For intrepid Contact lens fitters

[npdr]

The following three patients have come to your office for contact lenses. Each has never worn lenses before. Given that each has equal amounts of motivation, rate the probablilities of success of each and rank them with the most successful being the first. If you were to fit them, what would you fit them and why?

Patient A is a 22 year old Vietnamese Chinese woman, of 133 cm tall, 40.5 kg heavy with a 10-year history of systemic lupus erythematosus, severe arthritis that has deformed both hands. She is on Fosamx, 70mg, weekly; Prednisone, 5mg, daily; Plaquenil, 200mg, #2, daily; Ibuprofen, 600mg, TID. With her glasses she see 20/25 in each eye with her refraction not improving this. As expected, there were multiple dry spots on the cornea with rapid TBUT in either eye.

Patient B is a 41 year old T1DM of 32 years duration, having 20/60 best corrected vision in the right eye and LP in the fellow eye. Her spectacle Rx is a dramatic OD -12.00 -1.75 axis 010. In either eye, there has been signficant proliferative diabetic retinopathy with s/p PRP and focal laser treatment. In fact there was a large hard exudate placoid over the OS macula recently and extensive fibrous degenration of the posterior pole in that eye which probably contributed to the present level of vision. The corneas show early band keratopathy from persistent dryness at 3:00 and 9:00 mid peripherally.

Patient C is a 49 year old female social worker is s/p craniatomy secondary to frontal lobe astrocytoma. She is moderatly myopic with presbyopia and can achieve 20/30 best vision in either eye. Her corneas are normal appearance, but she does suffer from moderate long term memory loss. In other words, she cannot remember details of her life more than 2-4 weeks previously. She is ambulatory, can pick up dimes off of the floor with her thumb and forefinger of either hand and can brush her own teeth manually.

[Andrew Weiss]

Is these hypothetical situations, for fun? Or have you actually had these folks come into your office?

[npdr]

Is these hypothetical situations, for fun? Or have you actually had these folks come into your office?

Actual cases. There are contact lens fitters and there are fitters who can fit any patient so long the patient wants it and there are no significant downside to them wearing lenses. I offered up these scenarios because there has been so much talk about the 3 O's.

[chip anderson]

Unless there was a signifcant improvement in visual acuity I wouldn't do any of them. If there were I would concider a good well fitted PMMA or RGP and have patient use castor oil drops after removal.


Chip

[npdr]

Unless there was a signifcant improvement in visual acuity I wouldn't do any of them. If there were I would concider a good well fitted PMMA or RGP and have patient use castor oil drops after removal.


Chip

Why not?

[chip anderson]

npdr:

Because I really believe in "do no harm". These patients have enough problems already without taking a risk of further complications for no benefit (other than making a few bucks). I fit a lot of cones, a lot of damaged eyes, a lot "impossible" stuff but always with the objective of making a non-functional eye better, or more functional.

And yes, I do comprehend that all the "healthy eyes" we fit with contacts are taking a chance on complicating a healthy eye.

But patient's desire or my greed alone or combined doesn't motivate me to enter into situations that may be dangerous to the patient.

Chip

As to the Castor Oil, it can be very beneficial in those with "dry eyes" although not FDA approved.

[Andrew Weiss]

Just checked in on this thread again --

I wouldn't because I don't think I have the skill to do it. I'd also agree with Chip that just because someone is motivated to get CLs doesn't mean that it is the best interest of their general health. I would actively discourage all 3. If they all insisted, I'd send them to Chip . . . :D

[Ory]

As to the Castor Oil, it can be very beneficial in those with "dry eyes" although not FDA approved.

Refresh Endura (available in Canada at least) is castor oil. They were working on a new treatment for dry eye and decided that the vehicle worked as well as the medicinal ingredient, or so I've been told.

[Dave Nelson]

I see no specific contrainications for patient #3. She would have to monitered for proper compliance, and may need additional training in lens care, hygiene, and precautions. Patient #2 presents with a number of posterior complications that should not containdicate cl wear, but the diabetic history combimed with a mild band keratopathy and dryness would put the patient at risk of a keratitis which could be very difficult to resolve. I say no contacts. #1 patient: rapid tbut is not a very good indicater of cl sucess, so a number of different lenses may be evaluated and monitered. Manual dexterity may be an issue, but that will be obvious during a cl evaluation. Immune suppressed individuals should be monitered closely, and advised of any increased risks associated with contact lens wear. Compliance must be scrupulous. I would need more info, but based on what you have posted about these patients
#1 maybe
#2 no
#3 yes, probably

[npdr]

Let's suppose that you were associated with either an ophthalmologist or an optometrist and you were sent these three patients. How would you manage them then?

[Dave Nelson]

Contact lens wear for patient B is strongly contraindicated, in my opinion. To reiterate, a diabetic monocular patient with reduced acuity, dryness, and an already compromised epithelium places the patient at high risk for corneal infection. An ulceration under those circumstances could be very difficult to stop before permanent vision loss resulted in the only still functioning eye. A graft would not be a viable option. The prescriber would have to give me some pretty good justification before I would proceed with fitting a contact on this patient.

[npdr]

A 41 year old male presented to your office for a cosmetic contact lens to enhance or change the color of his eyes. You know his refill rate of his contact lenses has not correlated to the suggested replacement schedule for this lens. You have discovered that the patient is using Plano Fresh Look lenses under the OptiFree No Touch care system and claims daily wear only,

His only minor complaint is blurry vision with the left eye more than the right of recent onset, redness of both eyes and discharege intermittently. He appears not to be acute distressed.

On your slit lamp, you note a small amount of punctate keratitis centrally and pink conjunctiva in each eye. There is no discharge. He presents without lenses on. He wants a new supply of lenses. You have an acuity chart and you note 20/30 and 20/50 vision now, but have a lens prescription of 2 months previously of OU Plano

First, how would you manage this patient? Secondly, let's suppose you suggest something that is within your scope of practice and the patient returns 1 week later and there is no resolution. It is no worse nor no better. Lastly, what could you do within your power to help this patient?

[npdr]

I guess there aren't any intrepid contact lens fitters on the forum?

[eyekan]

Let's see... the visual acuity does corespond with the central PEK. There is no signs of infection, just overwear. I would discontinue the contacts for 1 week, and have the patient take preservative-free artificial tears every 1-2 hrs OU x 1 wk.

If at 1 week the redness, PEK, and poor vision (with over-refraction) are still present, then I would suspect poor compliance. If patient swears he was compliant, i would put him through a dilated comprehensive eye exam to rule out pathology (and charge him accordingly, of course). I would then start him on Tobradex or Zylet. The steroid component would get rid of any remaining corneal edema which could compromise his vision, and the antibiotic part will cover my a$$ if I misdiagnosed.

[npdr]

Let's see... the visual acuity does corespond with the central PEK. There is no signs of infection, just overwear. I would discontinue the contacts for 1 week, and have the patient take preservative-free artificial tears every 1-2 hrs OU x 1 wk.

If at 1 week the redness, PEK, and poor vision (with over-refraction) are still present, then I would suspect poor compliance. If patient swears he was compliant, i would put him through a dilated comprehensive eye exam to rule out pathology (and charge him accordingly, of course). I would then start him on Tobradex or Zylet. The steroid component would get rid of any remaining corneal edema which could compromise his vision, and the antibiotic part will cover my a$$ if I misdiagnosed.

This is a situation where an optician might be able to equivalently manage this case, but at what point would the LDO want to? When would the LDO / NCLE return the patient to themselves or to the prescirbing doctor?

[npdr]

Patient has had a ruptured globe with corneal perforation. You are advised to supply a management plan with a contact lens to facilitate best vision. How would you proceed?

[rbaker]

npdr said “I guess there aren't any intrepid contact lens fitters on the forum?” Considering the definition of “intrepid” that may not be such a bad thing.

resolutely fearless; dauntless

intrepid. Dictionary.com. Dictionary.com Unabridged (v 1.0.1), Based on the Random House Unabridged Dictionary, © Random House, Inc. 2006. http://dictionary.reference.com/search?q=intrepid (accessed: September 02, 2006).

It implies to me a fitter who might be a little to aggressive with a tendency to push ahead just to prove that he can fit these problematic patients; that is to say, put his ego ahead of patient welfare.

x

[npdr]

"...It implies to me a fitter who might be a little to aggressive with a tendency to push ahead just to prove that he can fit these problematic patients; that is to say, put his ego ahead of patient welfare.

x

The question here is that there are contact lens fitters who crave contact lens fittings. Ergo, you should also crave this kind of patient. If I saw a fitter who would avoid this kind of patient, why should I refer patients to them of another variety?

[npdr]

Let's suppose this patient presented to you with the following corneal picture. The patient is 62 y/o using soft lenses on monovision model. What is your course of action?

[HarryChiling]

npdr,

I think the reason for no one answering is the obvious fact that you have an axe to grind. In the previous case by the way there is obvious signs of overwear (punctate and neovascularization), I am no doctor so I would let the optometrist in my office take this one, however; if I had to make the call I would discontinue CL's all together, if the doctor for some reason decides that she is ready again for CL's I would recommend a high Dk GP (menicon or boston xo), or take a look at her cleaning and wear regimine (for possibility of chemical interactions) as well as a higher Dk silicone, I would assume that the doctor would have checked the tear BUT (he he).

[npdr]

Dear HarryChiling,

You're right but not what you think.

There has been much mention on this list about the relative abilities of dispensing contact lens fitters/opticians and optometrists. This case and other cases I see mainly from referrals of several emergency rooms.

These cases are usually a result of cosmetic contact lens fittings from both opticians and optometrists. Therefore, cosmetic fittings can lead to long term pathology.

I sometimes think that both optometrists and opticians are equally imbued with the ideal of being the "right person" for the job but do forget the responsibilites thereof. I'm sure that the posters here are not guilty of this kind of "evil" and such a trait befalls those who function in less demanding environments.

Nonetheless, how these patients come to this is regretful either way.

[HarryChiling]

npdr,

The right person to fit CL's is the person that the patient or client trusts the most in the office (optometrist or optician). I think sometimes the patients think of the doctors more highly when they hire and train individuals to the calibar that they feel confident enough to let the staff do the simple fits. I think in both our cases when we get caught in the optometrist, optician thing; we both think of the other proffesion in terms of the least common denominator, which is a shame.