Thanks for Asking:
Keys to Taking an Accurate Contact Lens Case History

By Christopher Miller, ABOC, NCLEC

Release Date: October 1, 2013

Expiration Date: October 7, 2018

Learning Objectives:
Upon completion of this program, the participant should be able to:

  1. Learn what information is required for a complete patient’s history and follow up visits.
  2. Understand which types of questions are most important for taking a case history.
  3. Learn how to correlate subjective symptoms with objective observations and tests.
  4. Recognize how to relate patient past medical history to the current visit.

Credit Statement:
TThis course is approved for one (1) hour of CE credit by the National Contact lens Examiners (NCLE). Course #CTWJH220-1

Taking a patient's case history is the contact lens fitter's most versatile diagnostic and therapeutic tool. However, interviewing is also one of the most difficult clinical skills to master. The demands made on the practitioner are both intellectual and emotional. The analytical skills of diagnostic reasoning must be balanced with the interpersonal skills needed to establish rapport with the patient and facilitate communication.

The diagnostic utility of the interview is complemented by its therapeutic power. As a positive relationship is established between the fitter and the patient, an empathetic, patient-centered interview can bolster the patient's sense of self-esteem. The alliance forged during the encounter provides the foundation for ongoing patient care and education.

Fundamentally, this initial interview is a purposeful conversation undertaken with a set of goals and priorities clearly maintained in the fitter's mind. Its direction reflects the respective needs of both participants—that of the patient and the fitter. The patient enters the interview seeking relief from discomforts and uncertainties, while the fitter actively conducts the interview in order to clarify the patient's problems and needs. The result is to derive a diagnostic lens selection plan for the patient.  For most of us, the most difficult aspect of interviewing is maintaining a balance between the patient's and our own agenda; between actively directing the encounter and facilitating the patient's spontaneous report of history. At its best, the interview becomes a dialogue between two people driven toward a common goal.

The information obtained in this way, together with clinical examination and test results such as a keratometer and slit lamp exams, enables the fitter to form a plan.

A contact lens fitter or the person responsible for taking the patent's history typically asks questions to obtain the following information about the patient: Start with the chief complaint or purpose for the current visit. If the patient is a child, mention which relative is present.

Compile a complete history of contact lens wear: any previous complaints and the details of how it was resolved. Lifestyle questions covering the patient's occupation, hobbies, sports activities, reading requirements, cell phone and computer usage help when deciding which lens choices to recommend. Take a step back when asking these questions and think which products work best for each. Remember that there are more than one solution for all of our optical needs and requirements.  Be ready to make recommendations for sun wear, OTC readers, computer/occupational eyewear, etc, besides contact lenses.

When recording the medical history portion, list any eye infections, diseases, surgeries, and medications including the use of birth control pills or antihistamines. Special notes should be added concerning any diabetic screening done recently, current blood pressure information, if available, or if the patient is on any hormone therapy. Recent pregnancies, as well as eye conditions including surgeries such as Lasik or cataract removal should also be noted in the chart.  Also list regular and acute medications including those prescribed by doctors, and others obtained over-the-counter or any alternative medicine being used.  Specially note the current disinfection solution being used and any comfort drop usage and frequency and any sensitivity or adverse reactions to prior solutions.

List the current or previous contact lens wearing conditions such as dry eyes, seasonal allergies, and solution sensitivity, especially any conditions relevant to the patient's chief complaint.  Note sensitivity to any medications, food, latex, and other environmental factors.

List the current wearing schedule and length of wearing as well as any handling and comfort issues. Besides the above questions we also need to be able to measure compliance to wearing schedules, cleaning and disinfection instructions, and previous wearing instructions. Remember to keep asking the types of questions that encourage the sharing of information and not the ones which harbor judgment or might cause embarrassment or secrecy.

Without jumping to hasty conclusions, try to measure value. Is the patient a full-time or part-time wearer? Do they have insurance coverage or are the costs to be borne entirely out of pocket. Do they have back up glasses? Now might be a good time to discuss different lens options comparing yearly prices, having them make a decision which lens modality they would like i.e., daily, bi-weekly, or monthly replacement. This saves valuable closing time at the end of the visit when you can reinforce the most important information given during the visit such as wearing times, cleaning instructions and other vital information. It also gives the patient opportunity early in the process to notify you how much of a priority price will play in their decision-making. Several things to consider with them is it better to have a better lens which might cost more per box and buy less boxes now or is it better to buy a year supply up front and use any rebates or in-office incentives.

As the patient's subjective symptoms are written, use a check off list which tests should be taken to get an objective measurement of its severity. Some of these tests might include taking visual acuities, keratometer readings, slit lamp examination, corneal topography, a tear break up test, a Schirmers test, and fluorescein staining.

At the conclusion write a 1 or 2 sentences Plan listing the chief purpose of the visit and the action(s) to be taken, such as: “Patient reports comfort issues with current 2 week lenses. Fit with another brand.” “Pt needs J4 near VAs for computer use. Fit with a +2.00 MF lens.” “Pt has neovascularization OU. Discontinue CL wearing for 3-5 days and return for observation before continuing CL wear”. These concise statements along with the test list make handoffs much easier to other staff or for the Dr's approval if needed and should be the first thing reviewed at the follow-up visit.

Case histories that made a difference. A few years ago, I was fitting a college student who had stinging in one eye only. Bilateral issues are harder to diagnose and one often has to be very observant of even minor details to figure things out. I noticed she parted her hair on the opposite side with bangs over the eye with the stinging.  This observation lead me to asking questions about her hair products and when she might had changed what she was using. She had that ‘aha' moment and said that it started after she changed her hair color and was currently using different products. We came up with the plan to have her clip her bangs off her face for a few days. When she returned she noted that the stinging had discontinued. She decided that she would change her hairstyle and try some other products for her hair. I might add that make-up also can often cause similar issues and one needs to remember to ask these types of questions when nothing else is making sense.

The Undiscovered - Then there was another patient who was late for her appointment and I started skipping some of my usual questions. When we got to the keratometer readings I saw that she had very flat corneas. I started asking questions about Lasik surgery or if she was ever told she had very flat corneas.  When I did the slit lamp exam, I saw what the problem was because she was still wearing her lenses! I hate to admit it, but it still happens every month or two, but at least now when it happens, I catch it more quickly than the first time it happened.

Review Case Histories

There are several different types of follow-up visits: new fits, toric fits, multi-focal fits, rigid gas-permeable fits, specialty lens fits, handling or comfort issues, and other patient initiated visits. Just as each type of fitting has its procedures and protocols it follows for each type of follow up visit. I suggest having a different template for each type of fitting and follow up visit. That way, the process used will be the same for each patient and nothing important would be overlooked because of time constraints or forgetfulness.

During follow-up visits, always review any previous chart entries noting the type of lens dispensed, solution being used, wearing and replacement schedules, fitting alignment and any rotation if wearing toric lens, visual acuities, and any special instructions given. The chart needs to be organized so that this information is readily seen and that the follow-up visit and notes taken relate to the original purpose of the first visit. Take any additional tests to validate conclusions if needed.

Information should also be in the chart if any lenses were ordered and need to be delivered. Go over handling, wearing schedules, and disinfection instructions. Make any further appointments if desired.

Fitting Chart Template Example (examples of information are in parentheses)

History: (New fit/refit/new rx/previous rx, lifestyle information)
Current comfort and vision with current lenses: (current and previous contact lens information, solution used)

Current RX per Dr's notes: (RX date, Dr’s name, Current rx)

Slit Lamp: (Corneas/sclera, vascularization, scars, pinguecula or pterygium, lids, tear quality, current lens fit quality, alignment if toric lenses)

Mires: (sharp and clear/distorted/blurry)

PLAN: (Fitting objectives and initial lens selection)

Trials: (Manufacturer and lens used)
OD: (Base cure/diameter/power)
OS: (Base cure/Diameter/power)
Replacement/wearing schedule: (1 month replacement/Daily Wear)

Fit/slit lamp evaluation: (Alignment @ 6:00 OU with no rotation)
VA: 20/20 20/20. Over Refraction: (didn't result in any better Vas)
Fit Characteristics: (Good movement, good centration, no lagging)

Lenses Dispensed: (Manufacturer and lens used)
OD: (Base cure/diameter/power)
OS: (Base cure/Diameter/power)
Replacement/wearing schedule: (1 month replacement/Daily Wear)

(For new fit) Trained insertion/removal/cleaning/disinfection regimen.

1st week wearing schedule: (6/8/10/12 hrs per day for the first few days to build up wearing time)

Dispensed (how many) trials and (name) care kit.
(Final instructions)
Discussed possible contact lens complications and patient responsibility.
Patient instructed not to sleep in lenses, wear lenses at least 3 hrs before any follow-up appt., and to see fitter for any comfort issues.

1 week follow-up appt booked with fitter (date optional)
(Signature and credentials)


Follow-up Chart Example

Patient is here for a follow up appt.

Wearing:(name of lens) up to (how many) hrs per day every day.
How many hours they have been wearing so far today (amount)hrs.

Fit/slit lamp evaluation:( (Corneas/sclera, vascularization, scars, pinguecula or pterygium, lids, tear quality, current lens fit quality, alignment if toric lenses)

VAs (20/30 20/25.)
Patient's report: (comfort and vision and any problems reported)

New trials/dispensed: (Manufacturer and lens used)
OD: (Base cure/diameter/power)
OS: (Base cure/Diameter/power)
Replacement/wearing schedule: (1 month replacement/Daily Wear)

Fit Evaluation: (Fitting characteristics/centration, movement, with no lagging.)

VAs: (20/20 OU)

(Final instructions) Patient instructed not to sleep in lenses, wear lenses at least 3 hrs before any follow-up appt., and see the fitter for any comfort issues.

Booked follow up appt.

(Signature and credentials)

Final Chart Template Example

Patient is here for a  contact lens final follow up appt.

Patient  reports that the lenses are great. Vision and Comfort are good.
No problems reported.

Wearing up to (amount)hrs per day every day.
Lenses worn (amount)hrs today so far.
Fit evaluation/slit lamp: (Fitting characteristics/centration, movement, with no lagging.)
OR didn't result in any better VAs.

Final RX:  : (Manufacturer and lens used)
OD: (Base cure/diameter/power)
OS: (Base cure/Diameter/power)
Replacement/wearing schedule: (1 month replacement/Daily Wear)

Care system being used: (name)

Patient instructed not to sleep in lenses, wear lenses at least 3 hrs before any follow-up appt., see the fitter for any comfort issues and to remove them when ill or discomfort.

Parameters sent to Dr (name) for rx release.

(Signature and credentials)

In closing, always keep the dialogue open. The same rapport that was established at the initial visit should continue with all subsequent ones. Keep in mind at all times that we need to be having conversations with our patients even when it involves the sharing of important facts or training. It should always be genuine and not feel canned or rushed. This will result in a patient's well-being and the willingness to tell it all, even when some of the information may be a bit self –incriminating. After all, excellent eye health and vision are the goals we share equally.