H and s , staining and ocular response to CL wear Flashcards
Why do we conduct an aftercare for cl ?
Ensure optimum comfort and optical performance
- Minimise drop-outs
- Answer patient queries/questions
- Address any compliance issues – Safety: reduce risk of infection
- Assess the ocular reaction to a lens
What are the 2 main routines we conduct during CL appt ?
- New fit
2. Refit- if px is new to clinic but already wearing CL
How does the routine for CL appt start for a new CL fit ?
- H and S
- check the eye and palpebral conjuctiva
- following lid eversion with white light as well as fluroscein and blue light
- Preliminary measurements - HVID, VPA, K’s , pupil size
- Choose one or 2 lenses to try on one eye then put both
- after lenses settled, check VA and conduct over refraction including binocular balancing
- With slit lamp - have to check for the CL fit and staining.
- Advise and recommended for px - and teaching session is booked.
How does the routine for an aftercare CL start ?
- H and S
- Check VA and over refraction
- Check for lens fit with the slit lamp
- Ask px to remove CL , observe their CL remove and washing hands
- check anterior eye and lids with blue and white lights before your provide advice and recommendation and prescribe the CL specification for another year.
How is the history and symptoms for CL fits ?
very specific
- no need to do like clinical skills
- focus on motivation for CL wear
- why does the px want to wear CL?
- is it appropriate for them , such as :cosmetic, sport, therapeutic, special occasions
How do you ask h and s for a new fit ?
Motivation for wear?
• Px expectations
• Are the expectations
realistic?
• FT/PT wear or occasional
wear?
-need to ask what is the VA like with specs?
-Determine the presence of any issues that may affect the VA through CLs e.g. amblyopia or
presbyopia
-check for ocular health - check for symptoms, Are there any contraindications
to lens wear? (pink eye etc), Does patient require treatment prior to fitting?
-if px has any symptoms - follow up with FLOADS
How do you ask h and s for a aftercare ?
What type of visit is it? • Routine? • Unscheduled visit? Determine if there are any problems Follow up any advice that was given at the previous visit e.g. • Use of eye drops • Advice regarding wear time - need to ask How is the VA through CLs? and Through specs? -need to understand if VISUAL STABILITY like : asking any ... • Fluctuating? • If so, when? • Does blinking affect VA? • Onset of presbyopia? - Ocular health - ask \:Any new problems? COMFORT • Issues when wearing CLs? e.g. Lenses drying out, ocular discomfort, redness, pain? QUS ABOUT LENSES • Age of lens/case? • Cleaning of lenses/case? • Solution? WEAR TIMES Days (/7), hours (/24), max, average, and today, as well as comfortable -if px has any new symptoms follow up with FLOADS
When is ocular health checked ?
-asking if px suffers from any of the symptoms of photophobia, pain or vision loss.
What are the different symptoms of ocular health issues ?
important symptoms: ! Light sensitivity ! Discharge ! Pain ! Vision suddenly blurry/ loss
How to ask using FLOADS with px reporting symptoms of OH problems?
WHEN • On insertion • During wear • End of wear • After removal TRIGGERS • Beginning/end of month
ONSET
• Recent –days? Weeks? HOW
• Longstanding-check previous records. Has there been a CHANGE in symptoms?
SEVERITY • Ask px to grade on a scale of 1-10 • How long do symptoms last HOW • How does px resolve this? • Are they using drops/medications?
TRIGGERS
- What causes symptoms
• Any associations?
What can the cause of discomfort on insertion or sudden onset of CL?
foreign body damaged lens decentered lens, excessive movement conjunctival irritation corneal abrasion
What can the cause of discomfort after period of wear of CL?
lens deposits
surface dehydration, wetting problems
trapped debris
CLPC
What can the cause of discomfort after removal of CL?
corneal abrasion
SEAL
inflammation/infection
What can the cause of constant blurred vision be of with CL?
switched lenses
incorrect rx
residual astigmatism
distorted lens
What can the cause of blurred vision fluctuating with blinking with CL?
better post blink- expect lens deposit
or worse post blink- excessive lens movement
lens sitting inside out
What can the cause of blurred vision occurring over time or at the end of the day with CL?
lens deposits
lens surface drying
What can some reasons for the triggers of symptoms in CL ?
Is it the lens? The solution? The case? The patient? The eye? The environment? Or a combination of the above?
What can some reasons for the severity of symptoms in CL ?
Quantifiable, but still subjective
• May help in monitoring any improvements/changes to symptoms
What do we ask for POH for cl ?
Havetheyever suffered from any eye conditions?
• Establishifthere is anything which might limit lens wear, lens type, or require more frequent monitoring?
What do we ask px refitted with a new lens - POH?
- what went wrong with the old lens
- previous lens details
- previous problems
What do we ask px with aftercare- POH?
Check previous records and confirm
• Anything new which has
occurred since the previous visit?
What to ask with GH IN CL wearers?
Youneedtoestablishifthereareanycontraindicationsto contact lens wear or conditions that may limit wear
• Rheumatoid arthritis- cause dry eye, scleritis or uveitis
• Diabetes- cataract, glaucoma ,diabetic macular oedema, diabetic retinopathy - leading to retinal detachment , CL related dry eye
• Eczema
- allergens- itching and redness - lenses may trap allergens which can make it worse
•Theremaybeanincreasedriskofocularinfectionand/or ocular discomfort with certain systemic conditions
What to ask about medication in CL wearers ?
Does the patient take any medication that may affect the eyes?
• We are particularly interested in medications that may affect the anterior eye e.g. cornea, the tears (keratacconus)
• The British National Formulary (BNF) lists the side effects of medications
Relevant FOH/GH
• Any hereditary anterior eye conditions that may affect contact lens wear?
What lifestyle questions can we ask to CL wearers ?
Does your px smoke?
VDU? How much? ,Driver ,Hobbies Occupation
What can we recommend for px using screens ?
20-20-20 rule
-every 20 mins look 20ft away for 20seconds
What is performed after the vision check?
anterior eye health check
What do we check in CL aftercare ?
check lens fit first in aftercare
What do we check in CL new fits ?
observe anterior surface of eye before inserting any lenses
-once we observe need to record findings
How do we start record keeping ?
pick a grading scale- most common CCLRU ,and effron grading scale
What are the advantages of the CCLRU SCALE ?
-use real eyes
What are the disadvantages of the CCLRU SCALE ?
-different eyes for all diff gradings
-different illuminations -
which can make it difficult to compare to your own px
What are the advantages of the effron scale ?
=precise severity shown
-image constancy
What are the disadvantages of the effron scale ?
-not real eyes
Why is a record keeping important ?
it is a legal document
therefore ensure you keep an accurate record of presenting signs and symptoms and respond to complaints
-proof that standard of care was met
What are the features of CCLRU scale ?
- Photographic scale
- 1- 4 scale
- Rating of slight (Grade 2) or less is considered within normal limits
- A change of one grade or more at follow up visits is considered clinically significant
What are the features of effron scale ?
• Pictorial scale • 0-4scale • Artist rendered • Grade 0 = no action required but Grade 4 = action required • Traffic light banding: Red (severe)
why is it important to grade to the nearest 0.1 ?
- accuracy better between observers - so can compare with colleagues in practice
- improves variabiluty
What do we use slit lamp routine for in CL?
-to check for corneal staining
How do we check for corneal staining on slit lamp ?
use 10-16x mag
wide beam
-wratten filter - yellow
-check under superior eyelid
-search for brightest area , increase the angle of the illumination system
-make beam thinner into an optic section , and increase mag to observe depth of staining
-depending on grading scale you use : RECORD- always write what scale you used and stick with that same one throughout since there is a difference, grade to nearest 0.1
How do we record corneal staining in CCLRU?
-type, extent (area covered) and depth
How do we record corneal staining in effron grading ?
micropunctate
What does a grade larger or equal to 1 mean?
clinically significant - specifically in enffron grading. scale
What does a grade larger or equal to 3 mean?
requires management plan
How is depth of corneal stain assessed using ?
a thin optic beam section - with wide angle and mag
- the latter to important to distinguish between the different corneal layers- identify brightest spot of staining and observe is fluroscien is leaking into the stroma
- high mag and illumination is therefore important.
What is a smile (Desiccation) corneal staining ?
from left to right
- dryness of inferior cornea in soft CL wearers- due to incomplete blink
- staining is visible just above the tear prism on the lower lid margin
What is a foreign body ‘linear’ staining like ?
foreign body trapped under the CL
-tends to be linear
What is a mechanical SEAL (superior epithelial accurate lesion ) corneal staining ?
due to mehcincal pressure due to the design or lens material
-causes inverted smile in the superior cornea below the lid margin
What is desiccation in RGP wearers corneal staining?
observed as 3 and 9 o’clock staining
-tends to cross limbus onto the conjuctiva
What is toxicity diffuse corneal staining?
shows diffuse stains all over the cornea
-observed after CL fit , if cornea responds to the contact lens solution in the CL blister pack
What are the 7 anterior eye adverse events in CL wearers ?
must be looked for and managed properly
AIK – asymptomatic infiltrative keratitis
• AI – asymptomatic infiltrates
• SEAL – superior epithelial arcuate lesion
• CLPC – contact lens associated papillary conjunctivitis
• CLARE – contact lens acute red eye
• CLPU – contact lens peripheral ulcer
• MK – microbial keratitis
What is AIK - asymptomatic infiltrative keratitis?
Sterile corneal infiltrates
• Inflammatory cells from limbal blood vessels form white spots in cornea
• In response to hypoxia, bacteria, lens deposits, allergic reaction, poor hygiene etc
What is the management of AIK ?
– Temporary discontinuation of CL until infiltrates disappear
– Careful monitoring
– Ocular lubricants and cold compresses
What is AI – asymptomatic infiltrates?
Aetiology: same as AIK – Milder
– No redness
– Smaller infiltrates
What is the management of AI?
Temporary discontinuation
– Careful monitoring
– Ocular lubricants and cold compresses
What is SEAL – superior epithelial arcuate lesion?
Mechanical pressure due to design or material
• Arcuate staining parallel to superior limbus
• Usually unilateral, asymmetric, mildly symptomatic
What is the Management for SEAL?
remove lens, cease CL wear for x days (depends on severity), issue lubricants, review lens fit
– Use thinner, more flexible lens material
– Change back surface geometry of the CL
What is CLPC – contact lens associated papillary conjunctivitis?
Conjunctival inflammation
• Immunological response due to hypersensitivity to lens deposits or solution
– Or mechanical response due to lens design or modulus
What is CLPC management ?
Manage if grade >2
– Lens wear can continue if symptoms permit
– Improve lens hygiene (cleaning and wearing time modality)
what is CLARE - Contact lens acute red eye?
Unilateral, acute hyperaemia, diffuse infiltrate keratitis, possibly anterior chamber reaction
• Woken at night with painful red eye
• Inflammatory response of cornea and conjunctiva subsequent to period of eye closure with CL wear
– due to endotoxins from gram negative bacteria (especially Pseudomonas spp)
What is the management of CLARE ?
Management: – Self limiting
– Temporary discontinuation CL wear – Careful monitoring
what is CLPU - Contact lens peripheral ulcer?
Up to 50% asymptomatic
– Lens intolerance, foreign body sensation, lacrimation, photophobia. Lens removal reduces
symptoms
• Localised hyperaemia, sterile circular infiltrate
• Inflammatory response to gram positive bacteria (esp staphylococcus spp)
– due to e.g. bacterial contamination, poor hygiene, hypoxia, solution toxicity
what is the management of CLPU?
-self-limiting on removal but close monitoring for 24hrs to ensure diff diagnosis from MK
– Ocular lubricants, lid hygiene, and referral only in severe cases (acute red eye or no improvement after lens removal)
What are the MK - microbial keratitis symptoms ?
– Pain,moderate to severe (acute onset, rapid progression)
– Redness,photophobia(may be severe), discharge, blurred vision (especially if lesion on visual axis)
– Awarenessofwhiteoryellow spot on cornea
– Usually unilateral
What are the signs of MK?
– Lidoedema
– Epiphora
– Discharge(muco)purulent
– Conjunctivalhyperaemiaand infiltration
– Corneallesionusuallysingle (central or mid-peripheral)
– Anteriorchamberactivity (flare, cells, hypopyon or coagulum if severe)
What is MK ?
- it is rare and is the only serious adverse event to occur in contact lens wear
– 5x more common with EW vs DW
– Risk of infection with RGP is approx 1/3
compared to daily SCLs
• Infection compromised cornea (epithelial break, hypoxia) from invasion
– Bacteria (especially Pseudomonas spp)
– Virus
– Fungus
– Amoebae
with excavation of epithelium, Bowman’s and stroma. With infiltration and necrosis of tissue.
• Potentially blinding
what is the management of MK?
discontinue CL wear and urgent referral to HES
check difference of symptoms in CLPU and MK on the lecture last slides .
slide 35
When do you provide px with advice and recommendations ?
-once checked anterior eye health, lens fit and over refraction
-in new CL fit- tell if eyes are unsuitable/ suitable for contact lens wear
• Address OH issues
• Book teach appointment
We will see you in ?? weeks
in aftercare: • Ocular health OK? • Lens wear OK? • Address any sx/signs • Continue with wear • Treat signs and sx We will see you in ?? months Give specification if appropriate -aftercare- once a year usually
What else might you have too do in CL wearers ?
May need to conduct posterior eye exam (check lens etc)
