1 When asking about comfort of lenses, which of the following approaches might elicit the most useful response?
Answer: Ask the patient to rate comfort on a scale of 1-10 for different times of the day and duration of wear.
A score rating is useful, allowing a quality judgement, and also multiple ratings for different times helps build a profile of comfort.
2 Which of the following is unlikely to be a cause of near vision difficulties in contact lens wear?
Answer: Increasing myopia.
Uncorrected myopia enhances near vision. For this reason, full distance correction of myopia in the very early stages of presbyopia is often resisted by patients.
3 With which of the following would you be unlikely to find improvement of vision with pinhole in front of the contact lens?
Answer: Increased hyperopia caused by macular oedema.
Serous elevation of the macula shortens axial length and induces hyperopia.
4 Studies show the normal distribution of tear prism heights peak at around what value?
Answer: 0.22mm.
There is obviously significant variation in tear prism height but these typically average out at around 0.22mm. Reduced height is a reasonable indicator of reduced tear volume, and this is considered in conjunction with tear debris levels and regularity of the tear prism along the lid margin.
5 If microcysts are to be usefully looked for, what is the minimum useful magnification your slit-lamp should be capable of?
Answer: 40 times.
Microcysts in the epithelium are useful indictors of short-term hypoxic stress but require at least 40 times magnification to be visualised meaningfully.
6 Which of the following statements is false?
Answer: Eversion of the lids is never necessary with low modulus lens wearers.
While it is true that wearers of low modulus materials are less likely to suffer adverse responses to mechanical insult such as GPC or SEALs, all lens wearers are constantly holding their inner palpebral surface to a foreign material and therefore assessment of the under-lid health is always important.
Interactivity
What in your view is an appropriate practice policy for booking aftercares in terms of their regularity?
We had approaching 1,000 participants in this exercise and the results were very interesting. Typical answers were ‘if there are no problems the next aftercare is in six months’ and ‘my colleagues and I will on the whole see patients at six-monthly intervals’. In fact over 50 per cent of respondents had a six-month frequency as the default period. Reasons for this were not always stated, though sometimes it was to do with the design of the appointment-keeping systems – ‘we see patients every three months or six months, but this is a case of trying to put value into the care plan that we operate.’ This was not always the case, and some highlighted that, where appointments were automatically generated, the frequency was controlled by the practitioner at each aftercare appointment. ‘Our computer system is set to issue a reminder when aftercare is due, the date of which is generated by the CLO.’
If not six-monthly, then over 10 per cent had annual frequency as default, as with the response ‘Contact lens aftercare appointments are generally scheduled annually once everything is up and running smoothly.’ This might be strongly enforced, as ‘We recommend annual aftercare for normal patients and send a stronger worded letter stating legal requirements if they have not attended coming up to two year date.’ Others were less strongly proscriptive and cited College guidelines implying annual check-ups.
Modality of wear and materials were not always mentioned, but in many answers they were the trigger to deciding which frequency of aftercare was chosen. Such responses included ‘I feel that with experienced compliant contact lens wearers aftercare appointments should be annually especially with daily wearers, monthly disposable recalls should be considered on a case by case basis but a minimum of six months at the most.’
A worrying trend mentioned by a good number of respondents was a feeling that a ‘proprietor’ or a ‘multiple’ wanted annual or biannual appointments while the registrant felt more comfortable with six-month checks. In none of these submissions was there any stated reason for either approach. However, commercial influence of clinical decision is not something we should accept.
My view, heavily influenced by discussion with very many clinicians and academics in this arena, has tended toward having no set aftercare frequency other than that decided on the day during the assessment. Without predicted concerns (for example those with existing concerns, extended wear regimes and so on), why not repeat as any eye check frequency? Surprisingly few (less than 10 per cent) reflected this freedom and flexibility. Here is an example: ‘We believe it does not have to be regimented and people should feel free to come into the practice whenever they feel they need to. But a set requirement should always be given to the patient after each appointment.’