Feedback: Contact lenses interactive – 1

A recent CPD article (Optician 04.02.22) by Neil Retallic and Dr Manbir Nagra discussed handling of contact lenses. The bulk of their article focused on patient reported outcomes from a survey exploring the handling experiences and wearing habits of 1,031 soft daily disposable contact lens wearers in the context of current literature and accepted clinical practice. The good news from this survey was that nearly a third (31%) of the wearers reported no handling difficulties.

They noted: ‘Although there is awareness of handling-related dropout issues, there is surprisingly little published on what specific aspects of handling cause the most difficulties or have the greatest influence on contact lens retention. Wearer experiences are likely to differ between lens materials, lens types and modalities. That is even before personal motivation, expectation and mind-set factors are taken into consideration.’

The top five handling related issues were:

• Difficulty determining if their lenses were inside out
• Lenses easily sticking to the finger
• The blister seal being perceived as hard to open
• Lenses becoming contaminated
• Challenges applying the lens onto the eye

This article was then the source material for an interactive CPD discussion exercise where you were asked for your views on the following case scenario.

Case for discussion

Helen, a 28-year-old women who has successfully worn daily disposable soft contact lenses for five years, phones your practice in a panic. For the first time, she has removed her lenses and noticed one of them is torn. Discuss the following questions:

1. What questions and advice would you expect the retail team member or support staff member to give during the phone call?
2. Based on details from this initial telephone conversation, what approach would you take to manage the situation. For example, would you undertake a follow-up phone call, a remote care assessment via a video link, or insist on a face-to-face appointment?
3. What signs and symptoms may there be if part of a lens is retained in the eye?
4. What investigation, management and advice would you provide, both to rectify the concern if any residual lens is identified or to reduce any future risk of this problem recurring?

Your Discussions

Retail team member actions

Most of you obviously have quite a well-rehearsed protocol to follow in such circumstances. Here is an example:

‘We would expect the team member to follow these procedures:

1. Firstly, establish if a patient of ours or not. If a patient of ours to pull the patient notes to see what lenses she is wearing, and perhaps usefully note if she is myopic or hyperopic. Hyperopes will find it more difficult to manage this scenario than myopes, sometimes reassurance can be supportive. If not, a patient some questioning about the lens type, how long has she worn lenses, again with some supportive reassurance.
2. Ask how long since this happened, is there discomfort, redness, is the vision affected? Ask the patient to put their spectacles on and check their vision with a distant target either outdoors or at least 10 feet three metres away.’

Another, based on a group discussion from colleagues north of the border, comprised the following recommended statements and questions:

• ‘Firstly, reassure the patient.
• There is no need to panic. SCLs, even if damaged or torn, rarely cause any (permanent) damage to the cornea.
• When did this happen?
• Please try not to rub your eye.
• What were the circumstances of the lens being noted as torn? Was there any problem inserting or removing the lens that morning? Had the lens been slept in? Was the irritation there prior to removal, and so on?
• Put on your spectacles (patient should have standby spectacles); if you look at the lens is it torn or is part of the lens missing?
• Is your eye red or painful and when you put on your spectacles is your vision good or is it still poor?
• Is the redness, pain or poor vision getting worse?
• Could you take a picture of your eye or get someone else to do so and send it to us?
• Could you take a picture of the lens and send in to us so we can determine if the lens is intact or if a part of the lens could still be in your eye?
• Do you think that there is any part of the lens still in your eye?
• Have you taken any steps to find or remove any missing piece of the lens from your eye?
• Do you feel you need to see or speak to an optometrist?
• I will pass on the information to the optometrist as soon as possible and someone will phone you back with further information and to discuss the best course of action.’

Management

As stated by most of you, management was very much dependent upon the responses and information from the first question. One of you stated: ‘As remote care will not show me a piece of lens in the eye, I will always ask for a face-to-face appointment. I have not stopped this at any point (during lockdown) for many reasons; the only way to know if a piece of lens is there is to look. I would advise the patient to come in straight away and I will see them between patients. If we don’t look, the patient will be anxious and may end up going into A&E unnecessarily. They need reassurance by the CLO or optometrist as soon as possible. You need to use fluorescein and lid evert in every case.’

Our Scottish colleagues had the following systematic approach:

• ‘Again, reassure the patient that any damage to the eye is extremely unlikely.
• If the image of the eye shows no damage and the image of the lens shows only a tear and no missing fragments a remote video assessment may be sufficient but a face-to-face may be just as quick and could be fitted in a 10-minute slot to allow a NaFl check. If the vision is good and not deteriorating and there is no significant irritation or redness or pain and there is no increase in either of the latter, a remote video assessment may be sufficient but a face-to-face may be just as quick and could be fitted in a 10-minute slot to allow a NaFl check.
• If the photographs show the lens to be intact, a face-to-face appointment may still be necessary if there is continuing pain or redness. If the lens is not intact, a face-to-face would be necessary to rule out any part of the lens being stuck under the lids, any corneal scratches from the patient trying to remove the rest of the lens and to try to establish why the lens split after five years of previous CL wear.
• Depending on the degree of anxiety of the patient, a short same day face-to-face may be good practice with advice not to wear lenses until seen.
• If the patient was reassured by advice, and images show intact lens and quiet eye, it may be acceptable and ask her to phone back if any symptoms worsen but to have a day out of lens wear.
• We would not suggest the use of lubricant or attempts to irrigate the eye with lubricant without seeing the patient first.
• At the very least, the practice would phone back with an initial decision – if no red flags, then give advice about when to return to lenses and what other symptoms would make further consultation advisable. It is important that this call is by an optometrist.
• Also, it is the optometrist who decides that further consultation is required and most likely if there is any concern then a face-to-face visit would be preferable. This may be necessary to rule out any part of the lens being stuck under the lids, any corneal scratches from the patient trying to remove the rest of the lens, and to try to establish why the lens has split after five years of previous CL wear – is it a bad batch or lapse in handling technique? If not possible, then the optometrist should again further evaluate the situation and may insist that patient does need to attend, making every effort to accommodate any time constraints the patient may have.

Signs and symptoms of lens-in-eye

As many of you pointed out, there may be surprisingly few indications of a lens retained in the eye. ‘Sometimes only minor symptoms of discomfort, sometimes virtually none; rarely hyperaemia unless overly-vigorous removal attempts have been made with direct finger contact onto eye.’

Another stated: ‘This will depend on where in eye in a couple of cases and how long it has been there. Signs may include hyperaemia, staining with fluorescein, mucus discharge, possibly raised papillae. Symptoms may include “feeling something there”, often where the lens will not be located (lattice nerves), sometimes sharp edge sensation on blinking, possibly vision affected if it is central, although more likely for the piece to be located under the lid.’

Advice and management

In most case, this relied on a face-to-face assessment to assess any damage. Importantly, most of you focused on future patient education regarding handling and compliance with instructions.

Final thoughts

Neil Retallic said: ‘This case reminds us that handling-related issues may occur for both new and experienced wearers. A prudent approach would be to always focus on communication and education.

‘In this scenario, the problem might be a one-off occurrence, triggered by handling in an unfamiliar environment, lack of concentration or poor technique. The good news is that careful questioning and observations of their handling habits followed by a reassuring coaching style approach will usually address these modifiable behaviours.

'Remote consultation offers the advantage of observing what happens in their usual handling environment, although challenges remain in assessing lens fragment retention or ocular surface disruption. For this, we have to wait for remote imaging technology advances. NaFl and lid eversion checks really need to be included, as lens fragments can be retained in the lid conjunctival fornix region.

‘Ensuring the whole team is trained according to a clear protocol is important. The first point of contact is usually a member of the retail team. Taking a proactive approach to identify any sub-optimal performance or non-compliance behaviours should be standard, with systems in place to provide “refresher training” and appropriate follow up, reviewing alternative contact lens product options (which may have different handling properties) and having a variety of educational resources to support the wearer can help maximise success.’