Section

Management FIVE

Aftercare 28CHAPTER

28.1 First aftercare visit

The first aftercare examination should ideally take place after 2–3 weeks. If good progress has not been made by this time, success with the initial lenses is unlikely and significant changes may well need to be made. If the timing is too soon, nearly all patients complain of a multitude of genuinely adaptive symptoms; if too long after fitting, disturbing signs may have arisen or patients may have discontinued because of problems which are not adaptive.

The timing of aftercare appointments is important. Daily wear patients should be examined during the afternoon following several hours of contact lens use, whereas extended wear patients should be seen in the morning so that any overnight effects can be observed.

The results of this and subsequent visits should be recorded according to one of the grading scales outlined in Section 3.3.

28.1.1 Initial discussion

Initial discussion should cover the following points which may require further assessment during the course of the examination:

•What progress the patient feels has been made.

•Are there any particular problems?

•Has the patient come in wearing the lenses – if not, why not?

•Maximum wearing time.

•Wearing time on the day of examination.

•Is handling satisfactory?

©2010 Elsevier Ltd, Inc, BV

DOI: 10.1016/B978-0-7506-7590-1.00011-X

Section FIVE Management

•Have all instructions been understood?

•Are instructions being followed?

•Are disposables being changed at the correct interval?

•Are solutions being used correctly?

•Is the wearing schedule being followed?

•Are lenses being worn in the correct eye?

•Are soft lenses inside out?

•Is the patient in a happy and positive frame of mind?

28.1.2 Visual acuity and over-refraction

Snellen acuities are recorded monocularly and binocularly in the normal way. The quality of retinoscopy reflex is particularly important during assessment of vision and over-refraction (see Section 28.2).

28.1.3 Assessment of fitting with white light

White light examination either with low magnification or unaided gives a preliminary assessment of:

•Lens centration in primary position.

•Lens movement on blinking.

•Lens position with lateral and vertical eye movements.

•Blink rate.

•Completeness of blink.

•Conjunctival injection.

•Head position.

•Eye movements.

•Palpebral aperture.

Some of these factors may well be different during slit lamp examination where the head position is unnatural and light intensity much greater.

PRACTICAL ADVICE

•Carefully distinguish between visual and physical symptoms. Patients often complain of discomfort which really relates to vision.

•Some conditions such as swelling of the bulbar conjunctiva or eyelids are seen more easily without magnification or with diffuse illumination on the slit lamp.

•With a soft lens, movement can sometimes be seen better by directing the beam from a hand-held pen torch, not necessarily from in front but from the side or below, so that the junction of the lenticular portion of the lens casts an easily observed annular light pattern and shadow onto the iris background. The movement of this is more easily discernible than that of the lens itself.

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Aftercare 28 Chapter

28.1.4 Assessment of fluorescein fitting with a

Burton lamp

Examination with fluorescein is mainly directed at rigid lens fittings, although it can also be used with other specialized lenses such as silicone elastomers. Ultraviolet light does not give a useful assessment of fitting with rigid lenses containing UV blockers (e.g. Boston EO) so these must be assessed with the slit lamp cobalt filter. High molecular weight fluorescein can be used with soft lenses, but generally adds little to white light observation. Fluorescein examination should reveal:

•The central fitting in respect of touch and clearance.

•Peripheral fitting and edge clearance.

•The speed of fluorescein mixing as an indicator of tear flow.

•Any lens adhesion.

•3 and 9 o’clock staining.

•Other areas of gross corneal staining or desiccation.

28.1.5 Slit lamp examination with lenses in situ

The slit lamp is the major diagnostic instrument, both at initial fitting and at all aftercare examinations. With lenses in situ, it is used with varying degrees of magnification to check:

•Lens fit (centration and movement, including push-up test).

•Tear lens with slit beam.

•Signs of gross corneal oedema.

•The bulbar conjuctiva for signs of vessel irritation.

•The condition of lenses.

•Any air bubbles trapped under the lenses.

•Any debris trapped under the lenses.

•Wettability of lens surface.

28.1.6 Supplementary procedures with lenses in situ

Supplementary procedures at this stage, with lenses still in situ, may include:

•Photography or digital image capture.

•Contrast sensitivity.

•Keratometry over the front surface of a soft lens.

•Placido disc or topography over a soft lens.

28.1.7 Slit lamp examination with lenses removed

Lenses are removed and ideally stored in the patient’s own case. Fluorescein is then instilled and the eyes examined for:

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•Any signs of corneal staining, noting both extent and depth.

•Any signs of corneal oedema (e.g. central clouding, microcysts, striae), with both sclerotic scatter and direct observation.

•Corneal indentation (from rigid lens adhesion).

•Scleral indentation (from tight soft lenses).

•Foreign bodies.

•Corneal desiccation.

•Qualitative assessment of tear film.

•Conjunctival injection or desiccation.

•Engorgement of limbal vessels.

•Irritation of lid margins.

•Lid oedema.

•Changes to papillary conjunctiva, seen with lid eversion.

28.1.8 Supplementary tests with lenses removed

Examination may indicate that supplementary procedures are advisable:

•Keratometry or topography.

•Quantitative assessment of tear flow (see Section 5.6).

•Staining with rose bengal or lissamine green.

•Photography or digital image capture.

•Pachymetry.

28.1.9 Clinical adjustments or changes

The practitioner is now able to decide whether any symptoms are purely adaptive and can be temporarily ignored or whether some action is required. There are several possible changes which may be necessary:

•Alteration to power or fitting. Rigid gas-permeable lenses may be either modified or exchanged, depending upon the laboratory policy. Soft lenses require replacement.

•Refitting with the same general type of lens. For example, a rigid gas-permeable lens with a higher Dk material; a soft lens with a different material.

•Refitting disposables with another make using either the same or a different replacement interval (e.g. daily with daily, or monthly with daily).

•Refitting with a totally different type of lens. For example: rigid gaspermeable with soft; silicone hydrogel with rigid gas-permeable; or spherical with toric.

•Different solutions, e.g. completely changing the regimen because of allergy, adding saline as an extra rinsing solution, or using a more efficient cleaner.

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