SUCCESSFUL CL PATIENTS
Psyched for Success
Take these approaches to fitting your contact lens patients and you'll find success and satisfaction.
By Robert Reed, OD
When a patient presents for contact lenses, it's usually not difficult to get him psyched up about the experience. In fact, in some cases a patient's enthusiasm is actually a problem.
Take, for example, the teenage girl who doesn't need vision correction, but wants to change the color of her eyes. Rather than coming in to my office for cosmetic tinted contact lenses, she went to the local tattoo and piercing establishment and bought them over the counter without instructions, solutions or -- that's right -- an exam or fitting. Unfortunately, after sleeping in these lenses, the teenager required treatment for the corneal ulcer that occurred.
Or the teen who wanted to wear contact lenses. She had lost her glasses six months previously and had borrowed a pair of two-week disposable contact lenses from her friend to get by. In spite of the fact that she was a spherical 2.50D myope and was wearing a 3.00 1.25 x 145 OD and
4.25 1.25 x 180 OS, she was quite content with 20/30 vision.
Yes, she noticed that her eyes were always red, but she thought it was because after six months of wear, the two-week lenses probably weren't working as well as they did when she first got them from her friend. She explained to me that if she had thrown them out, she wouldn't have been able to see at all, so she just kept using them.
Living By the "Rules of 3"
In practice, I try to keep things as simple as I can. And things always seem to go smoother if I operate by my assorted "rules of 3," which I'll explain. For the purpose of this discussion, three kinds of patients get contact lenses:
1. Those under the age of 20
2. Those between 20 and 45 years old
3. Those older than 45
Each group has its own special characteristics (both physical and psychological) and needs handling in different ways. You can't motivate someone to wear contact lenses or, once you fit them, make them continue to wear their lenses. In the two cases I just shared with you, motivation was high and, despite the great physical stamina of youth, problems occurred because of lack of care.
When a patient expresses a desire to wear contact lenses, I use another "rule of 3" revolving around things that may cause a contact lens wearer to succeed or fail:
3. The physical aspects of vision and comfort
To determine these factors we first need to talk to the patient, even after he fills out all the HIPPA forms, welcome-to-the-office forms and health history forms. After the paraoptometric has done all the preliminary history, automated pretesting and screening and "seed planting" about contact lenses with the patient, we still need to talk to the patient about his thoughts, desires and expectations about contact lenses.
Depending on "where a patient is coming from," (I'll explain below) each falls into one of three levels of difficulty for fitting:
1. Excellent candidate for successful wear
2. Typical candidate for successful wear
3. Difficult candidate for successful wear
Examples of what we look for include finding out if the patient wants to wear the lenses full time or part time. Does the patient want to wear the lenses or does someone else (such as a family member) want him to wear them? Does the patient's work or lifestyle include intense computer requirements or does he just want to wear them to work and to the gym? Is the patient hypersensitive when you attempt to perform Goldmann tonometry with anesthetic or can you bounce a pencil off of his cornea with no response? These, along with the patient's physical parameters, will determine how much his contact lens experience will cost, which invariably becomes a factor in a patient's decision to get contact lenses.
A Look at the First Group Who Gets Lenses
Generally the "under-20" group is highly motivated to get contact lenses, often by peer pressure and a desire for self image enhancement. Individuals who fall into this group tend to be less maintenance oriented, so care of their contact lenses isn't one of their priorities. They're also in the midst of their primary power development. With these variables in mind, GP lenses are a great option, as they're relatively easy to maintain, they're durable and they have the potential to keep a child's eyes from aggressively advancing into myopia.
Of course there's the battle that "everybody has disposables." By presenting the GP option confidently and by backing it up with a "guaranteed satisfaction" policy, many times you can overcome a patient's initial resistance. Another option is CIBA Vision's Night & Day 30-day extended wear contact lens. As long as the patient can remember the arduous task of removing the lens and throwing it away once a month, he'll have a good chance of success. The two-week standard disposable is typically the third choice we offer to the under-20 group. As you're dealing with an eye environment that's young and pristine, you're facing a high probability of success -- in spite of likely noncompliance of the system guidelines. The under-20 group has lower expectations for vision, higher tolerance for comfort issues and high motivation, so it's the easiest population with which to work.
Dealing with the Middle Group
People who fall into the 20 to 45 age group have different expectations and needs, making for a more difficult continuation of contact lens wear because of their much higher visual demands, their attitude of "wanting things their way," and their perception that technology can "do anything." These patients become less motivated by "peer pressure" and usually want contact lenses because they dislike eyeglasses for practical or aesthetic reasons. They usually require higher correction and still have a "good physical" set of characteristics with which to work. Many of the contact lens wearers in this group were fit with contact lenses as kids and are on a "maintenance" program. What we need to provide for them is convenience.
These patients are busy, some are early in their careers, starting families or raising the kids and being pulled in various directions by all of their children's activities and commitments. To maintain people in this group as wearers (and patients), we try to make things as low maintenance and noninterfering as possible. In fact, we base our hours of appointments on when it's more convenient for them to get in. We make sure to notify them when they're due for exams, batch lenses in year supplies to reduce running for replacement lenses and offer solutions in the office. We have a "back-up pair of glasses special" so they can have a good pair of glasses in their latest prescription for a low cost. We have nonprescription sunglasses at low cost or, for those motivated by status, expensive brand names.
This age group has grown up with modern technology and generally expects that "anything is possible" if you just throw enough money at it and use enough technology. When this group of patients is in the office, we make sure to explain why we perform topography and show them their maps as well as the comparison and trend analysis so they appreciate that our technology is serving them well. If they do choose to drop out of contact lenses, then we let them know about one-day lenses and explain that they can still wear contact lenses for special occasions or for short-term vacations.
Tweaking Specialty Lens Fits
Generally, the most technically difficult fit with which the 20 to 45 group will present is the need for toric contact lenses. With high visual demands from computer users, the lower amounts of astigmatism that these patients might have tolerated when they were younger and had more ability to overcome or ignore will cause more interference.
If they've been wearing spherical contact lenses and we find through over-refraction that they do have residual cylinder, then we'll use loose fit trial lenses over their contact lenses on a vision chart to show them what the difference feels like. When you start to work with a specialty design such as toric contact lenses, it's important to build an alliance with your patient, explaining to him that you're both in this together.
Another "Rule of 3" applies with specialty lens fits. I let patients know that:
1. I won't guarantee that they'll have 20/20 in each eye
2. Each eye won't necessarily see or feel exactly the same
3. Their vision won't be perfect all the time in all situations
I also explain to them that different companies have different styles of lenses, different manufacturing technologies and different methods of stabilizing lenses and that it usually takes about three attempts with a particular design to get it right. I base the first attempt on the patient's physical prescription, curve and topography of his eye and the standard fitting formulas the manufacturer has established. Once we've done trials with these lenses in the patients' world, they'll report to me what they like and don't like and what things I need to fix. Then we order a second set of lenses and have the patient trial these as well. I may need to make one final "tweak," and this is the final prescription or will show us that the second pair of lenses was the best we could do with this particular design.
However, if the first pair of contact lenses doesn't behave at all as I expected and the second pair doesn't improve visual and physical performance, then we'll try another style of lens and go through the same fitting process. By discussing the sequence of events, we try to establish a realistic expectation of time, visits and how my experience has shown that the fitting process will go. I also explain to the patient that although we reach a point in which I allow him to leave with lenses, that doesn't mean I finished the fitting. As time goes on, the patient's vision will change as will his eye's ability to tolerate the lens. We need to keep alert to changes from both the patient's standpoint as well as from our inspection of his eyes. That's why we need to keep monitoring him on a three,- six- or 12-month basis. Disposable contact lenses have made it easier to "recapture" a patient for follow up, but we prefer that the patient sees his annual visit as an expected part of his care rather than as a doctor-mandated visit to gain profit.
Generally, if a patient has been wearing contact lenses from his teens into his 20's, then there's a good chance that he'll remain a long-term contact lens patient if we can continue to provide him with care that fills his needs.
Managing Patients Older Than 45
The third group of contact lens patients are the "over 45" crowd. Years ago, these patients were the hard core stragglers that somehow survived the rigors of contact lens wear. They were too stubborn to admit that the lenses felt miserable and that their vision was poor, and they somehow tolerated them. Now this group has become one with a large potential for the future.
A primary characteristic of the people who belong to this group is that they tend to blame their vision for betraying them. It's one more verification that they're indeed getting older, yet they can't understand why it's happening. Those who've worn contact lenses for 20 to 30 years have been able to basically ignore their lenses, but now they're faced with the prospect of having to return to spectacle wear. And for individuals who are facing spectacle wear for the first time in their lives, contact lenses represent a way to cheat the relentless march of time. We let both prospective and long-term wearers know that "the game has changed." They're no longer kids and from here on out we'll have to work much harder to get less than what they desire. I read the summary from Drs. Benjamin's and Borish's article "Physiology of Aging and its Influence on the Contact Lens Prescription" out loud to prospective patients before we begin "bifocal fitting." The summary reads:
". . . contact lens prescribers may ignore the fact that the presbyopic patient is not presenting the young eye, which just happens to be failing in accommodative ability. Transmission of the media is lessened, retinal sensitivity is diminished, contrast sensitivity is greatly reduced and mesopic vision is severely affected. Many effects of aging (including lid changes, tear changes, corneal metabolism changes, as well as pupil changes) have additional deleterious and progressive physiological influence on ocular health and comfort that impact on the wear of even single-vision contacts. Present day contact lens bifocals, which tend to present relatively degraded retinal images through imperfect media to already handicapped photoreceptors, and by necessity of design further physiologically compromise ocular health and comfort, may destabilize an already precarious situation. Unavoidable exigencies of the aging eye demand that augmented rather than diminished images be presented for the correction of presbyopia and that lenses be both more comfortable and more physiologically acceptable. Unfortunately, at this time, both of theses conditions cannot be met. Thus, when correcting an aging eye with contact lenses the risk/benefit ratio is generally higher than when prescribing for young adults. Younger presbyopes may initially opt for bifocal or other contact lens correction, but as the progressive visual, physiological and psychological effects of aging continue to elevate the risks and minimize the benefits of wear, most will eventually return to spectacles in order to obtain the optimum optical correction."
When I'm finished reading this article summary, the patient and I take a break and pause for a minute. Then I explain that this article was the most comprehensive evaluation of all the challenges that contact lenses present to an individual over the age of 45 years. I also point out that it was published in 1991, and that tremendous advances in contact lens design have occurred since then. I assure the patient that I'm not trying to discourage him from contact lens wear, but to point out that the two of us will have to work much harder to satisfy his visual needs regardless of whether we use contact lenses or spectacles. I explain that we have the best technology ever available to make him a successful contact lens wearer and that we're definitely partners in this endeavor. I want this patient to realize that things may seem less than perfect, but that we'll try to obtain most of his needs and that he'll still need to rely on spectacles for certain tasks and perhaps even wear spectacles over his contact lenses.
I also review my "rules of 3" for bifocal patients who are considering contact lenses:
1. Contact lens wear with spectacles
2. Monovision contact lens wear
3. Bifocal designs
I point out that each option has it's own strengths and weaknesses. When working with the bifocal designs, again, I let the patient know that three bifocal designs exist:
I explain to the patient that we'll try to work with the most logical design based on what he wants and needs from his lenses and what I know based on experience. For each design that we try we may use up to three pairs of lenses. I explain that the level of difficulty with the fitting increases the cost of the services. Further, even when we have "successfully" fit the lenses, we'll probably need to modify the lenses on a yearly basis.
When examining a "successful" presbyopic contact lens wearer, the biggest difference is to not use the
phoroptor. Using a loose lens to detect an improvement at distance or near and using real reading material or a real window to the outdoors is invaluable. Small changes can have a profound effect.
If the patient doesn't complain of problems -- even if I find a change that I could make, then I'll tend to hold back for fear of upsetting the balance of the patient's visual system.
Appreciate the Value of Communication
Above all else -- in spite of advanced technology and various lens designs -- when it comes to retaining bifocal, toric or even simple spherical contact lens patients, talking with them is the strongest technique that we have at our disposal. Finding out each patient's wants, needs and expectations, giving him his options and then directing him with our professional expertise is the best form of care that we can offer to him.
To obtain references for this article, please visit
http://www.clspectrum.com/references.asp and click on document #106.
Dr. Reed has been in private practice for 25 years. He specializes in gas permeable lenses, laser vision correction and computer vision. He is a recognized national lecturer and a published
Contact Lens Spectrum, Issue: June 2004