Introduction
The quality of instruction and advice given to a patient contributes to the success or failure of the new wearer ( ). Therefore, the importance of the dispensing visit should not be underestimated, and this chapter covers some of the key aspects of this activity.
Objectives
Proper and careful instruction of a patient at a dispensing visit will facilitate confident lens handling by the patient and will help to nurture a sound appreciation of how lenses should perform and how to manage various situations that can arise in contact lens wear. Certainly, poor patient education can result in premature discontinuation from lens wear and increase the likelihood of unscheduled visits to the practice.
The dispensing visit seeks to:
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teach the patient the correct methods of lens application and removal
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explain the methods that optimize lens comfort, such as understanding when a lens is inside out or the removal of post-lens debris
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inform the patient about the likely adaptation issues that may be encountered
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outline the correct use of the prescribed care regimen.
Timing
The availability of diagnostic lens banks has negated the need for individual lens ordering (with the exception of more specialized lenses such as soft toric lenses and the majority of rigid lenses) and has made both the fitting and dispensing appointment possible on the same day. Some patients are so motivated following their first experience of contact lens wear that the dispensing can take place immediately after the initial trial fitting. On the other hand, rescheduling the dispensing visit for another day has the benefits of giving the patient a break after the fitting visit, and allows the patient to read through some preliminary literature and watch instructional videos about the wear of and care for contact lenses.
Creating the Optimum Teaching Environment
A trained member of support staff rather than the practitioner commonly adopts the teaching role; this person is sometimes referred to as the contact lens hygienist. Having a trained member of the support staff undertaking this task can have several advantages. Some patients feel pressured to have to ‘perform’ in front of the practitioner whereas they may feel more relaxed with a member of the support staff. The delegation of this role requires careful selection of personnel who can be relied upon to provide accurate information to the patient and refer back to the practitioner when necessary ( ).
The Covid-19 global pandemic created new challenges for teaching the new wearer due to the necessity of putting infection control procedures in place; for example, placing a plastic screen between the patient and the instructor and allowing the new wearer to practice for periods of time on their own ( ). An opportunity exists to develop a multi-camera system to facilitate the remote monitoring of a patient when first learning to apply and remove lenses. Such a system could allow the instructor to be located in a different area of the practice, separate from the patient, whilst giving the latter verbal instructions and monitoring them via a camera link (with the opportunity to intervene in person as necessary).
The Teaching Area
Patients who have elected to wear contact lenses are often apprehensive about the process of lens application and removal. For this reason, the teaching room should be of a comfortable temperature and well ventilated, as many patients become quite anxious in their frustrations if they do not apply the lens on the first attempt. The area should be reasonably private – perhaps screened off from the rest of the practice – and it is essential that the instructor and the patient are free from incidental interruptions. Patients require careful attention when they first handle lenses, and the instructor must not be taken away or distracted from this supervisory task.
Good lighting is important, along with suitable seating for both the patient and the instructor, as flexibility to be able to sit on each side of the patient is needed ( Fig. 36.1 ).
The patient’s chair should be set at a desk such that the patient’s knees can fit comfortably under the desk. This is helpful if the patient accidentally drops the lens during handling.
Accoutrements
An illuminated, double-sided (with one side that magnifies), height-adjustable and tilting mirror is ideal. The teaching area must be prepared in advance of the lesson, so that all the following necessary items are to hand:
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contact lenses – cross-checked with the record card and spectacle prescription
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lens case – which may be supplied with the solutions
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trial pack of solutions∗ – sufficient for the needs of the patient until the first scheduled aftercare visit (∗check expiry date)
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additional solution – for rinsing during the lesson
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comfort drops – to help alleviate any ocular discomfort
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box of tissues – with a spare box available
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handwashing facilities – soap (in pump dispenser) and lint-free paper towels
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mirror as described above – cleaned and free from fingerprints
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appropriately sized bag – for the patient to carry away lenses, solutions and accompanying literature.
Patient Instruction
Contact lens handling can be a very frustrating experience for the novice patient. Accordingly, patience and communication skills are the most critical personality traits of the member of staff chosen to instruct contact lens patients. The instruction session should not be rushed, and the patient should feel comfortable asking questions. A good technique is to alternate the practical side of lens application and removal with verbal advice on the wear and care of the lenses (e.g. care, product use, and do’s and don’ts). When suitable, coloured or iris-enhancing disposable soft contact lenses should be considered for use during the tuition appointment, and perhaps the first few days of wear, as they provide additional visibility and reassurance of on-eye lens location.
Hand Grooming and Hygiene
The nails of all fingers that are likely to be involved in lens manipulation should be cut short and filed smooth to avoid both lens damage and the potential for corneal insult. It is imperative that the importance of handwashing (and drying) prior to lens handling is reinforced throughout the instruction phase. The best way of achieving this without appearing to be patronizing to the patient is for the instructor to wash his/her hands prior to lens handling, in full view of the patient. A very brief explanation as to why this is so important – the prevention of lens contamination and reducing the risks of infection – can be given to the patient. The patient can then be invited to wash his/her hands. At all future instruction or aftercare visits, patients should be prompted to wash their hands if they forget to do this before proceeding to handle lenses.
Lid Manipulation
Touching the eye area can be awkward for many patients. The patient must first practice how to overcome the natural blink reflex, and this can be achieved by way of a ‘dry run’, in that the patient is not handling the lens at first. It is usual for the instructor to perform each part of the handling process before the patient tries. Effective upper-lid control is crucial to lens application.
Most patients will prefer to apply lenses onto each eye using the same hand, whereas some will use the right hand to apply the right lens and the left hand to apply the left lens. Consider, by way of example, a ‘dry run’ for lens application onto the right eye with the right hand. The patient is given the following instructions:
In order to take control of your right upper lid, look downwards so that the whole of the upper lid is exposed. Next, bring your left hand vertically over your forehead, place the fingertip of your middle finger on your lid margin close to the eyelashes and gently draw the lid upwards and hold it against your brow bone ( Fig. 36.2 ) .
Now look straight into the mirror, place the middle finger of your right hand on the middle of your lower lid and gently retract the lower lid ( Fig. 36.3 ). (This further increases the palpebral aperture and helps to stabilize the hand applying the lens.) The forefinger of your right hand is then free to apply the lens directly onto your eye .
Once the patient has mastered lid manipulation, lens handling can be taught.
Lens Inspection
Practitioners routinely inspect lenses prior to application for evidence of lens damage, debris and whether a soft lens is inside out or not. Patients need this basic level of instruction, even to the level of detail of explaining how to remove the lens from the lens packaging. It may be prudent to give a patient some trial lenses with which to practice lens inversion ahead of their instruction appointment, as greater familiarity with this essential handling skill will undoubtedly make for a smoother and more efficient instruction visit. Additionally, learning how to replace and remove a lens carefully from the lens case to avoid lens damage requires careful demonstration; this is particularly relevant to basket-style cases for soft lenses, which clip shut, and barrel cases with lens support for rigid lenses. Patients need reassurance that a soft contact lens applied inside-out is not harmful, but such a lens may be slightly uncomfortable and may be prone to move excessively, which in turn can affect vision performance and in some cases cause the lens to be blinked out.
For the experienced contact lens practitioner, a careful passive inspection of the lens on the tip of the finger will reveal whether the lens is inside out or not. However, for the novice, assessing soft lens inversion can be difficult. An active approach can be more enlightening; the lens is allowed to dehydrate for a few seconds, and then, with the lens placed in the crease of the palm of the hand, the lens edges are moved together by cupping the hand as if intending to fold it in half – this is called the ‘taco test’, as a lens that is the right way around curls up rather like a taco shell. If the lens edges appear to curl towards each other, the lens is the right way around ( Fig. 36.4A ), and if the edges appear to curl outwards, the lens is probably inside out ( Fig. 36.4B ). Typically, a practitioner would utilize this technique by placing the lens on the tip of the finger; however, by definition, a new wearer finds lens manipulation a challenge so the hand technique is both easier to teach and more practical for the patient.
It may be necessary to invert the lens repeatedly in order to confirm this; the drier the lens becomes, the more apparent the inversion status of the lens will be. For the novice wearer, the instructor may deliberately ask the patient to first apply one lens the correct way around and then the other lens inside out, asking the patient to comment on the difference. This serves as a good demonstration of the difference in sensation from an inside-out lens to a lens placed the correct way round – the direct comparison may be needed for the patient to appreciate the difference. New wearers may consider themselves to be ‘unsuitable’ for contact lenses if they intermittently apply one or both lenses inside out during their first few days of lens wear. Attention to teaching lens inversion, as well as proactively demonstrating the sensation of an inverted lens, may help to reduce drop-out rates at this early stage.
Some manufacturers mark their lenses with an inversion indicator. When viewed from a designated aspect, letters or a number sequence can be observed in the correct orientation. If the lens is inverted, the letters or number sequence will be reversed (incorrect) when viewed from the same aspect. Patients should be advised of any other markings on the lenses, and their purpose if known (such as toric lens scribe marks) so that they are aware that these features are meant to be present on the lens and are not a hair or defect.
When handling lenses, the forefinger applying the lens needs to be as dry as possible. On removing the lens from the case or packaging, it should be placed in the palm of the opposite hand to help drain off excess solution. The lens can then be ‘scooped up’ from the palm by the side of the fingertip of the forefinger with some aid from the forefinger and thumb of the opposite hand. Tissues on the desk – preferably lint free – can be used to dab the forefinger dry during this process. In the case of soft lenses, the lens may need to be lifted off the forefinger to dry the fingertip so as to prevent the lens from sagging back over a wet fingertip owing to surface tension. The complete circumference of the lens should be sitting proud of the finger.
Lens Application
Soft lens application requires a slow-motion approach. The patient must not release the upper lid too soon, as this can lead to the lens being ejected owing to air trapped behind the lens. The instructor should sit beside the patient rather than across the desk because, first, this is less confrontational, and second, a better view of the actions of the patient is possible. When the right lens is applied and removed, the instructor should sit on the right side of the patient and vice versa. The patient should be directed to apply the lower edge of a soft contact lens to the area 1–2 mm below the limbus at an angle of 45 degrees, having vaulted the lower lid ( Fig. 36.5 ).
Once contact with the tear film has been made, the contact lens is attracted to the cornea. If there are any air bubbles underneath the lens, these can be overcome by the patient looking downwards and slowly releasing the upper lid whilst still looking down and then closing the eye tight so as to squeeze out the remaining air.
A rigid lens, being of smaller diameter, is easier to apply, and its shape remains consistent throughout handling. Rigid lenses should be placed directly onto the central cornea, as failure to do so can lead to the lens being displaced onto the conjunctiva.
Some patients have flexibility problems with their arms and/or hands, so common-sense adaptations to the usual recommended approach will need to be made. For example, the one-handed application can be achieved with the patient dipping the chin towards the chest and looking upwards into the mirror. This serves to provide a larger area inferior to the limbus on which to apply a soft lens, and the lens, once applied, can be manipulated into place. A rigid lens can be applied directly onto the cornea using this method ( Fig. 36.6 ).
