Contact Lenses Competency 7.5

Competency 7.5: The ability to manage the aftercare of patients wearing rigid gas permeable lenses

This competency assesses your ability to take a good history and symptoms from an existing rigid gas permeable (RGP) lens wearer and to manage any contact lens related signs or symptoms that the patient may present with.  Despite the decreasing number of patients wearing this lens type, it is still necessary to have a good knowledge of the common complications associated with RGP lens wear and the subsequent management that is required.

Best Form Evidence

This competency could be assessed by Direct Observation during a quarterly visit.  However, your Assessor should be able to inform you in advance if this will be the case.   Whether you see a patient or not, you will certainly be asked to talk through at least three Patient Records from your Logbook.  It is well understood that if you have seen more than three patients in your first and second quarters, then you will be much better prepared for this competency.

  • History and Symptoms should be taken in a structured and logical manner
  • Assessment of the eyes’ response to RGP lens wear
  • Appropriate management of any reported contact lens wear related symptoms reported by the patient
  • Appropriate management of any observed contact lens wear related signs
  • Clear recording of all observations and advice given

History and symptoms

If you have not seen the patient before in your practice, make sure you ask about general history as well as about contact lens wear.  Start by asking the patient the reason for their visit.

General: general health, medication, allergies, previous ocular history, family history, hobbies/driving/occupation.

Current contact lens wear: vision, comfort, lens type, age of current lenses, frequency of replacement, daily care regime as well as periodic protein removal, wearing habits, insertion and removal difficulties, spectacle blur.

Previous lens wear: lens types, modality, care regimes, reasons for changing, total lens wear duration.

Other: last eye examination and aftercare intervals

Assessment of ocular response to contact lens wear

The eyes should be observed with the lens in situ to begin with.  The position of the lens in relation to the lids and the pupil should be noted and the movement of the lens with blinking and eye movements.  It is also important to note the interaction of the tear film with the contact lens especially as RGP lenses are replaced infrequently and often have surface scratches and sometimes deposits.

The lenses should then be removed.  The Assessor may ask you to do this so as to assess your contact lens removal technique.  A full examination of the anterior eye must then be carried out.

Lids

Pay particular attention to the lid margins and check for blocked ducts. Compare lid position to previous records to check for ptosis.

Lashes

Deposits on the upper lashes are best seen with the patient looking downwards

Conjuctiva/sclera

Differentiate between hyperaemia of these two layers by using the lids to move the conjunctiva. If the dilated vessels appear to move, then the hyperaemia is conjunctival.

Tear Film

Assess the tear quality by grading the amount of deposition in the tear film. Have a look at the tear prism too.

Limbus

Get the patient to look down and examine the superior limbal arcades. With RGP lens wearers, it is also important to look for vessel changes at the 3 and 9 o’clock position.

Cornea

Use a broad parallel piped to look for any opacities prior to inserting fluorescein.  Failure to do so may result in faint or small opacities being missed.  Pay particular attention to the 3 and 9 o’clock limbal area.

Tarsal conjuctiva should be examined after assessing the tear film as lid eversion may cause the release of excess mucous/lipids into the tear film.

Fluorescein assessment

This should be done at the end.  Both the cornea and the tear film should be assessed.

All findings should be graded and compared to previous findings where possible.  Diagrams are very useful for noting the location and relative size of any findings.

Appropriate management of contact lens wear related symptoms or signs

Where the patient has a specific sign or symptom that has prompted them to attend for an aftercare, make sure that you have resolved it or have a logical plan of action for its resolution by the end of the aftercare.

Common symptoms that you should be able to manage:

  • Blurred or unstable vision
  • Dry, gritty lenses
  • Sore eyes

Common signs that you should be able to manage:

  • Corneal staining – 3 and 9 o’clock and dimple veil are associated with RGP wear
  • Conjunctival hyperaemia
  • Follicles or papillae on the lids
  • Deposited lashes
  • Corneal opacities/lesions

The above lists are by no means exhaustive and you should read up on all contact lens complications.

Clear recording of all observations and advice given

You should explain to the patient, any changes that you observe in their ocular status and advise them of any changes that need to be made to their contact lens wear or care.  Give the patient a review date to ensure that any changes implemented have managed the presenting signs or symptoms appropriately.  Advise if a full eye examination is required.

Unacceptable Evidence

  • Insufficient patient episodes logged
  • Incomplete records which do not provide evidence of a complete aftercare being carried out
  • Incomplete history and symptoms elicited from the patient during an aftercare, or failure to act on a significant factor
  • Insufficient examination of the anterior eye
  • Failure to recognise any contact lens related changes to the eye
  • Failure to manage a reported sign or symptom correctly

Author: Michelle Hanratty

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