Education:

The Key to Delegation

BY MARY JAMESON, OPT. T., R.
SEPT. 1996

Many tasks associated with a contact lens examination are well within the capabilities of a qualified assistant. Don't overlook this valuable resource.

Your contact lens assistant can be a valuable resource beyond the traditional tasks of patient education and instruction. In this age of managed care and the incumbent demands on your time, delegating more responsibilities to your assistants will enable you to see more patients and still spend quality time with them. As Dr. Koetting says, "Why try to do it all yourself?"

WHAT TO DELEGATE

The tasks you delegate may be limited by your state's laws, but many tasks associated with a contact lens examination are well within the capabilities of an assistant. These include: patient history, entrance visual acuities, palpebral aperture measurement, visual iris diameter and tear film assessment. After proper instruction, you can also delegate corneal measurements using the keratometer and the topographer, lid eversion, ocular health assessment and contact lens assessment using the slit lamp biomicroscope.

PROPER INSTRUCTION: THE KEY TO SUCCESSFUL DELEGATION

Once you've made the commitment to delegate, your goal should be to train your staff accordingly. Don't overlook the importance of teaching your assistant basic ocular anatomy, as well as the effects of allergies, ocular disease, systemic conditions and medications on contact lens wear. While much of the contact lens examination is data collection, a basic level of knowledge in these areas is critical for assistants to answer patients' questions. I suggest the following:

Demonstrate -- Have your assistant observe while you perform the contact lens examination.

Explain -- Briefly explain procedures as you perform them. It's helpful for the assistant to know the sequence of the procedures even if they're not going to perform all of them. Take a few moments outside the exam room to discuss your findings and how you will use the information for the contact lens fitting.

Clarify -- This is also a good time to answer any questions that the assistant may have.

Reinforce -- Be sure to supplement this demonstration with written instruction such as self-study courses and journal articles to help your assistant understand the theory and the technical procedures.

Query -- Self-study courses can also form the basis for questions that you may want to ask your assistants to make sure that they're learning.

Next, instruct and observe while your assistant performs these procedures on fellow staff members. Be sure to verify measurements to ensure accuracy. When you're satisfied that your assistants are fully versed in each procedure, have them perform the procedures on patients while you observe and check readings for accuracy.

Once you and your assistants are comfortable with the procedures, they can perform them on patients. Spot check readings occasionally for accuracy.

SAMPLE LESSONS FOR ASSISTANTS

LESSON 1: The following measurements help determine the appropriate diameter for contact lenses. It can be very difficult to instruct a patient with very narrow apertures to apply a large diameter soft contact lens.

These procedures can be done simultaneously, saving examination time while gathering more information.

Measuring the palpebral aperture

• Sit facing the patient at eye level.
• Have the patient fixate on a target at distance.
• Using a PD rule, place the zero mark at the edge of the lower (or upper) lid, being careful not to hold the rule too close to the lashes causing the patient to squint.
• Measure at the widest vertical point between the lids, usually the center.
• Record the distance in millimeters. Repeat with the other eye.

Measuring visual iris diameter

• Sit facing the patient at eye level.
• Have the patient fixate on a target at distance.
• Place the zero mark of the PD rule at the temporal limbus of the patient's right eye.
• Measure the distance to the nasal limbus.
• Record in millimeters.

LESSON 2: The tear film is an important component of contact lens wear. Having information on tear quantity and quality on record can help identify the causes of symptoms that the patient may acquire during lens wear.

Testing tear quantity with the standard Schirmer tear test

• Bend the paper strip at an angle at the notch near the top and remove it from the package.
• Have the patient seated comfortably, able to lay his head back on the headrest.
• Instruct the patient to look up toward the ceiling, then gently pull down on each lower lid.
• Place one strip for each eye between the globe and the lid at the nasal canthus and note the time.
• Remove the strips after five minutes (or whatever is customary for the practice) and measure.
• Record the readings and note any difference between the two eyes.

Assessing tear quality with the slit lamp biomicroscope

• Instill fluorescein
• Position the patient into the slit lamp.
• Focus the slit lamp on the tear film using a semi-wide beam of light and the cobalt blue filter.
• Instruct the patient to close and open the eye two to three times to assure distribution of the fluorescein and the tear film.
• While the patient keeps the eye open, time how long it takes for dark spots appear on the cornea, indicating that the tear film is breaking up. Record the time.
• Repeat with the other eye. CLS

Mary Jameson is on staff at the Pennsylvania College of Optometry. She chairs the AOA Paraoptometric Section.