GP PRACTICE MANAGEMENT
GP Practice Management
GP lenses, virtually limitless in design
and optical correction, afford wearers uncompromising physiology and visual acuity.
By Susan Resnick, OD, FAAO
Eyecare
practitioners who regularly prescribe and fit GP lenses gain long-term patient loyalty
as well as the opportunity for practice differentiation and growth. Yet, according
to "International Contact Lens Prescribing in 2005" (January 2006) by Morgan et
al, GP lenses represented only 10 percent of new fits and 11 percent of refits worldwide.
And, as reported in "Contact Lenses 2005" (January 2006) by Joseph Barr, OD, MS,
FAAO, of the estimated 36 million contact lens wearers in the United States, only
about 10 percent to 13 percent wear GP lenses.
The
underutilization of such a valuable and versatile modality seems rooted, for the
most part, in practitioner apprehension, according to "Use of Presbyopic Contact
Lens Corrections in Optometric Practice" (April 2005) by Harris et al. Complexity
of design, increased chair time, and probability of patient rejection are some of
the most typical misperceptions about GP lens fitting.
While the prospect of fitting
GP lenses may foster real feelings of anxiety, you can easily overcome them. You
can readily navigate the learning curve to developing proficiency in evaluating
and prescribing GPs with proper patient management combined with a proactive, yet
systematic clinical approach. With today's advanced designs, materials and sophisticated
manufacturing techniques, even your first few GP lens patients are likely to adapt
in an exemplary fashion.
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TABLE 1 |
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GP Candidates
by Patient Population |
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GP CANDIDATES |
GP OPTIONS |
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Children and teens |
Conventional or corneal
reshaping |
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Moderate to high astigmats, any age |
Spherical, front- or
back-surface or bitorics |
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Marginal dry eyes |
Any design |
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Prevent possible ocular health
compromise |
Any design |
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Occupational/long wearing
time |
Moderate to high-Dk daily or
extended wear or reverse geometry/corneal reshaping |
|
Maintain binocular vision throughout presbyopia |
Bountiful multifocal
options |
Your Target Population is Likely Already in Your Exam Chair
Whether your goal is introducing GP lenses to
your practice or expanding your existing range of specialization and expertise,
your target population consists of both prospective new fits or refits .
Consider GP lenses as an excellent option
for children and teens who will benefit from their ease of handling, reduced chance
of allergic or infectious complications and lower frequency and severity of prescription
changes. Overnight corneal reshaping lenses are an increasingly attractive option
for this population. Successfully implementing this technology often serves as a
valuable practice builder.
Moderately to highly astigmatic patients
of any age invariably achieve better visual results with GP lenses. Consider spherical
GP lenses for your moderately astigmatic patients who are new to lens wear or for
those current soft lens wearers who aren't completely satisfied. Toric design lenses
present an even better option for patients who have greater than 2.50D of corneal
astigmatism or for those manifesting visually significant residual astigmatism.
GP lenses may be a better initial choice
for patients who have marginally dry eyes and, in particular, for soft lens patients
who experience reduced wearing time or are on the verge of dropping out of lens
wear. The excellent surface wettability and oxygen transmission, combined with the
fact that GP lenses do not undergo bulk dehydration and tightening on the eye, are
features which can reduce contact lens-induced dry eye symptoms.
Even with the increasing options in
silicone hydrogel lenses for occasional overnight or extended wear, GP lenses still
prove the safer option for patients of all ages desiring this wearing schedule.
GPs result in fewer incidences of inflammatory and sight-threatening conditions.
Whether in conventional spherical design for around-the-clock wear or in reverse
geometry design for overnight corneal reshaping, consider the convenience and freedom
this option might afford to patients who have occupational requirements to wear
their correction for long periods (such as police and emergency personnel and healthcare
workers).
Perhaps the largest untapped segment
of the current target population is new and existing lens wearers who have reached
presbyopic age. Today's improved GP multifocal designs allow you to offer current
lens wearers these more sophisticated and generally more visually and cosmetically
acceptable alternatives to monovision or reading glasses. In particular, consider
multifocal aspheric GP lenses for patients of all ages who spend a significant portion
of their day at the computer.
Table 1 summarizes how best to match
prospective GP candidates with an appropriate GP design.
Educating Your Staff and GP Candidates
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TABLE 2 |
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Identifying
GP Lens Candidates |
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IDEAL
GP CANDIDATES
• Patients
who express dislike of full- or part-time spectacle wear.
• Young
patients at risk for progressive myopia.
• Astigmats
who previously failed with soft lenses.
• Patients
who have irregular corneas.
• Patients
who have high visual demand or sensitivity. |
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LESS-THAN-IDEAL TO POOR GP CANDIDATES
• Patients
who have contraindicative pre-existing ocular or systemic medical
conditions.
• Patients
who use medications that significantly reduce tear volume.
• Patients
who exhibit greater than normal resistance to having their eyes touched.
• Patients
who report higher than average sunlight sensitivity.
• Patients
who report dust or particle sensitivity.
• Patients
who have pre-existing prejudices against GP lenses.
• Patients
who show little positive expression during your discussions. |
To be sure, as you gain experience in fitting
the various designs and modalities of GP lenses, your level of confidence will increase
accordingly. Over time, mere clinical proficiency develops into true expertise.
But this evolution is not an absolute guarantee of the personal success and professional
rewards to which you undoubtedly aspire. As with any aspect of your professional
endeavors, achieving success at what you do is largely a function of how you go
about doing it. Consider these key steps for developing and managing a successful
GP lens practice.
Implement Your Front Desk and Technical
Staff into Your GP Treatment Plan As important as proper patient communication
is to implementing a treatment plan for any form of vision correction or for managing
ocular disease, it's perhaps even more so when introducing and fitting GP lenses.
Educate your front desk personnel as
to the types of lenses you fit and the diversity of refractive errors they correct.
Be sure they understand it's their role to convey to a telephone caller that the
consultation and examination visit is the first step in determining whether GP lenses
are an option for that caller. The terminology your staff uses, combined with positive
intonation and reassuring body language, will go a long way in conveying the positives
and setting your patients at ease.
Finally, explain to your staff that
the majority of patients who do proceed with fitting will successfully adapt and
become excellent referral sources.
For patients who do not successfully
adapt to GP contact lenses, make sure your administrator is familiar with details
and positive verbiage to communicate any limited risk or refund policy that you
incorporate into your fee structure.
Identify GP Candidates
I discussed earlier that certain patient populations are rich in prospective
candidates for GP lenses. But not every patient from those groups will succeed.
You need to identify which patients would do well with GP lens wear. Table
2 outlines the different characteristics of ideal — and not so ideal —
candidates.
Patient/Practitioner Communication
When presenting GP lenses, it's important to present all contact lens options
neutrally. This allows patients to ask questions and participate in the decision
making process. While they are ultimately looking to you for a professional recommendation,
patients are more accepting and compliant with a treatment plan when they feel they
have a role in their care. Your discussion about various lens options should include
GP features and benefits applicable to vision, health, comfort and the patient's
lifestyle requirements.
Again, be aware of nonverbal communication
(body language and facial expression) when explaining lens options to patients,
who often tune in more to your tone and demeanor than to your words.
First Steps You've identified
your prospective GP wearer and the patient is on board with trying GP lenses.
Now you need to properly evaluate the patient to initiate the fitting process. The
sidebar on page 35 offers six GP clinical tips.
Tips for Successful GP Fitting
You're now ready to begin the fitting process.
The following tips will help you succeed in this endeavor.
Contact Lens Technician's Vital Role
in GP Success It's most helpful to have a well-trained contact lens technician
involved from the onset of the fitting process. Delegating tasks such as application
and removal of diagnostic lenses and patient training on lens application, removal
and care not only significantly reduces chair time, but permits efficient patient
flow. It also provides the patient with greater support, motivation and security.
Your technicians should be well versed
in patient-friendly GP terminology. For example, they should replace words such
as discomfort, irritation and pain with initial sensation, edge awareness and itchy
sensation. Tell patients before transferring them to your assistant that they will
feel a slight lid sensation. Once again, your technician must echo your words and
mirror your enthusiasm.
It's common practice among experienced
GP lens fitters to use a topical anesthetic during initial GP application with new
wearers. This allows you to more accurately perform your over-refraction and fit
evaluation.
Your technician should say: "This cushioning
solution reduces initial sensitivity and reflex tearing. The effect wears off after
a few minutes. By then, much of your initial adaptation will have occurred."
Recommended GP Diagnostic Fitting
Sets While you may need to fit GP lenses empirically from time to
time, diagnostic lens fitting offers several important advantages. Patients experience
and overcome the initial psychological hurdle of experiencing lenses on their eyes.
At the same time, you can most accurately judge fitting characteristics and perform
a careful over-refraction, which increases the chance of achieving a dispensable
pair on the first lens order.
Diagnostic fitting allows you to
confirm that you can achieve an acceptable fit and that the patient has a reasonably
good probability of adaptation. We are accustomed to having a large inventory of
prescriptions on hand, and with today's "on demand" mentality, patient satisfaction
is greatly enhanced with same day dispensing. Increasingly, experienced and busy
GP fitters are adopting the same approach for their workhorse GP lens designs.
If you're just starting out or slowly
building expertise in specialty designs such as toric, multifocal or keratoconus,
a minimum number of diagnostic sets will suffice. Even if you elect to use topographically
derived trial lens designs, don't underestimate the value of actually evaluating
a lens in a given material as it interacts with the patient's lid and tear film.
Fitting Myopia and Hyperopia
Spherical Designs Keep on hand powers of –3.00D and –6.00D
and standard overall diameter (OAD) of 9.4mm in a low or moderate (25 to 50) Dk
material. Your Contact Lens Manufacturers Association (CLMA) member laboratory consultant
will recommend peripheral curves for a tri-curve design, or alternatively you may
choose an aspheric design. For hyperopia, stock powers of +3.00D manufactured from
a high (51 to 100) Dk material ranging in base curve from 40.50D to 45.25D in 0.25D
steps.
Aim for a Korb upper-lid-attached fit
and order a final OAD large enough to allow an optical zone diameter larger than
the pupil size in dim illumination.
Tools for Meeting the Toric Challenge
Use a base curve toric, spherical front surface design when a patient has 1.50D
or more of corneal cylinder and you obtain a residual cylinder of more than 0.75D
upon over-refraction with a spherical GP. The residual cylinder should be at the
same axis as the corneal toricity and approximately one-half the amount.
Use a prism-ballasted, front-surface
toric when a patient has 0.75D or more of internal cylinder and the cornea is spherical
or minimally toric. Choose a bitoric design for higher degrees of corneal astigmatism.
These are typically greater than 2.00D to correct for the cylinder induced by a
back-surface toric and to provide better corneal alignment.
Diagnostic fitting with bitoric contact
lenses is virtually as simple as fitting spherical GP lenses. Many CLMA member laboratories
have bitoric fitting sets for loan or purchase. Spherical power effect bitoric lenses
are available in 10-lens sets with 2.00D, 3.00D or 4.00D of cylinder. I recommend
the 3.00D bitoric fitting set for most fits with 3.00D to 5.00D of corneal cylinder
to effectively cover a range of corneal toricity.
Select the indicated lens, usually
0.12D to 0.50D flatter than K. Then, perform a spherical over-refraction and add
this value to both diagnostic lens powers. Order the final design in a lens material
equivalent to what you'd choose for the corresponding power spherical lens.
Achieving Aspheric and Progressive
Multifocal Success Follow CLMA member laboratories' fitting guidelines
for your initial lens selection. While I prefer diagnostic fitting, many practitioners
do equally well fitting empirically by providing the laboratory with all necessary
information. This is certainly an excellent way to begin the process of trying different
designs on your first few fits to determine your designs of choice. A minimum of
two types of aspheric designs will generally cover most needs.
Both presbyopic patients new to lens
wear and current single-vision GP wearers are potentially excellent candidates for
aspheric multifocals. Although many sources report a relatively high success rate
with monovision, why abandon your goal of providing clear, comfortable, binocular
vision when managing GP wearers? Today's improved GP multifocal designs and sophisticated
manufacturing capabilities provide enhanced visual functioning that can lead to
greater patient satisfaction and higher success rates.
Aspheric multifocals are available
in a variety of designs in all varieties of GP materials, which offer superior
wetting capabilities and a range of oxygen transmissibility (Dk/t). Today's more
advanced designs incorporate low back-surface eccentricity or spherical back surface
with front-surface eccentricity. These newer design platforms offer easier conversion
of fit from the patient's current spherical lens parameters and reduced corneal
molding, which often occurs secondary to progressive GP lens wear.
Some aspheric designs now boast add
powers in a range of +2.50D to +3.50D. Manufacturers offer flexibility in available
optical zone sizes and/or incorporate greater adds through front surface modification.
Some CLMA member laboratories also provide aberration control to offer even better
visual quality through distance and intermediate transition zones.
When selecting patients for progressive
aspheric GP lenses, look for appropriate levels of motivation and high visual sensitivity.
Consider these designs for early presbyopes who don't have a highly critical distance
demand and for patients who spend much of their time at a computer. Athletes often
prefer them as well because they move less with the blink.
Anatomical considerations should include
pupil size of 5mm or less in normal room illumination and a well-centered corneal
apex with low or flaccid lower lids. These patients are not good candidates for
a translating (alternating or segmented) design.
The key to success with GP multifocals
is to have a positive and optimistic, but realistic approach. Set appropriate patient
expectations by:
• Advising patients that multifocal
lenses will adequately address 75 percent to 85 percent of their visual requirements.
• Suggesting auxiliary spectacles
may be necessary for tasks such as night driving or reading fine print.
• Reminding patients that optimum
lighting is necessary for maximum visual comfort. Tell them, "This is no different
from what you experience with your progressive spectacles."
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Six GP Clinical Tips
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1.
For
the preliminary exam to an actual diagnostic lens evaluation, use the same procedures
as you would for standard manifest refractive testing and anterior segment work-up.
2.
Measure
pupil diameter, horizontal visible iris diameter, palpebral aperture size, blink
rate and lid tension.
3. Corneal
topography is highly recommended but not absolutely essential. Diagnostic mapping
can help identify pre-existing corneal irregularities, determine the location of
the corneal apex and aid empirical fitting with software analysis.
4. Use
a biomicroscope to examine lids, cornea, conjunctiva and meibomian glands and to
perform tear film evaluation for volume and break-up time data.
5. Provide
pre-fitting therapeutic intervention for any pre-existing conditions such as papillary
hypertrophy, blepharitis, mild lid margin disease or mild tear film deficiency.
6.
When
warranted, outline ongoing treatment concomitant with lens wear in advance to the
patient. This might include lid hygiene or use of topical steroids, cyclosporine,
artificial tears and/or mast cell stabilizers.
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Follow-up Care and Problem Solving Pearls
Perform progress evaluations typically after one
week, one month and three months of lens wear, with semi-annual exams thereafter.
Evaluating New GP Wearers After
dispensing, it's good practice for technicians to conduct a follow-up call two to
three days later so they can immediately address any minor problems and review proper
lens care and handling. They can schedule a more immediate re-evaluation if any
patient-reported adaptation problems seem urgent.
For All Wearers:
• Use sodium fluorescein, which
is essential to evaluate the lens-to-cornea relationship.
• Use a Wratten filter in combination
with your slit lamp's cobalt blue filter to achieve better visibility of the fluorescein
pattern.
• Use larger diameter lenses (OAD/OZD=
9.8mm/9.4mm) especially for younger, more active patients and athletes to minimize
lens decentration.
• Check edge shape and design,
which are the most important parameters in initial lens comfort. A smooth and well-rounded
edge apex minimizes lens awareness during the blink. GP lenses are now of consistently
higher quality, but it's still important to inspect the lens edge before dispensing
to be sure it is free of defects.
• Check for foreign body tracks
and peripheral corneal drying (3 o'clock and 9 o'clock staining). These are less
common because of the new low-edge clearance designs (minimal, but adequate, distance
from the edge of the lens to the cornea). In the rare case you encounter these problems,
consult with your laboratory on modification of peripheral curve radii and width
or specify aspheric peripheral curves.
• To manage poor surface wettability,
first try to determine the cause and then differentiate between poor compliance
in cleaning and handling or physiologic causes such as tear deficiency, lid margin
disease, inherent material defect or poor blink pattern. Consider a change in lens
material if you appropriately address compliance and physiological factors but the
problem persists.
Another excellent remedy or preventive
measure is to use the newly available plasma coating. Surface plasma treatment to
increase the wettability of GP lenses is analogous to methods employed for this
purpose in the manufacture of silicone hydrogels and may improve overall lens comfort
and wearing time.
The Bottom Line
Over time, your success and confidence with GP lenses
will increase exponentially. To help ensure your success, a variety of professional
resources are available. The most valuable are trained consultants at your CLMA
laboratory. You can also use Web resources offered by the GP Lens Institute at www.gpli.info.
Dr. Resnick acknowledges Barbara Anan
Kogan, OD, for her help with this article.
Dr. Resnick is a principal in the New York
City based specialty contact lens practice of Drs. Farkas, Kassalow, Resnick and
Associates, PC. She is a Diplomate of the Cornea and Contact Lens Section of the
American Academy of Optometry and an advisory panel member of the GP Lens Institute.
Contact Lens Spectrum, Issue: October 2006