When Fitting the Mature Contact Lens Patient
By Christopher Miller, ABOC, NCLEC
Release Date: September, 2011
Expiration Date: July 28, 2016
Upon completion of this program, the participant
should be able to:
- Understand leading eye complaints
and diseases for the older patient.
- Be familiar with common tests
performed by the eyecare practitioner.
- Know the five steps to safeguarding
Christopher Miller started at SOLA Optical USA (1977) as Quality Control Department Lead manufacturing CR39 lenses. After completing several optical courses Miller became an optician at a retail optical chain, passed both the ABO and NCLE exams, and managed optical locations before opening his own optical boutique. In the Caribbean and South America he helped several doctors open practices and managed the government of Guyana's optical lab and dispensary before opening his own contact lens practice. In 2002 he returned to California and now works at a busy HMO as a contact lens fitter.
This course is approved for one (1) hour of CE credit by the National Contact lens Examiners (NCLE).
Course # CTWJMI025-2
They say 50 is the new 40, and 60 is the new
50. Current numbers indicate that a third of
the U.S. population was between 40 to 59
years of age at the end of 2010 with 14.5 million turning 40 within the next four years.
These aging baby boomers are more active,
more style-conscious, have access to knowledge never before possible, and have the
highest amount of disposable income than
any previous generation. Many currently
care for one or more parent, and the mix has
made healthcare the number one issue in
America. That's because no matter how
well we take care of ourselves, with age and
all its wisdom also come health issues; some
are avoidable, some not. The mature eye
has a wider range of conditions to consider
that suggests different spectacle and contact lens modalities.
COMMON ADULT EYE
COMPLAINTS AND THE
CONTACT LENS FITTER
The following common eye complaints are
age-related. Treatment can be easy. Sometimes they signal a more serious problem.
Presbyopia is a gradual loss of ability to see
close objects or small print. It is part of the
normal aging process. The lens itself stiffens making it increasingly harder to change
shape, get more convex and accommodate
near vision. Signs of presbyopia include
holding reading materials at arm's length,
difficulty reading in dim light, headaches or
tired eyes when reading or doing other
close work. For contact lens wearers, there
are several options such as the newer multifocal lenses, a monocular fit or reading
glasses worn over distance contact lenses.
Presbyopia at 60, 70 and 80: In the advanced
stages of presbyopia the patient often needs
higher reading Adds. These higher Adds
make it more difficult to see intermediate
distances starting at computer length and a
patient may notice it more when cooking,
shopping, doing craftwork or while in their
yard. There may be other problems as well
making driving or reading at night difficult.
Adequate lighting and low vision aids may
be needed as well. Many of these patients may have been fit previously as a monocular fit, i.e., one eye for distance and one eye
for near. The decision is yours and the prescribing doctor's, whether they would be a
good candidate for a multifocal contact
lens. Patient interest and a willingness to
try something different may open a whole
new vista for them.
Floaters are small shadows of spots or filaments that patients describe as floating
across their field of vision. They vary in
size and shape, and are located in the vitreous humour. They may be of embryonic
origin or acquired due to degenerative
changes of the vitreous humour or retina.
They're typically noticeable in a well-lit
room, outdoors on a bright day or when
reading a page with lots of light and a
bright white background.
Floaters at 60, 70 and 80: Floaters are typically normal. However, they can be a sign
of a more serious eye problem, like retinal
detachment. A retinal detachment is often
accompanied by flashes of light. If a patient
notices a sudden change in the type or
number of spots or flashes, advise them to
see an ophthalmologist right away. Floaters
are also common after cataract operations
or after trauma.
Excess Tearing: Excess tears may be from
sensitivity to light, wind or temperature
changes. Protecting the eyes by wearing
sunglasses is a simple solution to the problem. Sometimes excess tearing may mean a
more serious eye problem, such as an infection or a blocked tear duct, which can both
Eyelid Problems: Comes from a variety of
different diseases or conditions. Common
eyelid complaints include pain, itching,
tearing or being sensitive to light. Giant
Papillary Conjunctivitis (GPC) is a fairly
common one. GPC is not an infection, but
an inflammation of the inside surface of the
lid, caused by constant rubbing across a
contact lens or other foreign body. Normally, the undersurface of the upper eyelid
is completely smooth. In patients with
GPC, the undersurface of the eyelid
becomes roughened and inflamed, and the
entire eye becomes irritated. In addition to
mechanical irritation, contact lenses also
trap deposits on their surface, which add
to the inflammation. The condition is so
named because large bumps (papillae)
appear on the underside of the eyelid.
GPC occurs both in patients who use soft
and rigid gas permeable contact lenses,
though it occurs much more frequently in
soft contact lens wearers.
Conjunctivitis (also called pink eye) occurs
when the conjunctiva lining the inside of
the eyelids (and also is the top layer of the
cornea) becomes inflamed. It can cause
itching, burning, tearing or a feeling that
something is in your eye. Conjunctivitis can
be due to allergies or an infection. Infectious pink eye can easily spread from one
eye to the other and to other people.
Advise the patient to remove their lenses
until it clears up. Depending upon the
severity, they should either see their doctor
for further evaluation and treatment immediately or after a few days if conditions
Dry eye syndrome: Dry eyes are caused by
a lack of tears. Tears are necessary for the
normal lubrication of our eyes and to wash
away particles and foreign bodies. Most
patients who experience dry eyes may
describe a burning, scratching or stinging
sensation. They may also have strained or
tired eyes after reading, even for short periods of time. Reading reduces the blink rate
by more than half. If these patients wear
contact lenses full time, they will likely feel
uncomfortable, especially later in the day.
Having dry eyes can lead to tiny abrasions
on the surface of their eyes which will show
during fluorescein staining.
Common causes of dry eyes include
aging, dry environment or workplace
(wind, air conditioning), excessive time on
the computer, sun exposure, smoking or
secondhand smoke exposure, cold or allergy medicines, an eye injury or problem
with the eyes or eyelids (drooping eyelid or
bulging eyes, exophthalmos), Sjogren's
syndrome (includes dry eyes, mouth and
mucus membranes, and often rheumatoid
arthritis or other joint disorder); and previous eye surgery such as Lasik.
The following steps may help:
- Artificial tears, available as either drops
or ointment. Ointments last longer, but
are thicker and can cause blurry vision
especially with contact lenses.
- Reduce or eliminate smoking. Avoid
secondhand smoke, direct wind and air
- Use of a humidifier, especially in the
- Blinking more often.
- Periodically rest the eyes, looking away
at more distant objects, especially while
reading, watching television or using
Meibomian Gland Dysfunction: The meibomian glands (or tarsal glands) are a special kind of sebaceous glands at the rim of
the eyelids inside the tarsal plate. They are
responsible for the supply of meibum, an
oily substance that prevents evaporation
of the eye's tear film, prevents tear spillage
onto the cheek, makes the closed lids airtight and acts as a blockade for tear fluid, trapping tears between the oiled edge and
eyeball. There are approximately 50
glands on the upper eyelid and 25 glands
on the lower.
Dysfunctional meibomian glands often
cause dry eyes, one of the more common
eye conditions. They may also cause blepharitis, as the dry eyeball rubs off small pieces of skin from the eyelid, which may get
infected. Inflammation of the meibomian
glands (also known as meibomitis, meibomian gland dysfunction or posterior blepharitis) causes the glands to be obstructed
by thick secretions; the resulting swelling is
termed a chalazion. Besides leading to dry
eyes, the obstructions can be degraded by
bacterial lipases (water insoluble lipids or
fats), resulting in the formation of free fatty
acids, which irritate the eyes and sometimes cause punctate keratopathy.
Typical treatments for this condition may
include, depending on specifics of the condition:
- Warm compresses (to liquefy any secretions that have solidified and are clogging the glands)
- Lid scrubs
- Oral antibiotics (such as doxycycline)
or topical antibiotic ointments
- Omega 3 supplementation
Corneal diseases and conditions can cause
redness, watery eyes, pain, reduced vision
or a halo effect. The cornea is the clear,
dome-shaped “window” at the front of
the eye. It helps to focus light that goes
into the eye. Disease, infection, injury,
toxic agents and other things can harm
the cornea. Advise patients to always wear
eye protection for any sport activities,
when working with any equipment, when
using caustic cleaning chemicals or when
doing yard work.
Cataract is the clouding of the crystalline
lens. Common symptoms include blurry
vision, glare in sunlight, halos at night
around streetlights or car lights, colored
objects losing their original tone and an
increase in myopia (nearsightedness from
extreme flattening of the crystalline lens).
Glaucoma is one of the leading causes of
blindness. Glaucoma is a disease caused
by the collapse of the trabecular meshwork and/or the Canal of Schlemm,
resulting in increased eye pressure within
the eyeball. This results in the death of
capillaries that nourish the peripheral retina leading to a reduced visual field and
eventually blindness if untreated. In early
glaucoma, patients may not have any
symptoms. Therefore the condition is
often neglected. Early diagnosis and treatment will prevent blindness.
Age-related macular degeneration (AMD)
is a medical condition, which usually
affects older adults resulting in a loss of
vision in the center of the visual field (the
macula) because of damage to the retina. It
is a major cause of visual impairment in
older adults. Macular degeneration can
make it difficult or impossible to read or
recognize faces, although enough peripheral vision remains to allow other activities
of daily life.
The inner retinal layer of the eye contains
nerves that communicate sight. Behind the
retina is the choroid, which contains the
blood supply to the macula (the central
part of the retina). In the dry (non-exudative) form, cellular debris called drusen
accumulate between the retina and the
choroid, reducing the regeneration of the
chemistry required to send signals or the
retina can become detached. In the wet
(exudative) form, which is more severe,
blood vessels grow up from the choroid
behind the retina, and the retina can also
become detached. It can be treated with
laser coagulation, and with medication that
stops and sometimes reverses the growth
of blood vessels.
Although some macular problems affecting younger individuals are sometimes
referred to as macular degeneration, the term
generally refers to seniors or age-related macular degeneration (AMD or ARMD).
Diabetic retinopathy: Diabetes mellitus
(DM) can cause diabetic retinopathy, leading to retinal hemorrhage, vitreous hemorrhage and retinal detachment. In the diabetic, cell walls may not have all the factors
necessary to retain their wall strength and
tonicity. This results in vessel walls that
leak or burst. Depending on the duration
and the age of onset of diabetes, the incidence of diabetic retinopathy varies from
20 to 55 percent in diabetic patients. Early
diabetic retinopathy is asymptomatic.
Once diagnosed with diabetes, patients
should consult an eye doctor to have a
thorough baseline assessment of their eyes.
Regular follow-up eye examinations are
essential every six months to one year,
depending on the severity of the diabetic
TESTS FOR THE ADULT EYE
A comprehensive examination by the
doctor should include a dilated examination, screens for glaucoma, diabetic retinopathy, hypertensive retinopathy, macular degeneration and cataracts. It should
also include taking visual fields, corneal
topography (mapping), a scanner laser
exam which aids in early glaucoma diagnosis, and digital photography to ensure
there is a baseline image to aid in any further investigation of ocular disease. There
are several additional tests, which might
be done for contact lens wearers such as a
Schirmer's Test. This test measures tear
production. Fluorescein staining analyzes
the fit of a contact lens or can highlight a
scratched cornea. For the older patient,
many of these tests are done on a routine
basis to ensure optimal optical health as
some diseases have little or no symptoms,
and early treatment is best to halt any
Pachymetry: A pachymeter measures corneal thickness and is a useful tool for the
diagnosis of corneal disease, glaucoma risk and for assessment of potential Lasik
Visual Fields: Contributes to the diagnosis
of optic nerve disease and retinal pathology.
Digital Photography: Captures a baseline
retinal photograph for comparison at subsequent visits.
CURRENT OR POTENTIAL
CONTACT LENS WEARERS
The following tests might also be added:
Topography: Corneal topography, also
known as photokeratoscopy or videokeratography, is a non-invasive medical imaging technique for mapping the surface curvature of the cornea. Since the cornea is
normally responsible for 70 percent of the
eye's refractive power, its topography is of
critical importance in determining the
quality of vision.
The three-dimensional map is therefore
a valuable aid to the examining ophthalmologist or optometrist, and can assist in
the diagnosis and treatment of a number
of conditions; in planning refractive surgery such as Lasik and evaluation of its
results; or in assessing the fit of specialty
contact lenses. A development of keratoscopy, corneal topography extends the
measurement range from the four points
a few millimeters apart that is offered by
keratometry to a grid of thousands of
points covering the entire cornea. The
procedure is carried out in seconds and
is completely painless.
Tear breakup test: Sodium fluorescein dye is added to the eye and the tear film is
observed under the slit lamp while the
patient avoids blinking until tiny dry spots
develop. The longer it takes, the more stable the tear film. A short tear breakup time
is a sign of a poor tear film. Generally,
greater than 10 seconds is thought to be
normal, five to 10 seconds, marginal, and
less than 5 seconds, low (with high likelihood of dry eye symptoms).
An unstable tear film can explain dry eye
symptoms in patients who have a normal
quantity of tears. Unstable means the composition of the tears is imbalanced, resulting in tears evaporating too quickly or not
adhering properly to the surface of the eye.
A Schirmers Test measures aqueous tear
production. A premeasured strip of test
paper is placed in your lower eyelid and
measures how much tears are soaked up in
five minutes. A measurement less than 10
indicates inadequate tear production or
dry eye syndrome.
Fluorescein staining: This test is very useful for detecting injuries or abnormalities
on the surface of the cornea as well as the
fit of a rigid contact lens.
A piece of blotting paper containing the
dye is wetted with saline and touched to
the surface of the eye. As the patient blinks,
the dye is spread around and coats the surface of the cornea. A cobalt light is then
directed at the eye. Any problems on the
surface of the cornea will be stained by the
dye and appear green under the blue light.
The health care provider can determine
the location and likely cause of the cornea
problem depending on the size, location
and shape of the staining.
FIVE STEPS TO SAFEGUARD
- Recommend regular physical exams
with their primary doctor to check for
diseases like diabetes. Such diseases can
cause eye problems if not treated.
- Recommend a complete dilated eye
exam with an eyecare professional
every one to two years. This is the only
way to find some eye diseases, such as
glaucoma, that have no early signs or
- Take a thorough history. Does any family member have a history of diabetes or
eye disease? If so, recommend a dilated
eye exam every year.
- Advise the patient to see an eyecare
professional at once if they have any loss
or dimness of eyesight, eye pain, fluid
coming from the eye, double vision,
redness or swelling of the eye or eyelid.
- Advise them to always wear sunglasses
and a hat with a wide brim when outside. This will protect their eyes from
too much sunlight, which can raise the
risk of getting cataracts. Also advise eyewear protection whenever needed.
If any of your older patients wear contact
lenses, chances are they have done so for a
decade or more. This is a great time to
upgrade them to the new breathable materials or perhaps to try a multifocal design. For
some, it may be their first time trying contact
lenses, and we should be aware of any dry eye
issues as this is a common complaint in this
age group. Reduced wearing times and a
moisturizing eye drop may be part of every
successful fit. Dailies may be especially
appealing as cost may not always be the
deciding factor. In any case, have a variety of
trial lenses on hand; as we well know, eyes
come in all sizes and all ages.