Article Date: 12/1/2008

Upgrade for Comfort, Vision and Health
UPGRADING CL PATIENTS

Upgrade for Comfort, Vision and Health

Educate patients about the options and they'll upgrade their lenses without making you feel like a salesman.

By Thomas G. Quinn, OD, MS, FAAO


Dr. Quinn is in group practice in Athens, Ohio. He is a diplomate of the Cornea and Contact Lens Section of the American Academy of Optometry, an advisor to the GP Lens Institute and an area manager for Vision Source. He has served as an advisor or consultant to Coopervision, CIBA Vision and Vistakon and has received research or travel funding from AMO, Bausch and Lomb, CIBA Vision, Coopervision and Vistakon.

I believe that as eyecare providers, our goal should be to provide the highest quality, comprehensive care, which is something we can do only by embracing the newest technologies.

Southeastern Ohio, where I practice, is not a wealthy, high-tech area, yet almost everyone owns a computer, cell phone or gaming system. The message that contact lens technology is always improving is one that resonates with most people in our technology-driven society.

And as with all technologies, patients need education about what's new. We begin our patient education process with an intake questionnaire that asks whether patients are interested in contact lenses. Surprisingly, this simple question is too often not asked at all. For both new and current lens wearers, we ask whether they are interested in overnight wear, disposable lenses for part-time wear or multifocal lenses. Just by reading the questions, patients may learn about options they never knew existed.

Educating Yourself

I also ask questions during the exam, because the answers arm me with the information I need to educate patients properly. With established wearers, I start with an open-ended question: "How are you doing with your contact lenses?" That lets patients dictate the course of action and helps me focus immediately on their biggest concerns. If I just run down a checklist of possible problems (dryness, fluctuating vision, red eyes, etc.), it's harder to get a sense of prioritization.

I also like the approach that Charissa Lee, OD, an Irvine, Calif. optometrist and Professional Affairs consultant for Vistakon, takes. She asks patients what they use their eyes for and for what kinds of activities they wear contact lenses.

"I like to know in which order they prioritize comfort, vision and health, so I need to find out whether patients are wearing their lenses all day or just to go out at night," Dr. Lee explains. "Understanding a little bit about the patient's lifestyle and visual needs helps me quickly narrow down the best starting point from the hundreds of contact lens options we have."

Dig a Little Deeper

Both Dr. Lee and I have found that contact lens wearers are pretty passionate about their lenses and are willing to put up with a lot to continue wearing them. Often, the answer to our open-ended questions is, "Everything's fine, doctor."

When I hear that response, though, I like to dig a little bit deeper into the three support systems that help make a contact lens patient successful: comfort, vision and health.

If patients say their comfort is fine, I follow up by asking how many hours a day they wear their lenses, and how many of those hours are comfortable. I will often see some disparities in the responses in which patients are wearing their lenses a few hours longer than is really comfortable. That tells me that a more comfortable material might be beneficial.

With astigmats, I want to explore whether their vision is stable when their gaze changes, so I might ask how well they see when playing basketball or looking over their shoulder to back up the car. These more probing questions often reveal that vision isn't as good as it could be.

Dr. Lee told me about a recent experience with a patient who originally said everything was fine, but then acknowledged that he found it hard to read on the plane during his frequent business travels.

"This was a monovision patient whose low (0.75D) astigmatism in one eye had always been masked," says Dr. Lee. "But I wondered if the challenge of his eyes being tired and dry on the plane was too much for him to compensate for." The patient agreed to try an Acuvue Oasys for Astigmatism (Vistakon) lens on his near eye, and it made a huge difference in his comfort and productivity when flying.

"A few weeks later he came back absolutely elated and very appreciative," Dr. Lee says. "I think that sometimes practitioners are unwilling to try a specialty lens for a borderline patient such as this because it's a little more work and a little more expensive for the patient. But newer toric lenses can offer better stabilization with less visual fluctuation, so there's no downside to fitting astigmats for low amounts of cylinder. Certainly this small change made a big difference for this patient, and he was surprised that no other doctor had bothered to talk with him about toric lenses before. It was an enlightening moment for me," she says.

Christine Sindt, OD, of the University of Iowa, is another practitioner who has seen the impact of new technology on vision first-hand. "As a hospital-based contact lens specialty practice, we live and breathe new technology," she says. "New advances such as scleral lenses and advanced keratoconus designs have been able to help patients who would otherwise have very poor acuity. And for our patient population with more normal eyes, new multifocal lenses are so comfortable and easy to fit that presbyopia is no longer such a difficult transition for contact lens wearers."

Upgrading for Health

Your assessment of the eye is just as important as the history portion of the exam. Even if comfort and vision are great, I may still recommend a change in contact lenses if my slit lamp reveals microcysts, corneal or conjunctival staining, bulbar conjunctival injection or other physiological problems.

I always evert the lids and am shocked at how often new patients are surprised by this maneuver. Clearly, no one has ever looked at the underside of their lids before. That's unfortunate, because over-wear that leads to eyelid irritation and inflammation is one of the most common causes of contact lens problems. Just changing the care system is not going to resolve this problem, either. In the short term, the patient may need topical corticosteroid therapy or a combination mast cell stabilizer/antihistamine drop to help quiet the inflammation.

For long-term success, we need to talk about contact lens hygiene and replacement. Often I will recommend a one-day lens to prevent problems from recurring. The beauty of single-use lenses is that compliance with this modality is higher than with any other. Once patients get used to throwing the lenses away, they really have to go out of their way to be noncompliant.

For new wearers who are on a two-week or monthly replacement schedule, I try to nip in the bud the very common attitude that it's okay to wear your lenses until they start to bother you. I tell patients, "My goal is to provide you with consistent, quality vision, comfort and eye health, so dispose of your lenses before they become a problem."

Dr. Lee says she turns to technology to help patients stay on schedule. "Especially for young patients, I recommend the free Acuminder service (www.acuminder.com or register your practice at www.acuminder.com/doctor), which can send them an e-mail or text message reminder when it's time to change their lenses," she says.

Of course, it's easiest to move patients to a new lens design or material when you can show them how it directly addresses a problem. But Dr. Sindt says clinicians need to be proactive, too.

"There comes a time when we have a preponderance of evidence demonstrating superior health benefits," she says. "Right now, I think we're at that point with silicone hydrogel materials, so this is a good time to move remaining HEMA lens patients into silicone hydrogel lenses that can prevent future problems." Dr. Sindt talks with her patients about the long-term health benefits of higher oxygen transmission, UV protection and other benefits of different silicone hydrogel lenses. "Patients almost always agree that they want the healthiest option for their eyes, even if it costs them a little more," she says.

Monique Dawson, OD, a practitioner in Meriden, Conn., says patients also respond to the increased comfort of new silicone hydrogel materials. "Not only do they provide more oxygen, but patients can wear them longer and more comfortably," she says. "I tell them they have nothing to lose by taking home a trial pair of lenses. If they don't find it more comfortable they can always go back to their old lenses."

Effective Patient Conversations
Any time you suggest a contact lens change, be sure to convey your recommendation in a manner that gives patients confidence in you and empowers them to accept your recommendation.

Scenario A: The Unhappy Astigmat
In talking to an astigmatic patient who is dissatisfied with his contact lenses, the first step is to think beyond the chair — what does this patient do in his daily life that might be affecting lens performance? I ask more questions to see what is going on, examine the lens on the eye and make a clear recommendation that meets his needs.
1. Address the patient's chief complaint: "You mention your vision fluctuates a little bit."
2. Validate and add your expertise: "When I look at the lens on your eye, I notice that it rotates. That's what's causing the fluctuations."
3. Talk about the contact lens features: "I have a lens that I've found to be very stable on the eye."
4. Point out the direct benefit: "That will mean more consistent, clear vision for you during your daily activities."

Scenario B: A Patient Who Needs Single-Use Lenses
With a contact lens wearer who has been abusing his contact lenses and shows signs of lid irritation and inflammation, I use the "sandwich approach" to deliver the meat of my message between slices of good news:
Good news: "You've been really successful for years now with your contact lenses."
Bad news: "However, I'm starting to see some inflammation and irritation of your lids from dirty lenses."
Good news: "I recommend single-use lenses that are a really healthy option if you want to continue wearing contact lenses without this problem recurring."
Bad news: "The single-use lenses do cost a little more."
Good news: "When you break it down, it's only about 37 cents more per day for convenience, comfort, safety and clear vision."

Seize the Golden Moment

By the end of the exam, I understand a patient's concerns; I know what, if any, health concerns I have from the physical exam, and I know about all the various contact lens options available to serve the patient. This puts me in a unique position to synthesize all this information and make a clear recommendation to the patient during what Dr. Mark Wright refers to as the "golden moment."

I restate the patient's needs and explain how certain contact lens features offer benefits to meet those needs. This lowers any cost barriers right away. I never think of this process as "selling" the patient on a more expensive lens. Rather, my job is to recommend the lens that will best serve the patient. If I accomplish that, I benefit financially when happy patients stay with the practice and refer others to us.

What You Don't Say Can Hurt You

Today, people are accustomed to and expect a constant flow of information, says Dr. Lee. "Patients might hear about new contact lenses from their friends, relatives or even from a TV commercial. They can be offended or begin to doubt your credibility if you haven't bothered to share information about new technology with them," she says.

I had that point driven home to me by a spectacle patient early in my own career, and I've never forgotten the lesson. My patient talked to a colleague who had antireflective coating on his spectacle lenses. He called me later to say, "I would have liked that glare coating. Why didn't you tell me about it?" I was lucky; we usually don't learn about our failures to inform — rather, the patients just find other providers whom they perceive as being more up-to-date.

"People are surprisingly tuned in to the fact that contact lens technology is dynamic and ever-changing," agrees Dr. Sindt. "I think there is a great demand for healthier lenses, better wearing schedules, increased convenience and new lens designs that offer better vision."

Today, my goal is to educate patients about new options at every visit, even if they're doing well with their current lenses. I take that golden moment at the slit lamp to say, "Your vision is good, you have no complaints about comfort and your eyes look great. However, I do want you to know that there are new materials that provide added moisture and comfort late in the day and more oxygen to improve that safety margin." The sidebar "Effective Patient Conversations" (above) provides more tips on effective communication. I'm pleasantly surprised at the number of times people say they want the latest materials, even if they were happy with their current lenses.

With that in mind, I always start with what I feel is the best lens. If cost really is an issue, we can discuss alternatives or put off the change for a while, but at least I've given the patient the choice.

In the long run, providing quality care using the latest techniques and technologies available to us has ripple effects — both on your patients' quality of life and on your practice growth — that may be difficult to predict but are always positive. CLS



Contact Lens Spectrum, Issue: December 2008