History and symptom taking in contact lens fitting and aftercare

2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management

ABSTRACT

Detailed clinical assessment is critical to allow sensitive evaluation of the eye and its management. As technology advances, these assessment techniques can be adapted and refined to improve the detection of pathological changes of ocular tissue and their impact on visual function. Enhancements in optical medical devices including spectacle, contact, and intraocular lenses have allowed for a better understanding of the mechanism and amelioration of presbyopia and myopia control. Advancements in imaging technology have enabled improved quantification of the tear film and ocular surface, informing diagnosis and treatment strategies. Miniaturized electronics, large processing power, and in-built sensors in smartphones and tablets capacitate more portable assessment tools for clinicians, facilitate self-monitoring and treatment compliance, and aid communication with patients. This article gives an overview of how technology has been used in many areas of eye care to improve assessments and treatment and provides a snapshot of some of my studies validating and using technology to inform better evidence-based patient management.

A proposed methodology for conducting a remote rigid gas permeable contact lens consultation

PURPOSE

COVID-19 spread to numerous countries, overwhelming healthcare systems and economies worldwide. COVID-19 restrictions have prevented patients from attending consultations in person and led to the further development of telemedicine to provide health care. The situation also applies to contact lens (CL) practitioners and their patients; telemedicine enables practitioners to provide patients with regular and continuing care. This study aimed to investigate available tools to enable continuing care for rigid gas permeable (RGP) CL wearers who are unable to attend face-to-face consultations.

METHODS

The study consists of three components. Firstly, an approach to enable the assessment of a patient's CL fitting and cornea remotely. Secondly, to find an affordable and reliable method to obtain a patient's visual acuity (VA), and thirdly, to develop a questionnaire to provide practitioners with information to deliver optimal patient care.

RESULTS

The use of a macro lens, smartphone, and auxiliary materials enables high-quality images of the anterior eye and RGP CL to be obtained. Two free and validated smartphone applications (apps) for VA measurements were identified which are available on Android and iOS systems. Two questionnaires were also developed to enable practitioners to obtain additional patient information to facilitate optimal patient care.

CONCLUSION

This study has developed the components of a remote CL consultation to enable patients who cannot attend scheduled appointments to receive care and advice to ensure the safety of their RGP CL wear. The tools involved in this study are low-cost, affordable, and an adjunct, not a substitute, for face-to-face consultations.

Are Patients Sufficiently Informed about Contact Lens Wear and Care?

SIGNIFICANCE

Frequent and effective patient-practitioner communication is essential to ensure that instructions regarding contact lens use, care, and maintenance are understood and followed. Given the relevance of good patient compliance, the responsibility of practitioners to provide adequate information may not be neglected.

PURPOSE

This study aimed to determine the content and type of information licensed optometrists in Spain provide their patients during the first contact lens fitting and at follow-up visits.

METHODS

A self-reported ad hoc survey was distributed to licensed optometrists in Spain to investigate, among other factors, whether practitioners provided information on several aspects of contact lens use and maintenance, how was this information provided, and whether in-office practical demonstrations were conducted at all contact lens appointments.

RESULTS

Respondents of 321 surveys had a median of 20 years of contact lens fitting experience and worked on independent practices (67.6%), and national (29.0%) and regional chains (3.4%). Type of practice influenced continuous education habits ( P = .03). Overall, 28.0% of participants did not always instruct patients on the need to rub contact lenses, 34.3% did not always address contact lens replacement, and 6.8% did not always explain storage case hygiene and replacement. At the follow-up visit, only 8.4% of respondents asked their patients to demonstrate their care routines. Information was mostly oral (48.6%) or oral and written (43.0%). Contact lens-related complications were reported more frequently by participants with less continuous education training ( P = .01), by those not always recommending rubbing ( P = .002), and by those not providing written information about storage case hygiene and replacement ( P = .002).

CONCLUSIONS

Patient-practitioner communication was good, albeit several areas were identified where information was insufficient or not provided in a correct and timely format. Precise, written information on rubbing and storage case hygiene and replacement may improve compliance and assist in avoiding complications and dropout.

CLEAR - Evidence-based contact lens practice

Evidence-based contact lens -->practice involves finding, appraising and applying research findings as the basis for patient management decisions. These decisions should be informed by the strength of the research study designs that address the question, as well as by the experience of the practitioner and the preferences and environment of the patient. This reports reviews and summarises the published research evidence that is available to inform soft and rigid contact lens history and symptoms taking, anterior eye health examination (including the optimised use of ophthalmic dyes, grading scales, imaging techniques and lid eversion), considerations for contact lens selection (including the ocular surface measurements required to select the most appropriate lens parameter, lens modality and material selection), evaluation of lens fit, prescribing (teaching self-application and removal, adaptation, care regimen and cleaning instructions, as well as -->minimising risks of lens wear through encouraging compliance) and an aftercare routine.

CLEAR - Effect of contact lens materials and designs on the anatomy and physiology of the eye

This paper outlines changes to the ocular surface caused by contact lenses and their degree of clinical significance. Substantial research and development to improve oxygen permeability of rigid and soft contact lenses has meant that in many countries the issues caused by hypoxia to the ocular surface have largely been negated. The ability of contact lenses to change the axial growth characteristics of the globe is being utilised to help reduce the myopia pandemic and several studies and meta-analyses have shown that wearing orthokeratology lenses or soft multifocal contact lenses can reduce axial length growth (and hence myopia). However, effects on blinking, ptosis, the function of Meibomian glands, fluorescein and lissamine green staining of the conjunctiva and cornea, production of lid-parallel conjunctival folds and lid wiper epitheliopathy have received less research attention. Contact lens wear produces a subclinical inflammatory response manifested by increases in the number of dendritiform cells in the conjunctiva, cornea and limbus. Papillary conjunctivitis is also a complication of all types of contact lenses. Changes to wear schedule (daily disposable from overnight wear) or lens materials (hydrogel from SiHy) can reduce papillary conjunctivitis, but the effect of such changes on dendritic cell migration needs further study. These changes may be associated with decreased comfort but confirmatory studies are needed. Contact lenses can affect the sensitivity of the ocular surface to mechanical stimulation, but whether these changes affect comfort requires further investigation. In conclusion, there have been changes to lens materials, design and wear schedules over the past 20+ years that have improved their safety and seen the development of lenses that can reduce the myopia development. However, several changes to the ocular surface still occur and warrant further research effort in order to optimise the lens wearing experience.

Could telehealth help eye care practitioners adapt contact lens services during the COVID-19 pandemic?

The COVID-19 pandemic has necessitated government-imposed restrictions on social interactions and travel. For many, the guidance has led to new ways of working, most notably a shift towards working remotely. While eye care practitioners (ECPs) may continue to provide urgent or emergency eye care, in many cases the travel restrictions present a unique challenge by preventing conventional face-to-face examination. Telephone triage provides a useful starting point for establishing at-risk and emergency patients; but patient examination is central to contact lens patient care. The indeterminate period over which conventional practice will be suspended, and the risk that resumption of 'normal' practice could be impeded by a potential secondary peak in COVID-19 cases, hastens the need for practitioners to adapt their delivery of eyecare. Specifically, it is prudent to reflect upon supportive evidence for more comprehensive approaches to teleoptometry in contact lens practice. Smartphone based ocular imaging is an area which has seen considerable growth, particularly for imaging the posterior eye. Smartphone imaging of the anterior eye requires additional specialised instrumentation unlikely to be available to patients at home. Further, there is only limited evidence for self-administered image capture. In general, digital photographs, are useful for detection of gross anterior eye changes, but subtle changes are less discernible. For the assessment of visual acuity, many electronic test charts have been validated for use by practitioners. Research into self-administered visual acuity measures remains limited. The absence of a comprehensive evidence base for teleoptometry limits ECPs, particularly during this pandemic. Knowledge gaps ought to be addressed to facilitate development of optometry specific evidence-based guidance for telecare. In particular, advances in ocular self-imaging could help move this field forwards.

Pharmaceutical technology can turn a traditional drug, dexamethasone into a first-line ocular medicine. A global perspective and future trends

Dexamethasone is one of the most prescribed glucocorticoids. It is effective and safe in the treatment of a wide variety of ocular conditions, including anterior and posterior segment inflammation. However, its half-life in the vitreous humor is very short, which means that it typically requires frequent administrations, thus reducing patient adherence and causing therapeutic failure. Innovative dexamethasone delivery systems have been designed in an attempt to achieve sustained release and targeting. The FDA has approved dexamethasone implants for the treatment of macular edema secondary to retinal vein occlusion and posterior segment noninfectious uveitis. Lenses, micro- and nanoparticles, liposomes, micelles and dendrimers are also proving to be adequate systems for maintaining optimal dexamethasone levels in the site of action. Pharmaceutical technology is turning a classical drug, dexamethasone, into a fashionable medicine.

Synthesis and Characterization of Poly(2-hydroxyethylmethacrylate) Contact Lenses Containing Chitosan Nanoparticles as an Ocular Delivery System for Dexamethasone Sodium Phosphate

PURPOSE

Dexamethasone sodium phosphate (DXP) is an anti-inflammatory drug commonly used to treat acute and chronic ocular diseases. It is routinely delivered using eye-drops, where typically only 5% of the drug penetrates the corneal epithelium. The bioavailability of such ophthalmic drugs can be enhanced significantly using contact lenses incorporating drug-loaded nanoparticles (NPs).

METHODS

The mechanism of release from chitosan NPs (CS-NPs), synthesized by ionic gelation, was studied in vitro. The DXP loaded CS-NPs were subsequently entrapped in contact lenses and the optical and drug-release properties were assessed.

RESULTS

DXP release from CS-NPs followed diffusion and swelling controlled mechanisms, with an additional proposed impact from the electrostatic interaction between the drug and the CS-NPs. The release rate was found to increase with an increase in drug loading from 20 to 50 wt%. However, an inverse effect was observed when initial loading increased to 100 wt%. NP-laden lenses were optically clear (95-98% transmittance relative to the neat contact lens) and demonstrated sustained DXP release, with approximately 55.73% released in 22 days.

CONCLUSIONS

The release profile indicated that drug levels were within the therapeutic requirement for anti-inflammatory use. These results suggest that these materials might be a promising candidate for the delivery of DXP and other important ophthalmic therapeutics.