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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 W hat is malpractice? W hat are our responsibilities How to Avoid Possible Litigation and Concerns Product knowledge Study Attend seminars Patient knowledge 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 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 W hile opened Not always same size Contain Meibomian glands Contain Sebaceous glands Tear Film Tear Film/Precorneal Tear Film Three Layers Lipid Aqueous Mucin Outer Layer - Oily 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 Steady state W olfring Krause Lacrimal glands 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 Lysozymes Immunoglobulin Depressed in patients with tear deficiency Patients frequently suffer from blepharitis Tear Film/Precorneal Tear Film Inner Layer - Mucous Produced by goblet cells Attaches tears to cornea Decreases surface tension Tear Film/Precorneal Tear Film Tear drainage Through lacrimal punctua Into canaliculi Tear canals Into nose via lacrimal duct Kinetics of the tears 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 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 Both contact lens wearers and non-contact lens wearers Conjunctiva Thin mucous membrane, running continuous from lid to corneal limbus Palpebral - lids Bulbar Contains goblet cells Conjunctiva Produce mucins Glands of Krause Glands of Wolfring Inflammation Conjunctivitis Caused by bacteria or virus Symptoms Pain Photophobia Impaired vision Discharge Blood Supply Conjunctiva Conjunctiva Becomes injected when conjunctiva is inflamed Innervation Very sensitive Cornea Five distinct layers Epithelium Bowman’s layer Stroma Descemets membrane Endothelium Endothelium Cornea Innervation of the cornea Sensation Changes in sensation with age Changes in sensation with contact lens use Cornea Corneal metabolism Epithelium and endothelium have higher metabolism than stroma Avascular Requires oxygen and nutrients Cornea Corneal transparency Depends on cell formation and structure Depends on proper fluid and oxygen balance Depends on non-scarring Limbus Corneo-scleral junction Important in fitting contact lenses How to do Patient Histories W hat to include Name Address Telephone numbers Home Work Beepers – Pagers Cell phone Age Birthday Gender Identifying/Social Security number How to do Patient Histories Visual requirements Lifestyle Hobbies Work Other Part time wear Visual Requirements Near Intermediate Distant How to do Patient Histories Ocular History - Patient Ocular History - Relatives Visual Medications Allergies Diseases Injuries Surgeries Visual Medications Allergies Diseases Injuries Surgeries How to do Patient Histories Medical History - Patient Heart Diabetes Thyroid Blood pressure Pregnancy Cancer Any other disease - Headaches Medical History - Relatives Heart Diabetes Blood pressure Thyroid Cancer Any other disease - Headaches How to do a Personal Assessment W hat to include Hair Eyes Skin Nails General appearances General Hygiene Abnormalities of eyes, skin or nails Other things to include Tautness of lids Size and position of eyes Three sided white Aperture size Lid deformities or diseases Blink rate Tear break up time (BUT) How to Perform a Visual Assessment Corrected and uncorrected V/A Slit lamp evaluation Tear BUT K readings Refraction IOP Any abnormalities - Must be recorded Patient’s blood pressure and pulse rate for future use, if necessary Visual Field Refer patient back to doctor Types of Contact Lens Modalities Spherical Torics Soft Rigid Single Vision Bifocal Monovision Others - Bandage etc. Keratometer Mires Keratometry Measures approximately 3 mm of the central corneal cap Limits changes in the corneal topography 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 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 W RA 43.00@180o/44.00@90o Example 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 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 Handling lenses Solutions Instruct follow-up routine 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 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 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 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 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 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 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 Beauty Shops 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 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 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?