CL PATIENT MANAGEMENT
Contact Lens Prescribing Fees Aren’t High Enough
Practitioners need to set appropriate fees for contact lens services and to educate patients about what’s involved in prescribing contact lenses.
By Charles W. McMonnies, MSc
Charles W. McMonnies is an adjunct professor, School of Optometry and Vision Science, University of New South Wales. He has written three books, five text book chapters, and over 120 scientific and clinical papers. He is a recipient of the Joseph Lederer Award and the British Contact Lens Association Medal in recognition of his contributions to contact lens education and research.
The general public cannot be expected to know what is involved in evaluating their suitability for contact lens wear and determining what is the most appropriate type of lens for them. In cases involving refits, previous fittings may not have been thorough, and appropriate fees may not have been charged. Your fees for examinations and consultations may be misunderstood as a consequence. For this reason, your patients would benefit from knowing and understanding more about what is involved in prescribing contact lenses. This information can help them to better understand the correlation between your level of care and your fees.
A basic requirement when prescribing contact lenses is a standard eye examination that starts with a history of previous and current spectacle and contact lens use, general health and current medications, pregnancy, ocular health, relevant family medical history, current eye symptoms, etc. Patients’ occupations, hobbies, or other leisuretime activities may be considerations in contact lens wear. Questionnaires, such as a patient history questionnaire that I recommend by Dr. Alan Levitt, can help you elicit this information.
Lens dryness symptoms are so common that, apart from a regular external examination and biomicroscopy, a contact lens patient examination needs to include a more critical assessment of the presence of, or risk for developing, ocular surface disease. The high demands on tear function made by contact lenses mean that evaluating the signs and symptoms of even marginal dry eye is necessary for making a reliable prognosis, with the results potentially influencing lens choices. Again, this assessment of patients’ predisposition to dryness problems can be facilitated by using a questionnaire that identifies factors that may contribute to dry eye and dry lens conditions (McMonnies, 1986).
Practitioners employ a broad range of diagnostic tools in their assessments. With biomicroscopy, you can assess tear prism adequacy, the lid margin for blepharitis and adequacy of lid hygiene, as well as meibomian gland function when combined with tear breakup time and assessment of tear film interference patterns. You must also check for limbal and conjunctival hyperemia, conjunctival folds, vital staining of the cornea, conjunctiva, and lid wiper, and exposure stain, which usually indicates blink anomalies. Also, are there any skin conditions such as acne vulgaris or rosacea and atopic or seborrheic eczema that could negatively impact contact lens performance?
Knowing more about what is involved in prescribing contact lenses can help patients better understand the correlation between your level of care and your fees.
Because blink anomalies can significantly contribute to dry lens problems, we must assess vocational and leisure time spent using computers, laptops, tablets, iPads, and smartphones, which can be a critical issue for contact lens wearers. One study recently reported that the average time spent using such digital devices has increased in the United States: four to six hours for 33 percent of the U.S. population, seven to nine hours for 22 percent, 10 to 12 hours for 14 percent, and more than 14 hours for 10 percent of the U.S. population (The Vision Council, 2012). In addition, it is important to ascertain exposure to air conditioning because of the compounding effect that it has on deficient blink functions, especially during digital device use.
Given the predisposition for too many eyes to develop contact lens-induced papillary conjunctivitis, assessing the palpebral conjunctiva remains an important feature of pre-fitting, refitting, and aftercare examinations.
Contact Lens Fitting Considerations
Corneal topography is essential for determining whether standard diagnostic lenses would be appropriate or whether uncommon contact lens fitting parameters are indicated. In this way, topography data can reduce or even eliminate inappropriate diagnostic contact lens fittings. In addition, topography also can identify unusual conditions that are significant in contact lens applications, such as the corneal distorting effects of previous contact lens wear, corneal surgery, or keratoconus.
Given the association between rubbing-related corneal trauma and keratoconus (McMonnies, 2009), patients at risk for progressing or developing keratoconus should be identified (Edwards et al, 2001). These patients need to know about the risk for rubbing-related corneal trauma and how to control this habit (McMonnies, 2009).
Other preemptory action that may be necessary can include treating conditions such as meibomian gland disease, blepharitis, allergies, and other sources of hyperemia.
Improvements in contact lens materials and designs mean that the convenience of sleeping in lenses is a feasible option for some patients. However, contact lens outcomes cannot be predicted confidently; a careful following of any fitting is required, with staged reassessments to establish and maintain a successful pattern of lens use. Without thoroughly assessing suitability for daytime contact lens wear and then monitoring the effects of overnight lens wear in particular, patients may put themselves at risk for adverse outcomes unless specifically advised that extended wear lens use is appropriate for them.
Of the dozens of types of lenses available, patient-specific factors need to be carefully considered to achieve an optimum lens choice for comfort, vision, and use. Some patients are better suited for rigid lens designs. The more critical lens-to-cornea curvature relationship with these designs requires a more critical diagnostic lens assessment, adding another dimension of evaluation in determining the optimum prescription for fit and vision. This consideration is particularly important for patients who have irregular corneas resulting from keratoconus, post-surgery, and other corneal conditions.
Other considerations when choosing a lens type include oxygen transmission, correcting incipient or established presbyopia and astigmatism, and providing protection from ultraviolet radiation.
Patient Education is Key in Setting Appropriate Fees
The trivialization of contact lens prescribing is due in large part to the online availability of contact lenses, especially cosmetic lenses, as well as a lack of understanding among prospective patients of what is actually involved in a contact lens examination. Only patient education can reverse this lack of understanding.
Practitioners who wait for symptoms of wearing problems to develop often find that it is too late.
Telling patients what you are doing and why during the contact lens examination is extremely useful for this purpose and when discussing appropriate fees. The alternative is to leave your patients unaware of the scope of what you are doing for them.
Modern contact lenses are so easy to wear that their initial use seldom poses a problem. Unfortunately, many novice successful contact lens wearers eventually drop out. One of the key issues for continuing success is detecting and responding to lens-wearing problems that too often result in patients eventually having to abandon contact lens wear. Another key aftercare issue is the timely detection of problems, or potential problems, before they become intractable. Practitioners who wait for patients to develop symptoms to confirm wearing problems often find that it is too late.
Fees must be appropriate for the time involved in providing the requisite thorough examinations and follow-up care. Increasing cost pressures in eyecare practice make it essential for practitioners to charge appropriate fees for expending the time necessary to deliver a complete contact lens examination and aftercare. Even after having a thorough total fitting experience, patients will not know how thorough it was unless an explanation is provided.
The sidebar below titled, “Fees for Contact Lens Fittings and Refittings Include:” could serve as the basis for a handout to help educate your patients about what is involved in a contact lens examination and fitting. Microsoft Word file copies of this summary, the Dr. Alan Levitt patient history questionnaire, and/or the McMonnies dry eye questionnaire are available by request to firstname.lastname@example.org. CLS
To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #216.
|Fees for Contact Lens Fittings and Refittings Include:|
1 Consideration of general health and assessment of eye health including any risk of medication-related side effects relevant to contact lens use.
2 Evaluating past and/or intended use of contact lenses (vocational, leisure, sport, hobbies, etc).
3 Determining normality of corneal shape and transparency as well as detecting any active or ghost blood vessels.
4 Evaluating the inner surface and the margins of the lids, grading of eye redness, and assessing for allergies and other indications of overly sensitive eyes.
5 Prescribing treatment and management for conditions such as blepharitis and meibomian gland dysfunction as well as any other actions needed to sustain or improve contact lens performance (reduce the risk of contact lens dropout).
6 Estimating exposure to air conditioning and use of digital devices for the potential compounding effects that they can have on blink functions and lens drying.
7 Choosing the most appropriate lens type for intended use including optimum correction of astigmatism as well as both reading and distance vision.
8 Determining optimum lens fitting parameters using diagnostic lenses.
9 Assessing suitability for sleeping in lenses.
10 Instruction on correct handling and maintenance of lenses as well as the follow-up consultations needed to finalize the fitting and to assess eye responses and compliance with recommended patterns and methods of use required for ongoing successful lens wear.