Going Back to School to Fit Multifocal Lenses
Observing optometry students fit multifocal contact lenses reassures us that many of the lessons we learned as students and in practice have stood the test of time.
Dr. Quinn is in group practice in Athens, Ohio. He is an advisor to the GP Lens Institute and an area manager for Vision Source. He has been an advisor or consultant to Alcon, B+L, Ciba Vision, CooperVision, and Vistakon, has received research funding from Alcon, AMO, B+L, Ciba, CooperVision, and Vistakon, and has received lecture or authorship honoraria from Alcon, AMO, B+L, CooperVision, GPLI, SynergEyes, and Vistakon. You can reach him at email@example.com.
Dr. Brujic is a partner of a four-location optometric practice in northwest Ohio. He practices full-scope optometry with special interest in contact lenses and ocular disease management of the anterior segment and glaucoma. He lectures on contemporary topics in eye care and has received honoraria for either writing, speaking, performing research, or acting in an advisory capacity from VMax Vision, TelScreen, Rapid Pathogen Screening, Inc., Alcon, Vistakon, Aton Pharma (Valient), B+L, Odyssey, and Transitions.
By Thomas G. Quinn, OD, MS, FAAO, & Mile Brujic, OD
For the past several years, we have served as facilitators for The Industry Workshops developed and run by Teague Training Group (TTG). These workshops were developed by a contact lens professional specifically for optometry students, and they take place on-site at optometry schools in North America. They offer students hands-on contact lens fitting experience with real patients, as well as the opportunity to interact with faculty, other optometrists/mentors, and industry representatives. Each workshop covers one topic: communication, multifocal lenses, or toric lenses. What’s more, in this highly competitive market, each workshop is co-sponsored by several contact lens manufacturers. Thus, students can see how various contact lens designs and materials behave on different eyes. This allows them to exercise professional judgment to choose a specific lens for a specific patient.
For us, as workshop facilitators, the experience of going “back to school” gives us a unique perspective. Having observed the next generation of optometrists as they prepare for their careers, we can report that they are as bright and as dedicated to improving patients’ lives as we ever were. They are competitive but with an underlying sense of camaraderie, and their idealism is tempered by a realistic world view. They are tech-savvy—smartphones and iPads abound—and eager to embrace the newest ophthalmic tools, yet they respect the time-tested techniques passed on by experienced practitioners. (See “Your Future Associates” on page 36 for more on today’s optometry students.)
|Your Future Associates|
|If you are planning to expand your contact lens practice—perhaps bring in an associate or a partner—you can be confident that optometry school graduates have received a comprehensive education. Their knowledge of theory and clinical concepts, in addition to the hands-on experience that they have received in clinic and in workshops, positions them well to deliver high-quality clinical care. The students of today are the faces of the profession tomorrow, and the bottom line is: the better they are trained and the more equipped they are, the better and stronger the profession will be.|
|— Mile Brujic, OD|
Case in point: At a recent TTG presbyopia workshop, we observed second-and third-year students fit multifocal lenses, some for the first time. We were somewhat surprised to see that their success rates were rivaling those of more seasoned practitioners whom we have observed elsewhere. In fact, after every TTG multifocal workshop we ask, “How many of you had success fitting multifocal lenses today?” Virtually every hand goes up.
Of course, today’s technology far surpasses what was available 10 or even five years ago, but that is not the only reason why students were doing so well. We would like to think that the wisdom we imparted in our introductory presentations contributed to that success, but in reality, we had not revealed any secrets. It was the students’ willingness to try some of the tips they had been taught that seemed to make a difference. Here are some examples of lessons that practitioners have learned over the years that are still valid today.
Use the Fitting Guide
For students, using a fitting guide is a no-brainer because they are in learning mode. Those of us who have been in practice for a while, however, may feel that our experience trumps the fitting guide—but as multifocal contact lens designs have become more sophisticated, fitting “by the book” is more important than ever.
For example, if a patient is wearing multifocal contact lenses with a high add but needs more help with near vision, our first instinct may be to increase the add. But the proper adjustment for at least one design is to add +0.50D to the distance power or decrease the add power in one lens. The only way to know this is through trial-and-error (a time-consuming and frustrating approach) or by reading and following the fitting guides for each type of multifocal contact lens that we fit. Far from being company propaganda, fitting guides are thoroughly researched and based on the experiences of clinicians and patients in clinical trials. Contact lens manufacturers want us to be successful with their products, and they invest significant time, money, and energy into determining how those products will work best. We can make their investment pay off for us, too, by following the fitting guides.
|Presbyopia: The Game Changer|
|When presbyopia and multifocal contact lenses become part of the conversation during an eye examination, the rules of the game change for patients and practitioners alike. Patients who were accustomed to single vision contact lenses taking care of all of their visual needs may find that they need not just a new type of contact lens, but a combination of devices. As their eye-care practitioners, we need to help reorient these patients to this new normal. The “sandwich” approach—sandwiching the difficult-to-hear facts between some positive statements—can help. In most cases, you can reassure patients that their eyes are healthy, then explain presbyopia and its effects, and conclude with the good news that several excellent options are available to correct their vision. This approach keeps you from being too positive and over-promising or too negative and discouraging.|
The rules of the game in the examination room also change when fitting multifocal contact lenses. For example, pupil size is so important with multifocals that using the phoropter in a dimly lit examination room will not give you a true picture of how the lenses will work for patients in the real world. In terms of near vision, my favorite tactic is to ask patients whether they have a smartphone (almost everybody does). If they do, I ask them to take it out and read it. If they can read it, they realize immediately that the lenses will help them do something that they need to do every day. That way, if the same patients cannot read the bottom line on the acuity chart, they may not be too concerned because they already know that they can read their smartphone, a critical daily task.
Speaking of reading the bottom line, in my practice, we do not show the entire acuity chart when we check distance vision. We start with the 20/40 line and then move down. If a patient reads the 20/20 line, that’s great, but if he can only read the 20/25 line, that’s still good, and he will be able function well. Conversely, in checking near vision, I do not give patients a near acuity chart and ask them to read the 20/20 line right away. I start with something practical like a newspaper or a smartphone.
|— Tom Quinn, OD, MS, FAAO|
Talk to Your Patients
When it comes to talking to patients, experienced practitioners should have an edge over students because they are accustomed to doing this every day. As patients approach presbyopia, however, the conversation needs to be fine-tuned to help determine goals and set appropriate expectations. While many practitioners can discuss presbyopia as equals with their patients because they are in the same age category, students and new practitioners have the added challenge of broaching the subject of aging with patients who may be old enough to be their parents. It is amazing how much more empathy you have for people who have presbyopia as you approach that age yourself.
|What the Instructors Have Learned|
|DR. QUINN: I have become braver when approaching presbyopes who have low distance refractive error. These patients have performed surprisingly well at workshops utilizing today’s lenses that offer better distance vision compared to the earlier generations.|
DR. BRUJIC: Students often have no preconceived notions about who they think is a “good” multifocal contact lens candidate. They fit each patient according to the fitting guide, and in letting these patients experience the technology they have great success. Seeing their success has made me rethink which patients I fit with multifocal lenses. I now try multifocal lenses on patients who may not necessarily be considered ideal candidates, oftentimes with success.
Regardless of your age, however, we recommend avoiding the words “aging” or “old” when talking with presbyopes. A phrase like “maturing of the visual system” may be more tolerable to people who are likely already sensitive about getting older. We also suggest avoiding the word “compromise” when discussing presbyopia correction and instead tell patients, “I can meet most of your vision needs most of the time.” (See also “Presbyopia: The Game Changer” on page 38.)
Because communication is such an important aspect of an eye examination, we urge students to begin thinking about what they will say to patients while they are performing the technical aspects of the fitting. As they become more confident and adept at fitting, they will also become more skilled at describing lens technologies and explaining the reasons why they are recommending a specific type of lens. This technique works well for experienced practitioners who are introducing a new contact lens technology into practice. You might do a great job fitting the latest multifocal contact lenses, but if you cannot accurately describe the technology and realistically set goals and expectations, then you may fall short of your own goals and expectations of helping your patients and growing your practice.
Intangible Benefits of Student Workshops
Hands-on workshops provide opportunities for students to learn by hearing, seeing, and doing, all in rapid succession and in an environment where they can explore different aspects of practice without the pressure of being graded. The communication skills that they learn and their clinical experiences foster confidence and position these future eyecare professionals for success in practice. What we can learn from them is to be open to change and to be willing to hear new ideas and to approach some tasks differently. (See “What the Instructors Have Learned” at left to see how we have made changes in our own practices based on what we’ve experienced at the TTG workshops.) Changing our routine may be uncomfortable at first, but in the end it can be exciting, especially when success follows. CLS
Note to readers: Effective Jan. 1, 2012, this program was relaunched as the STAPLE (Soft Toric and Presbyopic Lens Education) Program (www.stapleprogram.com), a collaborative effort on behalf of Alcon, Bausch + Lomb, CooperVision, and Vistakon, a Division of Johnson & Johnson Vision Care.