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Identifying the need for contact lenses.

This article considers the potential to recommend contact lenses as a visual solution to a wide range of patients.

Optometrists [COMMUNICATION][CONTACT LENSES]

Dispensing opticians [COMMUNICATION][CONTACT LENSES]

Contact lens opticians [COMMUNICATION][CONTACT LENSES]

1 CET POINT

Introduction

Many articles deal with the subject of communicating the benefits of contact lenses to patients, but before beginning such a conversation, it is useful to fully explore the needs of potential lens wearers to ensure that every opportunity to offer an alternative to spectacles has been considered. This article will approach the subject systematically beginning, with paediatric fitting and then exploring the opportunities available to adults, presbyopes and the over 60s, thereby looking at the benefits provided by contact lenses throughout the lifetime of our patients. While this provides a useful framework to discuss the subject, the author is aware that many of the issues discussed affect age groups other than those directly referred to here. For example, while spectacle magnification is discussed with reference to our younger patients, it is no less a problem for adults, especially for those undergoing cataract operations where sudden anisometropia may be experienced after the first eye has been treated.

Children and teenagers

A very common reason for fitting contact lenses is to improve a person's self-perception and confidence, and this is especially true for younger patients. (1) However, self-confidence is not exclusively linked to what the patient sees in the mirror, as the author found when fitting a 10-year-old 7.00D hyperope who had experienced bullying at school due to the combination of his thick spectacles, a less than common forename and a beautiful head of red hair. After a few months of contact lens wear he confided that the bullying had ceased, and this was not due merely to his appearance as he still had the same hair. He was questioned as to what had changed, and he explained that he was no longer being bullied as he had started to stand up to the child in question. As the conversation progressed, the surprising result was that it was not merely the lack of spectacles that had increased his confidence, but the contact lenses had vastly reduced the amount of spectacle magnification, which could easily have been 10% or more, depending on the spectacle lens design. As a result of this, he was amazed and pleased to discover that the bully in question was not as big as he had previously thought, and he now felt able to stand up to his oppressor.

Quite apart from such considerations, his mother reported an improvement in his schoolwork, possibly because his heavy spectacles habitually slid down his nose while studying, whereas the contact lenses remained stable. If we assume a nasal slide of 15mm in spectacles, this would equate to an over-correction in the order of 0.75D, which would most likely impact negatively on concentration for looking up at the board. This was many years ago, and the child in question is now a confident, successful young man, and he firmly believes contact lenses have played a large part in his personal and educational development.

The sentiment described above is echoed in research published in 2010, (1) when a vision-specific quality of life study followed a group of 484 children who were randomly assigned either contact lens or spectacle correction. On average, over a period of three years, the quality of life scores improved by 14.2 units for the contact lens wearers but only 2.1 units for the spectacle wearers. The three areas that showed the largest improvements were activities, appearance and satisfaction with correction.

Some younger patients are reluctant to wear spectacles, especially if they are anisometropic and have functional vision in one eye, as the aniseikonia induced by spectacle magnification can be an uncomfortable visual challenge. (2) However, if left uncorrected, amblyopia may result, especially if the patient is hyperopic, as the child will find it easier to accommodate to the point where the eye with the lower prescription can see, (2) leaving the fellow eye blurred. During childhood, therefore, it is vital that the practitioner finds a method of correction with which the patient can see comfortably, and contact lenses are an ideal solution here. (23)

Significant astigmatism can also produce axial aniseikonia, as in the prescription below:

R-4.00/-2.00 X 180

L-3.00/-0.50 X 180

In this example, when looking down to read if we assume the patient will be looking through a point 10mm below the optical centres, and use Prentice's rule ([DELTA]= dF) to calculate the vertical prismatic effect, they will experience 2.5D of differential vertical prism, as well as some difference in image size. Adaptable as they are, many young patients will come to automatically adjust their head position to use the centre of the spectacle lens, but this is not always possible, especially for those experiencing postural problems due to injury or disability.

Children participating in sports and PE at school are discouraged from wearing jewellery and spectacles where practicable, with some education authorities actively encouraging the use of contact lenses where necessary. (4) This reduces the risk of frame-related injuries, or damage to the spectacles themselves, but the general lifestyle of children should also be considered, and perhaps those bulging dispense and repair records could be prevented by judicious fitting of contact lenses.

The subject of contact lenses for children cannot be complete without a mention of myopia control, although the topic is outside of the scope of this article. Interested practitioners should take time to investigate the options available to their younger patients so that appropriate advice can be given.

Adulthood

In taking history and symptoms, practitioners ask a variety of questions to establish occupation and leisure activities, and the responses to such questions can clearly identify situations where spectacles may not be the preferred form of correction. Some probing may be necessary to find out exactly what these situations are. For example, when the job title does not clearly convey the duties involved there may be elements of the role that the practitioner may not have considered, so asking what a typical day looks like can be useful. An assumed indoor role may have outdoor elements to it, rendering spectacles inconvenient in bad weather, for example, and the author has fitted a number of electricians and plumbers with multifocal contact lenses for those awkward moments when the wearer is under the stairs or sink, trying to see close work in an upward gaze (see Figure 1). As long as good advice about lighting is given (and usually an inspection lamp is in the toolbox) then this can be a very successful solution.

As far as leisure time is concerned, asking about hobbies tends to produce answers such as: 'I don't have time for hobbies,' or the typical response of: 'reading and walking.' A better question is: 'what do you do when you're not at work?' This gives the patient the opportunity to explain that they are redecorating the house, or remodelling the garden, or playing pool for the local team. This can then be followed up with: 'And how are your glasses when you're doing that?' which often elicits a response favouring an alternative to spectacles. The patient may have previously put up with the inconvenience without realising they may be suitable for contact lenses.

The benefits of regular physical exercise are of course obvious, indeed studies suggest that physical fitness can have a positive effect on eye health, (5) but spectacles tend not to be the best correction for this. Unless sports glasses are used, many frames lack the necessary stability for physical exertion and perspiration can cause damage to the colour and finish of a nice frame. It would perhaps be more cost effective for the patient to buy contact lenses for sports use, resulting in a more stable correction, and less likelihood of complaints regarding a frame losing its good looks while still relatively new. Contact lenses also allow for easier use of protective headgear and goggles when necessary for sports such as cycling, skiing, and other pursuits (see Figure 2).

Much advice is given to patients regarding the harmful effects of UV light, and how best they can protect themselves from such damage, and as eyecare practitioners, we should be encouraging the year-round use of sunglasses. Obviously practitioners can offer photochromic spectacle lenses or prescription sunglasses, but often patients are more excited by the prospect of a new pair of designer sunspecs. There is also the serious risk posed when a high myope drives into a tunnel or down a tree-lined, shady lane while wearing their prescription sunglasses. Research suggests that older drivers have difficulty seeing under low illumination, even in the absence of disease, (6) so these patients certainly need to be able to remove any unnecessary sunglasses quickly and easily. Many contact lenses provide adequate UV protection and also allow the safe removal of piano sunglasses in dim driving conditions while maintaining good vision.

Presbyopes

Mention has already been made of the self-confidence that can result from fitting younger patients with contact lenses but it is an equally valid reason for any age group. A national poll in the US found that there is significant perceived pressure for women to look younger in order to be successful at work, with 42% of women aged 50-59 believing they needed to look young to succeed, and while men were considered most attractive in their mid-thirties, women were considered at their best aged 307 Therefore, avoiding the use of reading glasses can be seen as an important factor in hiding one's age, and this can be easily remedied by the use of multifocal contact lenses, even if the patient has a negligible distance prescription.

Anisometropia has been defined as a difference between the eyes of more than 1.00D, (8) and can be a significant challenge for presbyopes. It is generally considered that tolerating more than 1[DELTA] vertically for any period of time is difficult for many subjects, (9) and this is obviously of major importance when dispensing a visual appliance that requires the patient to look through a point some 10mm away from the optical centres in order to read. Again, multifocal contact lenses can be of value here.

The over 60s

The population is definitely living longer, with Leeds City Council reporting that the average life expectancy of 78.4 years in 2001 rose to 80.78 years in 2010, (10) and many over 60s nowadays are considerably more active than over 60s used to be. A report published in 2012 discussed the benefits of remaining active after retirement." Social activity was a major benefit, as was gaining new skills, and 59% of those involved showed improved physical health as a result, with a lower risk of depression. Retirement can afford the opportunity to spend more time on leisure activities, so the use of contact lenses may become more important rather than less so in this age group. Even for those who are less active due to infirmity, contact lenses may be a useful option if posture prevents the successful use of spectacles.

Following a cataract operation, a patient may be rendered anisometropic by the introduction of an intraocular lens, possibly inducing large degrees of aniseikonia until the second eye is attended to. As a rule of thumb, for every ID of corrected anisometropia, 1% image size difference is introduced, (12) so in the case of a binocular 6D myope who has had one cataract operation, the difference could be ~6%. The human visual system is thought to be able to compensate for up to 3%, after which binocular visual function is affected significantly, (12) so a contact lens for the eye yet to be operated on can help in the interim.

Conclusion

Coming to a joint decision with the patient as to the best way of correcting their vision can only be successfully achieved after a thorough discussion of their prescription, lifestyle and preferences. Many patients are unaware of the benefits that contact lenses can offer, and although they may be initially wary of the idea, it is worth exploring all opportunities and discussing available options.

Sometimes a chance comment or situation offers all the clues, as with the patient with a prescription of +4.00 and a +2.00 Add who arrived in practice in tears after having a haircut, which she hated. She was unable to see what the stylist was doing, as she had to remove her spectacles for her appointment, and only got to replace them to see the result. She had never considered or been offered contact lenses, and is now a happy daily disposable wearer, especially when she's having her hair done.

Exam questions and references

Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 9 June 2017. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article.

CET points will be uploaded to the GOC within 10 working days. You will then need to log into your CET portfolio by clicking on 'MyGOC' on the GOC website (www.optical.org) to confirm your points.

Visit www.optometry.co.uk, and click on the 'Related CET article' title to view the article and accompanying 'references' in full.

Course code: C-55753 Deadline: 9 June 2017

Learning objectives

* Be able to elicit relevant detail from prospective contact lens wearers (Group 1.1.1)

* Understand suitable options to meet the contact lens needs of a wide range of patients (Group 5.1.1)

* Be able to elicit relevant detail from prospective contact lens wearers (Group 1.1.1)

* Be aware of available options to meet the contact lens needs of a wide range of patients (Group 5.1.1)

* Be able to elicit relevant detail from prospective contact lens wearers (Group 1.1.1)

* Understand suitable options to meet the contact lens needs of a wide range of patients (Group 5.1.1)

Wendy Sethi FBDO CL, FBCLA

* Wendy Sethi qualified as a contact lens optician in 2000 and is also a neuro-linguistic programming practitioner and certified professional speaker with over 10 years of experience of delivering CET content in a variety of environments. She has experience of practice management and has contributed clinical articles to Optometry Today and Dispensing Optics and is a fellow of the BCLA. She is now in part time practice while also working as a professional services consultant for Bausch and Lomb.

Caption: Figure 1 Multifocal contact lenses can be useful in numerous occupational scenarios

Caption: Figure 2 Contact lenses make it easier for patients to wear additional headgear and goggles for various pursuits
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Author:Sethi, Wendy
Publication:Optometry Today
Date:May 1, 2017
Words:2484
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