By JeanMarie Davis, OD
Patients who wear contact lenses sometimes develop medical eyecare issues. Be prepared to treat them and expand your services profitably.
Medical eyecare conditions that go beyond basic discomfort issues will afflict some of your contact lens patients. Helping patients successfully recover from these issues and resume wearing contact lenses comfortably is essential. It is important not only to patients who have become accustomed to wearing contacts, but to your practice as long-term contact lens patients are consistently shown to bring more profit to a practice than patients who only wear eyeglasses. Here are some of the contact lens medical eyecare lessons I learned while in practice.
Familiarize Yourself with Most Common CL Medical Eyecare Issues
The most common contact lens related medical eyecare issues I saw were corneal infiltrates, corneal edema, and GPC. I would see approximately three cases of infiltrates, two cases of corneal edema and one to two cases of significant GPC on average per month. Occasionally I would see a corneal ulcer. Of all the contact lens patients I saw, I would estimate that approximately 2 percent to 3 percent would develop some type of medical eyecare condition that caused them to be symptomatic and uncomfortable.
Invest in Necessary Instrumentation
A slit lamp with good optics is a standard instrument that every doctor will already have, as well as the standard ocular dyes (sodium fluorescene, rose bengal , lissamine green). A corneal topographer or orbscan can be useful. Other instruments that can be helpful in diagnosing contact lens-related conditions are often in the office for other purposes such as a keratometer or pachymeter.
Develop Protocol for Most Likely Medical Eyecare Conditions–and Bill Medical Insurance
Treatment plans will vary depending on the signs, symptoms and severity of the condition and are developed at the discretion of the practitioner. Treatment plans may resemble some examples listed below. In all of the following cases medical insurance should be billed.
Corneal Infiltrates and Corneal Edema: Advise the patient to discontinue contact lens wear, discard current contact lenses and lens case. Prescribe un-preserved ocular lubricant four times per day. If there is no epithelium disruption and the condition is severe, you can consider prescribing an ocular steroid two to four times per day depending on severity and an antibiotic or combination drop if necessary. Follow-up depends on severity of the case, but the patient is typically seen again in three to five days and one week later if necessary. In severe cases, daily follow up may be necessary.
Corneal Ulcer: Direct patients to discontinue contact lens wear, discard current contact lenses and lens case. It is always a good idea to culture. However, If the defect is small and peripheral, some practitioners may or may not culture prior to initiating therapy of antibiotic administered typically four times per day or more often if necessary. Follow the patient daily until the epithelial defect is completely resolved. Once the epithelium is intact if there was a residual infiltrate or edema I would initiate an ocular steroid treatment for a few days until signs and symptoms resolved. These patients would typically be followed daily until the epithelial defect resolved, then at least one to two times after until the corneal edema and/or infiltrate resolved and the patient is asymptomatic.
Central and/or large corneal ulcers: These should always be cultured prior to initiating treatment and followed daily. For high-risk cases it may be a good idea to refer to a corneal specialist. Cases not responding to medical therapy should be referred to a corneal specialist immediately.
GPC: If the patient is contact lens intolerant, instruct the patient to discontinue contact lens wear, discard current contact lenses and contact lens case. These patients have to discontinue contact lens wear for a prolonged period of time that can last as long as several months. Once the GPC is resolved they should be switched to daily replacement contact lenses and re-educated on proper contact lens replacement and compliance.
Make Key Questions to Patient Part of Protocol
Part of the treatment should include detailed probing to understand contact lens wearing habits and lens care regimen. Did they sleep in their contact lenses and for how long, how old were their lenses, and when was the last time they replaced their lenses with a new, fresh pair? What contact lens solution do they use, and how do they use it? Do they top it off? How old is their contact lens case? A detailed history usually would provide the cause of the condition–typically contact lens over-wear, not replacing lenses when they should, poor hygiene or sleeping in lenses.
While it is not very common, it is possible that some ocular complications may occur in patients who are being compliant. It is important to be direct and informative but not accusatory if you cannot confirm non-compliance.
Thoroughly Educate Patient So Issue Doesn’t Recur
The course of action is dependent on the history and details derived from probing, as well as clinical signs. Patients should always be re-educated on proper contact lens wearing and replacement schedules, proper hygiene and proper use of lens care solutions. Many times, switching lenses is necessary such as upgrading from a hydrogel to a silicone hydrogel, or switching to a contact lens with a higher Dk/t (oxygen transmissibility) or switching them to daily replacement contacts.
Explain the condition and factors that cause the condition and educate on proper lens wearing and lens care help to prevent future events. Patients sometimes become compliant once they understand that they put themselves at higher risk for these complications due to how they were handling and/or wearing or replacing their lenses. Written instructions that require the patient’s signature has proven to increase compliance. I would educate the patient and have the staff review this information again prior to the patient leaving the office.
Since the vast majority of the cases I saw were a direct result of the patient’s regimen or replacement/wearing schedule, thorough patient education had a great impact. Written instructions that the patient can take home with them that specifies how often to replace contact lenses and contact lens cases, lens wearing instructions and lens care/solution can improve compliance.
CL Patients Usually Motivated to Give Contacts Another Try
Most contact lens wearers are very motivated to keep wearing contacts. Reviewing the condition and what risk factors contributed to that condition is a good way to start the conversation. If the patient has provided information confirming that their behavior contributed to the event, it is important to point that out. Most of these patients want to know how to prevent something like this from happening again, so a conversation about contact lens materials and proper wearing schedules helps them understand. In addition, most are open to switching to a better material or daily replacement contacts.
But Beware of Chronic Non-Compliance
If the patient is chronically non-compliant and having recurrent complications, the doctor can decide to not prescribe contacts for that patient any longer. Sometimes there are ocular signs of past infection (corneal scarring) that may also point to chronic non-compliance. Proper documentation in the patient’s health record is strongly recommended for the doctor to protect herself legally should the patient continue wearing contacts (with what is left of their supply) against the doctor’s orders and then develop a serious condition.
Address CL Medical Eyecare Issues: Action Plan
Get a thorough history regarding the contact lens wearing regimen, replacement regimen and lens care/hygiene regimen.
Follow the patient closely until significant improvement is observed. Follow-up daily in higher risk cases and always see them through complete resolution. Provide written instructions on medication, discontinuation of lens wear and needed follow up visits.
Train staff to educate all contact lens wearers thoroughly–whether they are first-time lens wearers or long-time lens wearers. Provide written instruction on proper lens care, lens wear and lens replacement regimens before contact lens-related complications occur.
Photo documentation is advised for the doctor’s protection and is sometimes even billable.
Related ROB Articles
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Improve Compliance and Comfort: Three Conversations that Work
Retain Profitable Contact Lens Patients with Good Lens Care Recommendations
JeanMarie Davis, OD, is manager, technical, Global Performance Development for Alcon. To contact her: drdavis2020@yahoo.com.
