Download getting back to the basics - Heart of America Contact Lens Society

GETTING BACK TO THE BASICS
By: Diane F. Drake, LDO, ABOM, FCLSA
 Types of practices
 How to avoid litigation
 Terminology
 Patient Histories
 Evaluations
 Instruction
 Record Keeping
 Specialty
Introduction
Types of Contact Lens Practices
 Discount
 Multi-service Dispensary
How to Avoid Possible Litigation and Concerns
 We are not attorneys
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W hat is malpractice?
W hat are our responsibilities
How to Avoid Possible Litigation and Concerns
 Product knowledge
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Study
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Attend seminars
 Patient knowledge
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How to Avoid Possible
Litigation and Concerns
Find out the patient’s needs
W ork with the patients
Anatomy
&
Physiology
 Eyelids
 Tear Film
Terminology
Ocular Structures
 Cornea
 Limbus
 Conjunctiva
Eyelids
 Important in health of eye
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Help to keep eye moist
Help to distribute tears, ox ygen and nutrients
Protects the eye from light and injury
Lids are elastic
 Lose elasticity with age
Eyelids
 Termed palpebral aperture
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W hile opened
Not always same size
 Contain Meibomian glands
 Contain Sebaceous glands
 Tear Film
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Tear Film/Precorneal Tear Film
Three Layers
 Lipid
 Aqueous
 Mucin
 Outer Layer - Oily
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Tear Film/Precorneal Tear Film
Lipid
 Produced by meibomian glands
 Prevents evaporation
 Middle Layer - Aqueous
Tear Film/Precorneal Tear Film
 Volume
 Provides oxygen
 Provides nutrients
 Produced by lacrimal glands
 Reflex Tears
 Accessory glands
 Provides basic tear secretion
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Steady state
 W olfring
 Krause
 Lacrimal glands
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Tear Film/Precorneal Tear Film
Provides reflex tear secretion
 Irritation
 Coughing
 Sneezing
 Taste or smell
Newborns have minimal output of reflex tears
Tear Film/Precorneal Tear Film
 Normal tears contain various antibacterial and immune substances to clean and protect eyes
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Lysozymes
Immunoglobulin
Depressed in patients with tear deficiency
 Patients frequently suffer from blepharitis
Tear Film/Precorneal Tear Film
 Inner Layer - Mucous
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Produced by goblet cells
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Attaches tears to cornea
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Decreases surface tension
Tear Film/Precorneal Tear Film
 Tear drainage
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Through lacrimal punctua
Into canaliculi
 Tear canals
Into nose via lacrimal duct
 Kinetics of the tears
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Tear Film/Precorneal Tear Film
Forms thin film over both cornea and conjunctiva
Creates tear meniscus
 Prism
 Lake
Tear Film/Precorneal Tear Film
 Tears move upward and downward with each blink
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Spreads tears over entire eye and conjunctiva
Moves from temporal to nasal
Importance of Tear Layer to Corneal Health
 Interruption of three layers could result in dry eye
 Could make difficult or impossible to wear contact lenses
 Could affect corneal health
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Both contact lens wearers and non-contact lens wearers
Conjunctiva
 Thin mucous membrane, running continuous from lid to corneal limbus
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Palpebral - lids
Bulbar
 Contains goblet cells
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Conjunctiva
Produce mucins
 Glands of Krause
 Glands of Wolfring
 Inflammation
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Conjunctivitis
Caused by bacteria or virus
Symptoms
 Pain
 Photophobia
 Impaired vision
 Discharge
 Blood Supply
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Conjunctiva
Conjunctiva
Becomes injected when conjunctiva is inflamed
 Innervation
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Very sensitive
Cornea
Five distinct layers
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Epithelium
Bowman’s layer
Stroma
Descemets membrane
Endothelium
Endothelium
Cornea
 Innervation of the cornea
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Sensation
Changes in sensation with age
Changes in sensation with contact lens use
Cornea
 Corneal metabolism
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Epithelium and endothelium have higher metabolism than stroma
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Avascular
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Requires oxygen and nutrients
Cornea
 Corneal transparency
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Depends on cell formation and structure
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Depends on proper fluid and oxygen balance
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Depends on non-scarring
Limbus
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Corneo-scleral junction
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Important in fitting contact lenses
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How to do Patient Histories
W hat to include
 Name
 Address
 Telephone numbers
 Home
 Work
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 Beepers – Pagers
 Cell phone
Age
 Birthday
Gender
Identifying/Social Security number
How to do Patient Histories
Visual requirements
 Lifestyle
 Hobbies
 Work
 Other
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 Part time wear
Visual Requirements
 Near
 Intermediate
 Distant
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How to do Patient Histories
Ocular History - Patient
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Ocular History - Relatives
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Visual
Medications
Allergies
Diseases
Injuries
Surgeries
Visual
Medications
Allergies
Diseases
Injuries
Surgeries
How to do Patient Histories
Medical History - Patient
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Heart
Diabetes
Thyroid
Blood pressure
Pregnancy
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 Cancer
 Any other disease - Headaches
Medical History - Relatives
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Heart
Diabetes
Blood pressure
Thyroid
Cancer
Any other disease - Headaches
How to do a Personal Assessment
W hat to include
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 Hair
 Eyes
 Skin
 Nails
 General appearances
 General Hygiene
 Abnormalities of eyes, skin or nails
Other things to include
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Tautness of lids
Size and position of eyes
Three sided white
 Aperture size
 Lid deformities or diseases
 Blink rate
 Tear break up time (BUT)
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How to Perform a Visual Assessment
Corrected and uncorrected V/A
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Slit lamp evaluation
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Tear BUT
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K readings
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Refraction
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IOP
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Any abnormalities - Must be recorded
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Patient’s blood pressure and pulse rate for future use, if necessary
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Visual Field
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Refer patient back to doctor
Types of Contact Lens Modalities
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Spherical
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Torics
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Soft
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Rigid
Single Vision
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Bifocal
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Monovision
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Others - Bandage etc.
Keratometer
Mires
Keratometry
 Measures approximately 3 mm of the central corneal cap
 Limits changes in the corneal topography
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Keratometry
As with any other instrument, first adjust (focus) the eyepiece.
 Place a sheet of white paper in front of the keratometer and turn the eyepiece completely
counterclockwise
 Note the blurred cross and slowly rotate clockwise until it is in sharp focus.
 Notice the position.
 If more than one operator uses the keratometer, do it every time you use it
Keratometer
Clean the chin rest and the forehead rest with an alcohol wipe
Position the patient in front of the keratometer, with their chin on the headrest and their
forehead against the forehead rest
Begin with the right eye, and occlude the left eye
Position the patient so that the outer canthus is aligned with the alignment marking on the
keratometer
You can also the mires reflected on the patient’s eye if observed from the side
 The patient will also see a reflection of their own eye
Mires
 Focus the keratometer to adjust and align the crosshair into the lower right circle
Plus Mires
 With one hand on the focus and the other on the horizontal drum on the left, superimpose the
plus signs
Minus Mires
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W ith one hand on the focus and the other on the vertical drum on the right, superimpose the
minus signs
 Many ECP’s prefer to rotate the axis drum and focus the plus signs for each meridian.
 Record the readings for each axis
K Readings
 Example
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W RA
43.00@180o/44.00@90o
 Example
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ARA
43.00@90o/44.00@180o
With the Rule
Against the Rule
Keratometer range
The normal range of a keratometer is:
 36.00 D to 52.00 D
You can extend the range up to 61 D by placing a +1.25 D trial lens over the aperture closest
to the patient
 Extends up 9.00 D
You can extend the range down to 30 D by placing a -1.00 D trial lens over the aperture
closest to the patient
 Extends down 6.00 D
“Not Cause Harm”
 Should all consumers/patients be fit with contact lenses?
 Patients ARE consumers
 Don’t let patients self prescribe
 Teach insertion and removal
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How to Instruct the Patient
W atch the patient
Give personal attention and instructions
How to Instruct the Patient
 Teach cleaning and care of lenses
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Handling lenses
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Solutions
 Instruct follow-up routine
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How to Instruct the Patient
W earing schedule
Follow-up schedule for progress checks
Cleaning Solution
 Used to rid contact lenses of debris and contamination
 Needs to be used freely
 Needs to be mechanically applied
 Needs to be rinsed off
 Daily vs. Weekly cleaners
Soft Cleaning Solutions
Daily
 Are surfactant agents
 Are applied by gentle rubbing of the lens with a few drops of cleaner
 Mechanical rubbing reduces the bio-burden extensively
 Used to remove
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Soft Cleaning Solutions
Daily
fresh lipid
mucous
tear proteins
tear salts
other fresh debris
microorganisms
Soft Cleaning Solutions
Weekly
 Used to remove resistant protein deposits on the lens
 Proteins are harder to remove if they are allowed to build up
 Include surfactant cleaners and enzyme cleaners
Soft Cleaning Solutions
Weekly
 Surfactant weekly cleaners are safe and effective, and useful with most types of soft lenses
 Occasionally mild enzymatic cleaners are used as a daily cleaner
Soft Cleaning Solutions
Weekly
 Enzyme cleaners such as papain (plant enzyme), subtilisin, and pancreatin (derived from
highly purified pork) break down proteins
Rinsing Solution
 Used to rinse contact lenses, mechanical cleaning and thorough rinsing will eliminated 99.9%
of the bio-burden on lens
 Needs to be used freely
 Used for temporary storage
 Rinsing lenses prior to insertion
Rinsing Solution
 Preserved saline
• 0.9 % NaCL, compatible with tears
• buffered solution, to match tear
• preserved with chemical, to maintain sterility
Rinsing Solution
 Preserved saline
• preservative may attach to the lens surface or invade the lens material causing toxicity or
hypersensitivity
Toxicity vs. Hypersensitivity
 Toxicity produces immediate inflammatory reaction to a foreign agent
 Hypersensitivity is a delayed Immunological reaction to a foreign agent, usually follows an
initial sensitizing episode
Unpreserved saline
 Saline without any preservative
 Used to minimize toxicity or hypersensitivity
 Once opened, solution is not sterile
 Use small bottles and discard in two weeks
DO NOT USE TAP W ATER OR
ANY OTHER BOTTLED
W ATER ON SOFT CONTACT
LENSES
DO NOT USE
HOMEMADE SALINE

ON SOFT CONTACT LENSES
Disinfecting Solutions
Chemical Systems
 non-oxidizing systems
 oxidizing systems
 Use preservatives such as
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Non-oxidizing systems
thimerosal
chlorhexidine
quaternary ammonium compounds (e.g., benzalkonium chloride)
dymed (polyaminopropyl biguanide)
polyquad
ascorbic acid
Non-oxidizing systems
 Preservatives used for two reasons:


keep the disinfecting solution sterile
disinfect the lens
 a disadvantage is high incidence of ocular irritation, due hypersensitivity to thimerosal
 patients developing reactions to these chemicals are often switched to oxidizing
system
Switching out of chemical systems
 Chemicals should be removed from the lenses before switching, ideally start with new lenses
Patient Insertion & Removal
 It is important that you insert and remove the lenses, not the patient, unless the patient is
extremely experienced.
 All patients are apprehensive first time.
Patient Insertion & Removal
 Make it easier and comfortable for the patient not difficult.
 Be confident in your approach
 Insert Lenses

Insertion
Teach the patient proper insertion techniques
SCL- Insertion
• Wash your hands thoroughly
• Remove the right lens from the case
• Examine for lint or other particles on the lens
• Rinse, if necessary, with unpreserved saline
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SCL - Insertion
Ensure that lens is right side up before insertion
Edges should be straight up
if not, the lens will move around on the eye a lot more and will be more irritable to the patient
than usual remove, reverse and reinsert
Inside out lens
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Insertion
Have patient look straight ahead
Open eye wide
Hold the lids at the margins firmly
Have the lens ready for insertion
Talk to the patient, ask to keep the other eye open
Insertion
Insertion should be a clean one motion
Lids held in position
Bring lens in position quickly
W ill not have to fight the strong blink reflex
Removal
Hold the lids apart using left thumb and right middle finger
Have the right index finger and thumb ready
Removal
Pull the lens down with the right index finger
Use the right index finger and thumb to squeeze the lens
Removal
Alternative method
Holds the lids open with left thumb and the right index finger
Lids should be beyond the lens edges
Removal
 Squeeze lids together
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GP Lens - Insertion
Hold lids apart similar to SCL insertion
Lens on the tip of the index finger
GP Lens - Insertion
GP Lens - Removal
Holds lids apart beyond the lens edges
Patient looking straight ahead
 Wash hands, eyes and face
GP Lens - Removal
GP Lens - Decentered
GP Lens Locate
GP Lens - Stabilize
GP Lens - Look towards lens
Insertion

Use oil free, deodorant free, fragrance free soap

Rinse thoroughly

Dry with clean, lint free towel
Contact Lens Handling
Contact Lens Handling
 Apply cosmetics

Observe the Patient
Contact Lens Handling
Discuss proper application of cosmetics
Removal
 Wash hands
 Remove lenses
 Remove cosmetics
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Use oil free remover
Contact lens Case
 Wash case with disinfecting solution and allow to air dry
 Sterilize each week
 Replace case regularly
 Replace case if contaminated
Contact Lens Case
Solutions
 Discuss With Your Patients Which Solutions to Use
 Never Mix Solutions
 Never Use Expired or Contaminated Solutions
 Cosmetic Contact Lenses

Sharing of Contact Lenses
Colored Lenses
Bootleg Contact Lens Sales

Flea Markets
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Beauty Shops
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Out of Trunks

Others
How to discourage patients from purchasing contact lenses in this manner
Rigid Contact Lenses
 Materials
 Intended Use of the Lenses
 Fitting What is Best for the Patient

Lifestyle Questioning

Physical Requirements

Visual Requirements
Rigid Contact Lenses
Instructions – I & R

Teach the Patient

Observe the Patient

Solutions
Some instructions are the same as for soft contact lenses
General Instructions for Both Soft and Rigid Contact Lens W earers
Advise Patient That Lenses W ere Selected For Them Based On Intended Use And W hat Is Best
For THEM
General Instructions - Continued
 Never Share Contact Lenses
 Never Switch or Mix Solutions

Could cause problems
 Reinforce Insertion and Removal Instructions

W ritten instructions - Personalized
Symptoms That Something Could Be W rong
 Loss or Reduction of Visual Acuity
 Cloudiness or Smokey Vision
 Redness
 Pain
 Burning
Symptoms That Something Could Be W rong
 Itching
 Anything Oozing in or From the Eye
 Others
Symptoms That Something Could Be W rong
Instruct the Patient to Remove Lenses FIRST and Then Call you
Patient Must be Aware of Seriousness of Complications
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Follow – Up W ith The Patient
Giant Papillary Conjunctivitis
Do’s
Do Wash and rinse your hands before handling your lenses. Use oil free, lotion free,
perfume free, deodorant free soap
Do clean, rinse and air dry your lens case. Contact lens cases can be a source of
bacteria growth. Lens cases should be cleaned, rinsed, and allowed to air dry each
time the lenses are removed. Replace the lens case every three months, or more often
if needed.
Do see us as scheduled for follow-up care
Do replace your lenses as scheduled
Don’ts
Don’t wear your lenses beyond the prescribed wearing time. For example, don’t wear
your daily wear lenses while sleeping or keep your lenses longer than prescribed.
Don’t use saliva to wet your lenses
Don’t use unsterile home-prepared saline, distilled water or tap water for any part of
your lens-care regimen.
Don’t allow your lenses to come into contact with cosmetic lotions, creams or sprays.
It’s best to insert your lenses before putting on make up and remove them before
cleansing your face. Water-based cosmetics are less likely to damage your lenses than
oil-based products.
Don’t change lens care regimen or solutions without consulting us.
Don’t share your lenses with anyone
Your W earing Schedule
Day One____________________________
Day Two___________________________
Day Three__________________________
Day Four___________________________
Day Five___________________________
Day Six____________________________
Day Seven__________________________
Day Eight__________________________
Day Nine___________________________
Day Ten____________________________
Day Eleven__________________________
Your Follow Up Schedule
 Your follow - up visits are scheduled for:
___________________________
___________________________
___________________________
___________________________
Your cleaning and care solutions are:
 Cleaning _______________________
 Rinsing_________________________
 Disinfecting_____________________
 Protein cleaner___________________
 Rewetting_______________________
 Other___________________________
 ________________________________
Signature of person instructing patient
__________________Date________
I have been given a copy of the instruction booklet and agree to keep m y follow up appointments
as scheduled
I have also been instructed in the care and handling of my contact lenses and will only use them
as instructed by
XXX Vision Center
I have also been instructed to remove m y contact lenses immediately if there are any warning
signs that something could be wrong and contact XXX Vision Center immediately
___________________Date___
Effective Communication
Getting the Point Across
 Present yourself in a confident and knowledgeable manner
 Be interested in your patients
 Like your job
Effective Communication
 Like your patients
 Be professional and ethical
 Instructing the Patient
Trouble shooting
 Solutions
 Follow-up routine
 Documentation
Contraindications of Contact Lens Wear
INCLUDING BUT NOT LIMITED TO:
 Poor personal hygiene
 Uniocularity
 Immunosuppressed patients
 Abnormal lid function
Contraindications of Contact Lens Wear
 Previous ocular infections or some ocular surgery
 Use of certain topical medications
 Occupational Hazards
Contraindications of Contact Lens Wear
 Significant allergies
 Significant dry eye (unless used as bandage lens)
Contraindications of Contact Lens Wear
 Chronic ocular infections

Severe blepharitis, etc.
 Corneal neovascularization
 Diabetes mellitus
 Sometimes pregnancy
 Patients are consumers

Don’t Let Patients Self Prescribe
Consumers are patients
 Explain that you fit what is best for each patient
 Solutions are selected for the individual needs of the patient
 Patient files
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Record Keeping
Instruction sign off sheets
W earing schedule
Care system used
Lot numbers recorded
Return visits scheduled
 If it’s not recorded, it wasn’t done
Documentation
 Dates, times and signature of person who performed task
 Duty to Warn
 Documentation and signatures
 Get started
 Evaluate
 Educate
 Document
F DA
Conclusion
Thank You
Questions?