Rigid Lens Care and Patient Education

  1. CARE SYSTEM
    1. Preservatives
    1. Functions
    1. Eye compatibility
    2. Active against viruses, fungi and bacteria
    3. Appropriate level of activity
    4. Lack of toxicity
    1. Types
    1. Benzalkonium Chloride:

      2. •Common use in ophthalmic solutions and PMMA solutions

      •Quaternary ammonium compound

      •Effective against bacteria, fungi

      •High concentrations (greater than 0.0004% = SPK, desiccation, conjunctivitis). Meyerson study: 11 S/A patients with BAK-induced SPK initiating within 2 months, were switched to non-BAK preserved regimens and showed no reactions in 4 months

      •Exps. Wet n’Soak, Sereine

    2. EDTA – not a true preservative but often used in combination with other preservatives to enhance the bacteriocidal action against peusdomonas
      3.
    3. Thimerosal

      4. •Mercurial Compound (high sensitivity rate)

      •Slow-Acting

      •Being phased out

      •Exps. Barnes-Hind, Soaclens

    4. Chlorhexidine

      5. •Bacteriocidal, quick-acting

      •Problematic with soft lens solutions but used in several RGP solutions due to low binding capacity

      •Exps. Barnes-Hind, Boston Conditioning

    5. Benzyl Alcohol

      6. •Recently FDA-approved – was originally considered as a solvent

      •Benefits include low molecular weight, bipolar and soluble in water

      •Very little uptake on S/A and F-S/A lenses

    6. Polyaminopropyl Biguanide (PAPB)

•Hydrogel preservative recently introduced with the Boston system

•Low sensitivity rate

•Greater effectivity against Serratia Marcescans
    1. Wetting/Soaking solutions
    1. Functions

      2. •Enhance surface wettability

      •Maintain hydrated state

      •Disinfection

      •Mechanical buffer
    2. Wetting Agents

•Polyvinyl Alcohol – beneficial properties include:
    1. Water soluble
    2. Relatively Nonviscous
    3. Nontoxic
    4. Good tear spreading/wettability

•Methyl Cellulose Derivatives
    1. Successful in more viscous RGP solutions
    2. Comprised by retarding epithelial regeneration
    1. Three Functions

      2. •Viscosity

      •Material Specificity – Boston Conditioning Solution with cationic cellulose molecules

      •Preservative Interaction
    2. Wet Versus Dry Storage

Store hydrated due to:

•Disinfection

•BCR stability

•Enhance wettability

•Minimize surface scratches
    1. Surface Wettability/Cleaning
    1. Definition – surface wettability is the ability of the blink to spread tear fluid across the anterior contact lens surface.
      2.
    2. Importance:

      3. •Wettability problems have been noted as number 1 concern by practitioners

      •It is essential for a uniform tear mucin coating to be adherent to lens surface. There is an electrostatic attraction between silicone and lysozyme.

    3. Types of Deposits (Acquired)

      4. •Muco-protein haze

      •Muco-protein film

      •Lipids

    4. Management
    1. Non-abrasive Surfactants
    1. Most of the cleaners
    2. Detergents
    3. Use of digital pressure to remove lipids, mucoprotein, debris
    1. Abrasive Surfactants
    1. Use of abrasive particulate matter to remove deposits (Boston, Opticlean II)
    2. Very effective in protein removal
    3. Problems include:

•Minor scratches

•Power changes
    1. case reports show 1-3D increase in .04-.08mm decrease in center thickness. "Overaggressive" cleaning with abrasive implicated.
    2. CASE STUDY

      3. •20 yr. PMMA refit into Fluoroperm 92 (March, 1987) with Opticlean.

      BCR – 8.10, Rx = -2.25 O.U.

      CT = .19mm (OD); .18mm (OS)

      •January, 1990 pt presented asymptomatic for refit (first visit since 11/20/87. She had since switched to the Boston system.

      •CL’s verified as:

      OD: Rx = -3.75; CT = .14mm

      OS: Rx = -4.75; CT = .14mm

    3. Conclusions

•Minus results from circular motion during forceful cleaning

•Primarily lens center

•Patients must be educated to:
    1. Clean in Palm
    2. Apply gentle pressure (especially former PMMA wearers)
    1. Carrell et al Study:

•3 cleaners (Boston, Opticlean II, Resolve), 2 cleaning methods (palm, digital), 2 lens powers (-3.00, -8.00), 2 time periods (10 sec, 20 sec).

•Boston caused greatest changes
    1. Surfactant Soaking

      2. •Grohe study (1984) showed deposit-prone S/A wearers benefited by soaking in LOBOB

      •DeStat 3 (Sherman) – Disinfecting/cleaning
    2. Enzymatic

      3. •Effective in protein removal

      •2 Hour Soak 1x/week as needed
    3. Laboratory Cleaners

•In-office cleaning of very adherent/thick deposits

•Includes:
    1. Boston Laboratory Cleaner
    2. Miraflow
    3. Fluoro-Solve
    4. Boston Solvent
    1. "Hands-off"

      2. •HydraMat

      •Minimize rough handling/warpage
    2. Bottom Line

•Use of abrasive initially; add enzyme if film/haze results
    1. Rewetting/Relubricating Drops
    1. Rewet lens surface
    2. Stabilize tear film
    3. Rinse away trapped debris
    4. Break up loosely attached deposits
    1. Cases
    1. Important Factors Include:

      2. •Deep-welled

      •Leakproof

      •L vs. R

      •Ridges/Holes
    2. Exps. = Sentinel, Eaton Medical Corp.
    1. Principal survival strategy of bacteria; bacterial cells secreted in an exopolysaccharide glycocalyx slime which provides protection
    2. PAPB and Benzyl Alcohol – Surfactant combination have been effective
    3. Rinse case with soap/water and air dry
    4. Regular case replacement
  1. DISPENSING VISIT
    1. Visual Acuity
    2. Over-Refraction
    3. Slit Lamp Evaluation
    1. Fluorescein Pattern
    2. Centration
    3. Surface Wettability – if poor, it could result from dry storage, residual pitch or solvent, or poor finishing. Methods of enhancing wettability include:

•Pre-Soaking

•Conditioning Solution

•Laboratory Cleaner

•Polish???

•Wettability improves with tear film interaction
    1. Patient Instructions
    1. Insertion and Removal (2 times minimum)/Recentration
    2. Explain Care System
    3. Cleaning procedure

•Carefully in Palm of Hand (not between fingers) to minimize warpage
    1. Dk-RGP Lens Warpage (Ghormley)

      2. Material Dk # Total #Replaced

      Optacryl 60 18 40 1

      Optacryl K 32 30 6

      Paraperm EW 56 40 14

      Optacryl Z 84 36 13

    2. Carrell et al study showed significant difference in BCR change with digital cleaning

•clean upon removal (not A.M.)

•10 seconds minimum
    1. Handling

      2. •Ease of surface scratches

      •Handle over soft surface

    2. Cosmetics
    1. In General:
      2.

      •Contain preservatives, oils and solvents – discomfort/injection

      •Applied after CL’s

      •Don’t use "lash builders"

      •Bacteria is a problem

      •No eyeliner to inner lid margin

      •Use recommended products
    2. Tlachac

•Use water-based mascara (hypoallergenic/sensitive eyes) – discard after 3 months

•No lanolin-based or commercial soft soaps

•Use AO Soap, Optisoap or most bar soaps
    1. Swimming
    2. Adaptation/Wearing Schedule
    1. Length
      2.

      •10-14 days – varies but can evaluate via initial reaction

      •if d/c, they will need to build up wearing time

      •wear 4 hours (minimum) prior to visits
    2. Symptoms

      3. Normal Abnormal

      Mild Discomfort Pain

      Mild Injection Severe

      Mild Tearing Excessive

      Difficulty with

      Superior gaze

    3. Wearing Schedule

      4. Days One/Two: 4 Hours

      Three/Four: 6 Hours

      Five/Six: 8 Hours

      Seven/Eight: 10 Hours

      Nine/Ten: 12 Hours

      Eleven/Twelve: 14 Hours
    4. Visit Schedule (Daily Wear)

•One week (after dispensing)

•One month (after Visit One)

•Three Months (after Visit Two)

•Six Months (after Visit Three)

•Every 6 Months
    1. Educational Materials
    1. Verbal
      2.

      •Insertion, removal and recentration

      •Proper cleaning

      •Care system

      •Adaptation/Wearing schedule

      •Normal/Abnormal symptoms/signs

    2. Written
      3.

      •Instruction booklets should be simple, concise and legible

      •Anadem Publishing (1-800-633-0055)

      •Don’t expect patients to read instructions

    3. Video
      4.

      •Reinforces written and verbal messages; can be loaned to patient as well

      •Generic video on insertion, removal, cleaning and care is available from CLMA/RGPLI Video Library (1-800-343-5367)
    4. Progress Evaluation Reinforcement

•Reinforce solution use, case cleanliness and compliance

•Wilson study: contamination of care samples decreased from over 50% to 6% when instructions were reinforced
    1. Written Instruction Materials

      2. •agreement in duplicate (see attached)

      •Anadem Publishing
    2. Videos
  1. NON-COMPLIANCE
    1. Common Causes of Non-Compliance
    1. Does not clean as instructed (for example "Left Lens Syndrome")
    2. Does not adhere to wearing schedule
    3. Does not use disinfecting solution as prescribed (for example, "Topping off")
    4. Does not wash hands
    5. Uses inappropriate wetting solutions (for example, Saliva, tap water, "5 in 1")
    1. Tap Water Use
    1. Increased incidence of Acanthamoeba keratitis
    2. Contamination with rigid lens wear most likely occurs after disinfection
    3. Recommend:
    1. Only used for rinsing cleaner
    2. Package saline with RGP solutions

•Tap water
    1. Only for rinsing
    2. Never for wetting/rewetting (Acanthamoeba)

 

  1. CASES
    1. CASE ONE

Patient has the following pre-fitting information:
    1. Mild Allergies (no antihistamine use)
    2. Tear B.U.T. = 7 seconds

Otherwise a good candidate and high motivated for RGP’s
    1. What Material?
    2. What Care Regimen?