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Heidi Wagner, Robin L. Chalmers, G L. Mitchell, Meredith E. Jansen, Beth T. Kinoshita, Dawn Y. Lam, Timothy T. McMahon, Kathryn L. Richdale, Luigina Sorbara, CLAY Study Group; Gaps in the Contact Lens Case History: Identifying Items for a Soft Contact Lens (SCL) Risk Questionnaire. Invest. Ophthalmol. Vis. Sci. 2011;52(14):6500. doi: https://doi.org/.
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The purpose of this study was to retrospectively investigate scanned clinical records from SCL wearers presenting with infiltrative or infectious conditions in order to identify patient behaviors, risk factors and gaps in case histories that could prompt prevention of these events.
A multi-center retrospective chart review of de-identified clinical records from visits with infiltrative or infectious conditions among SCL wearers aged 8-33 years was performed. Reviewers were asked to note the presence or absence of various risk conditions in the patient case history at the presenting visit for the complication. Using the Turning PointTM software (Turning Technologies, Youngstown, OH) reviewers were polled in a focus group format to evaluate whether items generally existed in their records and to assess their importance for inclusion in a risk questionnaire (using a Likert scale).
In the chart review of 248 events, disparities between existing documentation in the clinical chart (C) and panel perceptions (P) were noted for patient behavior, symptoms, and health status. Compliance issues had the largest gap between chart presence and reviewer rating of importance ((C/P)% strongly agree or agree); back-up spectacle wear (50/88), swimming (33/63) care regimen (50/75), wearing schedule (67/88), hot tub use (17/38), and lens replacement schedule (67/75). Chart presence and reviewer rating of importance converged for overnight wear (83/88). Respiratory status was the most important and reported health system (50/75).
Important information on risk factors for SCL complications is often absent from the clinical case history. Development of a risk profile questionnaire will help define and document risk factors associated with SCL complications. Understanding these relationships can potentially improve the safety and efficacy of SCL wear.
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