Introduction

History and symptoms is critical to determining whether an individual is suitable for contact lens wear, to aid selection and to inform management. The aim is to comprehensively elicit relevant information in as concise a manner as possible, as time is limited in a clinical setting, but missing information can result in suboptimal clinical decisions. Clinical records have been found to underestimate actual care provided, suggesting that record keeping is not always as comprehensive as it should be ( ). The BCLA Contact Lens Evidence-based Academic Reports, which involved collating the available peer-reviewed evidence and a consensus of approximately 100 experts in the field, informed the recommendations in this chapter ( ).

The objectives for a new patient include:

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  to determine the suitability for contact lens wear based on:

  
  
  
  
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    an analysis of patient-specific indications and contraindications

    
    
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    a detailed examination of their eye health

    
    
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    a risk benefit analysis for the individual patient

  
  
  
  
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  to guide the patient as to the most suitable lens modality and type based on:

  
  
  
  
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    their lifestyle (including occupation)

    
    
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    aspirations for lens wear and financial outlay restrictions

    
    
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    the outcome of their ocular health examination

    
    
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    refraction

    
    
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    binocular vision

  
  
  
  
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  to ensure expectations are realistic, such as:

  
  
  
  
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    visual outcomes, especially in presbyopes

    
    
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    myopia control in children

    
    
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    wearing time

    
    
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    lens care requirements

  
  
  
  
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  to collate baseline patient information:

  
  
  
  
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    to justify clinical decision-making

    
    
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    to allow future changes to be compared at aftercares

  
  
  
  
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  to ensure the compliance implications of contact lens wear are communicated

examined the open-question regarding issues with the patient’s eyesight typical at the beginning of a consultation and demonstrated that uninterrupted statements of greater than 30 seconds were unlikely to provide useful additional information. How a contact lens consultation history and symptoms is conducted will depend on whether it is an initial fitting where past history, motivation and intended wearing pattern and environment will be the focus, compared to an aftercare where symptoms, changes in health and compliance aspects are foremost. Hence, ‘history and symptoms’ changes to ‘symptoms and (changes in) history’ for an aftercare ( ). Comprehensive capture of relevant information in a limited time will require a structured approach, ability to differentially diagnose and appropriate use of abbreviations.

Indications and Contraindications for Contact Lens Wear

Contraindications are often interpreted as a reason not to fit contact lenses, but in most cases with reflection on the management of the condition or a change in contact lens choice, successful and safe wear may be achieved.

Patients with compromised ocular health such as meibomian gland disease ( ), low tear stability ( ) or recurrent epithelial erosion need the condition to be managed before soft or rigid corneal lenses are fitted, but therapeutic lenses could be part of that management in extreme cases ( ). Poor tear film can be exacerbated by contact lens wear. This is due to the thickness of lenses relative to the tear film and the lens material or design’s interaction with the ocular surface and adnexia (such as the eyelids) changing the composition of the tear film through stimulating inflammation and binding to protein and lipids ( ).

Since patient compliance with practitioner instructions has significant impact on safe, long-term wear, it is important to judge the prospective patient’s ability to understand the full implications of lens wear. It is also important that the patient’s expectations that drive motivation are realistic and achievable. A particularly exacting personality type may find the adaptation period and the initial learning of handling techniques too intrusive to outweigh the overall benefits of lens wear ( ). Manual dexterity to apply and remove lenses and maturity, mental capacity or willingness for compliant use may also increase the risks of wear beyond the potential benefits.

It is debateable whether the financial aspects of not only the fitting but the continuing clinical care and the ongoing costs of lens care solutions and lens replacements should be taken into consideration. Fitting lenses to a patient without the financial means to care for them will inevitably lead to noncompliance and increase the potential for adverse events to occur. However, presumed compliance by eye care practitioner is known to be a poor indicator of real compliance ( ), and the patient’s financial situation is rarely actually known.

It is important to judge the motivation to wear contact lenses and the personality type of the potential wearer. Contact lenses are considered to give a more normal cosmetic appearance and may contribute significantly to overall appearance, particularly when the refractive error is high. In addition, there are cases where lenses can be used specifically to conceal significant cosmetic defects such as iris anomalies, corneal opacities, inoperable squint or microphthalmos. Also, if patients have extremely flat, steep or irregular corneas or the ocular surface needs protection, then therapeutic contact lenses may be appropriate such as scleral lenses.

History-Taking Structure

An initial comprehensive history will assist clinical decision-making. For aftercare visits, questioning should concentrate on what has changed since the last visit rather than repeating questions asked at the initial visit. Traditionally an ophthalmic examination would be structured so as to include the following elements.

Patient Education, Risk/Benefit Analysis and Informed Consent

When fitting patients new to lenses as well as those being refitted, it is important to get informed consent. Essentially this requires that the patient has a reasonable understanding of the main benefits of contact lens wear, as well as the potential risks that accompany lens wear.

Part of this process involves educating the patient on the various lens types and any that might be particularly suited (or unsuited) to the patient’s particular needs. Information on wearing schedules and use of lenses in overnight wear, appropriate lens care systems and replacement intervals are all relevant factors in the patient’s decision to proceed with lens fitting. While there are many positive features to contact lenses, including visual, cosmetic and potentially psychological benefits, the patient must be warned of possible adverse events.

Since there are so many factors that might be relevant to the decision on contact lens wear, it is difficult to know how much information to provide. In general, it is not necessary to disclose every possible risk, only those that a reasonable person or a member of the profession would expect to be told ( ). Patients may need specific advice on aspects such as driving with monovision or where a particular undesirable outcome is not unexpected. Equally, it should be remembered that a minor can neither give informed consent nor contract to pay for services.

In some countries, it is common practice to ask the patient to sign a consent form, but the legal protection that this affords is questionable.

Patient Compliance

Encouraging compliance is a key element of any aftercare symptom and history taking. Noncompliance is common throughout the world ( ) and perceived compliance is not a good indicator of actual patient behaviours ( ). Noncompliance has consequences which range in severity from reduced comfort on application and at the end of the day ( ), dryness and inferior vision ( ) to an increased risk of microbial keratitis from sleeping in lenses not prescribed for this purpose ( ). Other physiological signs of noncompliance include deposition on the contact lenses ( ), corneal staining ( ) and increases in papillae and hyperaemia ( ). Risk-taking tendencies have been linked to compliance and while not an easy direct question, they may become apparent from hobbies ( ).

The key aspects to emphasise are ( ; ):

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  Failure to replace lenses when scheduled – reuse of daily disposable contact lenses is motivated largely by wanting to save money (60%) and occurs in ~9% of patients (varying by country with 18% in Australia, 12% in the United States, 7% in the United Kingdom to 4% in Norway). Over half of patients wearing fortnightly and monthly lenses have been found not to follow the manufacturer’s or optometrist’s replacement schedule recommendation ( ). In both these studies, failure to replace lenses when scheduled was linked with lower reported comfort on application and on lens removal ( ).

  
  
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  Sleeping in contact lenses – 75% of daily disposable contact lenses admit to napping in their lenses and 28% to sleeping in them at least once a month. Sleeping in lenses at least once a week to a fortnight increases the relative risk of moderate and severe microbial keratitis ( ).

  
  
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  Inappropriate lens purchase and supply – internet purchase of lenses, rather than from a contact lens practice, appears to prevent patients from receiving the education, clinical care and follow-up required and has been shown to be associated with a greater risk of developing microbial keratitis ( ).

  
  
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  Use of tap water and failure to wash hands – generally patients report that they have been poorly instructed on the use of storage cases and tap water and have a general lack of awareness with respect to hygiene such as hand washing ( ) which leads to ~4.5 × greater risk of infection ( ).

  
  
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  Failure to clean and replace cases regularly – poor case hygiene has also been associated with a greater risk of microbial keratitis ( ). The lens storage case is rarely cleaned (only 25% every or most days), tap water is generally used (67%), the cap is left on by 76% of patients and the case is only dried open, face down as recommended ( ) and replaced monthly in a small percentage of users ( ).

  
  
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  Inappropriate use of care systems –infrequent use of care systems has been shown to be a risk factor for both microbial keratitis and sterile keratitis in daily wear users ( ), as has failure to wash hands ( ). Failure to rub and rinse lenses leaves deposits on the lens ( ) leading to a greater risk of developing microbial keratitis ( ) and leads to higher rates of signs and symptoms ( ). In both the outbreaks of Fusarium keratitis and Acanthamoeba keratitis, topping up, rather than the required completely replacement of solutions each day, was shown to be associated with a greater risk of infection ( ). Use of tap water to rinse is linked with higher rates of Gram-negative bacterial contamination ( ).

  
  
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  Swimming or showering in contact lenses – swimming allows accumulation of microbial organisms on or in the lens, especially first generation silicone hydrogel materials, which increases the risk on acanthamoeba infection ( ). The effect can be reduced by the use of swimming goggles ( ).

Verification of elements of compliance can be achieved by asking patients to describe or demonstrate lens cleaning, lens case cleaning and hands washing ( ). With limited contact time with patients and partial patient oral retention ( ), comprehensive, but concise written guidance should be provided to all patients ( ) at every visit ( ). This has been found to be one of the few ways to successfully improve compliance ( ), along with prescribing of daily disposable contact lenses ( ).

Conclusions

The initial assessment and history taking form the cornerstone on which all subsequent clinical decisions will be built. It is important that this aspect of patient care is conducted thoroughly and to the highest standards. Time spent on this initial stage of the patient assessment may prevent much wasted time later in the management of the patient, when clinical decisions have been made unadvisedly.

Sound and thorough record keeping will ensure both good continuity of care and a good defence in the hopefully unlikely event of a patient complaint.

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