contact lens case reports
When the Lights Go Out The Vasovagal Response
BY PATRICK J. CAROLINE, FAAO,
FCLSA, & MARK P. ANDRÉ, FAAO, FCLSA
The always alarming vasovagal response occurs in our university practice about once a year. This last time it occurred in a new contact lens patient that one of our fourth-year optometry students was examining. Fortunately, the well-trained student knew precisely what the patient was experiencing and what to do. Yet for many of us, no matter how often we experience this phenomenon, our blood pressure increases as the patient's drops.
This experience prompted us to think back to the last time that we read anything related to this topic in our contact lens literature. To our dismay, neither of us could remember. We'll try here to correct this oversight.
A vasovagal reaction can occur when a patient is being touched about the eyes, such as during drop instillation, IOP testing, foreign body removal or contact lens insertion. A vasovagal response may also occur if the patient anticipates discomfort, as when one faints at the sight of a needle.
The patient frequently reports a light-headed, clammy, nauseated feeling. This is quickly followed by a fainting episode and a brief loss of consciousness, secondary to the sudden decrease in blood pressure. A vasovagal reaction is beyond the conscious control of the patient and will typically proceed in spite of the patient's attempts to "tough it out."
What to Do
First, protect patients (especially their heads) from harm as they lose consciousness. Next, immediately lie patients flat in the exam chair or often on the floor, since they have frequently slid out of the chair. Elevate the legs to increase blood flow to the brain (Figure 1). You can use smelling salts to help facilitate consciousness. Generally, for the patient, the experience lasts only 10 to 20 seconds (minutes by our clock), and when patients regains consciousness, they are often confused, frightened and disoriented. Immediately reassure them that all is well and that they should remain lying down for about 10 minutes. It is a good idea to periodically monitor their blood pressure. Also, a cool wash cloth across the forehead often helps them feel better.
Figure 1. Lay the patient flat and elevate the legs.
Patients are often embarrassed, self-conscious and apologetic about "fainting" during such a routine examination. Reassure them that these episodes occur in young, healthy individuals and do not indicate any underlying weakness or disease. Also explain to patients that the episode was not an allergic reaction to the drops or contact lens that immediately preceded the response.
Our experience indicates that the vasovagal response is like lightning it usually doesn't happen twice to the same patient. We simply reschedule another visit in a few days. We advise patients not to drive unless they feel perfectly normal. If they opt to not drive, we will provide transportation for them.
A calm and professional manner while handling a vasovagal reaction goes a long way in reassuring the patient that everything will be ok. We recommend that all office personnel undergo a periodic review of the condition and its appropriate management.
Patrick Caroline is an associate professor of optometry at Pacific University and an assistant professor of ophthalmology at the Oregon Health Sciences University. Mark André is director of contact lens services at the Oregon Health Sciences University.