Medical Contact Lens Practice

Making the transition from routine contact lens fittings to being involved in the management of a medical condition with contact lenses seems to be a quantum leap. More often than not, knowledge is gained through hands-on experience and there are few texts available that introduce the subject to the inexperienced. Medical Contact Lens Practice is therefore a potentially valuable addition to the practitioner's clinical collection. Interestingly, the publisher describes this book as a 'comprehensive yet concise ready reference text' suggesting that the book would also be useful to the experienced fitter as well as the novice.
The first three chapters are concerned with examination of the external eye, tear film and the lids and lacrimal system. The author clearly states in her preface that the book assumes a basic knowledge of contact lens fitting, hence each chapter avoids prolonged discussion of subject matters that detract from the main subject areas.
Much of Chapter 1 (Examination of the external eye), concerns itself with assessment of the corneal topography and the varied ways of determining it (keratometry to videokeratoscopy). Videokeratoscopy gets the greatest airing here. Key information such as interpretation of clinical maps generated by a videokeratoscope is covered briefly; however, it would have been useful to novices to cover this in greater detail. This would ensure they have detailed knowledge of a subject, which has become central to fitting contact lenses for the abnormal ocular surface. For the experienced clinician some of the information in this area could be regarded as far too basic.
Chapter 2 (Assessment of the tear film) covers the assessment of the dry eye, its diagnosis and management. It adopts a clinical approach and is highly practical. But again, criticism can be levelled at the lack of detail given to an area, which should probably have been the root of this chapter, namely contact lens wear in dry eye. For example, the role of modern, surface-treated silicone hydrogel lenses is only very superficially addressed.
In a book covering medical contact lens practice, one would perhaps expect a chapter on the eyelids, lashes and lacrimal system (Chapter 3) to address the use of contact lenses in the management of conditions such as ptosis and entropion or trichiasis in some detail. Although these conditions and their management with contact lenses are discussed, the content is brief. It would have been more useful to the inexperienced practitioner - probably also the expert - to examine the management of each condition with the different types of lenses, particularly concentrating on the design and fitting of these lenses. The chapter could have been further enhanced with the use of 'before' and 'after' photographs.
Both Chapter 4 (Evaluation of the older patient) and 5 (Contact lens complications) are equally applicable to general optical practice as well as medical contact lens practice. Hence their inclusion in a specialised book of this nature seems a little strange. Particularly as from the outset this book assumes a basic knowledge of contact lens practice. Again a criticism is that the depth of coverage for a novice would be insufficient, and for an experienced clinician, probably too basic. It therefore seems questionable why these chapters have been included at all. Perhaps a chapter on orthokeratology would have been more relevant?

extended wear
Chapters 6 to 9 are concerned with contact lens-related red eyes, their diagnosis and management. These four chapters cover microbial keratitis, allergy and differential diagnosis of the red eye. Chapter 8 examines the closed eye and extended wear. Arguably, one of the most significant advances in this area is the introduction of silicone hydrogel lenses for extended and continuous wear, but this area is dealt with too superficially. One point of interest is that repeated reference is made to 'the previous generation of extended wear', but no mention of the modality of continuous wear with the new generation of silicone hydrogel lenses.
Not until Chapter 10 does the reader come across some of the core areas of medical contact lens practice. This chapter concentrates on keratoconus. Half of the seven pages here concentrate on the diagnosis and the clinical signs and symptoms of the condition, leaving very little space to discuss fitting of these complex patients. A more helpful approach might have been to use clinical images to highlight the fitting procedures, with each of the lenses mentioned. For an experienced practitioner, the lack of detail is also a hindrance. The same accusations can also be levelled at Chapter 11, which looks at fitting contact lenses post surgery.
Chapters 12 (scleral and prosthetic lenses) and 13 (therapeutic lenses) although rather concise, are excellent and the novice to the subject will find these a particularly useful introduction to each area. There are some good clinical examples where these types of contact lenses have been used successfully to manage various clinical conditions.
The final chapters of this book examine pharmacology and therapeutics; care systems and clinical record keeping. Each of these subject areas is equally applicable to 'routine' contact lens practice as it is to medical contact lens work. Hence their inclusion in this book is questionable but understandable.
This book addresses a complex and highly specialised area of contact lens work that has traditionally been the remit of a specialist clinic or the hospital eye service. It is a very basic introduction to the area of medical contact lens practice for a clinician wishing to be involved further in this area. However, it probably lacks enough depth and practical advice to allow the novice to put theory into practice.

Medical Contact Lens Practice by Elisabeth Millis is published by Butterworth-Heinemann. Hardcover: 224 pages. ISBN: 0750643277. Price 50. Visit www.optometryonline.net to receive a 10 per cent discount.

Dr Sandip Doshi is an optometrist practising in Hove, East Sussex