Introduction to Contact Lenses
Please watch the following videos introducing the different types of contact lenses.
Contact lenses can be categorized using at least three separate criteria:
RGPs (rigid-gas-permeable lens) are a smaller hard lens, hybrids (duettes) are a hard lens surrounded by a soft lens skirt, and sclerals are a larger hard lens that vaults over the cornea rather than resting on its surface
Material: Hard (RGPs or Sclerals) vs. Soft (Disposable) vs. Hybrid (Duettes)
Modality: daily, 2 wk, monthly, 3 month, 6 month, or year/several years replacement
Prescription Type: Spherical vs. Toric vs. Multifocal vs. Toric Multifocal
Not every combination of these criteria exist (i.e. there is no such thing as a daily RGP nor is their currently a soft daily Toric Multifocal), but many combinations do exist and some are made by multiple manufacturers. The doctor, either during the exam or a separate contact lens fitting appointment, uses these three criteria, along with other considerations such as lifestyle, age, and ocular disease, etc to select the most appropriate type of contact lens to fit the patient into. Now that we are familiar with the basic types to cls, let’s look at where we will record cl information in the chart.
Overview of the CL Tab
The CL tab is where a patient’s history of contact lens wear is documented. It contains two tables: the refraction table on the top, the same table found on the Workup and Binoc tab; and the contact lens table. The contact lens table functions exactly like the refraction table. Entries are added using the three dot ellipsis in the upper left corner of the table, and entries are sorted by date with newer entries at the bottom and older entries at the top.
To add a new contact lens entry into the table, you first need to find the sku number that corresponds to the brand of cls the patient wears. On every server desktop, there is a an excel spreadsheet titled CL Sku's (see below). This spreadsheet lists our sku numbers for the most common cl brands you will encounter, sorted by modality (daily, 2 wk, monthly), manufacturer, and supply. It is beneficial to open this spreadsheet up at the beginning of your day and minimize it so that it is readily accessible when you need it; you will use this alot.
Once you have found the correct sku number, click on the sku number cell to highlight the number and copy it using Ctrl + C. Next, you will add a new contact lens entry to the table using the three dot elipsis in the upper left corner of the contact lens table and select add. A new window will open where you can enter contact lens info; you want to paste the cl sku number in the manufacturer box (see below) for the appropriate eye.
You will need to input skus for each eye since a patient may wear different types of cls for each eye.
Once you click into any other field after entering the sku number, the tab will auto fill the correct Manufacturer, Name, Type, BC1 (unless there are multiple base curves) and DIA. From here, you can fill in the correct contact lens powers (sphere, cyl, axis, Add).
Every contact lens table entry must be titled. This facilitates ease of navigation through the table. For most contact lens related visits, there will be two table entries: one diagnostic entry titled after the type of appointment (exam, clck, dispense, etc); the second, either a finalized contact lens prescription (final) or demos the patient was given to try (demos 1,2,3, etc). The title is put in the Type field (see below). The diagnostic entry will be where all VAs, over refractions, compliance questions, comfort/vision questions, and fit information is recorded. The finalized order entry will only have “ok to order” listed in the order notes.
This is where the title will appear in the contact lens table.
CLS during an exam Workup
When an established patient returns for their yearly exam, rather than manually entering a cl entry for that day, it is preferable to find the previous finalized cl prescription in the cl table and forward it to prevent transcription error. The forwarded entry will be retitled exam, the make available for order box will be unchecked, and any previous diagnostic findings will be removed.
The OA will then inquire about the patient’s perceived comfort and vision with their current cls. They will also determine the patient’s level of contact lens compliance: how many hours a day the patient wears cls (AWT), if they ever sleep in their cls (EW), and how frequently they change their cls (change). These questions and answers are recorded in the Order notes box (see below) so that they are visible on the cl table by simply highlighting the entry.
Note: for contact lens checks, only questions of comfort and vision are asked, not cl compliance questions.
Anything not recorded in the Order Notes box can only be viewed by double clicking to open the cl entry.
For exams (not checks, fits, or dispenses) the OA will also have the patient sign the contact lens care form. This form can be found in the OA helpful things folder on the server desktop (forms subfolder). The OA will review several items directly related to the contact lens compliance questions described above. Here is an example of how to review this with the patient before they sign it:
“Lastly, we’ll review some things we go over with all our patients who wear contact lenses. Be sure to wash your hands before you insert or remove your contacts. If you have a case, try to change it every three months. You want to have a few hours at the end of every day without the contact lenses in your eyes just so your eyes get a chance to get some oxygen before you go to bed. Try not to sleep in your contacts. Change them according to their schedule which for yours is daily. I’ll have you sign in the bottom left corner, just saying that we reviewed those items.”
Have the patient sign the form, you can fill out the rest when you have a free moment (see below for what a completed contact lens care form should look like, the items reviewed are in the highlighted boxes). This form will then be scanned into the patient’s scanned documents table on their demographic page and titled "CL Care and Handling”.
Please watch the following videos on contact lens compliance.
Scribing and the CL Tab
Once the doctor enters the exam room, at some point, they will evaluate the patient’s contact lenses, double checking the overall “fit” of the lens as well as the patient’s current contact lens powers.
To evaluate the “fit” the doctor will use the slit lamp. They will then tell you several values including:
Position: Where the lens sits on the cornea. This is usually central, but can also be superior, inferior, temporal, or nasal.
Condition: Overall condition of the lenses including if there are tears in the lens or deposits on its surface.
Movement: Amount that the lens moves on the eye. Some movement is required but too much movement may disrupt vision. Is usually graded by fraction of a millimeter of movement (1/2 mm mvmt; 3/4 mm mvmt; 1 mm mvmt: etc)
Rotation: If the lens corrects for astigmatism then its astigmatic correction needs to be located at a certain clock our on the eye (i.e. the axis of astigmatism). Each astigmatism lens has markers on it that the doctor uses to asses if the astigmatism correction is sitting in the correct spot. If the marks are in their correct location then the doctor will say “no rotation”. if they are not, then the doctor will indicated the degree and direction the marks have rotated away from their natural position (i.e. 10 degrees temporal, 5 degrees nasal)
Each of these items should be recorded in the boxes shown in the example below
Note: note every doctor will give you all of these fit categories. So you will have to pay attention to which ones they tell you.
After assessing the fit on the contacts, they may do an over refraction. This is where they use free-lenses to demonstrate changes to the patient’s contact lens prescription to see if either more or less power improves their acuity. In the example below, the doctor presented -0.50 over OD and OS and found that the patient’s acuity improved to 20/20. These findings would be recorded as follows.
Note: Not every doctor uses an over refraction to adjust cl powers. Some doctors make changes to the patient’s cl powers solely based on their new glasses prescription.
After checking the fit and over refraction, the doctor may want to trial new lenses on the patient before finalizing them. In the above example, the doctor found the -0.50 over OD and OS improved the patient’s acuity. This over refraction changes the patient’s current powers from -3.00 OD to -3.50 and from -2.50 OS to -3.00. The doctor then had the OA pull these new powers from our demo stock to trial on the patient’s eyes. Every lens that is trialed on the patient in office must have a separate entry in the contact lens table. This new entry is made by forwarding the exam entry, updating the powers, and deleting all diagnostic findings and previous notes. It will also be titled demo 1 instead of exam as seen in the example below.
This will be the second entry for that date as seen below.
The doctor may recheck the fit and do an additional over refraction as seen below.
Here, the over refraction found -0.25 OS. The doctor again wanted to trial the change in power. The OA forwards the “demo 1” entry, changes the OS power, and titles this new entry “demo 2”. The doctor again, checks fit and over refraction this time finding Plano (meaning that no change in the contact lens prescription improves the patient’s vision).
This is the third entry for that date as seen below.
Since the doctor could not improve the patient’s vision with any additional changes in contact lens power, he decides to finalize these last demos. The OA forwards the “demo 2” entry, removes all diagnostic findings, checks the “Make Available For Orders” box which updates the title to “Final”, and writes “ok to order” in the order notes box. Checking “Make Available for Orders” is what allows the Eyewear Stylist to submit a contact lens prescription to be ordered for the patient.
This is the fourth and final entry for that date as seen below. Note that it is easy to tell which contact lens entry is finalized by noting the Y on the left hand side of the table. This is a helpful reference for which powers a patient should be wearing when they return for next years exam.
Ordering CL Demos
Sometimes we do not have the demos we want the patient to try in our demo stock (either because we do not carry the parameters or because they were already given to another patient and have not been restocked). In this case the demos will need to be ordered for the patient. Say, in the above example, the doctor also finds a -0.25 over refraction for the right eye. The OA forwards the demo 2 entry and retitles it demo 3, but when they go to pull these demos they find they are unavailable. The doctor decides they want the patient to try the new powers and has the OA make them available to order for OTC (over-the-counter) dispense. When demos are to be ordered, the OA must check both the “make available for orders” box as well as the “trial lens” box. Checking the Trial lens box in addition to the “make available for orders” box is what alerts the eyewear stylist that the patient is NOT ok to order a year supply of these lenses. The OA should also specify in the order notes that these are the demos that should be ordered (clearly distinguishing it from demo 1 and 2) and whether they should be OTC disp or Doc disp (dispensed at a scheduled appointment with a doctor). Lastly, the OA should specify whether a contact lens check is needed along with the time-frame. See the example below for how this entry should look.
Please watch the following video that illustrates the basics of charting contact lens findings.
Please take the Checkpoint Quiz