By Peter D. Bergenske, OD.
Many patients want to see well and clearly without the hindrances of glasses. Some are even willing to pay a handsome fee and accept the risks to undergo surgery on their eyes because they hope to attain "normal" vision. On the other hand, many patients with very high refractive errors, who we might expect to want a permanent "fix," are often not interested in exploring options beyond the ones they already use, as they are adequately satisfied and see no reason to risk losing any vision.
Clinicians today can offer many options to meet the vision needs of their patients. It is good practice and in the best interest of the patient to consider alternatives in each situation.
Break The "Same Old" Cycle
Many practices have a large percentage of happy patients who have been wearing the same type of contact lenses for years. Practitioners see them somewhat regularly, and, following the conventional wisdom that "if it's not broke, don't fix it," most practitioners will continue with the current form of correction unless the patient specifically asks about alternatives.
Most patients who come in for routine examinations want reassurance, and they expect their practitioners to update them on the newest and best in vision care. Patients today have access to a tremendous amount of information, but they still seek out their practitioners for the final word on their eyes. They know they want to see well and comfortably without glasses, but no matter how much they read about contact lenses or refractive surgery, they want to know what their practitioners think.
Consider the case of the 3.00D myope who for years has been wearing disposable lenses on a daily wear basis with a two-week replacement cycle. If there is no change in refraction, this patient will likely be content to reorder the same type of lenses for another six months or a year, if that is what the practitioner recommends. There is nothing wrong with that. However, why not at least give him some other options?
Fluorescein pattern showing a well-fitted reverse geometry
The mainstay of many contact lens practices has become the soft disposable lens worn on a daily-wear basis and replaced once or twice a month. We can reasonably expect that the current practice will continue to evolve such that daily wear will mean daily disposal, and longer wear will mean overnight for up to 30 days. Obviously these are not yet options for all soft lens wearers, and there will always be patients for whom rigid lenses offer significant advantages. But these disposable options are gaining momentum, and will likely constitute a large segment of contact lens practice in the future.
Single-use lenses have also become more affordable for patients who wear other single vision spherical soft contact lenses with longer replacement schedules. Patients may pay as little as $4 or $5 a month more to wear single-use lenses as opposed to two-week disposable lenses. Very rarely does a patient try this modality for three months and then wish to return to multiple-use lenses and the lens care required.
Not all patients need or want to wear lenses every day. Single-use lenses are exceptionally well suited to irregular wearing schedules. They are an appropriate alternative for virtually any other single vision spherical soft lens. Toric and multifocal versions are only a matter of time. The majority of practitioners have yet to catch on to the relative merits and safety of this modality, but it seems certain that this will continue to be an excellent option for a long time.
Newer generation silicone-hydrogel lenses like
PureVision have better resistance to bacterial binding.
Extend Their Wear
Extended wear is an option that few patients will inquire about on their own, but they show great interest when the practitioner brings it up. In discussing extended wear, also discuss the additional level of responsibility it requires. The new high permeability lenses coming on the market have brought hope that extended wear will be safer than in the past. Clinically, patients do very well with extended wear, whether in the one-week, weekly disposable soft lenses and high Dk rigid lenses that we've had for a decade, or in the newer, one-week wear, monthly replacement, high-Dk, silicone-hydrogel lenses. Whether or not the higher Dk will actually provide us with a greater margin of safety remains to be seen, but these lenses have shown great promise in terms of clinical results, patient acceptance and overall success.
In many ways, extended wear of contact lenses can deliver nearly the same benefits as refractive surgery. Waking up with good vision is one of the first benefits that many laser-corrected patients bring up. This is a great advantage of extended wear, along with relative absence of lens care. A large number of surgical candidates could alternatively be put into extended wear contact lenses. If a patient's principal wish is to see clearly without glasses, and without having to bother with contact lenses, extended wear may be the best and safest choice. Although extended wear carries greater risks than daily wear, the risk of losing best-corrected visual acuity is far less with extended wear than it is with surgical refractive procedures. In addition, extended wear is more flexible, allowing for adjustment of prescription, or trying new technologies as they develop. Although many, if not most, potential laser correction patients will reject the option of extended wear contact lenses, they all deserve to be made aware of its numerous advantages and lower risk of vision loss.
Don't forget that virtually every contact lens patient has at least some curiosity about refractive surgery. I generally assume that this is the case, and ask patients if they have any interest in, or questions about, refractive surgery. (I make the same assumption and inquiry of many spectacle wearers, and they are often more interested than my contented contact lens patients). Determining which patients are good candidates for laser vision correction involves more than gathering the refractive and other clinical data used to plan the procedure. You must also assess each patient's motivation, expectations and flexibility. There is no substitute for patient education and frank discussion of risks and limitations of these procedures.
For the successful contact lens wearer, the advantages of laser vision correction must be carefully weighed with the risks and the cost. I point out to many contact lens wearers that, should they have a refractive procedure such as LASIK, with a perfect result they will see just like they do with their contact lenses, not better. What they can gain has everything to do with convenience and very little to do with vision, unless of course they do not have a perfect result. Patients who postpone refractive procedures can expect the technology to improve in precision, safety and cost.
Even so, there are still many patients for whom long-term refractive change is strongly preferred. For some patients, this is a significant quality-of-life issue. In counseling patients about refractive surgery, practitioners must be aware of the numerous psychological factors that play in the decision to undergo an irreversible procedure for vision correction.
Include rigid lenses in every discussion about contact lens options. Not only are rigid lenses unparalleled for safety and quality of vision, the possibility of myopia control and myopia reduction via orthokeratology makes rigid lenses particularly valuable and appealing. Although the evidence regarding myopia control has been mostly anecdotal to date, the body of knowledge regarding the epidemiology of myopia continues to grow, and we can expect it to give us some real answers regarding the role that rigid lenses play. If rigid lenses prove to have a significant effect on myopia control, I anticipate that not only will practitioners routinely recommend them, but patients and parents will ask for them.
Some patients only occasionally need to see well without glasses or contact lenses. Orthokeratology offers good vision with lenses on that can be sustained when necessary with the lenses off. Orthokeratology can help patients who require myopic astigmatic correction, but engage in sports or occupations where wearing a lens on the eye could cause problems.
Post-LASIK corneal maps.
Know Your Options
The many challenges yet to be met in the contact lens industry offer us great opportunity. Eyecare practitioners must be aware of new products and services as they are developed in order to meet these challenges. Offering and recommending new products and services is not only good patient care, it is also good business. Successful contact lens practice will continue as long as products and technology continue to evolve, and practitioners remain devoted to providing patients with the best in service and products. Patients will always have the desire to see well, comfortably, safely and conveniently without the stigma or nuisance of glasses. Our challenge is to present and provide the products and services that will best serve their needs.
Bergenske, the Immediate Past Chair of the American Academy of Optometry's Section on Cornea and Contact Lenses, practices in Madison, Wisc. He has conducted clinical research and lectured on many contact lens-related products and issues.
Contact Lens Spectrum, Issue: June 2000