Training the New Contact Lens Wearer
Does your technician know these facts and techniques?
BY SHELLEY I. CUTLER, O.D., F.A.A.O., Lower Gwynedd, Pa.

Long-term successful contact lens wear begins with the correct fit. Equally important, if not more so, are proper hygiene and care. Most optometrists delegate instruction in this crucial information to a technician. To teach the new contact wearer, make sure your contact lens technician is well informed and has lots of tricks of the trade, as I'll explain here.

PROPER HYGIENE

The first step before handling a contact lens is to wash your hands to eliminate dirt, oils, bacteria and other germs. Soaps aren't all alike. Many contain creams and moisturizers which are a disaster for a contact lens. You and your technician should know which soaps are best. Some are specifically designed for contact lens use; others are acceptable commercial products you can obtain anywhere.

If a patient has tried many soaps and can't find one to eliminate skin oils, recommend a contact lens daily cleaner for the parts of the hand that contact the lens: the palm and certain fingers.

GENERAL INSERTION AND REMOVAL GUIDELINES

When your technician trains your patients, make sure she:

Keeps the working area clean. Stress the importance of cleanliness. If you set a good example, the patient is more likely to keep her working area clean too.

Has the patient observe herself. Initially, she should watch what she's doing as she's doing it.

Most patients are successful by observing themselves in a vertical, upright position. If the lens falls off the patient's finger, suggest that she hold the lens parallel to the ground until it reaches her eye. Then she should roll the finger towards the eye as the lens approaches. If this doesn't work, have her use a mirror that tilts and position it parallel to the ground or place a flat mirror on a table. As the patient leans over the mirror to observe what she's doing, the lens maintains a parallel position and doesn't slide around.

Some patients close their eyes reflexively as their fingers approach. Make sure they keep their eyes open. In time, when they become proficient, they can insert lenses without a mirror.

Many patients eventually insert their lenses over the sink. Remind them to always plug the sink drain.

Tells new patients what to expect ahead of time. A full explanation before the actual "hands on" is an excellent idea. If the technician wears lenses herself, she may want to demonstrate personally. Videos made specifically for this purpose are effective too.

An apprehensive patient will become less nervous if the technician has credibility. The technician should stay in control even if she experiences some difficulty, showing patience and confidence.

If your contact lens technician doesn't wear lenses, it would probably be beneficial to fit her with a new cosmetic tint or design. Enthusiasm is contagious.

LID POSITION

The basic lid position for both soft and rigid contact lens insertion is the same. Because patients need to secure their eyelids when inserting lenses, suggest the following two methods, which seem to work best.

The two-hand method. First, identify the patient's dominant hand. She'll use the other one to secure the upper lid. Using the forefinger, middle finger or thumb, she should grasp the lid under the lid margin and secure it against the bone of the superior orbital rim.

Often the lid seems to slip away, leaving your patient holding her eyebrow. Tell her not to do this, for now she can close her eye. A helpful hint for grasping the upper lid on the side of hand dominance (for a right-handed patient, this would be the right upper lid grasped by the left hand) is to have her grasp the lid from above. This will keep her arm away from her face and she can observe what she's doing. If she tries to reach across her face, the arm and hand block the left eye.

This patient has good control of her eyelids.

The middle finger of the dominant hand should grasp the lower lid. Test the patient to see if she can close her eyes. If not, she has a good grasp of her lids (see left).

Now the patient is ready to insert the lens. The contact lens will be on the forefinger of the dominant hand.

The one-hand method. This approach to lens insertion is a little trickier. The patient must use her left hand to hold the lids of her left eye open, and her right hand to hold the lids of her right eye open. The patient can use her thumb and index finger or first two fingers.

The left/left or right/right rule is necessary; otherwise the patient would get in her own way. This means that the patient will have to insert one of the lenses with her non-dominant hand. This may be problematic for some, especially in the beginning.

It's possible to hold the lids with the opposite hand (left hand holds the right eyelids, right hand inserts contact lens), but then the left hand crosses the face and blocks the left eye, making it difficult for the patient to see what she's doing in the mirror.

HELPFUL HINTS

• Many patients seem to be in a rush. They hold their eyelids properly, but as they approach the eye to insert the lens, their speed seems to increase. They should slowly place the lens on the eye, and not retract the finger until they make contact.
• The most helpful advice for inserting a contact lens is to control the eyelids. Remind patients to press the upper lid against the bone of the orbital rim and hold it there. Also remind them to hold their lower lids down until they see that the lens is on the eye. Slowly release the lower lid, then the upper lid.
• If your patient is tense, she may exhibit significant blepharospasm. It may seem impossible to get her eyes open. If this occurs, talk to her in a soothing voice. Try to get her to relax.
• The other eye may reflexively close. Remind her to watch what she's doing. Have her open her mouth. If patients concentrate on this, their eyes tend to open.
• Some patients are ultrasensitive and have extreme difficulty in the beginning. Depending on your philosophy, your technician could use one drop of anesthetic during the instruction class.

INSERTING RIGID AND SOFT LENSES

Have your technician follow these guidelines when teaching:

Rigid lenses

Insertion
Prepare the lens with the correct solution. Secure the lids. Place the lens on the patient's index finger and gently insert it directly on to the cornea. If the lens slides around, make sure the finger itself is on the drier side.

Removal
Have the patient hold her head down, parallel to the floor or table. Instruct her to open her eyes wide so the eyelids clear the edges of the contact lens. Simultaneously, insert her index finger or thumb between the eyelids at the lateral canthus. To tighten the lids, the finger must pull them toward the ear and slightly up. With a quick blink, the lid margin should catch the flanged edge of the contact lens and eject it. This should work in a second or two.

Sometimes, a patient can't master this skill. There are two alternatives.

1. The easiest is to use a DMV. You can obtain this little rubber plunger from contact lens suppliers. It comes in several shapes. All are used in a similar fashion.

To teach the use of a DMV, have the patient separate her eyelids, using the technique for contact lens insertion. Holding the DMV between the thumb and forefinger, or middle finger, she should touch the lens lightly with the DMV. The contact lens will stick to it. Then she can remove the contact lens.

2. The other technique is the same two-handed finger manipulation method that many O.D.s and technicians use for removing a lens from a patient. Position a tight eyelid under the edge of the contact lens. This will eject the lens.

Have the patient place both of her thumbs or forefingers at the inner canthus of the eye and pull her eyelids laterally to make them tight. When her fingers reach the 12:00 and 6:00 position of the corneas, make sure the lids have cleared the edges of the contact lens. Then take one of the eyelids and slip it under the edge of the contact lens. Simultaneously, hold the other lid in position against the eyeball. This acts as a fulcrum. With light pressure, the contact lens should pop out.

Soft lenses

Insertion
Prepare the lenses with the correct solution. The patient should check for nicks or tears and discern whether the lens is in the proper orientation (not inverted) as shown below.

Secure the lids. The lens should be placed on the patient's index finger with all edges "up." Gently direct the finger to the eye. Because of their dynamics, soft lenses don't necessarily have to be placed exactly on the cornea. If the patient looks into the lens, it should center. If it doesn't, a little manipulation through the eyelids will facilitate lens positioning.

Take care the lens edges remain "up." If an edge collapses against the finger, it will be impossible to apply to the eye. If this happens, the patient needs to reposition the soft lens and begin again. Make sure her finger isn't too wet, or the lens will adhere to it and not to the eye.

Removal
Removing a hydrogel lens is different than removing a rigid lens because you have to "pick" it off the eye. Have the patient secure her eyelids open. Place the finger pads of the thumb and index finger approximately at the 4:00 and 8:00 position on the contact lens, pinch, and remove the lens from her eye.

Some patients don't like the idea of "picking" directly at their eyes. Instead, they can slide the contact lens onto the sclera and remove it from there. Have the patient look in the opposite direction of where she plans to slide the lens -- for example, have her look up and slide the lens to the inferior sclera. Remove the lens from there. Because this takes a little longer, make sure she securely holds her eyelids open.

HELPFUL HINTS

When there's a problem, it's usually because the patient is afraid to touch her eye. She's too gentle. Sometimes she needs to exert a little pressure at the 4:00 and 8:00 positions to release the suction.

Long or sharp fingernails can damage soft lenses, but women can become adept working with the sides of their fingers. Soft tweezers (available from commercial suppliers) also might help.

CONTACT LENSES FOR SPECIAL POPULATIONS

Here's how to help special populations learn to use contact lenses.

First-time presbyopes. Many have a fear of touching their eyes and they won't hesitate to tell you.

If you first practice without the contact lens, the process goes more smoothly. Teach the patient how to hold her lids. Place a drop of artificial tears on her finger and have her touch the sclera. When she masters this, try a very light touch on the cornea. Once she sees that there's no pain, it's easier to introduce the lens.

Make a good magnification mirror available and suggest that the patient have one at home, and keep her glasses beside her as well.

Teens. Talk to and teach teens as if they're adults, but recognize that half of what you say will get lost. Make detailed instruction sheets and review them.

If parents accompany their children to the training class, invite them to observe. They need some idea of what's involved. If an overbearing parent makes the teen nervous, you may have to tactfully ask the parent to wait in the waiting room.

Children. Don't talk down to younger patients. Explain what you need to do in words that they understand. A parent may have to get involved until the child is capable. With very young children (ages 3 to 6), it's probably prudent to begin by teaching the parents. When the child shows interest in learning the skills, teach her.

Instruct all parents about contact lens care for the child, who will probably need assistance until the parent and you see she's mastered the necessary skills.

Infants and toddlers. Another person (usually the parent) is responsible for insertion, removal and care. First, assure the parent that they won't hurt the child.

Inserting a contact lens on a young infant isn't difficult. The muscles aren't coordinated enough to resist with any force.

Have the parent place the baby on a flat surface. Usually the baby's head is small enough that eyelid control is easy. If an arm or hand flies up, it's easy to control with another person's help or by the parent securing the baby's arm with their own.

Don't leave an infant on a table. Make sure the contact lens case is there. After the lens is removed and in the case, place the baby in a safe place before cleaning the lens.

Small, tight lids tend to invert, so smaller lens diameters are best. Lid control is essential. It may take a few attempts to secure the lids correctly so they won't invert.

Toddlers are probably the most difficult age for lens insertion and removal. They resist when someone holds them down and their eyelids are tight and will probably invert. Chances are they will be screaming.

Toddlers are the most difficult patient group.

Head control is vital since toddlers will attempt to swing their heads from side to side. It usually takes two adults: one to secure the child and the other to insert or remove the lens. Lay the toddler on its back on the table or floor. The assistant should amuse her until you're ready. Then the assistant should quickly straddle the toddler to secure her shoulders and head (see left). If the toddler is rambunctious, secure her hips so she can't twist her body.

Teach the parent to move fast and deliberately. It helps to have everything prepared beforehand so the procedure can be performed quickly. Once the toddler realizes that it won't hurt and she'll see better, her resistance lessens. Again, assure the parents that they're not hurting their child.

Elderly patients. Incapable elderly patients are easy to work with. Their eyelids are flaccid and easy to grasp. There's usually little resistance. If they understand you're there to help, they're appreciative.

Whoever will be responsible for this patient's care should grasp the patient's eyelids, direct the patient's gaze and insert or remove the lens. Since this person will also be the one to clean and store the lens, make sure he or she understands the procedure. Supply instructions.

PARTING WORDS

Contact lens success is never 100% guaranteed, but careful instruction can pave the way to success. Make sure your technician follows the tips I've presented and you'll be on your way to happier patients.

Dr. Cutler is a Contact Lens Consultant and Adjunct Faculty Member at the Pennsylvania College of Optometry and works in a corneal practice specializing in difficult contact lens fits. She is a Diplomate in Cornea and Contact Lenses and has lectured nationally and internationally on various contact lens related topics.

HOW TO ASSESS LENS INVERSION

It's important to insert a soft lens on the eye with the proper orientation. If the lens is inside out, it may not perform properly or it may feel uncomfortable to the patient.   The proper orientation is with the lens edges up, similar to a teacup (see left). It will usually hold its open position more easily this way than if inside out. A lens that's inverted has flanged edges, similar to the German army helmets used in World War II (see right). A lens that's inside out may flop on the finger more easily.