5.2.1 Manages aftercare of pxs wearing soft lenses Flashcards
What is required in Aftercare H&S?
Preliminary Questioning
* RFV
* LAC
* LEE
* Spectacles up to date?
* Vision c specs d&n
* Vision s specs d&n
* How long have you worn contact lenses for
Current CLs
* Which lenses are you wearing atm? Brand and Modality
* How old is your current pair
* WTT
* AWT
* MWT
* How many days per week
CL wear
* Vision through CLs
* Comfort in CLs
* Any
o Irritation
o Redness
o Dryness
* Do you
o Swim
o Sleep
o Shower
* Any current complications?
Handling Technique
* Talk me through how you put your lenses in and take them out
* If Monthly:
o How do you store your lenses?
o How often do you change your solution?
o How often do you clean and replace your case?
o How often do you clean and replace your lenses?
POH
* Have you been diagnosed with any eye conditions?
* Any
o HES?
PGH
* Any General Health Conditions?
* Medications?
* Allergies?
* HBP?
* DM?
* Smoker?
Lifestyle
* Occupation
* VDU Use
* Hobbies
* Driver
What is required in aftercare over refraction?
- Distance VA
- Over Refract
o +1.00
o Duochrome - Final Distance VA
- Final Near VA
What is required in aftercare assessment of CL fit?
- Diffuse Filter, look at CL:
o Centration
o Comfort
o Coverage
o PUT - Measure Using the slit beam:
o Lag
o Sag
§ A normal fit measures: 0.2-0.6 mm - 1mm Dot:
o MOB
§ A normal fit measures: 0.4-0.7 mm
What is required in aftercare health assessment?
- Diffuse, x16 mag
o Conjunctival Redness
o Blepharitis
o MGD - Indirect Retroillumination, x25 mag
o Limbal Redness
o Neovascularisation - Parallelopiped & Optic Section, x30 mag
o Corneal Ulcers
o Tear Quality - Sclerotic Scatter, x25 mag
o Corneal Infiltrates - Tear Prism Height, measure using beam or 1mm dot
o G1: >0.3mm
o G2: 0.2 mm
o G3: <0.1mm
Instill Fluorescein (include Exp Date, Batch No.)
Fluorescein binds to epithelial cells with increased permeability, suggesting they are dead
or damaged cells. - Cobalt Blue (16x-25x)
o TBUT
§ >15 Secs: CLs suitable
§ 10-15: CLs suitable
§ 5-9: CLs are limited
§ <5: Contraindicated
o Corneal Staining
o Conjunctival Staining
o Papillary Conjunctivitis
If making changes to a lens at aftercare, what do you base it on?
Base on:
* Over Rx
* Fit
o Lens too large: decrease TD
o Lens too small/too much corneal exposure: Increase TD, Alter to looser
(flatter) fit
o Poor Centration: Decrease base curve for tighter (steeper) fit.
* Health
* H&S
What is the management at an aftercare?
- Recall
- Health
- Care Advice – Redness, pain or vision loss = remove the CL. No Sleep/Shower/Swim, no water
contact and give written instructions. Replace CL on time, which sol needed and
store with fresh sol and clean case weekly.
Describe blepharitis and aftercare?
Grade 3 or 4: Cease lens wear until resolved as risk factor for corneal infection due to pathological
microbes close to ocular surface.
Lid Hygiene:
* Warm compress
* Tea tree oil wipes
* Ocular lubricants
Describe MGD and aftercare?
Lens wear can be continued if this is tolerated by the px, as more likely to experience discomfort
due to dryer eyes
Artificial tears
Low water content lens: prevents CL from acting like a sponge and absorbing the tear film
Describe CL related bulbar conj staining and aftercare?
Due to mechanical trauma of conjunctival epithelium due to
* lens edge, decentration, tightness.
* Dry eye and reduced blink rate
* Solution toxicity
Often asymptomatic, lens wear can continue, however px can improve this by:
* Blinking exercises
* Re-wetting the lens with lubricants
* Changing to a different solution
* Changing the lens fit
Describe bulbar conj hyperaemia and aftercare?
Can be due to:
* Solution toxicity
* Dry eyes
* Infection or Inflammation
* Corneal hypoxia
Lens wear can continue if sx allow, or:
* Refit with higher Dk/t
* Change to lower water content lens material
* Ocular lubricants
Describe LIPCOF and aftercare?
Arises due to mechanical forces between lower lid and conjunctiva
Manage if >G2 and px has sx:
* Refit with lower content CL (as px will experience dryness) and lubricants
* Change lens type from SiHy to Hydrogel to aid with mechanical force (Hydrogels are
thinner, lower modulus) or reduce wear time
Describe CLPC and aftercare?
Inflammation typically arising due to solution toxicity or mechanical force/trauma from contact
lens wear, prosthetics or sutures. Px will typically experience:
* lens awareness and intolerance
* FB sensation
* Itching that increases on lens removal
Lens wear can continue if px can tolerate, but can be improved by:
Changing care system
Reducing edge clearance on the lens
Lower modulus lens (in RGPs reduce lens thickness)
Describe limbal hyperaemia & staining and aftercare?
Typically due to:
* Hypoxia
* Tight lens causing inflammation
* Mechanical trauma due to poor lens fit
Manage by:
* Ceasing lens wear until it’s resolved
* Refit with higher Dk/t lens
* Switch to lower modulus
* Optimise lens fit
Describe neovascularisation and aftercare?
Hypoxia causes lactate accumulation in the stroma, reduced intracellular pH and increased
corneal hydration leading to stromal oedema (which reduces corneal transparency) and the
release of VEGF, causing the neovascularisation.
Manage by:
* Cease lens wear if grade 3 or 4
* Increase DK/t, cease EW or reduce lens wear to increase corneal oxygenation
Describe SMILE staining/Inferior epithelial arcuate lesion and aftercare?
Typically caused by rapidly evaporating tear film or incomplete blinking
* G2: Remove lenses for 24 hrs
* G3: Remove lenses for 3 days
* G4: Remove lenses for 7 days
* Use lubricants to reduce symptoms
* Blinking exercises
* Change lens to a lower water content
Describe Superficial Epithelial Arcuate Lesion (SEAL) and aftercare?
Typically caused by mechanical trauma due to edge of high modulus lens, hypoxia or dryness.
* G2: Remove lenses for 24 hrs
* G3: Remove lenses for 3 days
* G4: Remove lenses for 7 days
* Use lubricants to reduce symptoms
* Change lens to a lower modulus or try RGP
Lesion is between 10 and 2 o clock and is parallel to limbus. Often unilateral and asymmetric
Describe FB staining/abrasion and aftercare?
- Typically caused by FB under lens
- damaged lens
- clumsy lens application or removal
- excessive eye rubbing
Manage by: - G2: Remove lenses for 24 hrs
- G3: Remove lenses for 3 days
- G4: Remove lenses for 7 days
- Alleviate the underlying cause
Describe mucin balls and aftercare?
Due to tear film collapsing and forming spheres due to motion between the lens and corneal
surface as a result of EW or high modulus lenses. Usually disappear after lens removal.
Management not usually required, but if affecting vision reduce wear time/consecutive nights or
fit a lower modulus Lubricants may also help.
Describe epithelial microcysts, striae and oedema and aftercare?
Epithelial Microcysts:
Due to hypoxia across corneal surface leading to oedema and microcysts. If grade 3 or above,
cease lens wear until oedema resolves and refit with a higher Dk/t.
Striae:
Due to hypoxia, switch from EW to DW and refit with a higher Dk/t to increase oxygen supply to
the cornea.
Oedema – increase in tissue fluid content, normal during sleep and CL wear relates to
corneal hypoxia, Striae (oedema >5%) fine wispy white lines become thicker as oedema
increases doesn’t cause visual loss. Folds (oedema >8%) depressed grooves and raised
ridges in endothelium, increases with oedema. Haze (oedema >15%) loss of corneal
transparency, degradation of vision. Chronic oedema = stromal thinning. Increase Dk/t
and reduce WT.
Describe Dellen and Desiccation and aftercare?
Desiccation: Localised disruption of the corneal surface, greater with thin HWC lenses
/ incomplete blinking, punctate fluorescein staining often inferior band, dryness
symptoms, refit lens and use lubricants
Dellen: local saucer like depression in cornea caused by localised dryness and
desiccation, possible scarring, vascularisation and 3 & 9 o’clock staining, epithelium
intact, eliminate cause.
Describe CLARE - CL-induced Acute Red Eye?
Inflammation of the cornea and conjunctiva due to endotoxins from bacteria accumulating.
Usually due to:
* sleeping in CLs
* tight lens
* upper respiratory tract infection
sx:
* Painful red eye
* Photophobia
* lacrimation
*problem upon waking if mild, awakened if severe pain, tearing and photophobia due to tight fitting lens.
Signs:
* conjunctival and limbal hyperaemia and small corneal infiltrates near the
limbus, no movement of lens and trapped debris. Staining on removal of lens. AC flare,
endothelial bedewing, low grade neovascularisation, swollen epithelium and dry spots.
10-50% bilateral
Management:
* Cease CL wear, self-limiting on CL removal: Hyperaemia resolves rapidly, infiltrates take
longer
* Monitor for 24 hours to confirm diagnosis
* Refit with looser lens
* Advise px not to sleep in lenses
* Improve lens hygiene
Hot compress, cease lens wear till resolution, change to DW, improve hygiene, loosen lens fit, fit GP, 50% recurrence of CLARE if EW continued
Describe CLPU and aftercare?
Inflammation with focal excavation if the epithelium, infiltration and necrosis of the anterior
stroma (Bowman’s remains intact) typically due to:
* Bacteria/poor hygiene
* Hypoxia
* Tight lens
* Solution toxicity
* Protein deposits
Sx:
* Lens intolerance
* FB sensation
* Photophobia
* Lacrimation
oSigns – peripheral anterior stromal infiltrate, single or multiple, small >1.0mm,
overlying epithelium stains, Mild hyperaemia, Epiphora, AC quiet or mildly inflamed, no
lid oedema, usually unilateral
Management
* Monitor for 24 hours to ensure it is not microbial keratitis
* Cease lens wear until the epithelium heals over the lesion (approx 14 days)
* Lubrication to prevent lid rubbing and dilute the bacterial toxins
* Loosen lens fit
* Change solution or switch to DD
* Improve lens hygiene and care
Discontinue lens wear – most sign resolve in 48hrs, infiltrates resolve
over 2-3 weeks, no EW, possibility of recurrence, managed in clinic examine daily for a
week, no need to refer (only if unsure about MK) if no healing after 3-4 days or worsen
Refer
Describe microbial keratitis and aftercare?
Infection of a compromised cornea (epithelial break, hypoxia), leading to excavation of the
corneal epithelium, Bowman’s layer and stromal necrosis. Infiltrates present, typically singular,
unilateral, large >1mm, along with hyperaemia
Risk Factors:
* EW
* Hypoxia
* Swimming/showering/using tap water on CLs
* Smoking
* Poor lens and case hygiene
* Long wear times
Sx:
* Severe pain with rapid onset
* Photophobia
* Epiphora
* Severe Redness
* Reduced Vision
* Discharge
* Lid puffiness
Signs:
Lid oedema, Conjunctival Hyperaemia (Mild to Severe),
Large central corneal lesion (excavation of epithelium, bowmans, stroma), stromal
infiltration beneath lesion, endothelial fibrin plaque beneath lesion. AC flare, cells,
hypopyon
Management
* Cease lens wear
* Emergency referral to HES:
o Corneal scrape
o NSAIDs/Antimicrobial/Analgesics
* Reiterate no tap water, case/lens hygiene and 3s’
* Change to daily wear
Describe acanthamoeba keratitis and aftercare?
Acanthamoeba is a free-living amoeba commonly found living in water. It can cause a
parasitic infection most commonly see in CL wearers which is characterized by pain out of proportion to findings
with late clinic presentation.
o Symptoms – this condition is characterised by pain out of proportion to findings,
decreased vision, FB sensation, photophobia, tearing and discharge.
o Signs – Early signs may be mild or non-specific possible findings are: recurrent
breakdown of epithelium, epithelial or sub-epithelial infiltrates and pseudodendrites.
Later signs include stromal infiltration (ring-shaped, disciform or nummular), satellite
lesions, epithelial defects, radial keratoneuritis, scleritis, anterior uveitis with hypopyon.
Advanced signs include stromal thinning and corneal perforation.
o DD – in early stages is dry eyes, HSV keratitis, recurrent corneal erosion, CL associated
keratitis, bacterial, fungal, viral or sterile keratitis.
o College Management Guidelines – EMERGENCY REFERRAL due to sight threatening
nature
o Prognosis – the prognosis is worse than any other infective keratitis so therefore
prevention is therefore very important if caught early enough satisfactory outcomes can
be achieved.
What is the pneumonic PEDALs?
Differential of Infective vs Non-infective (P.E.D.A.L.S)
o PAIN: Sterile – Little/Absent relieved on lens removal / Infective – Intense worse on removal
o EPITHELIUM: Sterile – staining of overlying infiltrate / Infective – Often non as sub-epithelial (Deep if ulcer)
o DISCHARGE: Sterile – None / Infective – Muco-purulent discharge
o ANTERIOR CHAMBER: Sterile – No sign / Infective – Flare and cells from active infection
o LOCATION: Sterile - Multiple or single in periphery / Infective – Single located centrally
o SIZE: Sterile – Small <1mm / Infective – Large >1m
