FITTING SPECIALTY LENSES
Are You Prepared for Specialty Lens Success?
Successfully fitting specialty lenses requires preparation, practice and honing your communication skills.
By Jon Scott Walker, OD, MS
Fitting specialty contact lenses is similar to running a marathon. Successfully completing a marathon requires preparation, practice and mentally knowing how to attack and finish the race.
Great specialty lenses in the hands of someone who hasn't taken the time to learn how to fit them is like handing my exercise-challenged Uncle Charlie new Nike running equipment. Immediately sending him to run in the New York Marathon inevitably produces public failure.
Expectations of Preparation
The contact lens community experiences a similar scenario with new specialty products. Instead of taking time to learn about and practice with the lenses, practitioners blame failure on the manufacturers for making them work at competing in this specialty lens "race".
When competing in a race, great equipment benefits only those who put in the time to practice. Why does one practitioner fit on average a soft bifocal contact lens patient every other day, while only blocks down the road another practitioner averages one fit every few months? Why does one practitioner look at toric GPs as an opportunity and another practitioner cringes inside? The difference is related to preparation, practice, follow-through and ongoing introspection and evaluation.
Preparation starts with communication. Haven't we all learned how to explain glaucoma to patients who have no sensory or physiological signs or symptoms? Most of us spent time working at our communicating skills in this area. Do we devote the same time for specialty lenses? Learning how to effectively communicate in all areas of our practice is the first step in preparation.
Finding the Right Words
Initial and ongoing communication should lead to appropriate patient expectations. It's imperative for the practitioner to be cognizant of what he's communicating. Remember: Words matter.
The following two sentences are meant to elicit patient experiences. Unfortunately, they'll generally produce two entirely different patient responses.
Usual Question: "Are you having any problems?"
Even though many believe that this cuts directly to any patient issues, this is rarely the case for specialty lenses. This type of question has the result of directing patients to focus on any perceived shortcomings of their visual correction. Even patients who are doing fine will usually state a negative issue or two, (my lenses dry out when the car airs blows on them). This type of question rarely results in better fitting results. It does result in backtracking and side issues, with a resultant increase in inefficient chair time.
Better Question: "How are you doing with these lenses?"
This question allows patients to focus on both the positive and negative aspects of their visual correction. This balanced question then lets us determine the level of any real and perceived issues.
Listen to Your Patients
Asking the right question is only the beginning to understanding what a patient communicates about his visual experience. Every practice has had a patient present with "teary" eyes. Upon further discovery, it's not an ephirora issue but a cataract. What did the patient communicate and what path do I follow? Without a clear understanding of the perceived patient issue, appropriate resolution won't occur.
Response Example: "Overall, I like the lenses (soft bifocal contact lenses), but my near vision is blurry."
What we know:
1. Distance vision is acceptable.
2. Intermediate vision is acceptable.
3. Near vision is unacceptable to some degree.
Our next question is not: "What problems are you having with your near vision?" The better question is: "Tell me about your near vision."
Response Example: "I'm doing okay, but my vision gets blurry at times with these new toric contact lenses."
What we know:
1. For a significant amount of time, the patient is seeing acceptably.
2. The lens design is meeting his or her needs for comfort, handling and other intangible areas.
Our next question is: "How often and when do they get blurry?"
With every patient response, take a step back and reflect on what the patient said. A mental list of the positives and negatives helps balance the responses. In the first example, the patient is successful and may need only some minor adjustment, if any. Is this a patient wanting J1+ in dim illumination or is he or she truly needing near enhancement via additional optical power?
The second example may be as simple as rewetting drops or occasionally changing lens powers or types. Unfortunately, many practitioners hear only the blur issue and either overcompensate or state that the lenses aren't working. Both responses generally lead to patients discontinuing contact lens wear and another failure snatched out of the mouth of success.
Recognizing Personal Bias
It's imperative to always reassess our preferences and biases. Recently I had a practitioner in his mid-50s tell me that he would never refer a patient for refractive surgery. His response to my inquiry was, "They'll go blind and I make more money from glasses." At least he was honest about his misinformed bias, but was he doing anyone other than his bank account a favor?
I've observed these same biases toward specialty lenses. Practitioners need to both develop the skills to become successful with specialty lenses or be honest to themselves and to the patient and refer patients to a practitioner who's successful within that scope of practice.
I've never been particularly drawn to vision therapy. Therefore I've always sent these patients out for appropriate care. My patients and fellow practitioners have never considered this anything other than appropriate care. Is referring specialty contact lenses a patient care issue or a self-esteem issue?
Understanding Specialty Lenses
Understanding lens designs, materials and fitting techniques is the last step in preparation. We all obsess over new glaucoma and antibiotic medications, wanting to know every nuance about its structure, side effects and indications. Yet many practitioners couldn't intelligently discuss the difference in material between the Acuvue 2 and a Focus Night & Day contact lens.
Reading manufacturer literature and journal articles, attending lectures and talking to sales representatives and other successful practitioners helps sort reality from fiction.
The most successful practitioners interact with other successful practitioners. If I want to understand the new glaucoma medications, I interact with a successful glaucoma specialist. If I want to understand a new keratoconic contact lens, I interact with a successful keratoconus practitioner. The majority of successful practitioners are more than willing to talk to others about what has made them successful.
Fine-Tuning Your Skills
When I started golfing several years ago, I didn't break 90 for years. Even now, living in Florida with year-round golf doesn't assure continuous rounds in the 80s. I must get out to the driving range and hit ball after ball and then practice putting. Only after that can I have a reasonable chance of scoring in the 80s. Why then do we practitioners pronounce a specialty lens a failure without any practice?
I remember fitting soft toric contact lenses in the early 1980s and being called a fool because PMMAs and early GPs were perceived as better options by some of my colleagues. Yet I practiced and ultimately was successful years before the rest of my colleagues discovered the positive role of soft toric contact lenses in their practices.
I needed 20 soft bifocal contact lens fits before I had even a rudimentary knowledge of the lens. I needed more than 100 encounters before I was completely comfortable fitting soft bifocal contact lenses. I then needed about 10 GP bifocal fits to be comfortable with that modality. No one is an expert at the first fitting, nor are we ever finished in upgrading and updating our skills.
Waiting for the Resolution
When treating medical issues, we rarely see immediate- or near-term resolution. Corneal ulcers may take weeks to resolve and daily evaluation doesn't make the outcome any quicker.
Specialty lenses require patients to leave with the lenses for a number of reasons. Resolution will usually take some degree of time and quite often requires the practitioner to keep his hands off changing lenses or modalities. Don't expect perfection at the initial visit. The main reasons are patient adaptation to lenses, toric lens settling, bifocal or monovision adaptation and any number of other time related patient adaptations.
The lesson is: Don't play too much at the initial visit -- most of the visual experiences are related to the patient needing time to adapt to one or several factors. Therefore, let the patient go and experience the lenses.
I always tell my patients that they will improve visually as they adapt to the lenses. If I find the need to "tweak" the lenses, I adjust them at the follow-up visit. I never say I'll make it perfect at the follow up.
Finishing the Race
Kenny Rogers stated, "You've got to know when to hold 'em, know when to fold 'em, know when to walk away, know when to run." All contact lens fits have a final end point, which the practitioner, patient or both determine.
A caveat is that patients seem to always want perfection. I tell them up front, "If you're looking for perfection, you need to talk to God. If you want pretty good, that's in my hands." If a patient tells you he's doing fine with the lenses, then stop. One more tweak to the lens usually results in failure. Trust a patient's acceptance of a lens modality, don't keep playing.
I've seen practitioners tell a patient he can't have a soft bifocal contact lens because he's only seeing 20/25 and he's 20/15 with glasses. Try telling our 20/40 LASIK patients they just spent $4,000 to see worse than they did with their glasses. Acceptable is relative.
On the other hand, if you have reasonable visual results, don't let the patient drive you to try more options. If he's 20/20 and wants 20/15, it's time to explain why this is the end point. If you correctly educate patients in the beginning, they will realize that contact lens vision is different than glasses vision (water content, variable axis, etc.) One isn't better, only different.
If vision is unacceptable to the patient and practitioner, then reassess your fitting process. Every manufacturer has a fitting guide that, if followed, gives specific directions for resolution of visual issues. Most errors that I've seen in patient resolution are related to not following the fitting guide. Don't use past history, guesses, crystal balls or any other methodology. Follow the fitting guide.
Success with Specialty Lenses
Success in fitting specialty contact lenses requires educating yourself, practicing and knowing how to finish the process.
The contact lens fitting process begins with effective communication: Knowing what your patients are saying and addressing the appropriate issues without bias. Then follow through by either finishing the fitting process or by referring the patient to another practitioner.
Dr. Walker is currently with a group practice in Jacksonville, FL. He has worked with several contact lens manufacturers, including four years with Vistakon in the research, quality assurance and professional affairs consultation departments.