The Case of the Mail-Order Patient

William K. Ramsay, OD
April 1999

Mail-order contact lens purchasing made it easy for this non-compliant patient to bypass a proper eyecare schedule.

Do you fear the "horrible patient?" You know the kind, they never listen to your advice while risking their eye health and maybe even your license to practice.

I had one recently, named Chris. She presented to my office complaining of a discharge in her right eye and excessive movement of her soft contact lenses. She told me that she was wearing a pair of "loaner" soft contact lenses. Chris showed me the blister-pack labels: 8.00D sphere, 8.7/14.0, Bausch & Lomb Seequence II trials. She said she had been wearing these disposable lenses as extended wear for 10 days at a time for the past 18 months. She mentioned that they were prescribed by a local ophthalmologist and that she had been purchasing them via mail order from Lens Express. Her contact lens history included wearing daily wear soft lenses for 17 years. She also brought in a copy of her last spectacle prescription: -8.00D sphere OD and -8.25D sphere OS.

Chris' visual acuities were 20/25 OU with her contact lenses. Slit lamp biomicroscopy revealed 360 degrees of 0.5mm superficial corneal neovascularization. The central corneas were unremarkable. Her tear film indicated Grade 2 debris in each eye. Chris' lids and conjunctivae exhibited a Grade 4 GPC OD and Grade 3 GPC OS. The contact lenses had a Grade 3 protein film.

I digitally imaged Chris' eyelids, showed them to her on the computer monitor and explained her condition at great length. Because Chris did not have spectacles and wanted a new frame with polycarbonate lenses, I loaned her a pair of 7.50D sphere, Seequence II trial lenses until her eyeglasses arrived in two days. I advised her to discontinue her lens wear for one month and then we would consider refitting her into rigid gas permeable contact lenses. I prescribed her a mild topical ocular steroid for two weeks until her eyes were comfortable. She was then scheduled to return in one month. Two days later, Chris picked up her eyeglasses, but never returned for follow-up.

Discovering The Truth

I was able to obtain her last exam records one week after she initially came to my office, which revealed that she presented in a similar manner at another office three months before she saw me. She told the office that she had lost her right soft extended wear disposable contact lens and had no replacements. She mentioned that she wore the Seequence II contact lenses continuously for two to three weeks at a time. Through slit lamp biomicroscopy, the other office noted the same GPC, but also that Chris had slight corneal SPK in each eye. Chris' left contact lens was noted as appearing "terrible." The office also gave her a trial pair of Seequence and advised her of one week maximum wear time and then to refit to RGPs. A note of discussing RK surgery was also delineated. Her keratometry readings were 45.75/47.37 @090 OD and 46.50/47.50 @090 OS, indicating to me that she actually may require an 8.4 base curve Seequence II. She never bothered to return to the other office for follow-up either.

The next time I saw Chris was one year later when she came into the office as an emergency. She explained that her left eye was hurting her that morning after she removed her left contact lens. She then reinserted the soft disposable contact lens and it hurt even more. Her eye was now swollen, and she claimed that she was not wearing the left lens when she came in. She told me that she threw it away that morning after attempting insertion.

Chris admitted that she had been getting her contact lenses via mail order from Lens Express without a prescription for two and a half years. She merely gave them the prescription on the trial lens blister packs that the ophthalmologist had given her. Her usual replacement schedule was every two weeks. Chris stated that she rinses her contact lenses each morning with Bausch & Lomb Sensitive Eyes saline solution because she awakens each morning with debris on her eyes.

Visual acuities tested at 20/20 OD and 20/25 OS (pretty good vision OS for an "uncorrected" 8.00D myope). Slit lamp examination revealed a soft contact lens on her left eye. Her GPC was now Grade 3 OD and Grade 4 OS and there was slight debris under the left lens. No corneal staining was found OD, but her left eye had a dense, centrally located, arcuate-shaped area of superficial corneal abrasion.

Repeat Offender

I discussed the finding at great length with Chris. I digitally imaged the findings and again showed Chris her eyelids and her abraded cornea. I explained the 24 to 48 hours needed to heal her cornea and advised her to not wear her contact lenses for at least one month. I prescribed a mild topical ocular ointment for prophylaxis. I scheduled her to return in two days to check her corneas, then in one month to check her eyelids, and again one week later to receive a comprehensive eye exam.

Chris returned in three days. Her corneal abrasion had resolved and only a slight bit of SPK was observed on her left cornea. Her visual acuities measured 20/50 OD and 20/40 OS with her spectacles. I advised Chris to discontinue the ointment and prescribed artificial tears every three hours for the next two days. To help treat her GPC, I instructed her to use Alcon's Alomide ophthalmic drops after two days in both eyes. She never returned to my office one month later for the scheduled checkup of her eyelids.

A Sight-Saving Lesson

As we all know, patients have different motivations for wearing contact lenses, as well as different motivations for purchasing them from alternative sources. Apparently, this patient was convinced that mail order was her best option for contact lens purchase. She had little concern for proper eye health monitoring. Her repeated misuse of her contact lenses led to severe GPC and potential vision loss, though additional corneal damage may be in her future.

This patient shows us how easy it is to purchase mail-order lenses without any prescription verification by the vendor. Contact lenses are prescription medical devices that can alter our body's tissues. They should be given the respect they deserve and mail-order companies that dispense them must be held responsible and should be susceptible to state and federal regulations. CLS

Dr. Ramsay has been in solo private practice in fort myers, Florida since 1992. He practices full-scope primary eye care, with sub-specialties in lacrimology and specialty lenses.