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 By Neil B. Gailmard, OD, MBA, FAAO, Editor June 21, 2006 - Tip #231 
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Pretesting the Contact Lens Wearer

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Additional Information

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.

  • 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.
Pretesting sequence by technician

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 dilating drops.
  • 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.
  • Stereopsis.
  • 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.
Doctor's exam
  • 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 case.
  • Doctor tells patient when and why he should return for re-examination and states how he will be reminded.
  • Doctor thanks patient for choosing the practice for eye care.
It's interesting to note that the majority of the tasks for the doctor are in patient communication, not data gathering.

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.

Another approach

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,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

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