Case Study/ 6 Month Follow up Troubleshoot

Question 1

What are two common reasons that patients have decreased vision with cls?

Answer 1

They have switched the lenses or the lens is inverted

Question 2

Pt. Has worn soft lenses for 15 years
He has come in on an unscheduled basis as he notices reduced vision OS and a mild burning sensation. After CL removal, he notices that vision still seems reduced with spectacles.
VA is reduced to 20/80 OS, no improvement with over-refraction or pinhole. The biomicroscope reveals a central coalesced area of staining. What is wrong with this patient?

Answer 2

Abrasion or Ulcer

Question 3

New wearer comes for an unscheduled follow-up visit. They wear hydrogel monthly lenses. She comes in without the lenses on and complains of discomfort immediately upon insertion. What is the solution

Answer 3

Edge Tear/damage Inspect the lens with or without slit lamp

Question 4

Care regimen: ReNu Fresh
Wearing time 8-10 hrs.
VA OU 20/20
Patient complains of dry eyes and increased lens intolerance. She received her lenses in April and it is now November. She finds the symptoms to be worse at work. Possible solution/problem? 4

Answer 4

Preservative sensitivity
Pregnancy
Any new medications or systemic issues?
What is her environment like? heat on?

Question 5

Patient is a new CL wearer. She wears the lenses for awhile, but can’t increase time above about 8 hrs.
Possible solution?

Answer 5

If fitting in a lens material known to be good for dry eyes and using hydrogen peroxide disinfection or daily disposable wear doesn’t help, consider dry eye therapy- Steroids, fish oil, lid scrubs and massage, lubricants and then refit

Question 6

What is the main cause of a pt reporting a burning sensation? and 3 other potential reasons?

Answer 6

MAIN
Solution sensitivity
OTHER
Others can be dry eye, lens contamination, cigarette smoke

Question 7

When a patient comes in complaining of photophobia, what should we think?

Answer 7

corneal injury

Question 8

What are the major causes of itching? 2

Answer 8

1. Allergy
2. GPC

Question 9

What should you think when patients come in complaining of seeing halos or having hazy vision? 2

Answer 9

1. Deposits on the lens
2. Corneal edema

Question 10

When should we be concerned about corneal vascularization?

Answer 10

When the vessels look like they are headed straight into the cornea and they are more than 1.5mm in length

Question 11

What is the treatment if corneal vascularization is seen?

Answer 11

1. Change to Silicone Hydrogel lens to increase the O2
2. Reduce wearing time to DW

Question 12

What are striae and which type of lens are the likely seen with?

Answer 12

They are folds at Descemet’s level and are very rarely seen with Silicone hydorgel lenses. Will see with hydrogel lenses

Question 13

What are microcysts?

Answer 13

They are trapped metabolic debris that occurs after 2-4 months of chronic hypoxia

Question 14

What is the treatment for corneal edema? 2

Answer 14

1. Refit into a higher Dk/t lens (SiHi)
2. D/C lens wear in severe cases

Question 15

Rx OU -5.00
K’s OU 45.00/45.00 @ 90
Contact Lenses: 8.4/-4.75/Acuvue Oasys
VA OU 20/20
SLE: Good centration, lag 0mm,
-push-up, Injection 1+

Answer 15

The lens is too tight, use a flatter BC

Question 16

If you want to loosen a lens, what needs to be done?

Answer 16

smaller diameter
flatter bc

Question 17

If you want to tighten a lens, what needs to be done?

Answer 17

larger diameter
steeper bc

Question 18

What is the number one complication to SiHi lenses?

Answer 18

GPC

Question 19

What is GPC?

Answer 19

Giant Papillary Conjunctivitis which is an autoimmune reaction to deposits on the lens the patient is wearing.

Question 20

What are symptoms of GPC?

Answer 20

1. Minimal increase in mucus secretion, mild itching on lens removal
2. Lens awareness, minimal itching with lens wear, blurred vision
3. Increased lens movements, mucus secretions, and decreased wearing time
4. Lens intolerance, mucus discharge

Question 21

What is the treatmentS for GPC?

Answer 21

Provide the wearer with a clean lens
change to DD if persistent

Question 22

Patient has worn monthly replacement lenses for > 5 years. She does not necessarily replace them monthly. She is experiencing decreased WT, discharge upon awakening and itching with CL wear.

Answer 22

GPC, evert the lid and look for papillae and hyperemia

Question 23

What are SEALS?and what causes it?

Answer 23

Superior Epithelial Arcuate Lesions. They are on the superior cornea and are from an increased lens modulus. usually in SiHi lenses

Question 24

How do you treat SEALs?

Answer 24

Use a flatter BC or change to a lens with a design of lower modulus

Question 25

What is CLARE? and what causes it?

Answer 25

CL induced Acute Red Eye.

Gram negative organisms on the lens which release endotoxins. Pt wakes up with red, watery, painful eyes. Caused by overnight cls wear

Question 26

What is the treatment for CLARE?

Answer 26

D/C lens wear and use lubricants

Question 27

What are infiltrates and where are they typically located?

Answer 27

They are typically located near the limbus and are inflammatory cells lying within the stroma.

Question 28

What is the treatment when a pt has infiltrates?

Answer 28

D/C lens wear until the infiltrate disappears

Question 29

Patient wears their lenses for 30 days at a time. At the annual visit, you notice grade 2+ papilla and the patient admits to mild itching.
potential cause? and solution.

Answer 29

GPC: Probably not a good EW candidate. ClearCare may help, fresh lenses, DD lenses

Question 30

Patient has been fit with CW lenses. She has complained of redness and discomfort. Upon slit lamp examination, you note grade 2 injection OS>OD and moderate edema OU. What do you decide to do?

Answer 30

Refit into higher Dk lens, decrease WT (wearing time may need to be reduced to 7 days EW or occasional EW), ask about compliance (how long are they leaving lenses in before removal, do they take an overnight break)

Question 31

Patient experienced CLARE with CW lenses. The patient is a high myope and desires to continue some extended wear.

Answer 31

Put in a higher Dk/t lens, occasional EW, More frequent removal

Question 32

Patient comes in to the office with pain, photophobia & tearing. He has D/C lens wear. Minor discomfort first noticed at 4pm the day before. Used an old bottle of lubricant and it improved. He did not remove the lens until the following morning when his eye became extremely uncomfortable. Staining reveals a small 1mm circular area of staining surrounded by haziness in the cornea.
Problem?

Answer 32

Ulcer. Especially concerning with disruption of cornea and old solution use (introducing bacteria to a break in the cornea)

Question 33

Patient comes for 1 week check after wearing lenses extended wear Air Optix Night & Day. There are small bubbles which do not move on the blink.

Answer 33

Most likely mucin balls, could be microcysts If disappear upon removal, mucin balls. Unusual to have microcysts with high Dk lens

Question 34

Lenses are 1 1/2 yrs. old. The patient has been wearing them for 2-3 mths. without removal. Compliance to care is questionable. They woke up Sat. with a red painful eye, photophobic, watering. Injection is grade 3, there’s an infiltrate at 11o’clock, no staining.
What is the Problem and what has caused it why?

Answer 34

CLARE- CL acute red eye
Overwear