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I've written frequently about delegating clinical procedures, but I'm often asked about pretesting
techniques for the contact lens patient. It can get a little complicated, with lenses coming out for
some tests and going back on for others.
Admittedly, a wide variety of clinical philosophies exist on what tests to include and what sequence
to do them in. Show me five ODs and I'll show you five different ways to approach an eye exam and
contact lens evaluation. Here are some ideas that may make you more efficient in a routine eye exam
for a patient already wearing contacts.
Pretesting sequence by technician
- Patient arrives at the office wearing their contact lenses as usual.
- Technician calls the patient in from the reception area and they enter a pretest room.
- Brief, friendly greeting; technician states his or her name and explains about pretesting before
the doctor sees the patient.
- Contact lenses are removed by patient and placed in a flat pack case with saline. A small table
with flat packs, saline, tissues, mirror and hand disinfectant is available.
Here is the pretest sequence we have used in my office.
- Technician instills two drops of 2.5% phenylephrine in each eye after describing them as mild
- Autorefraction / auto-keratometry is performed (without CLs).
- Non-contact tonometry.
- Automated visual field screening.
- Auto-lensometry (unless we made the previous glasses and have a record of the Rx). In any case,
the habitual spectacle Rx is recorded on today's exam form.
- Move to another room for corneal and retinal imaging, taking contact lenses along in flat pack.
- Corneal topography.
- Digital retinal photography.
- Move to an available exam room.
- Assist patient with reinserting the contact lenses.
- Case history; record chief complaint, medications, allergies and other pertinent information.
- Visual acuity with contact lenses. Monocular at far, binocular at near.
- Color vision.
- Blood pressure.
- Navigate to and display corneal maps and retinal images on the exam room computer work station.
- Ask patient if he would like to view video clips on eye care topics on desktop computer.
- Page doctor on silent paging device.
- If contact lenses are rigid and not fitted by our office, the technician measures lens base curve
and diameter. Any additional paper work may be partially completed.
It's interesting to note that the majority of the tasks for the doctor are in patient communication, not
- Doctor greets patient, shakes hands, and engages in friendly conversation about non-eye related topics.
- Technician stays with doctor to assist and record data.
- Doctor washes hands while talking.
- Review and expand on case history.
- Over-refraction with phoroptor.
- Slit lamp exam and contact lens fit evaluation.
- Fundus examination with slit lamp lens and with direct and indirect ophthalmoscopy.
- View and explain corneal topography images and retinal photographs.
- Discuss contact lens status, review new advancements and make recommendations.
- Review eyeglass prescription and make recommendations.
- Review eye health status and discuss any need for additional testing.
- Based on the patient's status and needs, carry out additional procedures which may include inserting
new trial contact lenses, removing contacts for subjective refraction, instilling additional mydriatic
drops. Doctor may provide instructions to technician and leave the room to return later to complete
- Doctor tells patient when and why he should return for re-examination and states how he will be
- Doctor thanks patient for choosing the practice for eye care.
I recommend charging a comprehensive exam fee, a refraction fee and a separately itemized contact lens
evaluation fee. The contact lens fee covers the corneal topography and lens fit evaluation. I don't feel
the exam fee needs to relate to the amount of doctor time spent. Even with a contact lens patient, as
described above, the exam could be performed fairly quickly. I think patients actually prefer eye exams
that don't take a long time.
My practice purchased two computerized refraction systems six months ago and these have proven to be even
more efficient than the protocol above. The digital exam rooms are equipped with an auto-refractor/K,
autolensmeter, digital refractor with display pad and a digital acuity chart. Each of these computerized
exam rooms also has a table-mounted slit lamp. In addition to all the pretests mentioned above, a subjective
refraction is obtained by the technician when the lenses are off. The tech may also perform a basic lens fit
evaluation with the slit lamp and can check anterior chamber angles.
Food for thought
Most of us were trained to always take visual acuity first, before any other testing, to avoid the potential
for liability if it were alleged that we caused some eye damage with our exam procedures. Also, some contact
lens fitters would say that the slit lamp exam and fit evaluation should be performed by the doctor before the
lenses are removed, so that the lens surface, fit characteristics and tissue integrity are not disturbed in
the act or removing and re-inserting. I don't find those issues to be a concern in the vast majority of
contact lens cases today, but if you do, by all means adjust your sequence of procedures accordingly.
I do think it's necessary to remain flexible in your approach with testing, and adapt to the needs of the
patient. A well-trained staff is key here, since a technician most likely sees the patient before the doctor.
For example, if the exam was not routine and a medical emergency is present, the entire sequence would change.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
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Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
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