C38369: Professional conduct - part 7

Closing Date: 13/11/2014

Standards of practice Standards of practice Interactive

Work through the following scenarios. At each stage when prompted, think about your answer to the questions raised before moving on.

At the end of the exercise you will be asked multiple choice questions. You can answer these multiple times. Once all are correct, you will be given details of a simple interactivity subject for you to discuss with another GOC registered colleague. Submission of evidence of this discussion will earn you the interactive point

Some time ago, a patient attended your practice to be fitted with contact lenses.  It had been eighteen months since their last sight test.

Were you able to proceed with fitting contact lenses?

Yes. 

Only a registered optometrist, medical practitioner or dispensing optician may fit a contact lens.  To do so you must have a prescription from a sight test that is less than two years old on the date the fitting begins. Alternatively, the fitting must  begin before a specified re-exam date on the prescription. While you may consider it is sensible to undertake a new sight test, so that you are confident you have the correct prescription and the eye is healthy, you are able to commence with fitting.

You should also, as always,  only act within the limits of your competency.

You fitted the patient and are happy that the contact lenses were suitable for the patient.

Are you legally required to issue anything to the patient at this stage?

Yes.

Following completion of a contact lens fitting the patient must be given a copy of their specification sufficient to enable the recommended lenses to be replicated.  This should be when you are satisfied that the lenses give good vision, the patient has adapted to the lenses and ocular health will not be compromised.  Professional guidance, from both ABDO and The College of Optometrists, suggests that this should be within three months of the initial fitting, and if a longer period elapses,  this should be noted on the record and the patient advised accordingly about the delay being longer than would be advised.

The specification will include:

  • The patient’s name and address
  • Date of birth if under sixteen
  • The date the fitting was completed
  • Sufficient details of any lens fitted to enable a person who fits or supplies a contact lens to replicate the lens
  • The date the specification expires
  • Such information of a clinical nature as the person fitting the lens considers to be necessary in the particular case.  This should include when the next contact lens review is required, which is normally the expiry date of the specification.

The patient must also be given instruction on the care, wearing, treatment, cleaning and maintenance of the contact lens.

One year on, the same patient attends for a yearly aftercare and you find that the current lenses are working well, with no modifications required.  You are happy for the patient to continue to wear the same specification lenses for another year.   The patient says they would like to purchase lenses from the internet and would like a copy of the specification.

Do you have to give a copy of the specification?

Yes. 

Effectively this is a fitting and the patient will require a copy of the specification to enable them to continue wearing lenses and have uninterrupted supply.   You may not be happy that the patient is choosing to purchase product elsewhere, however the patient is legally able to do this.

A contact lens can also be sold by an unregistered person with the caveat that they are under the general direction of a registrant.  General direction  is not clearly explained, but thought to be that a registrant has put in place proper processes, such as  training, protocols, audit, risk management. In this case the seller should have the original specification or a copy that is verified with the person who provided it and the sale must be made before the expiry of the specification.  The seller must make arrangements for the patient to receive aftercare.

You may want to ask the patient the reason for their purchasing elsewhere to better understand their motives for doing so and to make sure they are aware of the benefits of purchasing from the practice.  This may also inform your future fee structure for the practice.

The patient continues to purchase from the internet, but today attends the practice for a sight test and  they comment that their lens do not seem as comfortable as they were.    You find they are wearing lenses purchased from the internet, but not the lenses you fitted  the patient with a year ago.

Should you proceed with an aftercare?

Yes.

It is in the best interests of the patient for you to continue with the aftercare and to check the health of their eyes. You should also explain to the patient the importance of aftercare.  Although it is a legal obligation of the supplier of a contact lens to make arrangements for aftercare, this may not always be the case.

You find that the lenses are not fitting well. They appear too tight, but have not caused lasting damage as yet.

What would you advise the patient?

While the patient can quite legally purchase contact lenses over the internet, you should explain that it is important they receive the lenses they were fitted with and not a near equivalent.  Not to do so could cause long term damage to the health of the eyes and a short term gain in cost of the lens may lead long term problems. It is wise to record this advice having been given.

Again it would be useful to understand why the patient is electing to purchase product elsewhere and you should on completion of the aftercare, give the patient an up to date specification.

Another patient of your practice purchases lenses regularly from you and comes into today to purchase a month’s supply.  Your receptionist  noticed she has not had an aftercare for fourteen months and the record card indicates you advised a one year aftercare.

Are you able to supply the lenses?

No. 

You have responsibility for the supply and to operate within our legal framework, to supply contact lenses you need to have a signed written specification,  or a copy that is verified with the person who provided it, that is in date and you should not supply lenses significantly beyond the expiry date.  In this case the specification will not be in date and so you should not supply lenses.

You offer to do an aftercare later in the day, in order that the patient can purchase, however the patient reports that they have to urgently drive to visit a ill relative and also have no spectacles.

How would you proceed?

You could consider supplying spectacles, if you have glazing facilities. Failing all else, based on your professional knowledge and your conversation with the patient, you could supply the contact lenses, using your professional judgement and booking the patient for an aftercare as soon as possible. Finally, give clear advice that in future they should carry a spare pair of spectacles for emergencies and make a note of all advice given on the record card.

You notice on a practice record card that a contact lens optician colleague has changed the prescription of a patient’s contact lens by one dioptre, but not the fitting.  The patient is in their late teens and this is clearly to improve vision due to an increase in myopia.

Is this acceptable?

No.  

The contact lens optician should have referred the teenage back to an optometrist to confirm the new prescription.  It would be sensible to discuss this within the practice to ensure the contact lens optician is aware that an obvious change in refraction should be referred back to an optometrist for a new sight test.

You see a patient who has returned having been given contact lenses following a fitting, to ‘try’ for two weeks with the expectation that you will conclude the fitting.  They are not silicone hydrogel and you feel this would be a preferred option.

What should you do?

As you are potentially the last person who sees the patient before completion of the fitting, you take responsibility for the fitting.

In this case you should advise the patient that you feel there is a different contact lens material that would benefit them and the reasons this is the case.  You would then proceed to fit the silicone hydrogel contact lens.

On a broader front, you should always keep abreast of developments in practice and be able to explain to the patient the options they have and the benefits of each option.  With contact lens it is generally accepted that silicon hydrogel lenses will give ocular health benefits for patients and so would be the lens of choice.  Although cost may then come into the patient’s decision, they should be given informed choice.

This is within the GOC code of conduct; ‘Give patients information in a way they can understand and make them aware of the options available’, and also the College guidelines; ‘Prior to the fitting of lenses, advice should be given to the patient about the risks and complications of contact lens wear, available lens types, their advantages and disadvantages and any types which might be particularly appropriate or contra-indicated, together with a suitable explanation of the reasons, the care systems required by the different lens types and the total estimated costs. Patients should be given sufficient information to make an informed choice’.  Further;   ‘Following the preliminary assessment the optometrist has a duty to ensure that each individual contact lens wearer is fitted with the most appropriate lens type to meet his or her needs’.

Finally, at the end of a busy day, a 15 year old girl attends the practice and would like to be fitted with contact lenses for occasional social wear.  She is unaccompanied.

Are you able to fit?

Yes. 

In order for you to undertake the fitting, you need to have consent. This means the patient must be competent, have sufficient evidence to make a choice and is able to give consent freely.   In this case a 15 year old is likely to be considered ‘Gillick competent’, a term from English law relating to whether a child is able to consent to their medical treatment.

When dealing with a child under 16, the individual practitioner will have to take each case on its merits and assess the individual circumstance.   It may be a difficult decision to make as to whether the child is Gillick competent, and you may take note of part of the original legal judgement: ‘...it is not enough that she should understand the nature of the advice which is being given: she must also have a sufficient maturity to understand what is involved.’

In this case a 15 year old child is likely to be able to understand what contact lens fitting involves.