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Attendance of contact lens wearers at an ophthalmic Accident and Emergency unit
Ophthal. Physiol. Opt. Vol. 18, No. 1. pp. 63-65, 1998 8 1998 The College of Optometrists. Published by Elsevier Science Ltd Printed in Great Britain 0275.5408198 s19.00 + 0.00
ELSEVIER
PIk SO2755408(97)00074-4
CLINICAL
RESEARCH
NOTE
Attendance ophthalmic
of contact lens wearers at an Accident and Emergency unit
C. F. Radford.‘,*V.
Gastaldo-Brat’
and A. R. Hill*
‘Moorfields Eye Hospital, London, UK and ‘Oxford Eye Hospital, Woodstock OX2 6HE, UK
Road, Oxford
Summary Contact lens (CL) complications account for 2.2-10.0% of patients attending ophthalmic Accident and Emergency (A&E) units. A survey was conducted to evaluate disease severity among CL wearers attending the Oxford Eye Hospital A&E Unit. CL wearers without a medical indication for CL wear completed a short questionnaire eliciting CL type and wear schedule. Subsequently, A&E Senior House Officers indicated the diagnosis and whether, in their opinion, the patient could have been managed by their optometrist or contact lens practitioner. Approximately half of the CL wearers (321/653, 49%) presented with CL related disorders, but only 16% (53/321) of these had potentially sight-threatening disease. More than a third of these patients were deemed to be inappropriately attending (125/321, 39%), presenting with minor problems such as cornea1 abrasions, CL handling difficulties and CL solution ‘accidents’. Better patient instruction, together with encouragement to consult their optometrist or contact lens practitioner first if problems occur, would greatly reduce the burden of A&E attendance by CL wearers with minor complaints. 0 1998 The College of Optometrists. Published by Elsevier Science Ltd
Introduction
Stapleton et al., 1992; Heaven and Hutchinson, 1993; Radford, 1995; Chatterjee et al., 1995). A survey was conducted to evaluate the spectrum of disease severity among CL wearers presenting to an ophthalmic A&E department, and to estimate the proportion of initial attendances that are inappropriate.
A national survey reported a marked increase in the contact lens (CL) market during 1995; at least 7% of the UK population now use CL (Eyecare Information Service, 1995). Introduction of an increasing number of individuals to the optical, cosmetic and practical benefits of CL wear is to be encouraged, provided it is accompanied by good CL education. This should include a discussion of the risk of complications, how to avoid them, and what to do if they occur. Although most CL complications can be managed by the CL practitioner (Dart, 1993), CL related disease accounts for 2.2P10.0% of patients attending ophthalmic Accident and Emergency (A&E) units, even though only a small proportion of these (4414%) present with potentially sight-threatening cornea1 ulcers (Franks et al., 1988; Hardman Lea et al., 1990;
Methods Study procedure
The study was conducted at Oxford Eye Hospital A&E Department, which provides the only 24-hour ophthalmic emergency service for a population of approximately 600 000 and sees approximately 15 000 new patients per year. A nursing triage system is used, whereby senior trained ophthalmic nurses carry out the initial assessment of each patient in order to establish priorities for treatment. During the two year period 1.10.93330.9.95, patients identified as CL wearers making an initial
Recmvd: 23 May 1997 Revisedform: 28 July 1997
63
64
Ophthal. Physiol. Opt. 1998 18: No 1 Table 1. Diagnoses for 653 CL wearers attending Oxford Eye Hospital A&E Department Inappropriate Diagnostic group
No.
CL related disorders: Microbial keratitis Sterile keratitis Toxic Metabolic & hypersensitivity disorders Mechanical disorders
disorders
Tear Miscellaneous resurfacing (e.g. disorders CL handling) Total: Non CL related disorders: Total CL wearers:
(%I
53 16
0 2
(13)
25 58 110
257 49
;;J (45)
20 39
357
~~~;
321
125
(39)
332
53
(16)
653
178
(27)
visit were invited to complete a short questionnaire eliciting the type of CL they used and whether they wore it overnight (as categorised below). Patients with a medical indication for CL wear (such as ocular surface disease, keratoconus or aphakia) were excluded. Subsequently, A&E Senior House Officers indicated the diagnosis and whether, in their opinion of the individual case, the patient could have been managed by their optometrist or CL practitioner. Classification plications
No.
attendees
of contact lens use and lens related com-
To be classified as a CL wearer, the patient had to have worn CL within the four week period preceding their presentation to A&E. Disposable lenses were defined as soft lenses for disposal after no more than four weeks’ use. Overnight use occurring at least once per week was classified as extended wear. Contact lens complications were grouped according to probable pathogenesis (Dart, 1993).
Results During the two year period, 653 CL wearers attending A&E completed a questionnaire. A third (2X/653, 33%) were wearing rigid CL, 51% (330/653) were daily-wear soft CL users, and 10% (68/653) were using daily-wear disposable lenses. Only 6% were using conventional or disposable CL for regular overnight use (40/653).
Approximately half (321/653; 49%) of the CL questionnaire respondents were presenting with CL related disorders, but only 16% of these (53/321) were attending with clinically diagnosed (or subsequently proven) microbial keratitis (Table I). The proportion of CL wearing patients deemed to be inappropriately attending was 27% (178/653), rising
to 39% (125/321) when patients with CL related disorders are considered in isolation (Table I). For 13% (82/653) of patients in the survey, A&E doctors failed Table 2. Diagnoses for 178 CL wearers classified as inappropriate A&E attendees Diagnoses CL related disorders: Cornea1 abrasion (CL related) CL handling difficulties (CL dislodged/ stuck/lost) Toxic keratitis (from CL solution ‘accidents’) Superficial punctate keratitis CL intolerance (non-specific) Dry eye (CL related) CorneaVsubtarsal foreign body Acute epithelial necrosis (‘Overwear’ syndrome) Papillary conjunctivitis (CL related) Hypoxia Sterile keratitis CL deposits Cornea1 scar Total: Non CL related disorders: Conjunctivitis (not CL related) Normal examination Chalazion Subconjunctival haemorrhage Meibomianitis Allergic conjunctivits Blepharitis Chemical injury/ocular trauma (mild) Conjunctival cysts Episcleritis Subtarsal foreign body (not CL related) Marginal keratitis Recurrent cornea1 erosions Trichiasis Total:
No.
(%I
29
23 20
(16)
14 IO
(‘(A;
76 5
1651 (4)
25 2
‘(z’,
1
(2) yr; <
125
(100)
18 9 4 4
(34) “(:i (7)
32
Ii{
2 2 2 2 1 1
I:/ (4)
1
53
ii;
(2) (2) G-9 (100)
Contact lens wearers and A & E unit attendance: to indicate and/or were uncertain as to whether or not the patient could have been managed by their optometrist or CL practitioner. Among the inappropriate attendees, the most common diagnoses were cornea1 abrasions, CL handling difficulties and toxic keratitis resulting from CL solution ‘accidents’ (Table 2).
Discussion The proportion of CL wearers attending with a problem associated with their lenses (49%) was comparathis probably because low in study, tively conjunctivitis (other than CL related papillary conjunctivitis) was classified as a non CL related disease (Dart, 1993); other studies have assumed all cases of conjunctivitis to be CL related, resulting in apparently much higher proportions of CL related disease (766 95%) (Hardman Lea et al., 1990; Heaven and Hutchinson, 1993; Chatterjee et al., 1995). A previous study (Chatterjee et al., 1995) reported a higher proportion of inappropriate attendance at A&E by CL wearers (170/405, 42%), perhaps due to their retrospective collection of data and assumption that certain types of disorder can always be managed by the optometrist, regardless of severity, differential diagnosis and other factors. In this study, A&E doctors gave their opinion as to the appropriateness of attendance at the time of the patient’s first visit, when diagnosis may still have been tentative. It is therefore likely that the A&E doctors in this study may have been more cautious regarding the suitability of optometric management. Inappropriate attendance unnecessarily increases the workload on A&E doctors, and may prolong the waiting time for patients with more serious complaints. For the patient, there may be a long wait, in some cases accompanied by needless anxiety, to see a clinician who will treat the presenting condition but, if it is CL related, may not be able to give suitable advice to prevent its recurrence. Management of CL related disorders often requires a very detailed history and knowledge of CL and care solutions (Dart, 1993); an A&E ophthalmologist is unlikely to have this information. In order to minimise the study’s demands on A&E staff, the time of day of patient attendance was not recorded on questionnaires. It is likely that, for some patients, the availability of a 24-hour help line may have removed their need for hospital consultation. Patients with solution accidents, for example, could have been advised to irrigate the eye with sterile saline and leave the CL out for 24 hours. Unfortunately,
C. F. Radford et al.
65
however, the concept of out-of-hours emergency telephone numbers, as recommended in the College of Optometrists’ revised CL practice guidelines (The College of Optometrists, 1993) has not been well received by the profession (Anon, 1993). The results of this survey suggest that more thorough patient instruction in CL manipulation, care solutions, and self-evaluation, together with encouragement to consult the CL practice first (if possible) when problems occur, would considerably reduce the burden of trivial CL related complaints on hospital time and resources. This will become increasingly important as CL wear is adopted by a rapidly increasing proportion of the population.
Acknowledgements We acknowledge the support of all the nursing, medical and clerical staff of Oxford Eye Hospital A&E Department, Liz Wall for liaising assistance, Natalie Wood (Patient Services), and Mr John K. G. Dart for reviewing the manuscript. We are also grateful for financial support from Vistakon (UK).
References Anon (1993). Out-of-hours cover plan meets stiff resistance. Optician 206, 5.
Chatterjee, A., Bessant, D. A. R. and Naroo, S. A. (1995). Ophthalmic Accident and Emergency Department contact lens wearers. Optometry Today 35, 23-25. Dart, J. K. G. (1993). Disease and risks associated with contact lenses. BY. J. Ophthaln~o1. 77, 49-53. Eyecare Information Service, London (1995). Cited in: Optonzetyy Toda,v 35, December 4, 54. Franks, W. A., Adams, G. G. W., Dart, J. K. G. and Minassian, D. (1988). Relative risks of different types of contact lenses. Br. Med. J. 297, 524-525. Hardman Lea, S. J., Neugebauer, M. A. Z., Smith, R. G. and Vernon, S. A. (1990). The incidence of ophthalmic problems in the contact lens wearing population. Eye 4, 706-711.
Heaven, C. J. and Hutchinson, S. M. (1993). The demands of contact-lens-related ocular problems upon a provincial eye casualty department: a 6 month prospective study. J. Br. Contact Lens Assoc. 16,. 95-98. Radford, C. F. (1995). The epidemiology of contact lens related disease in users of disposable lenses. PhD thesis, City University, London. Stapleton, F., Dart, J. K. G. and Minassian, D. (1992). Nonulcerative complications of contact lens wear. Relative risks for different lens types. A~lz. Ophthalmol. 110, 16011606. The College of Optometrists. (1993). Contact lens practice. In: Guidelines for Professional Conduct, Chap. 5. The (British) College of Optometrists, London.
ELSEVIER
PIk SO2755408(97)00074-4
CLINICAL
RESEARCH
NOTE
Attendance ophthalmic
of contact lens wearers at an Accident and Emergency unit
C. F. Radford.‘,*V.
Gastaldo-Brat’
and A. R. Hill*
‘Moorfields Eye Hospital, London, UK and ‘Oxford Eye Hospital, Woodstock OX2 6HE, UK
Road, Oxford
Summary Contact lens (CL) complications account for 2.2-10.0% of patients attending ophthalmic Accident and Emergency (A&E) units. A survey was conducted to evaluate disease severity among CL wearers attending the Oxford Eye Hospital A&E Unit. CL wearers without a medical indication for CL wear completed a short questionnaire eliciting CL type and wear schedule. Subsequently, A&E Senior House Officers indicated the diagnosis and whether, in their opinion, the patient could have been managed by their optometrist or contact lens practitioner. Approximately half of the CL wearers (321/653, 49%) presented with CL related disorders, but only 16% (53/321) of these had potentially sight-threatening disease. More than a third of these patients were deemed to be inappropriately attending (125/321, 39%), presenting with minor problems such as cornea1 abrasions, CL handling difficulties and CL solution ‘accidents’. Better patient instruction, together with encouragement to consult their optometrist or contact lens practitioner first if problems occur, would greatly reduce the burden of A&E attendance by CL wearers with minor complaints. 0 1998 The College of Optometrists. Published by Elsevier Science Ltd
Introduction
Stapleton et al., 1992; Heaven and Hutchinson, 1993; Radford, 1995; Chatterjee et al., 1995). A survey was conducted to evaluate the spectrum of disease severity among CL wearers presenting to an ophthalmic A&E department, and to estimate the proportion of initial attendances that are inappropriate.
A national survey reported a marked increase in the contact lens (CL) market during 1995; at least 7% of the UK population now use CL (Eyecare Information Service, 1995). Introduction of an increasing number of individuals to the optical, cosmetic and practical benefits of CL wear is to be encouraged, provided it is accompanied by good CL education. This should include a discussion of the risk of complications, how to avoid them, and what to do if they occur. Although most CL complications can be managed by the CL practitioner (Dart, 1993), CL related disease accounts for 2.2P10.0% of patients attending ophthalmic Accident and Emergency (A&E) units, even though only a small proportion of these (4414%) present with potentially sight-threatening cornea1 ulcers (Franks et al., 1988; Hardman Lea et al., 1990;
Methods Study procedure
The study was conducted at Oxford Eye Hospital A&E Department, which provides the only 24-hour ophthalmic emergency service for a population of approximately 600 000 and sees approximately 15 000 new patients per year. A nursing triage system is used, whereby senior trained ophthalmic nurses carry out the initial assessment of each patient in order to establish priorities for treatment. During the two year period 1.10.93330.9.95, patients identified as CL wearers making an initial
Recmvd: 23 May 1997 Revisedform: 28 July 1997
63
64
Ophthal. Physiol. Opt. 1998 18: No 1 Table 1. Diagnoses for 653 CL wearers attending Oxford Eye Hospital A&E Department Inappropriate Diagnostic group
No.
CL related disorders: Microbial keratitis Sterile keratitis Toxic Metabolic & hypersensitivity disorders Mechanical disorders
disorders
Tear Miscellaneous resurfacing (e.g. disorders CL handling) Total: Non CL related disorders: Total CL wearers:
(%I
53 16
0 2
(13)
25 58 110
257 49
;;J (45)
20 39
357
~~~;
321
125
(39)
332
53
(16)
653
178
(27)
visit were invited to complete a short questionnaire eliciting the type of CL they used and whether they wore it overnight (as categorised below). Patients with a medical indication for CL wear (such as ocular surface disease, keratoconus or aphakia) were excluded. Subsequently, A&E Senior House Officers indicated the diagnosis and whether, in their opinion of the individual case, the patient could have been managed by their optometrist or CL practitioner. Classification plications
No.
attendees
of contact lens use and lens related com-
To be classified as a CL wearer, the patient had to have worn CL within the four week period preceding their presentation to A&E. Disposable lenses were defined as soft lenses for disposal after no more than four weeks’ use. Overnight use occurring at least once per week was classified as extended wear. Contact lens complications were grouped according to probable pathogenesis (Dart, 1993).
Results During the two year period, 653 CL wearers attending A&E completed a questionnaire. A third (2X/653, 33%) were wearing rigid CL, 51% (330/653) were daily-wear soft CL users, and 10% (68/653) were using daily-wear disposable lenses. Only 6% were using conventional or disposable CL for regular overnight use (40/653).
Approximately half (321/653; 49%) of the CL questionnaire respondents were presenting with CL related disorders, but only 16% of these (53/321) were attending with clinically diagnosed (or subsequently proven) microbial keratitis (Table I). The proportion of CL wearing patients deemed to be inappropriately attending was 27% (178/653), rising
to 39% (125/321) when patients with CL related disorders are considered in isolation (Table I). For 13% (82/653) of patients in the survey, A&E doctors failed Table 2. Diagnoses for 178 CL wearers classified as inappropriate A&E attendees Diagnoses CL related disorders: Cornea1 abrasion (CL related) CL handling difficulties (CL dislodged/ stuck/lost) Toxic keratitis (from CL solution ‘accidents’) Superficial punctate keratitis CL intolerance (non-specific) Dry eye (CL related) CorneaVsubtarsal foreign body Acute epithelial necrosis (‘Overwear’ syndrome) Papillary conjunctivitis (CL related) Hypoxia Sterile keratitis CL deposits Cornea1 scar Total: Non CL related disorders: Conjunctivitis (not CL related) Normal examination Chalazion Subconjunctival haemorrhage Meibomianitis Allergic conjunctivits Blepharitis Chemical injury/ocular trauma (mild) Conjunctival cysts Episcleritis Subtarsal foreign body (not CL related) Marginal keratitis Recurrent cornea1 erosions Trichiasis Total:
No.
(%I
29
23 20
(16)
14 IO
(‘(A;
76 5
1651 (4)
25 2
‘(z’,
1
(2) yr; <
125
(100)
18 9 4 4
(34) “(:i (7)
32
Ii{
2 2 2 2 1 1
I:/ (4)
1
53
ii;
(2) (2) G-9 (100)
Contact lens wearers and A & E unit attendance: to indicate and/or were uncertain as to whether or not the patient could have been managed by their optometrist or CL practitioner. Among the inappropriate attendees, the most common diagnoses were cornea1 abrasions, CL handling difficulties and toxic keratitis resulting from CL solution ‘accidents’ (Table 2).
Discussion The proportion of CL wearers attending with a problem associated with their lenses (49%) was comparathis probably because low in study, tively conjunctivitis (other than CL related papillary conjunctivitis) was classified as a non CL related disease (Dart, 1993); other studies have assumed all cases of conjunctivitis to be CL related, resulting in apparently much higher proportions of CL related disease (766 95%) (Hardman Lea et al., 1990; Heaven and Hutchinson, 1993; Chatterjee et al., 1995). A previous study (Chatterjee et al., 1995) reported a higher proportion of inappropriate attendance at A&E by CL wearers (170/405, 42%), perhaps due to their retrospective collection of data and assumption that certain types of disorder can always be managed by the optometrist, regardless of severity, differential diagnosis and other factors. In this study, A&E doctors gave their opinion as to the appropriateness of attendance at the time of the patient’s first visit, when diagnosis may still have been tentative. It is therefore likely that the A&E doctors in this study may have been more cautious regarding the suitability of optometric management. Inappropriate attendance unnecessarily increases the workload on A&E doctors, and may prolong the waiting time for patients with more serious complaints. For the patient, there may be a long wait, in some cases accompanied by needless anxiety, to see a clinician who will treat the presenting condition but, if it is CL related, may not be able to give suitable advice to prevent its recurrence. Management of CL related disorders often requires a very detailed history and knowledge of CL and care solutions (Dart, 1993); an A&E ophthalmologist is unlikely to have this information. In order to minimise the study’s demands on A&E staff, the time of day of patient attendance was not recorded on questionnaires. It is likely that, for some patients, the availability of a 24-hour help line may have removed their need for hospital consultation. Patients with solution accidents, for example, could have been advised to irrigate the eye with sterile saline and leave the CL out for 24 hours. Unfortunately,
C. F. Radford et al.
65
however, the concept of out-of-hours emergency telephone numbers, as recommended in the College of Optometrists’ revised CL practice guidelines (The College of Optometrists, 1993) has not been well received by the profession (Anon, 1993). The results of this survey suggest that more thorough patient instruction in CL manipulation, care solutions, and self-evaluation, together with encouragement to consult the CL practice first (if possible) when problems occur, would considerably reduce the burden of trivial CL related complaints on hospital time and resources. This will become increasingly important as CL wear is adopted by a rapidly increasing proportion of the population.
Acknowledgements We acknowledge the support of all the nursing, medical and clerical staff of Oxford Eye Hospital A&E Department, Liz Wall for liaising assistance, Natalie Wood (Patient Services), and Mr John K. G. Dart for reviewing the manuscript. We are also grateful for financial support from Vistakon (UK).
References Anon (1993). Out-of-hours cover plan meets stiff resistance. Optician 206, 5.
Chatterjee, A., Bessant, D. A. R. and Naroo, S. A. (1995). Ophthalmic Accident and Emergency Department contact lens wearers. Optometry Today 35, 23-25. Dart, J. K. G. (1993). Disease and risks associated with contact lenses. BY. J. Ophthaln~o1. 77, 49-53. Eyecare Information Service, London (1995). Cited in: Optonzetyy Toda,v 35, December 4, 54. Franks, W. A., Adams, G. G. W., Dart, J. K. G. and Minassian, D. (1988). Relative risks of different types of contact lenses. Br. Med. J. 297, 524-525. Hardman Lea, S. J., Neugebauer, M. A. Z., Smith, R. G. and Vernon, S. A. (1990). The incidence of ophthalmic problems in the contact lens wearing population. Eye 4, 706-711.
Heaven, C. J. and Hutchinson, S. M. (1993). The demands of contact-lens-related ocular problems upon a provincial eye casualty department: a 6 month prospective study. J. Br. Contact Lens Assoc. 16,. 95-98. Radford, C. F. (1995). The epidemiology of contact lens related disease in users of disposable lenses. PhD thesis, City University, London. Stapleton, F., Dart, J. K. G. and Minassian, D. (1992). Nonulcerative complications of contact lens wear. Relative risks for different lens types. A~lz. Ophthalmol. 110, 16011606. The College of Optometrists. (1993). Contact lens practice. In: Guidelines for Professional Conduct, Chap. 5. The (British) College of Optometrists, London.