Whenever you make a major purchase (for example, to construct a home), do you simply think: “I know exactly what I want, how to design it, where to build it, and what furniture and appliances would be optimum”? Similarly, what if you or a loved one develops a systemic health condition that will require frequent monitoring from an appropriate medical specialist? Would you simply throw a bunch of names against the wall and see which one sticks? We didn’t think so.
Let’s say that over the course of a week, you treat a severe dry eye patient, a keratoconus patient who is seriously considering some form of corneal transplant, and a post-refractive surgery patient—all of whom have failed with conventional contact lenses. In addition, two other patients are young, progressing myopes who are interested in contact lens wear. In your heart, you know that there are multiple specialty lens options that could be the answer for the first three patients, and orthokeratology could allow the latter two patients to have freedom from correction during the day while potentially slowing myopia progression. However, the perceived complexity of the fits and their associated learning curve makes you very hesitant. You wonder where you could go for assistance. The answer is provided in this article and is stated in the following three words: the laboratory consultants.
THE BENEFITS PROVIDED BY LABORATORY CONSULTANTS
1) Guidance Consultants can help guide eyecare practitioners (ECPs) through every step of the process, from material and design selection through fitting and troubleshooting. Once ECPs establish initial contact with a laboratory consultant, it becomes evident that there is no such thing as a “dumb” question. A consultant’s primary motivation is to partner with ECPs to help make their patients successful while increasing the practitioners’ confidence in lens fitting.
2) Design Education Every contact lens laboratory has a large and varied portfolio of lens designs to match the needs of many different types of contact lens candidates. They can discuss which design may best fit a patient’s needs and can make recommendations based on their extensive experience.
Laboratory consultants understand the nuances of their designs because they consult on hundreds if not thousands of cases per year on that particular product. This includes making minor design modifications that may or may not be documented in their fitting guides.
Additionally, they can help ECPs feel more confident in making lens design and troubleshooting decisions for future patients. The consultants are true experts in their designs, and they deal with their unique lens designs on a daily basis. This expertise and experience should not be taken lightly; the consultants want ECPs to ask them questions, and they want to help educate those practitioners.
3) Material Recommendations In a world with a large and expanding number of GP and latheable soft lens materials, “Which lens material should I use?” is a common question. Laboratory consultants can recommend specific materials—this is particularly important when the design being ordered is available only in certain materials. When troubleshooting a particular case, consultants can also recommend whether a lens treatment or coating would benefit a particular patient or whether a change in material may be helpful in certain circumstances (e.g., to help improve the wetting angle or oxygen permeability of a lens).
4) Specialty Assistance This is where the laboratory consultants are worth their weight in gold. For beginning practitioners, consultants can make recommendations in a variety of areas, ranging from educating patients, making specific design suggestions, fitting and evaluation procedures, and where to go for help. For experienced practitioners, laboratory consultants can make recommendations about how to improve the fit or give other troubleshooting input to help optimize patient success.
5) Reassurance For novice as well as experienced contact lens practitioners, it may take several lenses to achieve success with a challenging specialty contact lens-wearing patient. The consultants are right there assuring the ECPs that this is not their fault and that it represents a normal process with some patients. Consultants will also work with the practitioners to make these patients successful.
6) Online Resources Laboratories have many extremely beneficial online resources, especially for the fitting and troubleshooting of their specific designs. This often includes calculators to determine the lens parameters to be ordered, fitting guides, and problem-solving guides that often include photos, videos, and webinars. They will also often recommend the resources available from industry organizations. For instance, the GP Lens Institute (GPLI; www.gpli.info ) offers more than 70 archived webinars, an interactive empirical GP fitting program called “Click n’ Fit,” a spherical and toric GP lens empirical fitting calculator, and a “Lab Consultant FAQs” module. In addition, the Scleral Lens Education Society (SLS; www.sclerallens.org ) has information about everything scleral, such as care and handling instructional videos for patients, videos and a living library for practitioners, and calendars detailing upcoming SLS hands-on workshops. These two examples are just the tip of the iceberg, as many other industry groups and schools of optometry also have free and downloadable useful resources.
The GPLI Advisory Board members were surveyed as to what they perceived were the benefits of laboratory consultants for them and their practices. The sidebar on p. 32 provides some representative responses.
We asked many laboratory consultants what common questions they receive from practitioners. The following six areas were given as most likely to be asked.
1) Warranties/Return Policies This is a commonly asked question, and it should be. When ECPs consider the cost of some of the specialty lens designs (notably scleral lens designs), the warranty policy provided by the laboratory can factor into whether or not practitioners will fit a specific contact lens. A liberal return policy is especially important for practitioners who are trying to get started with scleral lenses or with other specialty lens designs. It is also important to inquire about return fees and cancellation fees, because these can play a role when developing a system for a contact lens fee structure.
2) Scleral Lenses Consultants are often asked questions pertaining to scleral lenses, including: “Should I use a scleral in this case?” “What type of scleral lens should I prescribe?” “What constitutes a good fit?” “How do I manage problems such as lens decentration or tear debris?” or “What online sources are available?” Consultants can guide ECPs through the fitting and troubleshooting process, recommend workshop programs (sometimes occurring within the laboratory facility itself), and customize the type of scleral lens to be used based upon the ECPs’ experience with scleral lenses.
3) Multifocal Lenses Consultants are often asked about how to approach presbyopic patients with GP and/or custom soft multifocal lenses. Consultants will not only assist with what contact lens to use and how to approach the fitting, but also with how to have that conversation with patients. For an established multifocal practitioner, no one can assist with problem-solving a specific lens design better than a consultant from the laboratory that manufactures that design. Over time, this results in fewer refits, more successful contact-lens-wearing patients, many patient referrals, and greater practice revenue.
4) Irregular Corneas For patients who have all types of irregular corneas (e.g., due to keratoconus, corneal transplant, or refractive surgery), laboratory consultants are invaluable in recommending a specific design, which could include small-diameter corneal GPs, intralimbal GPs, sclerals, or hybrid lenses. Once again, the design selection is only the beginning of a process in which they can assist throughout the fitting and follow up of a patient who has an irregular cornea.
5) Assistance with the Lens-to-Cornea Fitting Relationship For all GP lenses, laboratory consultants can assist with both describing and also providing resources pertaining to how a specific design should fit, beginning with basic spherical lens fluorescein patterns. Sending a patient’s topography and photos or videos of the contact lens fit can be immensely helpful to consultants. Instead of saying “I see touch on the cone and some midperipheral pooling,” it is much more helpful for consultants to actually see the contact lens fit with their own eyes.
6) Insurance/Third-Party Billing and Reimbursement This area is especially important for the success of any practice that fits specialty contact lenses, and laboratory consultants are well qualified to provide assistance to commonly asked questions on this topic. Some consultants will also recommend the GPLI’s coding and billing module under the direction of Clarke Newman, OD, and available at www.gpli.info/coding-billing .
NECESSARY INFORMATION TO PROVIDE
We asked both laboratory consultants and specialty contact lens practitioners about what information needs to be provided to get the most out of their interaction. The responses can be placed into the following five categories.
1) A Good History It is important to have an initial conversation with a consultant that details a patient’s contact lens history (if applicable). What design(s) has a patient already attempted, and why did he or she desire to change? Describe what lenses are currently being worn, and provide information such as hours of comfortable wearing time, symptoms (if present), and a thorough description of the fit. This helps a consultant determine which design a practitioner should fit first. For example, if patients have irregular corneas, consultants can provide the appropriate diagnostic fitting set to initiate the fitting process.
2) The Basic or Minimum Information Most GP lenses today are fit empirically, including spherical, toric, multifocal, and orthokeratology designs. The laboratory consultants advise that the more information they can obtain, the better. At minimum, however, provide a patient’s refraction, keratometry values, and horizontal visible iris diameter; for presbyopic patients, also obtain the photopic pupil diameter and possibly the lower lid-to-limbus relationship. Consultants will often suggest that practitioners reference the lab’s online calculator and ordering system as well.
3) Corneal Topography Maps If corneal topography maps are available, they can be of great assistance in both lens design selection and problem solving. Certainly, these maps are essential when fitting patients into orthokeratology, but they can be invaluable for most other contact lens patients, notably those exhibiting irregular corneas. At a minimum, providing the sim Ks and axial maps are beneficial; however, it is ideal to export the files to laboratory consultants so that they can have more extensive information, including tangential and elevation maps.
4) Photos and Videos of the Fit If a picture is worth a thousand words, then imagine how valuable a video would be. Both are easy to obtain and share with consultants, even in the absence of an anterior segment camera. With numerous slit lamp adapters available today that can be attached to a cell phone, ECPs can obtain good images and videos of the contact lens/eye fitting relationship. This makes it much easier for consultants to see what practitioners see and to know what specific modifications to the lens design are indicated. For scleral lenses, this can assist with the central fit, the limbal transition zone, and the peripheral fit.
5. Optical Coherence Tomography (OCT) The application of OCT with scleral lens designs has been very beneficial to their success, and consultants both welcome and embrace this technology. In particular, consultants desire accurate information for the amount of central clearance (i.e., something more specific than “good” or “plenty”), as this can result in the success of failure of a given design. OCT is ideal for that purpose. Likewise, OCT can assist as to whether there is clearance at the limbal transition area as well as ensuring that the lens periphery is resting on—not embedded into—the conjunctiva or underlying sclera.
WHAT BENEFITS DO LABORATORY CONSULTANTS BRING TO YOUR SPECIALTY CONTACT LENS PRACTICE?
- “Consultants offer the benefit of being intimately familiar with their custom lens designs. Taking advantage of this familiarity and expertise is a regular part of my practice. From design to material and lens care recommendations, consultants are a valued resource in my practice. Engaging a lab consultant is like having another expert in the practice to collaborate with on complex cases!” –TOM QUINN, OD, MS
- “They are invaluable to our specialty CL practice. We consider them ‘partners’ in our efforts to care for our most challenging patients. With the advent of so many new GP designs that are quite proprietary to each lab, the knowledge and experience of the consultants often make the difference to achieve success for our patients.” –BARRY EIDEN, OD
- “Lab consultants know all of the nuances of their lenses well. When I’m learning how to fit a new lens, they provide invaluable ‘on-the-job’ training!” –MURIEL SCHORNACK, OD
- “Consultants typically consult in more patient cases than a practitioner does in a given center, so their experiences are invaluable when guiding a clinician to customize a lens for given patient presentations—this is especially true when a practitioner is starting to explore a new lens design or when encountering an atypical presentation that requires more modifications.” –CLARK CHANG, OD
- “At a teaching institution, consultants play a big role in the learning process. Students need to learn how to order lenses and how to communicate properly with consultants to ensure that the correct lenses arrive for the patient.” –KAREN LEE, OD
- “When you find good consultants, they become integral in your clinic. I often know what I want to do with a lens, but I like to troubleshoot the idea with the consultants to see if we could make it better. Often, they will tell me about new materials and ideas that their lab is getting or working on. This is great because I know what I can offer my patients in the future.” –MELANIE FROGOZO, OD
- “Consultants know their lenses well, so adjustments are made in a way to reduce the overall number of lens reorders, making the patient and practitioner happier as well as guarding the chair time and money of the practice.” –JAMIE KUHN, OD
- “Consultants bring experience and familiarity with their lens designs that they have gained from all-day, everyday exposure to lens fitting and troubleshooting. They can also very quickly order lenses empirically that would otherwise take the practitioner’s time away from patient care to design. They can assist in fitting decisions and also give advice when warranty or other financial issues arise. A good relationship with laboratory consultants is vital to the success of any specialty lens practice.” –ROXANNA POTTER, OD
- “Bottom line: they make the practitioner the rockstar! They are phenomenal at troubleshooting and always providing strategies for improved vision and comfort.” –MILE BRUJIC, OD
PHONE OR ONLINE CONSULTATIONS
It is evident that, although phone consultations are still predominant, the use of online consultations is increasing. One large GP laboratory has no less than 10 full-time consultants, with one completely dedicated to online consultations.
Phone consultations offer many benefits because consultants can quickly and accurately determine how they can assist ECPs while being able to ask the right questions to help with a given patient. The use of the phone would minimize any possible miscommunications that could occur via email. There is also the option of using a video chat system to have a visual consult with a laboratory consultant.
There are benefits, however, to using online consultations. Certainly, any topography maps, OCT images, photos, and videos can be sent online, and some ECPs initiate a phone consultation after sending this information to a consultant. It is also evident that younger practitioners tend to prefer email over phone consultations.
For very busy specialty lens practitioners, online consultations provide numerous benefits. Dr. Woo noted that in her practice, which can see 50+ patients per day, waiting on the phone to talk to a consultant was very inefficient. She says that email has become an excellent way to communicate with consultants. Specifically, it works well because she is able to give the consultants all of the information about the fit (via photos, videos, descriptions, etc.), the consultants are able to view the information and obtain opinions from their team, and then they can get back to her when it is convenient for them. It works the same on the practitioners’ end, because they can view emails at their convenience; patients don’t have to wait for them to finish a phone call.
HOW OFTEN SHOULD PRACTITIONERS USE THEIR LABORATORY CONSULTANTS?
The members of the GPLI Advisory Board communicate with their consultants quite frequently (Table 1). In fact, 68% of the respondents interact with their laboratory consultants more than once per week, and almost 30% contact them daily.
|FREQUENCY||# OF RESPONSES|
|> Once per week||13|
|Every 1 to 2 weeks||5|
|< Once per month||3|
|*Results reflect responses from the GPLI Advisory Board.|
THE FUTURE ROLE OF LABORATORY CONSULTANTS
The future role of laboratory consultants is even more beneficial to ECPs. This is due not only to advances in ease of photography, corneal topography, and OCT, but also with the increasing availability of online virtual fitting and troubleshooting resources. One laboratory has already introduced an online program that allows practitioners to select and modify their scleral lens parameters (e.g., sagittal depth, limbal height, midperipheral clearance) with a visualization of the post-lens fluid layer with those modifications. Practitioners can also observe the calculated Dk value with lens thickness and lens clearance.
On the horizon for ECPs is the ability to perform live virtual consults with consultants who would be able to see what the ECPs see through the slit lamp in real time. There already exists an app-based software that allows for HIPAA-compliant, secure, and encrypted peer-to-peer communication. The system is currently being adopted by multiple contact lens laboratories to facilitate improved consultation and outcomes while reducing consultation time, remakes, costs, and chair time. By simply attaching a smartphone or tablet to the slit lamp oculars via an adapter, the platform allows practitioners to connect with laboratory consultants to aid in the lens design process. These communications can be synchronous (i.e., real-time consultation via a live video call that shows a laboratory consultant a first-person view through the slit lamp of the contact lens on a patient’s eye); asynchronous (i.e., an anytime consultation in which images, video, tests/scans, and other pertinent information are submitted and reviewed by a consultant); or via secure and HIPAA-compliant chat messaging.
THE BOTTOM LINE
The recent advances in contact lens designs, not to mention material and coating technology, are extremely exciting and allow more options and often better alternatives for patients. However, the successful application of these new designs and technological advancements is only as good as the ability of practitioners to design, fit, and troubleshoot them. For this to occur, an integral part of the formula (and often the difference between success and failure of a contact lens patient) is the active and ongoing engagement of laboratory consultants to serve as partners in the management of these patients. CLS
Acknowledgements: Roxanne Achong-Coan, OD; Josh Adams (Valley Contax); Mark André; Mile Brujic, OD; Manoel Carvalho (BostonSight); Carmen Castellano, OD; Clark Chang, OD; Gloria Chiu, OD; Robert Davis, OD; Richard Dorer (Blanchard Contact Lenses); Barry Eiden, OD; Rob Ensley, OD; Melanie Frogozo, OD; Linda Hammann (InnoVision); John Hibbs (Contamac); Jason Jedlicka, OD; Mike Johnson (Art Optical); Beth Kinoshita, OD; Jamie Kuhn, OD; Karen Lee, OD; Michael Lipson, OD; Derek Louie, OD; Ken Maller, OD; Marsha Malooley, OD; Langis Michaud, OD; Troy Miller (AccuLens); Heidi Noorany (SynergEyes); Keith Parker (AVT); Tom Quinn, OD, MS; Phyllis Rakow; Renee Reeder, OD; Susan Resnick, OD; Monica Sanders (Visionary Optics); Pam Satjawatcharaphong, OD; Ann Shackelford (ABB Optical Group); Jack Schaeffer, OD; Muriel Schornack, OD; Brian Silverman, OD; Jeff Sonsino, OD; Jan Svochak (TruForm Optics); Maria Walker, OD; Jeff Walline, OD, PhD; Ron Watanabe, OD.