Reader and Industry Forum
Consequences of a Cavalier Attitude Toward Lens Care
By Bezalel Schendowich, OD, FIACLE
A cavalier attitude (marked by or given to offhand and often disdainful dismissal of important matters, according to Merriam-Webster's 11th Collegiate Dictionary) toward contact lens fitting and patient education leads to a secondary but just as cavalier outlook on the part of patients toward their eyes, their contact lenses, and the relationship between them.
In contact lens care, we as eyecare practitioners must determine the most efficacious care protocol for each patient; we must clearly explain this protocol and the principles involved. If care of the lenses and therefore the eyes is continuing, we must review and repeat our instructions periodically to co-opt the patient's compliance in pursuing the goal of optimum care.
I feel it to be an imperative of our profession that we use the time we spend with our patients to encourage them to follow our prescriptive instructions for the healthy use of their contact lenses. Without this, the likelihood of their developing lens-related eye-health issues grows quickly.
A Case in Point
My case involves a referred 19-year-old student with four years of soft contact lens experience; he was fit in another country but came to me because I am more local. Because he was a new patient to me, I requested that he come in wearing his glasses for his first visit. He was to bring with him his current pair of spherical, HEMA, two-week disposable soft contact lenses and their original package. His current pair had been in use for three or four weeks, he was not certain.
Some Patient History His last eye examination was around two years ago, at which time he had his spectacle correction updated. His contact lens prescription dated from some four years ago. He claimed that there had been no significant changes in his prescription over the intervening years. I neglected to ask him the identity of his most recent lens supplier. He reported no allergies, headaches, or medications. He also denied pus, pain, itching, or redness.
Contact lens wearing time was generally 16 or more hours each day with a brief nap (lenses in situ). The patient reported some end-of-day ocular dryness. Lens care consisted of soaking without rubbing in a name-brand Polyquad/Aldox multipurpose solution, which he reportedly changes completely every day.
The Examination Visual acuity and refraction showed his current glasses to be a bit weak, but a small change sharpened his vision. Corneal topography was regular with around 1.00D of toricity.
The slit lamp exam was very instructive. Around his lashes I noted some matted tear material. His palpebral conjunctiva showed a follicular response.
His corneas, though, provided much more that I was able to use in understanding this patient and the many points in which it was necessary to educate him. His presentation consisted of superficial neovascularization, swollen peri-limbal bulbar conjunctiva, and, to me the most important finding, at four o'clock on the right cornea and at eight o'clock on the left were areas of desiccation that lit up with fluorescein dye with adjacent areas of injected conjunctiva. This was after 18 hours without his lenses. I wondered how much worse the state of his eyes had been when he removed his lenses the night before.
Central fundus examination was normal.
Analysis What has this patient told me about himself and his abuse of his eyes and contact lenses? I have two sources of information with which to work: that which the patient has admitted and that which I understand through my evaluation of this information and what I observe while examining his eyes.
The fact that the patient was unclear as to when his current lens prescription was given to him or even when his last eye examination took place showed me immediately how little emphasis his previous practitioner had placed on the relationship of contact lenses to eyes. Neither, it seemed, did the fitter seem interested in the possible ramifications upon ocular health that a contact lens can have, nor did he make basic efforts to teach his patient to respect his eyes.
What Happens When You Don't Cultivate Compliance
I have found that follow-up visits reinforce the relationship between my patients and myself. They allow me the opportunity to review contact lens care and to probe patients for small contact lens-induced irritations that might in fact be harbingers of large problems in the making. These, if caught and remedied early, can, in many cases, improve contact lens tolerance and comfort. No one is born knowing everything there is to know about contact lenses and their care. Learning the basics is a continuing process that requires time, patience, and dedication. Each contact lens fitter is an educator—we must take the time to teach our patients how to most healthfully live with their ocular prosthetics.
My patient's previous practitioner may have been delegating patient education to reduce professional chair time. Admittedly, delegation can help to build a practice, but the practitioner's instructions must be reinforced and repeated by his ancillary staff to complete the cycle of care. This patient was happy to receive his contact lens prescription and probably provided refills for himself through less professional sources. He was also relieved of presenting himself for any sort of follow-up care. My patient has overworn his two-week lenses for some years. He was either not cleaning them between usages or was minimally cleaning them. Somehow he stumbled onto the importance of using a recognized name-brand solution and changing it every day.
The effects of overwear, overuse, and under care of these HEMA lenses were evident from the superficial neovascularization. But more dramatic than the neovascularization were the areas of corneal fluorescence and nearby conjunctival injection.
These areas of corneal erosion result from localized drying induced by partial blinking. Full blinking is required to ensure that the lower third of the cornea is properly wetted with tear fluid. Without this protective surface of tears, the areas known as “three o'clock and nine o'clock” will dry; the epithelial cells will die, leaving the lower layers of the cornea unprotected. It seems that this happens even when a “bandage” contact lens is in place. The bandage as well as the cornea needs to be kept hydrated. On a normal eye—one with enough tears of proper constituency—wetting occurs through frequency and completeness of blinking. Frequent and unhealed erosions can lead to localized thinning and dellen formation in addition to opening the cornea to infection. Dellen are treated by frequent rewetting of the desiccated surface. If action is not taken to promote healthier corneal epithelium, short-term problems may arise.
On the other hand, neovascularization is a long-term complication. Neovascularization comes in two types: superficial and deep. My patient's eyes showed superficial corneal neovascularization, more in the right eye than in the left. The importance of this finding is that it confirms my impression of soiled contact lens over-wear and the consequent corneal suffocation. The implication for continued contact lens usage is also twofold: new blood vessels laid down into corneal tissue cannot be removed, but with a reduction in contact lens usage, improved oxygen transmissibility, and better contact lens hygiene, they can be emptied and their growth curtailed. However, they will refill spontaneously when conditions again deteriorate.
All my patient really wanted was more contact lenses. He wanted them on the terms that he was used to. He wanted no questions. But, he made two mistakes: he came to me and brought his parents with him. So, in alliance with the patient's parents, I prescribed first and foremost a week away from his lenses in the hopes that his corneal epithelia would resurface. In addition, I instructed him in blink improvement exercises. My next step is refitting him into a silicone hydrogel lens and training him in their proper care. I shall also be certain to schedule his return visits in advance.
Primum non nocere—First and foremost: Do no harm. All of us who work in the medical professions should value this piece of advice and maxim. Our obligation to our patients and clients is based on the teachings imbued in these three words. Our relationship to our patients and clients is defined by the advice that we give and by the prescriptive devices that we recommend. Contact lenses are medical devices. They require prescription, they require instruction (application, removal, and care), and their use requires periodic follow-up re-evaluation.
As much as I would love to claim that none of my patients ever develops a contact lens-related problem, I cannot. I have found that I cannot claim such success because of the ultimate unknown factor: the patients. As much as I educate, cajole, and even warn of problems likely to be encountered, I still have emergency appointments from time to time. Or worse, as in the case I have described here, the problem exists and gradually worsens, but the patient is oblivious.
Nonetheless, it is our responsibility to invest the time required in patient education. I believe that I must use the time that the patient has bought in showing him how contact lenses, while proven to be safe, must be used carefully and according to instruction. This instruction begins during the history taking with questions designed to prove to me that the patient before me understands and practices good contact lens care. CLS
Dr. Schendowich is a Member of the Medical Advisory Board of the National Keratoconus Foundation, USA, a Fellow of the International Association of Contact Lens Educators, and an adjunct assistant clinical professor of optometry at SUNY-Optometry in the ophthalmology clinic at the Sha'are Zedek Medical Center in Jerusalem, Israel.