  • aspirations for lens wear and financial outlay restrictions

  • the outcome of their ocular health examination

  • refraction

  • binocular vision

• to ensure expectations are realistic, such as:

  • visual outcomes, especially in presbyopes

  • myopia control in children

  • wearing time

  • lens care requirements

• to collate baseline patient information:

  • to justify clinical decision-making

  • to allow future changes to be compared at aftercares

• to ensure the compliance implications of contact lens wear are communicated

examined the open-question regarding issues with the patient’s eyesight typical at the beginning of a consultation and demonstrated that uninterrupted statements of greater than 30 seconds were unlikely to provide useful additional information. How a contact lens consultation history and symptoms is conducted will depend on whether it is an initial fitting where past history, motivation and intended wearing pattern and environment will be the focus, compared to an aftercare where symptoms, changes in health and compliance aspects are foremost. Hence, ‘history and symptoms’ changes to ‘symptoms and (changes in) history’ for an aftercare ( ). Comprehensive capture of relevant information in a limited time will require a structured approach, ability to differentially diagnose and appropriate use of abbreviations.

Indications and Contraindications for Contact Lens Wear

Contraindications are often interpreted as a reason not to fit contact lenses, but in most cases with reflection on the management of the condition or a change in contact lens choice, successful and safe wear may be achieved.

Patients with compromised ocular health such as meibomian gland disease ( ), low tear stability ( ) or recurrent epithelial erosion need the condition to be managed before soft or rigid corneal lenses are fitted, but therapeutic lenses could be part of that management in extreme cases ( ). Poor tear film can be exacerbated by contact lens wear. This is due to the thickness of lenses relative to the tear film and the lens material or design’s interaction with the ocular surface and adnexia (such as the eyelids) changing the composition of the tear film through stimulating inflammation and binding to protein and lipids ( ).

Since patient compliance with practitioner instructions has significant impact on safe, long-term wear, it is important to judge the prospective patient’s ability to understand the full implications of lens wear. It is also important that the patient’s expectations that drive motivation are realistic and achievable. A particularly exacting personality type may find the adaptation period and the initial learning of handling techniques too intrusive to outweigh the overall benefits of lens wear ( ). Manual dexterity to apply and remove lenses and maturity, mental capacity or willingness for compliant use may also increase the risks of wear beyond the potential benefits.

It is debateable whether the financial aspects of not only the fitting but the continuing clinical care and the ongoing costs of lens care solutions and lens replacements should be taken into consideration. Fitting lenses to a patient without the financial means to care for them will inevitably lead to noncompliance and increase the potential for adverse events to occur. However, presumed compliance by eye care practitioner is known to be a poor indicator of real compliance ( ), and the patient’s financial situation is rarely actually known.

It is important to judge the motivation to wear contact lenses and the personality type of the potential wearer. Contact lenses are considered to give a more normal cosmetic appearance and may contribute significantly to overall appearance, particularly when the refractive error is high. In addition, there are cases where lenses can be used specifically to conceal significant cosmetic defects such as iris anomalies, corneal opacities, inoperable squint or microphthalmos. Also, if patients have extremely flat, steep or irregular corneas or the ocular surface needs protection, then therapeutic contact lenses may be appropriate such as scleral lenses.

History-Taking Structure

An initial comprehensive history will assist clinical decision-making. For aftercare visits, questioning should concentrate on what has changed since the last visit rather than repeating questions asked at the initial visit. Traditionally an ophthalmic examination would be structured so as to include the following elements.