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Deep Breath In And Out
Breath In
T
oday, many spectacle lens wearers also enjoy successfully wearing contact lenses. When patients do have difficulties with contact lenses, their first interaction is usually with the office staff. A knowledgeable staff can help the patient get the appropriate care in a timely and efficient manner. If patients experience problems, often they are the result of normal adaptive symptoms, lens defects, ocular infections, or non-compliance t o wearing schedules or solution use. This article will review normal adaptive symptoms, steps for handling contact lens emergencies, and common sources of contact lens problems.
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VORMAL ADAPTATION .Most patients today are fit with soft contact lenses. Typically, new soft lens wearers will comment that they barely feel the contact lens the first time they experience one on their eye. If a patient reports any initial discomfort, the lenses should be removed and examined for defects and t o ensure that they are oriented correctly (right side out). In the rare event where a patient fitted with a soft lens continues t o report a sensation with a new lens, they should be assured that after a few minutes the lens will settle down and any awareness and tearing they have will subside. Most patients are able t o wear their soft lenses a full 8 t o 12 hours on the first day, or as recommended by their practitioner. Patients who have been fit with toric soft contact lenses t o correct astigmatism may experience some blurred vision when they first apply the lenses. This occurs because these lenses have different powers in different meridians, which may not be lined up until the patient blinks a few times and the lens positions itself correctly. Toric contact lens patients should be told that after a few minutes the lenses will settle down and vision will become clearer. Placing the lens on the eye initially near the correct orientation will also speed settling time. For patients fit with soft bifocal contact lenses or monovision, some adjustment t o the new images seen at distance and near is quite normal during the adaptation period. It may take a few days t o a few weeks for the brain t o learn t o interpret both the distance and near vision signals that enter the ocular system. While the doctor will have already explained this t o the patient, it is always reassuring t o hear it again. SWERING THE CALL Becoming comfortable handling contact lens emergencies takes training and experience. What patients consider an emergency varies and can be anything from a torn or lost lens to a corneal abrasion. When contact lens patients call with a problem, it's important t o interview them t o determine the proper course of action. It's helpful to have a prepared form t o document the information for the doctor t o review and t o keep as a record in the patient's
SEPTEMBER 2004lSUPPLEMENT TO OPTOMETRY
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Pain could also be the result of solution misuse. Some contact lens care products are a multi-purpose or "all-in-one" solution. These solutions can be used for cleaning, rinsing, and disinfection and their chemical composition is developed to be compatible with contact lenses, the tear film, and ocular surfaces. Other care systems have separate bottles for cleaning, rinsing, and disinfection. With these systems, using the wrong bottle may cause complications ranging from mild irritation to severe pain. It is especially painful if a contact lens disinfected in a hydrogen peroxide solution isn't properly neutralized, which makes it compatible with the ocular surface. If a patient has used the wrong solution or improperly used a solution, they should remove the lens and rinse the eye with saline solution. If the eye remains painful, they should see the doctor immediately. Patients should be told that pain should never be tolerated and the best philosophy is "when in doubt, take i t
chart. The role of the office staff is to gather information for the eye care practitioner so they can determine the proper course of action. When patients call with a contact lens problem, they will often volunteer much of the information needed. Listen carefully, write down what they've said and inquire about any missing information. All patient issues need to be resolved. Some problems can be handled over the phone and some need to be seen by the doctor immediately. If there is any question as t o how quickly a patient should be seen, take down the information and ask the eye care professional. BEHIND THE SYMPTOMS To help determine how to schedule a patient, it may be helpful t o have some background knowledge as t o what may be causing the symptoms. Pain is not a normal adaptive symptom and can be caused by something as simple as a slight tear or nick in the lens to something as serious as an abrasion or infection. If the contact lenses are damaged, they should be removed and thrown out immediately. If the patient has removed their lenses and they still feel pain, this could be the sign of a more serious problem. The patient should be instructed to keep the contact lenses
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SUPPLEMENT T O OPTOMETRYISEPTEMBER 2004
Contact lens related red eye can be caused by wearing old, dirty, or damaged lenses. This complication can be avoided if the patient replaces the contact lenses as prescribed by the contact lens professional. A red eye can also be caused by a lack of oxygen to the eye. This can be the result of overwearing or sleeping in lenses. Solution sensitivity, inadequate rinsing of cleaners and disinfectants, contamination from soaps and cosmetics, can all result in a contact lens related red eye. If this occurs, contact lens wear should be discontinued until the source of the red eye is determined. Patients who experience discharge should discontinue lens wear and be seen by the doctor soon. Discharge can be caused by infection, allergies or GPC (giant papillary conjunctivitis), an immune response to protein deposits on the lenses. GPC also has other symptoms the patient would notice, such as itching. Fluctuating vision and intermittent blurring can be associated with dry lenses, lenses applied with the improper orientation (inside-out), or can be due to defects or deposits on the lens. When contact lenses become dry, vision and comfort can decrease. There are many causes of dry eye symptoms, including dirty or deposited lenses, incomplete blinking, allergies, systemic conditions, and prescription and over-the-counter medications. Some patients may only experience dry eye symptoms with their contact lenses in certain wear-
es before placing in disinfecting solution also helps t o remove loosely adherent films, deposits and debris. Patients mean well, but they can forget or misinterpret instructions given by t h e doctor. Therefore it's important for everyone on the eye care team to support and educate the patient on proper contact lens habits. When interviewing a patient regarding complications, if it is discovered that they are not following the recommended wearing or replacement schedule, it is appropriate t o reinforce the doctor's instructions. For example, a patient who adI mits they sleep in daily wear contact lenses and extend t h e replacement cycle should be re-educated on how they were preI scribed t o be worn. Non-compliance invites contact lens complications, some of which may cause short-term problems, such as lens discomfort; and some that may cause long term vision threatening problems, such as corneal infections with permanent scarring. The office staff are the eyes and ears for the doctor. When a noncompliant patient is identified, it should be mentioned t o the doctor and a notation made in the patient file for follow-up. All patients who call with an emergency should be brought t o the attention of the doctor. If it is something that needs immediate attention and the eye doctor isn't in the office or can't be reached, the "on call" doctor should be contacted for a recommendation. Create a system t o keep track of these patients. If the patient doesn't come in for the scheduled appointment, they should be called t o follow up on them. It can be a little frightening when first fielding questions from patients with contact lens problems and emergencies. To gain experience, ask the eye doctor how patients' contact lens complaints were ultimately resolved. While it's not the office team's role t o diagnose, a better understanding of complications and their management will help the office member feel more confident that they are scheduling patients in the correct appointment slots, and that they are reinforcing the instructions the eye care professional intended.
ing environments, such as department stores and airplanes. Tearing and itching are also symptoms that can be associated with dry eyes. Patients with ongoing dry eye symptoms should see the eye doctor t o evaluate the underlying cause. A reduction in vision can be caused by a lost or dislodged lens or by inadvertently switching the lenses. While it can be alarming GIANT PAPILLARY CONJUNCTIVITIS (GPC) for the patient when this happens, the remedies are quite simple. However, i f a patient has sudden vision loss unrelated t o the contact lenses, especially if it persists when lenses are removed, they should be seen immediately. THE ROLE OF PATIENT COMPLIANCE Patient compliance can help t o avoid, eliminate, or reduce many MUCUS contact lens complications. Compliance with the prescribed wearing time and lens replacement interval can reduce problems associated with dryness, dirty and deposited lenses, and reduced oxygen. Patients who sleep in contact lenses, even if it's just for a nap, need t o be evaluated and fit with a more oxygen permeable or extended/continuous wear lens. Patients who experience irritation with their contact lenses may drop out because they believe their eyes aren't compatible with contact lenses. In many cases, this general irritation that patients describe as dryness, low grade red eyes, fluctuating vision, and itching, is the result of wearing deposited lenses. Elements from the tear film and debris from the environment contribute t o deposits on contact lenses. For maximum comfort and vision, patient compliance with the lens replacement schedule prescribed by the eye care professional is vital. Proper cleaning and disinfection is also necessary for successful contact lens wear. If the patient isn't wearing single use disposable contact lenses, they must be cleaned t o remove deposits. Cleaning the deposits off the lens surface also helps with lens disinfection. After each use, the contact lenses need t o soak overnight in fresh disinfecting solution. The next day, the used solution should be thrown away and the lens case rinsed with hot water and turned upside down on a clean surface t o air dry. Rubbing and rinsing the lens-
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SEPTEMBER 2004lSUPPLEMENT TO OPTOMETRY
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T
oday, many spectacle lens wearers also enjoy successfully wearing contact lenses. When patients do have difficulties with contact lenses, their first interaction is usually with the office staff. A knowledgeable staff can help the patient get the appropriate care in a timely and efficient manner. If patients experience problems, often they are the result of normal adaptive symptoms, lens defects, ocular infections, or non-compliance t o wearing schedules or solution use. This article will review normal adaptive symptoms, steps for handling contact lens emergencies, and common sources of contact lens problems.
I I
VORMAL ADAPTATION .Most patients today are fit with soft contact lenses. Typically, new soft lens wearers will comment that they barely feel the contact lens the first time they experience one on their eye. If a patient reports any initial discomfort, the lenses should be removed and examined for defects and t o ensure that they are oriented correctly (right side out). In the rare event where a patient fitted with a soft lens continues t o report a sensation with a new lens, they should be assured that after a few minutes the lens will settle down and any awareness and tearing they have will subside. Most patients are able t o wear their soft lenses a full 8 t o 12 hours on the first day, or as recommended by their practitioner. Patients who have been fit with toric soft contact lenses t o correct astigmatism may experience some blurred vision when they first apply the lenses. This occurs because these lenses have different powers in different meridians, which may not be lined up until the patient blinks a few times and the lens positions itself correctly. Toric contact lens patients should be told that after a few minutes the lenses will settle down and vision will become clearer. Placing the lens on the eye initially near the correct orientation will also speed settling time. For patients fit with soft bifocal contact lenses or monovision, some adjustment t o the new images seen at distance and near is quite normal during the adaptation period. It may take a few days t o a few weeks for the brain t o learn t o interpret both the distance and near vision signals that enter the ocular system. While the doctor will have already explained this t o the patient, it is always reassuring t o hear it again. SWERING THE CALL Becoming comfortable handling contact lens emergencies takes training and experience. What patients consider an emergency varies and can be anything from a torn or lost lens to a corneal abrasion. When contact lens patients call with a problem, it's important t o interview them t o determine the proper course of action. It's helpful to have a prepared form t o document the information for the doctor t o review and t o keep as a record in the patient's
SEPTEMBER 2004lSUPPLEMENT TO OPTOMETRY
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25
Pain could also be the result of solution misuse. Some contact lens care products are a multi-purpose or "all-in-one" solution. These solutions can be used for cleaning, rinsing, and disinfection and their chemical composition is developed to be compatible with contact lenses, the tear film, and ocular surfaces. Other care systems have separate bottles for cleaning, rinsing, and disinfection. With these systems, using the wrong bottle may cause complications ranging from mild irritation to severe pain. It is especially painful if a contact lens disinfected in a hydrogen peroxide solution isn't properly neutralized, which makes it compatible with the ocular surface. If a patient has used the wrong solution or improperly used a solution, they should remove the lens and rinse the eye with saline solution. If the eye remains painful, they should see the doctor immediately. Patients should be told that pain should never be tolerated and the best philosophy is "when in doubt, take i t
chart. The role of the office staff is to gather information for the eye care practitioner so they can determine the proper course of action. When patients call with a contact lens problem, they will often volunteer much of the information needed. Listen carefully, write down what they've said and inquire about any missing information. All patient issues need to be resolved. Some problems can be handled over the phone and some need to be seen by the doctor immediately. If there is any question as t o how quickly a patient should be seen, take down the information and ask the eye care professional. BEHIND THE SYMPTOMS To help determine how to schedule a patient, it may be helpful t o have some background knowledge as t o what may be causing the symptoms. Pain is not a normal adaptive symptom and can be caused by something as simple as a slight tear or nick in the lens to something as serious as an abrasion or infection. If the contact lenses are damaged, they should be removed and thrown out immediately. If the patient has removed their lenses and they still feel pain, this could be the sign of a more serious problem. The patient should be instructed to keep the contact lenses
26
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SUPPLEMENT T O OPTOMETRYISEPTEMBER 2004
Contact lens related red eye can be caused by wearing old, dirty, or damaged lenses. This complication can be avoided if the patient replaces the contact lenses as prescribed by the contact lens professional. A red eye can also be caused by a lack of oxygen to the eye. This can be the result of overwearing or sleeping in lenses. Solution sensitivity, inadequate rinsing of cleaners and disinfectants, contamination from soaps and cosmetics, can all result in a contact lens related red eye. If this occurs, contact lens wear should be discontinued until the source of the red eye is determined. Patients who experience discharge should discontinue lens wear and be seen by the doctor soon. Discharge can be caused by infection, allergies or GPC (giant papillary conjunctivitis), an immune response to protein deposits on the lenses. GPC also has other symptoms the patient would notice, such as itching. Fluctuating vision and intermittent blurring can be associated with dry lenses, lenses applied with the improper orientation (inside-out), or can be due to defects or deposits on the lens. When contact lenses become dry, vision and comfort can decrease. There are many causes of dry eye symptoms, including dirty or deposited lenses, incomplete blinking, allergies, systemic conditions, and prescription and over-the-counter medications. Some patients may only experience dry eye symptoms with their contact lenses in certain wear-
es before placing in disinfecting solution also helps t o remove loosely adherent films, deposits and debris. Patients mean well, but they can forget or misinterpret instructions given by t h e doctor. Therefore it's important for everyone on the eye care team to support and educate the patient on proper contact lens habits. When interviewing a patient regarding complications, if it is discovered that they are not following the recommended wearing or replacement schedule, it is appropriate t o reinforce the doctor's instructions. For example, a patient who adI mits they sleep in daily wear contact lenses and extend t h e replacement cycle should be re-educated on how they were preI scribed t o be worn. Non-compliance invites contact lens complications, some of which may cause short-term problems, such as lens discomfort; and some that may cause long term vision threatening problems, such as corneal infections with permanent scarring. The office staff are the eyes and ears for the doctor. When a noncompliant patient is identified, it should be mentioned t o the doctor and a notation made in the patient file for follow-up. All patients who call with an emergency should be brought t o the attention of the doctor. If it is something that needs immediate attention and the eye doctor isn't in the office or can't be reached, the "on call" doctor should be contacted for a recommendation. Create a system t o keep track of these patients. If the patient doesn't come in for the scheduled appointment, they should be called t o follow up on them. It can be a little frightening when first fielding questions from patients with contact lens problems and emergencies. To gain experience, ask the eye doctor how patients' contact lens complaints were ultimately resolved. While it's not the office team's role t o diagnose, a better understanding of complications and their management will help the office member feel more confident that they are scheduling patients in the correct appointment slots, and that they are reinforcing the instructions the eye care professional intended.
ing environments, such as department stores and airplanes. Tearing and itching are also symptoms that can be associated with dry eyes. Patients with ongoing dry eye symptoms should see the eye doctor t o evaluate the underlying cause. A reduction in vision can be caused by a lost or dislodged lens or by inadvertently switching the lenses. While it can be alarming GIANT PAPILLARY CONJUNCTIVITIS (GPC) for the patient when this happens, the remedies are quite simple. However, i f a patient has sudden vision loss unrelated t o the contact lenses, especially if it persists when lenses are removed, they should be seen immediately. THE ROLE OF PATIENT COMPLIANCE Patient compliance can help t o avoid, eliminate, or reduce many MUCUS contact lens complications. Compliance with the prescribed wearing time and lens replacement interval can reduce problems associated with dryness, dirty and deposited lenses, and reduced oxygen. Patients who sleep in contact lenses, even if it's just for a nap, need t o be evaluated and fit with a more oxygen permeable or extended/continuous wear lens. Patients who experience irritation with their contact lenses may drop out because they believe their eyes aren't compatible with contact lenses. In many cases, this general irritation that patients describe as dryness, low grade red eyes, fluctuating vision, and itching, is the result of wearing deposited lenses. Elements from the tear film and debris from the environment contribute t o deposits on contact lenses. For maximum comfort and vision, patient compliance with the lens replacement schedule prescribed by the eye care professional is vital. Proper cleaning and disinfection is also necessary for successful contact lens wear. If the patient isn't wearing single use disposable contact lenses, they must be cleaned t o remove deposits. Cleaning the deposits off the lens surface also helps with lens disinfection. After each use, the contact lenses need t o soak overnight in fresh disinfecting solution. The next day, the used solution should be thrown away and the lens case rinsed with hot water and turned upside down on a clean surface t o air dry. Rubbing and rinsing the lens-
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I
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SEPTEMBER 2004lSUPPLEMENT TO OPTOMETRY
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