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Clinical Decision Making - contact lens

complications in routine practice
30
19/09/08 CET

Dr Christine Astin
Contact lens complications can affect the contact lens corrected visual
acuity (VA), the lens comfort and wearing time and the lens condition.
The problems arising can cause disturbances to the eyelids and ocular
surfaces that can result in long-term changes and reduction in contact
lens tolerance. The clinician should try to help the patient overcome the
lens-related problems, not only to promote satisfactory lens wear and to
prevent the patient giving up contact lenses, but to prevent future ocular
infections, inflammation and eyestrain.

There are five aspects one should

consider when faced with a clinical
problem presented by the patient
attending for contact lens aftercare.
These are: Symptoms, Signs, Tests,
Initial Diagnosis, and Management.
One should also take into account the
history, general health and medication,
as these can be major influences. The
clinician should carefully question the
patient and study the previous records
to build-up a collection of information
to help solve the case.
Here are ten examples of contact lens
related problems and recommendations
on how to tackle them:

1) Stinging sensation
Symptoms: Stinging sensation in both
eyes especially at the initial insertion of
soft lenses. The eyes become sensitive
and suffer increased discomfort in
reaction to dust, allergens, lens deposits
and/or lens care solutions. The patient
may therefore report an ocular redness
response to the lenses and may
complain of reduced wearing time and
lens intolerance.
Signs:
Using
the
slit
lamp
biomicroscope the clinician will notice

surface. If the soft lenses are reinserted

into the eyes, the red eye reaction (Fig.
1) and discomfort are likely to recur,
especially if originally caused by the
lens care solution.
Initial diagnosis: Toxic or allergic
reaction to the soft lens solution.

Management
< Figure 1
Red eye reaction
slight bulbar conjunctival hyperaemia,
especially if the lenses have been
inserted a short time earlier, indicating
the presence of an active ocular
reaction. Prolonged irritation may
result in tarsal conjunctival swelling,
hyperaemia and papillae. The lids may
become tensed, narrowing the palpebral
apertures.
Tests: Examination of the eyes after
instillation of fluorescein into the tear
film is likely to reveal toxic epithelial
reaction staining. The staining appears
as a general diffuse pattern of many
scattered punctate epithelial erosions
over the cornea. Often there may also
be some epithelial staining on the tarsal

Refit the patient with new soft lenses.

As the original lenses are likely to
retain the toxic solution chemicals,
these should be discarded together with
remaining lens solution.
A more suitable lens solution and
fresh storage case should be offered or
the patient should be refitted with daily
disposable soft lenses.
The patient should be advised that
recovery from the ocular reaction may
take some time and that they should
resist from wearing their lenses, or at
least keep their wearing time to a
minimum, for several days.

2) Sticky lens and hazy

vision
Symptoms: The patient complains that
the lenses feel sticky and less
comfortable. They are aware of lid
sensations on blinking and feel that the

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Management
< Figure 2
Mucous spots on lens
lids are pushing the lens, increasing
lens movement. The VA is liable to
decrease and is reported to be hazy,
smeary and variable.
Signs: A toric soft lens may be pushed to
an incorrect axis orientation by the lids,
which tend to adhere to the lens rather
than smoothly glide over the lens
surface. Sometimes there is increased
lid attachment such that a rigid gas
permeable (RGP) lens is lifted to a high
riding position and the back optic zone
no longer fully covers the pupil. Sticky
lens deposits, for example mucous
spots (Fig.2) and protein films, reduce
the wettabilty of the lens surface, which
reduces the optical quality and retinal
image contrast, causing a reduction in
VA. This can be exacerbated by the
adherence of debris, dust or make-up to
the sticky lens deposits.
Tests: Over refraction may not be able to
improve the VA. Full blinks to spread
the tear film over the lens may
temporarily help VA.
Observation of the tear film reveals
poor tear quality and more frequent
mucous strands. Thorough cleaning of
the lens may partly improve the surface
wetting and help VA.
Slit
lamp
observation
with
fluorescein shows patches of poorly
wetting protein deposits on the lens
surface. Sometimes these cause areas of
corneal and tarsal epithelial staining.
On questioning the patient regarding
their general health, a history of cold,
flu or other viral infections is likely to
be reported, since increased mucous is
produced with these conditions. Also,
for those with allergies such as hay
fever, the lids and likely to become
irritated and this can also increase the
production of mucous and protein. The
protein deposits lead to increased

Leave the lens out until the infection

or allergy recovers.
Reduce lens wearing time.
Try regular lens treatment with
protein removal tablets, ensuring the
patient
correctly
follows
the
instructions for their use.
Try lens re-wetting drops.
Refit the patient with a better lens
material less liable to attract protein
deposits.
Refit with daily disposable lenses.
Give a refresher lesson on hand
washing, lens care and the avoidance of
getting make-up and contaminants on
the lens.

< Figure 3
Grease film on lens

3) Variable hazy vision with

contact lens
Symptoms: VA decreases during the
day. The reduction in image quality can
vary from day to day and can make
perception of low contrast images
difficult. Eyestrain and problems with
discerning detail, both for distant and
near objects, may lead to symptoms of
tired eyes and accommodation spasm.
Fatigue and headaches may result. The
patient may demand a stronger lens
power than is really needed as they
strain to see more clearly.
The lens comfort decreases as the lens
surface retains a film of grease (Fig.3),
which has poor wettability and a greater
coefficient of friction. The lids feel as if
they drag over the lens during blinks.
Signs: Poor condition of the lens

surface, greasy film and patchy dried

grease deposits are seen on the lens
using the slit lamp.
Sometimes
scratches on the lens due to lens ageing,
normal wear and tear, or rough lens
handling, act as a site for dried grease
deposits to adhere to the lens.
Persistent deposits may inhibit correct
disinfection of the lens surface by some
soaking solutions.
Examination of the eye using the slit
lamp shows increased grease disturbing
the normal lipid patterns of the tears.
Whilst watching the specular reflection
of the tear film over the lens surface, the
clinician observes the rapid drying of
the tears on the greasy lens, indicating
poor surface wettability.
Tests: Tear film assessments of invasive
and non-invasive tear break-up time,
lipid layer quality using the Tearscope,
and Schirmer tear volume test can be
carried out.
Examination of the lens and lid
margin movement during blinking,
with high magnification, can provide
clues on any interaction, e.g. RGP
lenses with excessive edge clearance
may stimulate excessive production of
lipid (grease).
Ask the patient to demonstrate their
usual method of lens handling,
cleaning and soaking in the lens case.
Observations may discover that they do
not wash their hands properly before
touching the lens. They may still have
greasy skin cream on their hands and
lids which is transferred to the lens.
Bad habits can include forgetting to use
surfactant cleaner, not rubbing the lens
properly to loosen deposits, inadequate
lens rinsing, placing the clean lens into
a dirty lens case, and topping-up old
solution in a lens case as opposed to
replacing this with fresh solution.
Discussion with the patient may
indicate that they are unwilling to buy
fresh lens solutions and/or cases, or are
perhaps unwilling to replace their
lenses regularly. For example, some
may try to make a lens last longer than
its actual replacement date, and then
wonder why the comfort and VA
decreases.
Although
the
increased
lens
awareness can be a symptom of dry
eyes, where the aqueous portion of the
tears evaporates in air conditioning and

31
19/09/08 CET

friction between the lids and the lens.

Therefore, what was initially a good
fitting lens may apparently become a
loose fitting lens, as it can be more
easily decentred and rotated by the lids.
Initial diagnosis: Deposition on lens
surface.

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4) Reduced vision with the

lenses, feeling off-balance

19/09/08 CET

32

< Figure 4
Excess RGP lens edge clearance
dry atmospheres, some patients
mistakenly try inappropriate artificial
tears. Some preparations, e.g. Viscogel, are not compatible with contact
lenses as they are too viscous (thick) and
make the lens surface sticky. Some have
preservatives, which are retained by the
soft lenses and build up in
concentration in the lens to trigger an
allergic reaction.
On discussion, some patients admit
that they borrow a relatives artificial
tears, e.g. thick hypromellose drops, to
soothe the eye but this also makes the
lens sticky.
They may even use
lacrilube at night to reduce dryness
symptoms, but if this remains on the
lids it will be transferred to the lens the
next day and will seriously impair the
lens surface wettability.
Initial diagnosis: Greasy tear film causing
lens surface greasing.

Management
Give a tactful refresher lesson on
correct methods of lens cleaning
and care.
Explain the importance of hygiene and
regular replacement of lenses.
Advise on appropriate lens rewetting drops and the need for full
blinks.
Possibly refit the patient with a more
appropriately contoured RGP lens or
with a lens material that does not attract
lipid deposit build-up.
Encourage the patient to change to a
soft lens of more frequent replacement
pattern, e.g. from monthly to daily
disposable lens.
The patient may benefit from
medical advice regarding a general
health problem or greasy skin condition,
if this was the cause of greasy tears.

Symptoms: Recent reduction in contact

lens acceptance. The VA with the lenses
is reduced and is not improved by
cleaning or re-wetting. A feeling of
being off-balance may be reported.
Comfort may not be affected if the lens
contours are similar for right and left
eyes. However, if they are dissimilar
then one eye has a loose fitting lens and
the fellow eye has a tight fitting lens.
Depending on the lens movement and
edge contours, the patient may
complain of excess awareness of the
loose fitting lens, or may describe
corneal hypoxia-type symptoms in the
eye with the tight fitting lens. This is a
particular problem with RGP lenses
where the lens edge can irritate the lids
or press into the corneal epithelium.
Signs: The loose fitting RGP lens will
have poor centration, increased
movement and will show central touch
and excess edge clearance on
fluorescein assessment (Fig.4). The
tight fitting lens can ride low or
centrally and will display sluggish
movement. The fluorescein pattern will
reveal central pooling and inadequate
edge clearance.
Tests: VA and over refraction should
indicate that a similar power change in
preferred is each eye but of opposite
sign, e.g. right eye 0.50D = 6/6, left eye
+0.50 = 6/6. In some cases with RGP
lenses this does not hold true,
depending on the power of the tear lens
produced behind each lens.
The focimeter can be used to discover
the powers of the cleaned RGP lenses
and the results compared to those noted
in the records.
The cleaned lenses can also be
inserted into the correct eyes and the fit,
VA and over refraction rechecked.
Initial Diagnosis: Lenses mixed up.

eye, followed by the left eye, which

decreases the likelihood of error if they
are tired or distracted.
Contact lens cases with distinctively
coloured lens caps for right and left sides
are helpful. Daily disposable lens
packets can be marked with an easily
seen R and L.
For patients with poor vision, ordering
the RGP lenses in differing colours is
useful, e.g. grey tint for right lens and
blue tint for left lens.
If the patient has persisted with
incorrect RGP lens wear for a few days,
conjunctival hyperaemia and epithelial
erosions may have resulted. The loose
fitting lens edge may have caused
abrasions on the lids or limbal
conjunctiva. The tight fitting lens edge
may have caused arcuate corneal
epithelial erosions, localised corneal
oedema or epithelial dimpling due to
trapped bubbles beneath the lens (Fig.5).
If ocular damage has occurred, the
patient is advised to cease lens wear for
a few days to recover, and then gradually
rebuild the lens wearing time.

5) Blurring of vision
with the contact lens,
especially for near ranges
Symptoms: There are complaints of
eyestrain, especially after prolonged
periods of detailed near work, causing
blurring of near vision. This can persist
even if the patient changes to a larger
print size, reduces the amount of
detailed work carried out at near, or
stops
reading.
The
strain
on
accommodation may cause headaches
and increased difficulty in changing
focus from distance vision to near vision,

Management
Once the lenses are inserted in the
correct eyes, the patient can be
reassured that the VA and lens fit are
satisfactorily restored. They can be
tactfully advised about ways to avoid
this problem from recurring. For
example, the patient can develop a
pattern of always inserting and
removing the right lens from the right

< Figure 5
Epithelial dimpling

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Management
Take time to explain presbyopia to
the patient, discussing the substantial
help that can be gained from simple
measures such as using better lighting
for near tasks, using bigger print font
sizes, holding objects further away
from the eyes and taking regular
breaks to rest accommodation
between prolonged periods of near
work.
The various contact lens options
for correcting presbyopia, including
near-focused
spectacles
worn
over single vision distance contact
lenses, monovision and simultaneous
vision multifocal (varifocal) contact
lens options, ought to be discussed,
along with the advantages and

disadvantages of each.
Further trial fitting sessions with
several lens types are usually required.

6) The VA with the lens is

blurred for distance and
near detail
Symptoms: The patient reports
smudging of lettering or image
ghosting, particularly when studying
detailed objects. This occurs even
with new or cleaned contact lenses.
This problem may be more noticeable
in dim light conditions e.g. driving at
night or reading numbers on a TV or
video in a dimly lit room. Eyestrain
and headaches can result. The up-to date distance spectacle correction is
likely to give a superior VA to that
achievable with contact lenses.

< Figure 6
Lateral conjunctival redness
Signs: On examination using the slit
lamp, the lenses and eyes appear
undisturbed. The patient may adopt a
habit of narrowing the palpebral
apertures to give improved vision by
the pinhole effect.
Tests: Full refraction over the lenses
reveals residual astigmatism which,
when corrected, restores good
distance and near VA. The ocular
astigmatism may have increased
naturally and therefore the patient
may simply be comparing their vision
with new, clear spectacles to the
reduced VA provided by the now old
contact lens correction. They may also
have changed to a thinner soft contact
lens material. Thin lens materials
mould more closely to the natural
corneal contour compared to thicker
lenses and may therefore reveal

previously
existing
corneal
astigmatism that was otherwise
masked by the thicker lens.
The patient may have changed from
a monthly toric contact lens design
that provided a full astigmatic
correction to a daily disposable toric
contact lens that has a limited range of
correctable powers and axes, or even a
spherical lens design, due to issues
relating to lens cost.
Initial Diagnosis: Residual astigmatism
disturbing VA.

Management
The problem should be carefully
explained to the patient and various
options offered to help them to cope
or adapt to the situation. Examples
include:
Revert to the monthly disposable
soft toric contact lens that provides
the full astigmatic correction, and
only use daily disposable lenses
where the best VA is not vital, e.g.
sports, holidays or social occasions.
Allow time for adaptation to the
residual astigmatic blur (easier with
binocular vision), but wear contact
lenses or spectacles that provide the
best VA for critical tasks such as
driving.
Wear top-up spectacles, which
correct the residual astigmatism, over
the contact lenses for occasions when
the best VA is critical e.g. driving at
night.
Refit the patient from spherical to
toric contact lens designs or to RGP
lenses.
Refit the patient to a more
appropriate toric contact lens
design that can better correct the
astigmatic
refractive
error.
Consider specially made or
piggyback lenses in some cases.

7) Lateral conjunctival
redness at the end of lens
wearinng time
Symptoms:
Careful
questioning
regarding the location and timing of
the conjunctival hyperaemia is
important. The patient reports that
during the 12 to 14 hours of normal
soft lens wear, comfort is fair and VA
is good. No significant hyperaemia is
noticed until the end of the day, when
they report that the lenses stick to the

33
19/09/08 CET

and vice versa. They may also report

intermittent blurring of distance
vision. The slowness of this
readjustment may also apply to
convergence, leading to symptoms of
decompensated
esophoria
with
distance fixation. In some cases
intermittent
binocular
diplopia
results as the binocular control of the
phoria decreases with fatigue.
Signs: No signs of problems are found
on slit lamp examination of the
contact lens and the eye. However, the
practitioner may notice that the
patient tends to frown or narrow their
palpebral aperture in an attempt to
accommodate or to improve VA by the
pinhole effect. The typical patient is
in the age group of 45 to 55.
Tests: Over refraction with the lenses
on the eyes may indicate that
excessive minus power had initially
been prescribed/supplied. As such,
when new lenses of the correct power
are inserted, the patient may cope
better
with
the
reduced
accommodative demand, therefore
comfortably resuming contact lens
wear.
Near vision can be helped by the
prescription of a positive reading
addition power, reducing the demand
on natural accommodation and
improving the range of clear vision.
Tests assessing the quality of
binocular vision, such as fixation
disparity, should be carried out for
distance and near vision.
Initial Diagnosis: Presbyopia.

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19/09/08 CET

34

eye and are more difficult to remove

even with fingernails.
Signs: Long or rough fingernails.
The practitioner observes that the
patient has only slight lateral
conjunctival redness when the lens is
on the cornea. However, immediately
after the patient has pinched out the
lens (especially if several attempts
were made) conjunctival redness and
limbal vessel engorgement appears at
the four and eight oclock locations.

< Figure 7
Allergic conjunctivitis due to lens solution

production. Symptoms of itching may

increase on lens removal.
The mucous will disturb the VA and
also make the lens sticky so that the lid
will adhere to the lens and attempt to
decentre it on version movements.
Signs: Many papillae are noted on the
upper tarsal conjunctival area with
hyperaemia and oedema of the surface.
Mucous strands in the tear film,
increased lens movement and poor
wetting of the lens surface are also
observed. The foreign body sensation
may trigger reflex lacrimation and
bulbar conjunctival hyperaemia (Fig.7).
Tests: Slit lamp examination using
fluorescein shows the irregular surface
of the tarsal regions and likely staining
of the tops of the papillae.
Tear assessments indicate reduced
quality of the tears. The lens condition
is poor, often with protein deposits
noted.
Initial Diagnosis: Contact lens associated
papillary conjunctivitis.

Tests: Epithelial abrasions may be seen

Management

on fluorescein staining.
By watching the patients technique for
removing their lenses, the practitioner
can discover whether the cause of the
redness is related to a faulty lens
handling technique or not.
Examination of the lens may show nail
damage at the lens edge.
Initial Diagnosis: Conjunctival trauma
due to faulty method of lens removal.

Advise the patient to cease lens wear

for several days if symptoms are
significant. Possibly revise the cleaning
and disinfection routines. Try changing
to another lens care solution in case
there may be an allergic reaction to
certain chemicals. Try using protein
removal tablets on the lenses to remove
any sticky protein deposits.
Try refitting with a different lens
design e.g. a more wettable material,
smoother lens surface with a lower
modulus of friction, to assist the lids to
glide smoothly over the lens during
blinks. Try refitting with a more
frequent lens replacement schedule,
e.g. changing from monthly to daily
disposable lens types.
The more severely affected cases may
require topical medication e.g. mast
cell stabilisers, for long-term control of
the inflammation. If the patient is
taking antihistamines to control other
allergies e.g. hayfever, these can also
help to reduce the lid inflammation.

Management
Give the patient a refresher lesson on
the correct pinch-out lens removal
method.
Advise the patient tactfully on
cutting/smoothing their fingernails.
If the nails are long, an alternative
lens removal method can be taught e.g.
fingers on the outer edges of top lid and
lower lid, using a lid squeeze method.
Advise on the use of lens re-wetting
drops if the lenses become dry and
static by 12 hours of wear. Several
blinks may also allow the lens to
become lubricated and this can make
the lens easier and safer to remove.

8) Reduced contact lens

tolerance and itchy, sticky
eyes
Symptoms: Complaints of discomfort,
lens awareness, and increased mucous

9) Dry eye feeling with

contact lens wear at work
Symptoms: The patient reports that they
are coping satisfactorily with soft lens
wear at home or at weekends but
experience ocular dryness and

irritation during lens wear at work.

The patient might claim that they
have been supplied with faulty
lenses since they were able to tolerate
them well, but are now experiencing
discomfort and a need to rub their
eyes, which has reduced the amount
that they can wear their lenses. It is
only with further questioning that
they will usually indicate that they
are now working in a dry, possibly
air-conditioned, environment or
perhaps need to concentrate on a
computer screen, or other visual
display unit (VDU), for long periods
of time. Alternatively, the dry feeling
is worse when staring or driving a car
with either air-conditioning or a fan
heater blowing dry air onto their
eyes.
Signs: Lens surface drying and poor
wettability.
Often there are incomplete blinks, so
the lower portion of the soft lens
dehydrates and draws moisture from
the corneal epithelium beneath. This
shows as punctate fluorescein
corneal staining. The lower region of
the lens dries and attracts grease and
protein films, further reducing
surface wettability.
There may be signs of many small
deposits on the lens e.g. spots from
the fine mist of hairspray at a
hairdressers job, or dust or particles
if the workplace has a dusty
atmosphere.
Tests: Tear volume and quality
assessments can be performed. If the
patient experiences dry and irritated
eyes at work, even whilst spectacles
are worn, this is likely to indicate a
work environment cause, e.g. dust,
dry air-conditioning or warm and dry
offices where there are computers.
Initial Diagnosis: Reduced contact lens
tolerance
due
to
the
work
environment.

Management:
Keep to spectacle wear at work,
wear lenses at home or outdoors.
If possible, adjust the work
environment, e.g. ensure regular rest
breaks from the visual display
screen, use dust extractors, use air
humidifiers, or move the desk away
from hot air blowers, radiators or
fans.

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10) The patient complains

of a lost contact lens
Symptoms: Contact lens wear had
been satisfactory but yesterday the a
lens disappeared during removal.
The patient reports intermittent
discomfort, slight redness and
stickiness in one eye, whilst the
fellow is eye fairly comfortable.
Signs:
Some
conjunctival
hyperaemia, often in the superior
region.
Sometimes increased lacrimation
or mucous strands in the tears. There
may be lid oedema and hyperaemia,
especially if the patient had
repeatedly prodded the eye as they
suspected the lens or a part of the
lens remains on the eye.
Tests: Slit lamp examination using
fluorescein will show erosion stains
if the lens edge or the patients finger
has abraded the ocular surface. The
fluorescein will be retained by the
soft lens material, which makes the
contact lens easier to find using blue
light. The patient is asked to look in
each direction of gaze as the
practitioner lifts the lids to inspect
the fornices for the remaining portion
of the lens.
Initial Diagnosis: Contact lens lost
under the lid.
Management
If the folded lens or half of a torn
lens is discovered in the upper
fornix, the lid is gently massaged
while the patient keeps looking
downwards. The irritating lens is
gradually nudged from beneath the
lid until safely removed by the
practitioner. Sometimes instilling
saline drops lubricates the lens and
assists the lens movement.
The
ocular
surface
and
tarsal conjunctival surface on lid

eversion are examined for erosions,

using the slit lamp. Mucous strands
and lens debris can be washed out if
the eye is irrigated with several drops
of sterile saline.
The condition of the retrieved lens
is inspected. If possible, the lens
should be discarded. However, if this
is an annual replacement RGP or soft
lens soft lens, destruction is not
feasible and the lens must be cleaned
thoroughly, rinsed and soaked
overnight in fresh solution.
The patient is advised to allow the
eye to recover for a few days before
resuming
lens
wear.
Some patients require further
tuition in lens handling and care to
prevent this problem from recurring
in future.

Further Reading:
1) Phillips AJ & Speedwell L, Eds.
(2007) Contact Lenses, 5th edition.
Butterworth Heinemann, Edinburgh,
UK.
2) Kruse A, Lofstrom T, Meyler J, &
Sulley A, Eds (2006) A handbook of
contact lens management, 2nd Edition.
Johnson & Johnson Vision Care &
Synoptik.
3) Efron N, Ed. (2004) Contact lens
complications,
2nd
Edition.
Butterworth Heinemann, Edinburgh,
UK.
4) Stapleton F (2003) The anterior eye
and therapeutics diagnosis and
management. Butterworth Heinemann,
Sydney, Australia.
5) Bruce A & Loughnan M (2003)
Anterior eye disease and therapeutics
A-Z. Butterworth Heinemann, London,
UK.
6) Efron N, Morgan P, & Jagpal R (2003)
The combined influence of knowledge,
training and experience when grading
contact
lens
complications.
Ophthalmol. Physiol. Opt. 23(1);79-85.
7) Hom MM, Ed. (2000) Manual of
contact lens prescribing and fitting
with
CD-ROM,
2nd
Edition.
Butterworth Heinemann, Boston, USA.
8) Ruben M & Guillon M, Eds (1994)
Contact lens practice. Chapman and
Hall, London, UK.
9) Tomlinson A (1992) Complications
of contact lens wear. Mosby
International, St. Louis, USA.

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19/09/08 CET

Practise full blinks and try lens rewetting drops.

Try refitting with another lens
design, which resists dehydration or
provides supplementary moisture to
the eye.
Consider lifestyle changes such as
reduce caffeine intake, drink more
water, increase omega-3 supplements
in the diet and walk in the fresh air
during work breaks.

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Module questions

Course code: c-9521

Please note, there is only one correct answer. Enter online or by the form provided

An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-9521)
OT, Ten Alps plc, 9 Savoy Street, London WC2E 7HR by October 17 2008
1)

19/09/08 CET

36

a.
b.
c.
d.
2)
a.
b.
c.
d.
3)
a.
b.
c.
d.
4)
a.
b.
c.
d.
5)
a.
b.
c.
d.
6)
a.
b.
c.
d.

For a patient experiencing a lens care solution toxic reaction, which of

the following is the most appropriate alternative?
Change the out of date bottle for a new one of the same solution.
Change to silicone hydrogel lenses using the same solution.
Change to daily disposable soft lenses.
Change to any other multipurpose solution.
For a patient wearing soft lenses with many protein deposits, which of
the following is the most appropriate advice?
Change to a daily disposable lens of a material with delayed
dehydration.
Use protein removal tablets each week.
Change to a peroxide disinfection method.
Re-teach how to rub the lens with surfactant cleaner before soaking.
For a patient experiencing dry eye symptoms at an office, computerbased job, which of the following is the most appropriate advice to
obtain short-term relief?
Practise full blinking of the lids.
Use appropriate contact lens re-wetting drops.
Take breaks from staring at the VDU screen
All of the above plus resist rubbing the eyes.

7)
a.
b.
c.
d.
8.
a.
b.
c.
d.
9.
a.
b.
c.
d.

Which of the following symptoms is indicative of visual problems

due to presbyopia?
Near detailed vision is a strain, distance VA is sometimes blurred, and
the patient is aged 45 or over.
Near detailed vision is a strain and distance VA is sometimes blurred.
Near detail strain for RE, OK for LE, distance VA good each eye.
Distance and near VA are both blurred and are worse with longer
contact lens wear.
Which of the following features indicates that a visual problem is
due to residual astigmatism?
Astigmatic readings on keratometry.
Letters blur in one meridian with image ghosting but soft lens clean.
Astigmatism shown on keratometry but spherical soft lens worn.
Blurred distance vision with lens, also with two year old spectacles.
Why may a presbyope be happy that his lenses are in the wrong eyes?
They are reassured that they have not lost a lens.
Relief that there is no eye pathology reason for the changed vision.
They are pleased that they wont have to buy a replacement for a
scratched lens.
They like the inadvertent monovision effect achieved.

For the patient in Question 3, which of the following is the most

appropriate advice to obtain long-term relief?
Refit the eye with another lens of better material.
Move the desk further from the air conditioning vent or fan.
Add omega-3 supplements to the diet and drink less caffeine.
All of the above, including drink more water.

10) Which of the following is the most likely cause of grease build-up
on lenses?
a. The patient eats too much fat in their diet.
b. They do not wash their hands correctly before inserting the lens.
c. They instill viscous artificial tears drops on the lens if eyes feel dry.
d. They insert the lens after applying mascara.

Which of the following are the primary symptoms of contact lens

related papillary conjunctivitis?
Itchy lids and sticky eyes.
Lid oedema.
Tarsal papillae and hyperaemia.
Mucous deposits on the lens.

11)
a.
b.
c.
d.

Which of the following is the most significant sign of a faulty technique

for soft lens removal?
Lateral conjunctival hyperaemia if there is a long lens wear time.
Long fingernails.
Lateral conjunctival redness immediately following lens removal.
Split in the soft lens.

When may a presbyope wear his distance spectacles over his lenses?
In a dusty environment, to protect the lenses from dust.
In sunshine, if the spectacles have a dark brown tint.
To help his binocular control.
To assist near vision, if the prescription is of low positive power.

12) Which method is best to find a daily disposable lens under the top lid?
a. Instill fluorescein so that the lens shows easier on blue light slit lamp
examination.
b. Avoid fluorescein as the lens will need to be reinserted once found.
c. Hold the lids apart for a minute, forcing lacrimation to wash the
lens out.
d. Drag the lens back onto the cornea using a dry cotton wool bud.

Please complete online by midnight on January 14 2009 - You will be unable to submit exams after this date answers to the module will be published in our January 16 2009 issue

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15/08/08 CET

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