General Aftercare Flashcards
1
Q
Should px wear lenses to aftercare?
A
Px should wear lenses to this appointment – if routine or following initial fit/refit
If px has acute problem e.g infection – then THEY SHOULD NOT BE WEARING LENSES – bring lenses with them
2
Q
What factors can influence aftercare recall intervals?
A
- Corneal pathology – hint of NV see px back in couple months (don’t leave them 6mths-1yr), dry-eye & px trying new rewetting drop see px in 1mth to see what staining looks like
- Cornea physiology
- Application of lenses – if px is a mountaineer & they are in altitude then want to bring px back sooner, if px is flight attendant in v dry atmosphere then bring back sooner
- Compliance – if px is over-wearing lenses may want to bring them back sooner to keep an eye on them
- Acute problems – the px has shown up for an aftercare out with their recall
- Px may also present thinking they have a CL issue when in fact it is pathological at fundus
3
Q
What questions do you ask in H&S for aftercare?
A
- RfV – start w/ open Q
- Confirm type of lenses – never know what has happened in between, px may have gone elsewhere or gone online
- How often?
- What time do you put your lenses in? and take them out?
- Age of current pair and hours in today – if lens is monthly or 2-weekly, try to see the px at different time in this period to see what their compliance/cleaning regime is like
- Do you sleep in lenses? Do you swim in lenses? – CHECKING DO’s & DON’Ts
- Cleaning regime (look at lens case, ask how old it is) – ASK PX TO SAY IT BACK TO YOU
o “talk me through your cleaning regime” - Comfort – 1 to 10 scale, any problems with comfort?
- Any redness/pain/itching/dryness. If yes LOFTSEA
- Distance/Near/VDU vision
- Do you have back up glasses? – look at record card to see when the last purchase was
- GH – keep this relevant
- Meds
- Allergies
- Occupation/Hobbies – v important as if something has changed then may want to adjust lense
- Driving
- Smoke
4
Q
What happens if at an aftercare the px reports sudden loss of vision?
A
If px presents with sudden loss of vision in one eye -> thinking not CLs and will need to dilate
5
Q
Which investigations do you complete at an aftercare with lenses in?
A
- VA:
o Monocular & binocular – needed when checking monovision - Over-refraction:
o Spherical if VA good
o Sphero-cyl if necessary to improve VA
o If fairly large change in Rx needed – consider doing a sight test
o Remember impact the fit of lens can have on VA & Rx – problem in RGP lenses – any rotation of toric lens can cause effect on Rx - Over keratometry:
o w/ B&L keratometry - Lens surface assessment:
o Looking for:
Deposits
Surface or edge defects – any splits, any cracks – for RGP look for scratches
Wetting of lens (esp RGP) – nice, spread of tears over lens
Tear film interactions – is px fully blinking? - Fitting assessment:
o Same as when fit lenses initially
o But assess fit at certain times for different lenses
1st thing in morning for EW
Towards end of day for DW (& just before lens will be thrown away) - Want to see lens at its worst
No point checking for deposits on day 1 of a monthly wear - Lens-eye interactions:
o Looking for any adverse interaction between lens & ocular surface
o E.g. 3 and 9 o’clock staining from an RGP
o Or indentation (particularly from a soft lens) – look at fine vessels for soft lens – is there nipping of BVs?
6
Q
What is the next step of the aftercare after the investigations with the lenses in?
A
Now get px to take lenses out -> px has to so to show you their technique -> looking for handling & hygiene – look for px taking lens out w/o washing hands etc
7
Q
Which measurements are done with the lenses out in aftercare appt?
A
- Keratometry/topography:
o If suspect corneal shape changes
o Compare to baseline values
o 3 common changes:
1. Oblate shape – flattening central cornea, happens in EW SiHy
2. Inferior steepening – happens in low Dk RGP or hydrogel lenses
3. Impression arcs – RGP induced, usually inferior – seen well on topography
o Can take up to 6mths to resolve - Refraction:
o To check for changes induced by corneal warpage
o Use ret reflex to look for cornel distortion – do ret over CL - SL biomicroscopy:
o Note grading scale – CCLRU designed specifically for CLs but Efron scale has bleph & MGD – be clear on record card which scale you used
o Lid margin/lashes – clean & health? Ant bleph? MGD? Excessive make up? – makeup in wrong place e.g. posterior to lashes & so blocking meibomian glands?
o Bulbar conjunctiva – grade any hyperaemia. Any pterygium? Pinguecula?
o Palpebral conjunctiva – LID EVERT – assess inferior & superior. Grade redness and roughness
o Cornea – grade staining. Must comment on depth of staining (optical section) – DRAW what you see
o Limbus – grade redness. Measure NV – add this to drawing
o Tear film – TBUT (non-invasively w/ B+L Keratometry, invasively w/ NaFl), debris (deposits or make up) in tear film? - Lens inspection:
o May need to do focimetry on RGP lens if there is lens warpage or focimetry on any lens to check the Rx in case think been sent something wrong
o Can be held up in front of SL w/ rubber tipped tweezers
o Looking for any damage to lens - Other applicable tests:
o Pachymetry if corneal oedema is suspected – works well if have baseline or are monitoring over time
o Corneal endothelial analysis w/ specular microscope if suspected polymegathism or pleomorphism – rarely used in standard practice
o Any symptoms that require further investigation, do not ignore symptoms because it is booked in as a CL appointment
If see mascara debris, let px know to be more careful when applying
8
Q
What questions do you ask yourself if the eye is red in aftercare?
A
- Is lens causing the problem?
- Is it conjunctival hyperaemia? Or a deeper structure?
- General rules (ALWAYS EXCEPTIONS):
o Conjunctival redness w/ a quiet limbus & no pain = conjunctival problem
o Conjunctival redness w/ an injected limbus & pain = corneal problem
o Then go through possible diff diagnosis
DO NOT JUST THINK ABOUT CL COMPLICATIONS
9
Q
What questions do you ask yourself if there is discomfort with the lenses in aftercare?
A
- Bilateral or unilateral?
o Bilateral suggests toxic problem e.g. solutions
o Unilateral suggests problem with that lens - Still there when lenses removed? -> Suggests ocular problem
- Gone with lenses out? -> Suggests lens problem
- Do ocular lubricants provide relief?
o If yes then consider mechanical or abrasive source or dryness - Possible causes:
o Poor fitting
o Damage to lens
o FB on or under lens
o End of day dryness – ASK when feel the discomfort
o Older lenses
o Deposits on lens surface
o Toric lenses can be less comfy due to stabilisation methods – did they have spherical lenses and now on toric lenses?
o Pathology or complications
10
Q
What questions do you ask yourself if there is poor vision with the lenses in aftercare?
A
- Investigate:
o Severity
o Consistency – there all time or is it variable
o Onset
o Distance or near – or both?
o Description – is it blur, it is like a curtain, is it like the lights have been switched off? - Vision better after removing lenses? lens problem
- Sustained vision loss after removing lenses? ocular problem
- Bilateral? toxic reaction, allergy, refractive, systemic
- Worse after blink? lens movement, flat fit
- Improved after blink? tight fit
- Refractive causes:
o Lens missing – lens may be off to side/under lid or have fallen on floor & px thought they had put it in
o Change in Rx
o Incorrect lenses – either from supplier or by px
o Thick lens causing corneal warpage
o Uncorrected astigmatism
o Mislocation of toric lens
o Monovision lenses (one distance, one near) in wrong eyes (presbyopic method) - Ocular pathology
11
Q
What are the 3 questions the patient should ask themself everyday when wearing lenses?
A
- Do my eyes look good? – Is the conj white, quiet?
- Do my eyes feel good? – Any pain?
- Do my eyes see well?
12
Q
What are the steps of an aftercare?
A
- Px record analysis look at px’s records before they come in
- History & symptoms
- VA check & OverRx
- SLB: lens condition
- SLB: lens fit assessment
- Px removes CL, Observe I&R, Demo care regime – px touches the lens, you do not
- SLB: ocular health check with NaFl
- Devise appropriate management
- Communicate management plan to px
13
Q
What are you looking for at aftercare?
A
- Establishing compliance -> seeing how they follow the rules
- Identifying risk factors – are any risk factors higher or lower for this px?
- Ensuring optimal care -> any advice you can give – changing lenses/wear time, advising lubricants?
14
Q
Describe Px record analysis in aftercare?
A
- Need to know what has previously occurred or what lenses they have worn
- Cannot make a decision about px compliance w/o:
o Previous clinical findings
o Past px behavioural concerns -> previously good but this time they have not been as good - Need to appreciate what previous CLs have been tried/tested/not worked
- Confirms which Rx & CL type is currently worn
- Makes the over-Rx process simpler
- Comparing current fit to previous recorded
- What were previous ocular health gradings?
o Have things changed or remained stable?
o Allows comparison to baseline - Difference in approach for:
o 1st offender vs repeat offender - Helps form a more appropriate px-centred management plan more personable – not making any judgements
- Prevents us from looking under-prepared/unprofessional
RARELY MAKE A CLINICAL DECISION BASED ON A SINGLE CONSULTATION
15
Q
What are the important Q’s to ask in H&S in aftercare?
A
- What time do you normally put your lenses in at? And what time do you take them out at?
- Can you show me what you would do when removing your lenses at end of day?
- How old are your current lenses?
- How far into the month are these lenses?
o If they do not know, shows they’re not keeping on top of it - It’s quite common for folk to overlook, CL removal when napping or after a night out, is this something you have done? How often, roughly, has that happened?
