ocular response to CL wear Flashcards
(99 cards)
1
Q
what is the most important thing to do when monitoring a patient with their contact lens aftercare
A
record keeping
2
Q
list the 5 reasons for why record keeping is so important
A
- monitoring progression
- record across time, within and between practitioners
- impact new therapies or management
- medico-legal requirements
- patient communication
3
Q
what type of language does a standardised grading scale use
A
it uses a common language, which can be interpreted as the same by everyone
4
Q
why is a common language used by a standardised grading scale
A
it reduces intra/inter observer variability
5
Q
name an advantage to the CCLRU grading scale
A
it uses real eyes
6
Q
list 2 disadvantages to the CCLRU grading scale
A
uses:
- different eyes
- different illumination
7
Q
list 2 advantages to the efron grading scale
A
- illustrates the precise severity
- image constancy
8
Q
name an advantage to the efron grading scale
A
does not use real eyes
9
Q
list the three reasons for having a legal document, in the form of a patient record
A
- an accurate record of presenting sings and symptoms
- respond to complaints
- proof that standard of care was met: if its not written, it means its not done
10
Q
list the three different ways of range/steps of a grading scale
A
- 1-4
- 0-5
- decimal scale
- +/- sign
(from non-severe, to very severe)
11
Q
what is the severity of a grade 0
A
normal
12
Q
what is the clinical interpretation of a grade 0
A
no action required
13
Q
what is the severity of a grade 1
A
trace
14
Q
what is the clinical interpretation of a grade 1
A
action rarely required
15
Q
what is the severity of a grade 2
A
mild
16
Q
what is the clinical interpretation of a grade 2
A
action possibly required
17
Q
what is the severity of a grade 3
A
moderate
18
Q
what is the clinical interpretation of a grade 3
A
action usually required
19
Q
what is the severity of a grade 4
A
severe
20
Q
what is the clinical interpretation of a grade 4
A
action required
21
Q
list 4 things to look for during the slit lamp routine a CL aftercare
A
- palpebral conjunctiva
- corneal staining
- CL deposits
- any CL adverse events
22
Q
how many areas is the palpebral conjunctiva divided into, and name the areas which are the most relevant for CL wear
A
5 areas
areas 1,2,3 are most important for CL wear (in the vertical middle area)
23
Q
which areas of the conjunctiva generally has more bumps, and what is its importance
A
areas 5 and 4 tend to have more bumps, but as its in the peripheral conjunctiva with least contact with the CL, it is not as important as areas 1, 2 and 3
24
Q
what aspect of the conjunctiva are you grading when observing with the slit lamp
A
the redness and roughness, of the tissue underneath the eyelid
25
what symptom does a bumpy/rough eyelid cause with a CL patient
when the patient blinks, the CL will move with the eyelid as it grips onto the roughness
26
what two things can possibly cause a red and rough palpebral conjunctiva
- hay fever season
| - sleeping in CL's
27
what does the effort scale tell you about a corneal staining
of micropunctate (the little dots seen on the cornea)
28
what 2 things does the efron scale not tell you about corneal staining
it does not tell you about:
- the foreign body type
- the mechanical type (SEAL)
29
what three things does the CCLRU scale tell you about the corneal staining
- type
- extent (area covered)
- depth
30
how many areas does the CCLRU scale split the cornea in and tell you about with staining
5 areas
31
what filter is best used with observing corneal staining and state 2 reasons why
```
use the yellow filter
because:
- you can see the staining much clearer
and
- without flourescein
```
32
how do you set up the slit lamp to investigate the depth of the corneal staining and what does this help with
use a wide angle
| helps to distinguish between whether its an epithelial staining or a stromal staining
33
as well as writing the type, extent and depth of the corneal staining, what else is important to write in your record card about corneal staining
which scale you used to grade it with
and don't guess the scale, always look it up when measuring the corneal staining
34
what is grade 1 or more of corneal staining regarded as
clinically significant
35
what grade of corneal staining, requires a management plan
grade 3 or more
36
in how many CL patients can corneal staining be insignificant (0.5-1) and asymptomatic
60%
| where the severity signs are not related to the symptoms
37
why do 35% of non CL wearers get corneal staining
due to incomplete blink or closure
38
list the 5 types of corneal staining
- desiccation 'smile'
- foreign body 'linear'
- mechanical 'SEAL'
- desiccation '3 and 9 o'clock'
- toxicity 'diffuse'
39
what type of corneal staining does an incomplete blink cause
desiccation 'smile' staining
40
what causes a foreign body linear, corneal staining
caused by blinking whilst something is stuck underneath the eye and is scraping over the cornea, hence 'linear'
41
what does SEAL stand for in a mechanical corneal staining and what is it caused by
superior arcuate epithelial lesion
| a stiffer material of a silicone hydrogel material SCL
42
what type of corneal staining does a RGP CL cause
desiccation 3 and 9 o'clock corneal staining (caused by RGP and not SCL, because RGP lenses are smaller)
43
what can an toxicity staining be caused by
CL cleaner or allergy response to solution
44
what 2 types of CL deposits is formed as hydrophobic spots on the lens with mucous or calcium
- calculi
| - jelly bumps
45
which type of contact lens is calculi lens deposits most commonly found on
monthly, FDA group 2, high water non-ionic hydrogel lenses
46
why are calculi lens deposits not found on daily hydrogel lenses
because the calcium deposits take time to develop
47
what do calculi look like as seen with an optic section with the slit lamp
raised bumps sitting on the front, but not embedded in the CL
48
what are jelly bumps formed on a contact lens caused by
the amount of mucous on the tear film and the quality of the tears
49
what type of contact lens is jelly bumps and calculi lens deposits most commonly found with
FDA group 2, high water, non-ionic hydrogel lenses
50
what is the appearance of a lipid coating on the contact lens
the tear film has a coloured fringe and only if the lipid is fat and not oil
lipid appears fatty and greyish
51
what 2 types of contact lenses is a lipid coating most commonly found with
- FDA group 2, high water, non-ionic hydrogel
| - silicone hydrogel
52
what does a protein film on the contact lens look like
a dirty tear film which is not clear and looks oily
53
what type of contact lens is a protein film most commonly found with
FDA group 4, high water, ionic hydrogel
54
list the two types of non-significant, asymptomatic CL adverse events
- asymptomatic infiltrative keratitis AIK
| - asymptomatic infiltrates AI
55
list the 4 types of significant, mostly symptomatic CL adverse events
- superior epithelial arcuate lesion SEAL
- contact lens associated papillary conjunctivitis CLPC
- contact lens acute red eye CLARE
- contact lens peripheral ulcer CLPU
56
name a serious CL adverse event
microbial keratitis MK
57
what are the signs of a asymptomatic infiltrative keratitis AIK
- sterile corneal infiltrates
- inflammatory cells from limbal blood vessels which form white spots on the cornea (close to the limbus)
- limbal injection: BV's are dilated
58
what 5 things is a asymptomatic infiltrative keratitis AIK, as response to
- hypoxia
- bacteria (e.g. in lens solution)
- lens deposits (so lens needs to be changed)
- allergic reaction
- poor hygiene
59
what 3 things will you do to manage someone with a asymptomatic infiltrative keratitis AIK
- temporary discontinuation of lens wearing
- careful monitoring (so doesn't become worse, ask px to come back after a week and not wear lenses during that week)
- ocular lubricants and cold compresses (is theres a gritty sensation, use sterile water and never tap water, especially if its a non-sterile infiltrates as that can result in microbial keratitis)
60
what is the appearance of asymptomatic infiltrates AI
- little white dots close to the limbus
- no redness
- smaller infiltrates than asymptomatic infiltrative keratitis AIK
- milder than AIK
need high mag on slit lamp to spot the infiltrates and swing the light to catch a view of it
61
what is the aetiology of asymptomatic infiltrates AI (5 things)
same as asymptomatic infiltrative keratitis AIK:
- hypoxia
- bacteria (e.g. in lens solution)
- lens deposits (so lens needs to be changed)
- allergic reaction
- poor hygiene
62
how will you manage someone with asymptomatic infiltrates AI
same as asymptomatic infiltrative keratitis AIK:
- temporary discontinuation of lens wearing
- careful monitoring (so doesn't become worse, ask px to come back after a week and not wear lenses during that week)
- ocular lubricants and cold compresses (is theres a gritty sensation, use sterile water and never tap water, especially if its a non-sterile infiltrates as that can result in microbial keratitis)
63
what is a description of a SEAL
mechanical pressure due to lens design or material
64
where is the staining found with SEAL
arcuate staining parallel to the superior limbus, usually unilateral and asymmetrical
65
how symptomatic is a SEAL
mildly symptomatic: can feel the lens, but not the staining as the lens covers it and acts as a bandage
66
what 4 things will you do to manage someone with a SEAL
- remove lens
- cease CL wear for x days (depends on severity) avg 2-7 days
- issue lubricants
- review lens fit
67
what two things can you change with a lens for a px who has a SEAL
- use thinner, more flexible lens material (esp in periphery)
- change the back surface geometry on the CL (but not always able to change)
68
what will a px complain of with a contact lens associated papillary conjunctivitis
can feel lens all the time
69
why is giant papillary conjunctivitis seen in a CL clinic more
because the patient can feel the CL a lot more, so can notice the symptoms more
70
what is a contact lens associated papillary conjunctivitis described as
conjunctival inflammatory
71
what two things is a contact lens associated papillary conjunctivitis a response to (i.e. the aetiology)
- immunological response due to hypersensitivity to lens deposits or solution (make sure lens is clean)
- mechanical response due to lens design or modulus (use flourescein to check for staining)
72
what three things will you do to manage a patient with contact lens associated papillary conjunctivitis
- manage if grade is 2 or above on the scale
- lens wear can continue if symptoms permit
- improve lens hygiene (cleaning and wearing time modality) or change to dailies from a 2 weekly lens etc
73
when will you decide to manage a patient with contact lens associated papillary conjunctivitis
if its a grade 2 or above on the scale
74
what is the symptoms of a contact lens acute red eye CLARE
woken at night with painful red eye, very sudden acute
75
what are the 4 signs of a contact lens acute red eye CLARE
- unilateral
- acute hyperaemia
- diffuse infiltrate keratitis
- possibly anterior chamber reaction: flare and cells
76
what is the cause/aetiology of a contact lens acute red eye CLARE
an inflammatory response of the cornea and conjunctiva due to a period of eye closure with CL wear (whilst wearing the CL) e.g. sleeping in CLs
- due to endotoxins from gram negative bacteria (especially pseudomonas)
77
how severe is a contact lens acute red eye CLARE
self limiting
78
what two things will you do to manage someone with a contact lens acute red eye CLARE
- temporary discontinuation of CL wear
| - careful monitoring: see after 2 days and on a weekly basis until everything is gone
79
how many % of people can be asymptomatic to a contact lens peripheral ulcer and why
50%
| because it is in the periphery, it is flat and the lens acts as a bandage
80
list 4 symptoms of a contact lens peripheral ulcer
- lens intolerance
- foreign body sensation
- lacrimation
- photophobia
50% of px are asymptomatic
81
what can reduce the symptoms of a contact lens peripheral ulcer
lens removal
82
what are the 2 signs of a contact lens peripheral ulcer
- localised hyperaemia
| - sterile circular infiltrate
83
what is the 4 cause/aetiology of a contact lens peripheral ulcer
- bacterial contamination
- poor hygiene
- hypoxia
- solution toxicity
all cause an inflammatory response to the gram positive bacteria (esp staphylococcus)
so make sure the lens is high oxygen transmissibility and no toxicity to the solution
84
how severe is a contact lens peripheral ulcer
self limiting on removal of CL, but must to close monitoring to ensure DDx from microbial keratitis, so make sure the epithelium is closed
85
what three things will you do to manage a patient with contact lens peripheral ulcer
- ocular lubricants
- lid hygiene
- referral only in severe cases such as acute red eye or no improvements on lens removal
86
how will you know that a px with contact lens peripheral ulcer has an open ulcer causing an open epithelium
by instilling flourescein and viewing with an optic section
| if it is open the ulcer will have a bright glow to it
87
what does a sterile contact lens peripheral ulcer mean
no bacteria or viruses can go into it
88
what is it called if bacteria had gotten into the contact lens peripheral ulcer
non sterile
89
why can someone get microbial keratitis
due to poor hygiene, swimming in lenses or sleeping in lenses (or if using extended/continuous wear)
90
list the 7 symptoms of microbial keratitis
- pain, which is moderate to severe, with an acute onset and rapid progression
- redness
- photophobia: may be severe
- discharge
- blurred vision: especially if lesion in on visual axis
- awareness of white or yellow spot on cornea
- usually unilateral
91
list the 6 signs of a microbial keratitis
- lid oedema
- epiphora
- discharge: mucopurulent
- conjunctival hyperaemia and infiltration
- corneal lesion: usually single, central or mid periphery
- anterior chamber activity: flare, cells, hypopyon or coagulum is severe (white blood cells)
92
what is the DDx of microbial keratitis
ulcer
93
in which type of CL is it 5x more common to get microbial keratitis in compared to daily wear lenses
in extended wear lenses
94
how much lower is the risk of getting microbial keratitis in a RGP wearer than a daily SCL wearer
1/3 compared to a daily SCL wearer
95
what is the aetiology of microbial keratitis
an infection causing a compromised cornea with epithelial break and hypoxia from invasion of:
- bacteria esp pseudomonas
- virus
- fungus
- amoebea
with excavation of the epithelium (open), bowman's and stroma (goes all the way into the stroma). with infiltration and necrosis or tissue
96
what can microbial keratitis potentially cause
blinding
97
what will you do to manage a patient with microbial keratitis
discontinue CL wear and urgent referral to HES
98
what is the incidence of microbial keratitis in CL wearers/year
18-24 per 10,000/year
99
what is the incidence of visual loss with microbial keratitis
2 per 10,000
