I. PATIENT SELECTION

A. Indications
1. Spherical refractive errors
2. Low astigmats
          a. Spherical equivalent used as contact lens Rx
          b. Hydrogel toric lenses
3. Patients with lenticular astigmatism
          a. Hydrogel toric lenses
4. Athletes, actors, models
          a. To eliminate spectacles
          b. To look younger
          c. To change eye color
          d. Easier to wear for sports than RGP’s and spectacles
5. Occasional wear
6. Corneal sensitivity -unable to adapt to RGP’s
7. Responsibility - Age restrictions
8. Motivation to wear, care and handle hydrogel lenses
9. Chronic RGP adherence or 3&9 staining

B. Contraindications
1. Inflammation or disease of the anterior segment
2. Any systemic disease which may be complicated by contact lens wear, such as diabetes, epilepsy, mental incompetency
3. Pregnancy
          a. Dry eyes
          b. Changes in corneal shape due to edema and refractive changes due to increased
              corneal thickening
          c. Decreased corneal sensitivity
          d. Increased tear viscosity, which increases deposits
          e. Exceptions, such as, long-term wearer who needs replacement lenses
          f. First time fits/Patients experiencing difficulties with dryness, variable vision, etc.
             should wait 6 weeks post-partum or 6 weeks after they have ceased breast-feeding
             to reduce the risk of a re-fit.
4. Poor hygiene
5. Lack of motivation
6. Irregular corneas (keratoconus, ocular trauma)-exceptions are cosmetically covered ocular
     trauma.
7. Radial keratotomy
8. Chronic allergies
9. Chronic antihistamine use
10. Giant Papillary Conjunctivitis or Contact Lens-Related Papillary Conjunctivitis (GPC or
      CLRPC)
11. Corneal astigmatism greater than 1D
12. Work environment- dry, dusty, dirty, unsanitary
13. Poor tear quality or quantity

C. Preliminary Evaluation is very important for giving the practitioner a feel for patient suitability

D. Cases

1. A 35 y/o male presents to your office desiring to be fit with contact lenses. He works at a bank and enjoys many sports in his spare time. He is happy with his glasses except that they get in the way when he participates in sports. He finds they are always getting broken from being knocked off while playing basketball, volleyball, etc. He wishes to wear contact lenses for these sporting activities.

2. A 24 y/o female presents to your office to be fit with contact lenses for the first time. Upon taking a case history, you discover she is 3 months pregnant.

3. Your auto mechanic finds out you specialize in contact lenses. He comes to your office desiring to be fit with contact lenses. At his visit, his hands are stained with grease and oil and his overall appearance is one of poor hygiene.

II. LENS SELECTION & FITTING

A. Empirical vs. Diagnostic Fitting
1. "U4 and out the door" philosophy Lens designed by use of K readings and spectacle Rx - same method as determination of predicted power.

Case 1: Patient has 39.50/40.00 @90 K readings OU and a spectacle Rx of OD -2.00DS and OS -1.75-0.50 X 180. Empirically designed lenses: OD BCR 8.9mm, Rx -2.00D & OS BCR 8.9mm, Rx -2.00D

Case 2: Patient has K readings of OD 43.00D Spherical & OS 42.50/43.50 @ 90 and a spectacle Rx of OD -4.50D, OS -4.50-1.00 X 180. Empirically designed lenses: OD BCR 8.6mm, Rx -4.25D & OS BCR 8.6mm, -4.75D

        b. Study done at UM-St. Louis comparing empirical vs. diagnostic fit RGP lenses revealed:

             1) Patients demonstrated greater confidence in lenses which were diagnostically fit.
                   They appreciated the time the practitioner took to make sure lenses fit them
                   correctly.
              2) Patients fit empirically demonstrated lack of seriousness as compared to
                   diagnostically fit patients. Diagnostically fit patients were conscientious about
                    coming to CL progress evaluations.
              3) Greater lens reorders with empirically fit lenses.

          c. Predicted lenses don’t always work out. There can be a small tear lens under the lens.

2. Diagnostically fit lenses
          a. Predicted lens parameters are selected in the same manner; however, trial lenses
              are tried on the patient to verify that predicted lens parameters are the lens
              parameters to dispense.

B. What type is the patient interested in?
1. Is it realistic?

C. Does the refractive error dictate a certain type of lens?

D. Are there predisposing conditions that warrant a certain type of lens?
1. Dry eyes
2. Prone to deposits
3. GPC
4. Corneal edema
5. Ocular trauma
6. Poor compliance

E. Fitting
1. Insert the patient’s lenses and allow the lens to settle 10-15 minutes.
2. Assess positioning, coverage & movement
          a. Centered
          b. Complete corneal coverage and extending onto the sclera at minimum 0.5mm in all
              directions
           c. Movement 0.5-1mm in straight ahead gaze is ideal. As much as 2mm movement
              when gazing superior.

                    1) Too tight - Little to no movement, conjunctival drag, negative push-up test
                    2) Too loose - Greater than 2mm movement, moving partially off the cornea,
                        decentered inferiorly, edge lift inferiorly, slides inferiorly upon upward gaze
                    3) Movement varies with lens thickness-Thin lenses move less (i.e., 0.5mm) &
                        thicker lenses move more (i.e., 1mm)
                    4) Push-up test

3. Determine visual acuity and over-refraction
          a. Best sphere
          b. Sphero-cylindrical over-refraction
          c. Is acuity stable?
          d. Is visual acuity equal to or very close to spectacle acuity?
4. Over-keratometry will aid in determination of fit
          a. Steep fit - clear mire immediately after blink which then becomes distorted and
             blurry
          b. Flat fit - Mire distortion which becomes more distorted on blink
5. Assess Patient Comfort
6. Dispensing out of inventory
7. Parameters required to order lens
          a. BCR
          b. Power
          c. Name of material
          d. Name of manufacturer
          e. Diameter (?)
          f. CT (?)
          g. Tint
Example: BCR 8.6mm, Rx -3.50D, CSI Clarity DW, WJ, Diameter 13.8mm, Tint-Visibility tint BCR 8.7 (Sag I), Rx -4.00D, Optima 38, B&L, Tint-Visibility tint

8. Verify lens vial specifications prior to dispensing

III. DISPENSING

A. Evaluate lens performance
1. Visual Acuity
2. Position
3. Coverage
4. Movement

B. Educate the patient on lens care procedures
1. Provide the patient with written instructions
2. Don’t bombard the patient with information
3. Nuggets
          a. If minor FB in the eye and can’t remove the lens, push off on the sclera
          b. If lens edges stick together, roll apart with a viscous solution; for example, the daily
              cleaner

C. Provide the patient with a wearing schedule
1. First time wearer - 4, 4, 6, 6, 8, 8 hrs. Remain at 8 hrs. until 1 week progress examination
2. Previous wearer - Full time wear if going from 1 lens to another

D. Teach insertion and removal methods
1. Insertion
          a. Fingers dry
          b. Make sure the lens is right side out
          c. Inspect lens for damage or deposits
          d. Place lens on sclera and blink lens into place or place directly on the cornea
2. Removal
          a. Slide the lens down onto the sclera and pinch off the sclera with the pads of fingers

E. Provide an informed consent for patients to sign
1. Specifies that patient was taught insertion, removal & lens care.
2. Patient copy and file copy
3. Telephone number to contact in an emergency
4. Risks

IV. PROGRESS EVALUATIONS

A. Case History
1. Problems/complaints
2. Wearing time (12-14 hours DW/ 3-7 days EW)
3. Solutions
          a. Are they compatible?
          b. Have they switched?
          c. Are they disinfecting?
          d. Are they enzyming?
          e. Are they compliant?

B. Visual Acuity
1. 20/25 or better ideally
2. Over-refraction (best sphere/sphero-cylindrical)

C. Over-keratometry

D. Slit Lamp Evaluation with lenses on
1. Clear, white eye
2. Position
3. Coverage
4. Movement
5. Lens condition

E. Slit Lamp Evaluation upon lens removal
1. Edema (striae, microcysts, polymegethism)
2. Neovascularization
3. Limbal engorgement
4. Injection
5. Lid eversion
6. Fluorescein evaluation
          a. Fluorescein strip
          b. Fluorosoft - Large molecule, less fluorescence
7. Rinse fluorescein out before inserting lenses or wait 2-4 hours before re-insertion.
8. Purging- 3 X 8 hours of distilled water, then place in saline or 2 X 10 minutes of distilled   water and 2 X 10 minutes of saline
a. Peroxide bleaching

F. Keratometry

G. Refraction check
1. Myopic creep

H. Frequency of progress evaluations
1. Daily wear -1 week, 1 month, 3 months, 6 months & every 6 months thereafter
2. Extended wear -1 week DW, 24 hours EW, 3 days, 1 week, 2 weeks, 1 month, 3 months & every 3 months thereafter

V. Cases

A. Case 1: Patient is interested in obtaining soft extended wear bifocal toric lenses.

B. Case 2: Patient had ocular trauma to the left eye which resulted in a large distorted pupil. The patient is unhappy with the cosmetic appearance. The iris color of the OD is blue.

C. Case 3: Patient desires to wear hydrogel lenses; however, he desires very little care regimen.

D. Case 4: Patient is prone to GPC and protein deposits. He desires new hydrogel lenses. Previous lenses were Cibasoft. Lenses would become deposited after about 6 months.

E. Case 5: Patient returns to your office for 1 month progress examination. Slit lamp evaluation reveals red engorged limbal vessels and conjunctival drag.

VAH 1999

(Taken from Chapter 10 of text Clinical Manual of Contact Lens,

Bennett & Henry)

Lens Insertion ____

Lens Removal ____

Taco Test or other method of determining lens inversion ____

How to clean a lens ____

How to disinfect a lens ____

When to use saline ____

How to use the enzymatic cleaner ____

When to use a lens lubricant ____

Hygiene ____

Swimming with lenses ____

Sleeping in lenses ____

Lens care products to use and not to use ____

Cosmetics ____

Case replacement and cleanliness ____

Lens replacement ____

Normal & abnormal adaptive symptoms ____

Risks of noncompliance ____

Emergency numbers ____

Was the patient reminded to call the office with any

questions regarding symptoms or lens care? ____