Contact lens records

Contact Lens Records

Contact lens records

The following details the areas which should be addressed when making records of patients’ appointments:

 

A. For initial appointment of a new patient:

(1) General Information

  • Date fitting commenced Name
  • Address
  • Telephone numbers
  • Date of birth
  • Referring optometrist/OMP
  • Spectacle prescription and VAs
  • Any initial contraindications to CL fitting
  • Patient’s reason for wanting contact lenses
  • Occupation and working environment
  • Sports, hobbies and pastimes
  • Allergies/Hay Fever (Seasonal allergic conjunctivitis)
  • Personal and family ocular history
  • Personal and family general health and specific pathologies
  • Medications
  • Smoker
  • Driving
  • General practitioner
  • Contact lens history

(2) Detailed examination of the anterior eye

Should include space for assessments of:

  • Each layer of the cornea Limbus
  • Conjunctiva
  • Lids, lid margins, and lid position (upper and lower) Lid tensions
  • Tear assessments – quality and quantity
  • Other relevant data (e.g. horizontal visible iris diameter, pupil diameter [varied illumination], vertical palpebral aperture)
  • A grading scale and diagrammatic recording should be used.

(3) Keratometric information

Type of instrument, values measured and mire quality; dioptric values, radii and axes/meridians. Topographical information if available.

(4)   Lens options discussed with the patient

Should be recorded.

(5)   Contraindications found in the examination

(6) Trial lenses used

With full details of fit assessment, over refraction and visual acuities.

(7)   Details of lenses to be ordered

(8)  Next scheduled appointment

B. For collection appointment

(1) Instruction given to the patient

Lens handling and ability to insert, removal, recentration; case hygiene, personal hygiene, care system and wearing schedule.

An assessment of the patient’s ability to handle their lenses should be recorded.

(2)   The recommended care system

(3) Assessment of lens fit and visual acuities

(4) Recommended next aftercare appointment and attendance record

(5) Patient acknowledgement form

(DoHCL1 – now discontinued) Should be completed and attached to the record.

C. For subsequent appointments:

(1) General information

History and symptoms since last visit Wearing pattern

Patient’s impressions of vision and comfort Care system, compliance and handling

(2)   Over refraction

Visual acuities with lenses

Objective assessment where appropriate (retinoscopy/autorefractor) Subjective assessment and acuities

Confirmation tests (duochrome, + 1.00 blur, pinhole) where appropriate

(3)   Examination of lenses on the eyes

Assessment of lens condition

(4)   Other examinations the practitioner considers appropriate

e.g. Pre-lens tear break-up time, keratometry.

(5)   Detailed examination of the anterior eye

Should include space for assessments of:

  • Each layer of the cornea Limbus
  • Conjunctiva
  • Lids and lid margins
  • Tears
  • Where possible a grading scale and diagrammatic recording should be used.

(6)   Conclusions/Advice/Actions

Space should be available for practitioners to record, for instance, changes in wearing pattern, refit, replacement, discontinue lens wear (temporary or permanent), change in care system, adjustments to power or fit, etc. This should include the rational for changes including patient requests to meet any specific challenges, circumstances and requirements. Also included under this heading would be advice on time of next contact lens aftercare check and/or full eye examination.

(7)   Contact Lens Specification

The issue of the contact lens specification and its expiry date should be noted – and it is advisable that a copy be made of the document issued and kept in the patient’s records.