A red eye, a demand for steroids and a withheld contact lens prescription
A 34-year-old, Mrs. D, wears monthly soft lenses on an extended-wear basis and presents with a red, painful right eye after sleeping in her lenses for two nights. Vision is 6/12 right; there is a 1.5 mm epithelial defect with an underlying stromal infiltrate about 1 mm from the visual axis. You suspect microbial keratitis. She asks for "steroid drops to calm it down" and mentions that an urgent care clinic gave her chloramphenicol last time. She also wants her contact lens prescription emailed to an online retailer. The file contains a refraction from three years ago but no recorded base curve, diameter or brand. The practice's receipt states that prescriptions are released "on request after purchase of a 12-month lens supply". The jurisdiction requires contact lens prescriptions to be released with all parameters and states that they expire after 12 months.
1. How do you manage the red eye, and why is the steroid request refused? Address prescribing and sample-handling obligations.
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Diagnosis first. A red painful eye, reduced vision and an epithelial defect with an underlying infiltrate in an extended-wear lens wearer is microbial keratitis until proven otherwise - a sight-threatening emergency. Steroid at this stage is contraindicated: it can worsen fungal or acanthamoeba infection, suppress the inflammatory signs you need to monitor, and does not substitute for antimicrobial cover. The previous chloramphenicol is also inadequate for a corneal infiltrate.
Action. Stop lens wear. Document the lesion's size, position and depth with a diagram (and a photograph if available) or take a corneal scrape if your scope and equipment allow. Start intensive topical fluoroquinolone, typically hourly while awake with a taper, add a cycloplegic for comfort, and arrange same-day or next-day ophthalmology review. Give written instructions and an after-hours contact.
Prescribing hygiene. Write a proper prescription - drug, strength, directions, quantity, date, repeat status - and record the indication and advice given. If you dispense a sample: label it with the patient's name, drug, strength, expiry and directions, and record in the file that it was a sample, with the lot number. An unlabelled bottle is unsafe and, if a dispute arises, unverifiable.
At review, do not escalate to a steroid-antibiotic combination to satisfy her. If the defect has not healed, refer. Tell her, and record, why she is not getting the drops she asked for.
2. What are your obligations regarding the contact lens prescription she has asked to be sent to the online retailer?
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The prescription belongs to the patient. In most jurisdictions the practitioner must, on request, provide a written contact lens prescription containing enough to be filled elsewhere: lens type and brand, base curve, diameter, power, cylinder and axis, colour if relevant, material, wearing schedule, prescriber identification, date of issue and expiry. Under this jurisdiction's rule it expires after 12 months.
The policy is unlawful. Conditioning release on purchasing a 12-month supply from the practice is a tie that regulators treat as a professional-conduct breach and that consumer law may also catch. Remove the wording from receipts, signage and the website, and retrain staff at the counter.
What you actually hold. The file contains a three-year-old refraction and no base curve, diameter or brand. You cannot invent parameters, and you should not release a document labelled as a contact lens prescription that omits required fields. Explain that a current assessment is needed, offer to perform it at your usual fee, and note that the cornea must be healed and quiet before any refitting.
If she declines, she is still entitled to a copy of her record, including the refraction - but that is not the same as a current contact lens prescription, and you should say so plainly.
Document the request, what was supplied, what was declined and why, and keep the correspondence with the retailer if it contacts you to verify.
3. A manufacturer's representative later offers the practice a box of steroid-antibiotic samples plus a sponsored lunch in exchange for "using more of the combination in red eye cases". How should this be handled?
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Separate the two issues. Accepting a meal at an educational event is usually low-risk and often permitted within a cap set by the board or by the practitioner's employer; accepting it as payment for a prescribing pattern is not. The phrase "in exchange for using more" converts a gift into an inducement, and prescribing driven by supply rather than diagnosis is a conduct matter regardless of whether money changes hands.
Sample handling. Samples may generally be used for patient care where the jurisdiction allows it, but they must be recorded as samples (drug, strength, quantity, lot, date, patient), labelled for the patient, stored correctly and never sold. A box held "for the practice" with no accountability is a stock control and recordkeeping failure waiting to be found.
Clinical objection. The representative's premise is wrong: more steroid-antibiotic for red eyes is exactly the pattern that harms patients with undiagnosed herpes simplex, fungal keratitis or acanthamoeba. Declining on clinical grounds is easy to defend and easy to document.
Practical response. Decline the inducement, accept or decline the lunch on the practice's usual policy, and record the interaction in whatever gifts/industry-contact register the practice keeps (many jurisdictions and employers require one). Brief the team so no one else accepts on the practice's behalf. If the representative persists, refer the matter to the company and, if necessary, to the board.