point TOPIC: Comparative Fittings
Making a Case Against Comparative Fittings
BY JACK SCHAEFFER, OD
There are many who would love to equate a contact lens to a soda and a contact lens evaluation to a simple customer purchase — no practitioner needed. Should a patient go to a store and “buy” a pair of contact lenses or stay home, order three or four brands, try them out and decide which is best? Why not have patients get free lenses on the Internet and see us only if they have a problem? Who needs a doctor? Answer: Everyone.
A UCLA study (Forister et al, 2009) analyzed the types and prevalence of contact lens-related complications in 572 patients, about 50 percent of whom had at least one contact lens complication. The study concluded that “the prevalence of CL-related complications, regardless of lens design, material, and wear modality, highlights the importance of early detection with appropriate professional management and treatment.”
The question is, how do we prevent complications and create a healthy ocular environment for our patients? The answer is simple: deliver a comprehensive, medically oriented contact lens evaluation. This includes proper follow-up visits within the first months and again 6 months after dispensing contact lenses and care systems. It's not just about the lens, but the lens-solution interaction. Whether you believe staining is an issue or not, it's still important to document what level of staining is present. This necessitates an office visit so the practitioner can evaluate the eye post-dispensing. Another interesting part of the study was the high degree of complications reported when patients switched to generic care systems.
We give our patients a reference guide that explains the importance of a medical contact lens evaluation in addition to the eye examination. The guide explains the tests needed to determine the health of the ocular system and the effect of contact lenses and solutions on that system. A thorough examination can help us diagnose any changes including giant papillary conjunctivitis, neovascularization, corneal edema, corneal/conjunctival staining, meibomian gland disease, lid wiper epitheliopathy and so on. These are just some of the conditions caused or exacerbated by contact lenses.
Silicone or HEMA-based?
The issue of whether to use a silicone hydrogel or a HEMA-based contact lens by itself is another area that requires a practitioner's expertise. In a 2002 study, Skotnisky showed the incidence of GPC was greater with SiHy than with HEMA but the results were not significant. In the UCLA study, the research indicated a higher incidence of GPC with HEMA lenses, but again, the results were not significant. These complications occur regularly and it takes the trained eye of a doctor to determine which product is best for each patient. This can only be accomplished by seeing the patient, evaluating the eye and lens complex and monitoring changes over time.
Children Need Extra Attention
My most important message is regarding children and contact lenses. What is the best modality and what is the best follow-up schedule? Not only is the “Pepsi Challenge” contradictory to the health care of children, I believe a practitioner has a responsibility to see every child, every 6 months to determine the efficacy of the contact lens-solution complex and to check on compliance.
It's important that we as practitioners take on the responsibility of enhancing the ocular health of our patients and that we take the time to do a comprehensive contact lens evaluation on every patient, every year. And that is the real challenge. CLS
For references, please visit www.clspectrum.com/references.asp and click on document SE2010.
Dr. Schaeffer practices in Birmingham, Ala., where he's also president of a 12-location group practice and a refractive laser center. He lectures internationally and is involved with many clinical studies on contact lenses, pharmaceuticals and equipment. He authored a mini series on the history of contact lenses and the contact lens specialty practice. He was executive associate editor of the International Contact Lens Leadership Summit, organized by Eye and Contact Lens journal. Dr. Schaeffer also served as chairman of the Contact Lens and Cornea Section of the American Optometrie society. He has been a consultant and/or advisor to Alcon, Allergan, AMO, Bausch + Lomb, CooperVision, Ciba Vision, Essilor, Inspire, Hoya and Zeiss.
Reviewing the Benefits of Comparative Fittings
BY MILE BRUJIC, OD
Patients are more educated than they've ever been. The Internet has made information instantly accessible to many. As such, we as primary eyecare providers need to be sensitive to the unique needs of today's patients. Offering options when fitting contact lenses allows a unique opportunity for our patients to experience multiple lens technologies.
When fitting patients, I fit them with two different contact lenses, one on each eye. I make sure each contact lens fits the eye in a physiologically acceptable manner and that the patient is comfortable with each lens. Additionally, I don't tell the patient which lens is on which eye as this could influence their decision based on brand recognition of certain lenses. My method allows patients to experience two different contact lenses under the same environmental conditions. They can compare general handling of the lens, comfort and vision and determine which of the two lenses seems to work best for them. I usually let patients wear the lenses for a period of time, depending on the modality, and then have them back for a follow-up visit to finalize the prescription.
There's a certain premise that needs to exist for this to work well. The patient's anterior segment health should be similar in both eyes. This allows for an accurate representation of what the lenses will feel like in either eye. Certainly there are rare exceptions to this rule. For example, there are some patients who always feel like a contact lens is less comfortable in one eye. In this instance, a comparative fitting won't work well. Additionally, multifocal contact lenses may not be the right arena to use this fitting strategy because most multifocal contacts are designed for binocular use with a single design. In my mind, ideal patients for comparative fits are single-vision spherical or toric candidates.
When selecting contact lenses to utilize during a comparative fitting, there's significant value in selecting two contact lenses that are of a similar modality. For example, if a monthly replacement modality is determined to be in the patient's best interest, selecting a monthly disposable lens from two different manufacturers gives you and the patient valuable insights into the advantages and disadvantages of each lens. Certainly this logic would hold true for 2-week disposable and daily disposable modalities as well.
Practitioners may choose to compare different modalities as well. For example, over a period of 2 weeks, a patient could wear a daily disposable in one eye or a 2-week or monthly replacement lens in the other eye. Depending on the wearing experience, there may be a strong preference for one modality over the other.
As stated earlier, this fitting strategy may not necessarily be applied to all of your contact lens fits. But for patients new to contact lens wear or those having problems with their current contact lenses, you give them the ability to “test drive” two different technologies. This allows equal environmental exposure and minimizes variability in the wearing experience that may occur from simply wearing lenses at different times of the year and in different environments.
A comparative fitting strategy will add value to the patient experience in your office, because it will show that their best wearing experience is your primary focus. Patients appreciate the opportunity to experience two different lens technologies and their perception of the care that you deliver will be enhanced.
Comparative fitting strategies offer significant clinical benefits and add value to your services. I find it works extremely well for new fits and patients that I'm refitting. Consider a comparative fit the next time you have a patient who would be a good candidate and you'll see the benefits of incorporating this strategy in your office. CLS
Dr. Brujic is a partner in a four-location optometric practice in Northwest Ohio, where he practices full scope optometry with a special interest in contact lenses, ocular disease management of the anterior segment and glaucoma. He's a clinical examiner for the national board of optometry. Dr. Brujic has received research funding from Ciba Vision. He has served on advisory panels for Alcon and Vistakon.