Soft Contact Lens Fitting Template

Soft Contact Lens Fitting Record Patient Details: Name: Sarah Jane Smith Date of Birth: 15/03/1990 Patient ID: SJ-1990-CL Date of Visit: 01/11/2024 Subjective: Reason for Visit: "I want to try contact lenses for sports and social occasions, as my glasses get in the way." Ocular History: * Wears spectacles daily for myopia since age 12. * No previous contact lens wear. * No ocular surgeries. * Occasional dry eye symptoms, relieved with over-the-counter drops. Medications: * Oral Contraceptive, 20mcg, daily Allergies: * No known allergies to contact lens solutions or materials. Current Vision and Prescription: Uncorrected Visual Acuity: OD: 6/60 (Snellen), 1.0 (logMAR) OS: 6/60 (Snellen), 1.0 (logMAR) Current Spectacle Prescription: OD: -3.50 DS OS: -3.75 DS Best Corrected Visual Acuity with Spectacles: OD: 6/6 (Snellen), 0.0 (logMAR) OS: 6/6 (Snellen), 0.0 (logMAR) Ocular Measurements: Keratometry: OD: Flat K 7.80mm (43.25D) @ 180, Steep K 7.60mm (44.34D) @ 90 OS: Flat K 7.75mm (43.53D) @ 175, Steep K 7.55mm (44.63D) @ 85 Horizontal Visible Iris Diameter: 11.8 mm bilateral Pupil Size: 4.5 mm in dim light bilateral Tear Break-Up Time: 8 seconds OD, 7 seconds OS Trial Lens Parameters: Brand and Material: Acuvue Oasys, Senofilcon A Base Curve: 8.4 mm Diameter: 14.0 mm Power: OD: -3.50 DS OS: -3.75 DS Lens Assessment: Lens Centration: Well-centred bilateral Lens Movement: Optimal movement, approximately 0.5 mm on blink bilateral Comfort: "Very comfortable, can barely feel them." Vision Quality: Clear and stable vision bilateral Over-Refraction: OD: Plano OS: Plano Final Visual Acuity with Trial Lenses: OD: 6/6 (Snellen), 0.0 (logMAR) OS: 6/6 (Snellen), 0.0 (logMAR) Insertion and Removal Training: Training Completed: [x] Yes [ ] No Patient Proficiency: Good proficiency, able to insert and remove lenses independently after initial instruction. Additional Comments: Patient initially struggled with placing the lens directly onto the eye but quickly adapted. No issues with removal. Expressed confidence in managing lenses at home. Care Instructions Provided: Lens Care Solutions: Opti-Free PureMoist Multi-Purpose Disinfecting Solution Cleaning Instructions: Rub and rinse method, daily cleaning and disinfection. Wearing Schedule: Day 1-3: 4 hours daily Day 4-7: 6 hours daily Week 2 onwards: Up to 8-10 hours daily, as comfortable. Replacement Frequency: Two-weekly replacement Advised to Avoid Tap Water: [x] Yes [ ] No Advised to Avoid Showering in Lenses: [x] Yes [ ] No Advised to Avoid Swimming in Lenses: [x] Yes [ ] No Patient Education: Advised on Symptoms of Complications: [x] Yes [ ] No Emergency Removal Instructions Provided: [x] Yes [ ] No Handling Tips Provided: [x] Yes [ ] No Follow-Up: Scheduled Follow-Up: 15/11/2024 Follow-Up Notes: * Assess comfort and vision with continued wear. * Check ocular health for any signs of complications. * Reinforce care instructions and wearing schedule. Efron Grading: Blepharitis: Grade 0 OU Meibomian Gland Dysfunction: Grade 0 OU Superior Limbic Keratoconjunctivitis: Grade 0 OU Corneal Infiltrates: Grade 0 OU Corneal Ulcer: Grade 0 OU Endothelial Polymegethism: Grade 0 OU Endothelial Blebs: Grade 0 OU Corneal Distortion: Grade 0 OU Conjunctival Redness: Grade 0 OU Limbal Redness: Grade 0 OU Corneal Neovascularisation: Grade 0 OU Epithelial Microcysts: Grade 0 OU Corneal Oedema: Grade 0 OU Corneal Staining: Grade 0 OU Conjunctival Staining: Grade 0 OU Papillary Conjunctivitis: Grade 0 OU Additional Notes: Patient expressed enthusiasm for contact lens wear. She has a good understanding of the care regimen and the importance of follow-up. Discussed the option of daily disposables if two-weekly lenses prove challenging for her lifestyle in the future. No immediate concerns noted during the fitting process. Practitioner Signature: Dr. Thomas Kelly Date: 01/11/2024