Article

CONTACT LENS PRACTICE MANAGEMENT

Whether patients wear daily disposables or specialty lenses, follow these guidelines for delivering quality care.

In spite of challenges to the market over the years, contact lenses remain an excellent mode of vision correction for patients and a potential source of significant revenue for eyecare practices. Back in 1961, long before man landed on the moon, my mentor, Dr. Bob Koetting, had the foresight (or the audacity!) to limit his practice to contact lens care. At that time, when only lenses made of polymethyl methacrylate (PMMA) material were available, not many practitioners were fitting them, and few patients were wearing them.

What convinced Dr. Koetting and other pioneers of his generation to risk their future on these tiny pieces of plastic? Perhaps it was the realization that patients wanted to see clearly without the burden of wearing eyeglasses. Even now, this is a major reason why so many patients opt for contact lenses or consider refractive surgery.

Today, our armamentarium consists of far more advanced materials than PMMA, so that virtually every patient can be successfully fitted with contact lenses. The key is to present the option, take the time to work toward success, and, importantly, charge appropriately for your time and expertise.

EMPHASIZE THE VALUE OF YOUR EXPERTISE AND QUALITY OF CARE

Even today, after years of discussion, many practitioners are reluctant to offer contact lenses to patients, because the misconception persists that contact lenses are not profitable. Separating service from materials remains a struggle for too many practitioners, who are uncomfortable charging for their knowledge and expertise.

Fitting contact lenses requires skill and a thorough knowledge of corneal physiology if the lenses are to be worn safely and to fulfill patients’ visual needs for long periods. While many patients who have simple requirements tolerate modern contact lenses dispensed with an emphasis on fulfillment rather than care, many other individuals who want to see without eyeglasses are perfectly willing to pay a legitimate fee for optimal vision and care.

This is where specialty contact lenses in particular come in. Patients who have presbyopia, astigmatism, irregular corneas, or poor ocular surfaces need to know that options are available for them, and it’s imperative that practitioners educate them with enthusiasm and persistence.

And please, if you’re hoping to develop a contact lens specialty practice, wear contact lenses yourself! If practitioners expect their patients to show an interest in contact lenses, they should be willing to “walk the walk” and to encourage their staff to do so, too.

Here are some additional ways to ensure that a practice is more conducive to quality contact lens care:

Figure 1. Various customized in-office pamphlets covering a variety of contact lens topics.

  • Have the proper equipment. Patients appreciate the use of highly technical instrumentation, which demonstrates that practitioners are at the forefront of their field. I also recommend investing in contact lens laboratory equipment to verify and modify rigid lenses on site.
  • Keep convenient hours. This might include Saturdays and/or evenings. Also, be available 24 hours per day for emergencies.
  • Carry an inventory of both diagnostic and revenue lenses. In our practice, we’ve carried a large inventory of GP lenses for many years. Patients appreciate the convenience of same-day service.
  • Offer full service. Patients prefer one-stop shopping, so in addition to a full-service eyewear dispensary, consider providing recommended contact lens solutions, eye drops, and nutraceuticals along with medical eye care.
  • Make contact lens instruction an integral part of the practice. Historically, the contact lens market has seen about a 16% dropout rate per year.1 In my opinion, one reason for this is that patients don’t handle and care for their lenses properly. In my practice, we provide one-on-one instruction for all new contact lens wearers. We give each patient a customized instruction book with information on proper lens handling and care methods as well as tips on proper blinking techniques, makeup, and sun wear (Figure 1). We also prescribe a lens care solution and emphasize that patients should not deviate from that prescription without checking with our office.
  • Provide convenient ordering and dispensing options. Offer online ordering with mail delivery or easy pick-up of ordered lenses. Consider a courier for emergency situations, and, of course, make payment easy.
  • Recognize that your staff is an extension of you. Hire the best people possible and train them diligently. Hold regular staff meetings so that everyone is on the same page. Offer educational courses, and support formal certification programs available for ophthalmic staff. In our office, we prefer that staff members wear a uniform with a logoed top or sweater, and they must wear a name tag at all times.
  • Make the office a pleasant place to visit. Appoint your reception area with comfortable furniture, Wi-Fi if practical, quality reading material, and refreshments. We have for many years offered coffee, soft drinks, and cookies (for which many patients now come in looking!).
  • Play the “PR” card. In this case, PR stands for patient relations. We reserve a section in the electronic medical record—not part of a patient’s case record—for notations by the staff or practitioner to help personalize the experience for the patient. This can include events such as the expected birth of a child or grandchild or an upcoming vacation. This will help jog the practitioner’s memory for conversation at a subsequent visit.
  • Recognize referrals. The lifeblood of any practice is the continuous infusion of new patients. Some patients are prolific when it comes to sending in friends and family. We recognize these individuals with a token of appreciation, ranging from flowers to a box of steaks to a simple “Thanks a Million!” note with a lottery ticket attached.

Patients recognize the quality of the care that they receive and are willing to pay for exceptional service. Service is really the primary thing that practitioners have to sell, and our service will set us apart. Paying attention to details in every aspect of your practice will help you provide a level of service that keeps patients coming back and inspires them to refer friends and family.

The ever-changing and improving world of contact lenses provides many options for our patients. Here is a closer look at the innovations that will set your practice apart.

DAILY DISPOSABLE LENSES

The advancement of daily disposable contact lenses has resulted in many opportunities for prospective contact lens wearers. The health advantages of discarding a lens after a single use have been well documented.2,3 What’s more, a great way of introducing contact lenses is to offer this modality on a part-time or occasional-wear basis for patients who may not be interested in full-time wear.

Daily disposable contact lenses have been well accepted in Europe and Asia for many years, but practitioners in the United States were slow to embrace them, citing resistance by patients primarily because of cost. This has changed in recent years, and the use of these lenses has increased. Cost concerns can be easily abated by 1) emphasizing the eye health benefits of discarding a lens after each use; and 2) educating patients on the savings that they will realize by not needing to purchase lens care products over the course of a year.

Most patients who currently wear soft contact lenses are candidates for daily disposables, which are available in a wide range of parameters, designs including toric and multifocal, and silicone hydrogel materials.

PRESBYOPIA CORRECTION

The age demographic that has the greatest disposable income in the United States—people between the ages of 45 and 64 years—happens to be the demographic that has entered presbyopia.4 Yet, most of these individuals haven’t tried contact lenses, either because they didn’t know that it was possible for them or because no one ever asked whether they were interested. We need to embrace our presbyopic patient population and educate them on the advantages of contact lenses.

People are staying active for much longer in life and are often engaging in activities that are best enjoyed while being free from spectacles. With a well-trained staff and a mindset that most presbyopic patients can wear contact lenses successfully, there’s no reason why we shouldn’t be offering them to all of our presbyopic patients. With refinements in multifocal soft and GP designs, as well as the availability of toric multifocals and custom designs, virtually any motivated presbyope can be successful. And don’t completely dismiss monovision; it’s still a tried and tested mode of correction for many patients.

One of the keys to success when prescribing for presbyopia is to manage patients’ expectations. Listen carefully to what patients do and how they use their eyes to understand their needs and desires. For example, a translating GP bifocal may provide excellent distance and near acuity but may not be the best option for someone who spends the day in front of a computer. Conversely, a retiree who enjoys fishing and tying flies and who spends a great deal of time reading may do well with this design. Emerging plano presbyopes may not like their distance vision through a multifocal soft lens, but they may tolerate a low-plus single-vision lens on their nondominant eye quite well. To explain the difference between multifocal contact lenses and monovision, I tell patients that with multifocal lenses, the eyes are seeing similarly, but there might be a slight degradation in visual quality that requires some adaptation. With monovision, each eye sees clearly individually, but the eyes are not focused on the same target.

Once patients understand what to expect, and with practitioners’ willingness to make changes or adjustments along the way, most patients can be successful and satisfied. When you have made a presbyopic patient happy, you can often expect many new referrals in return.

ASTIGMATISM CORRECTION

How many times have we heard patients say, “I’ve always been told that I can’t wear contact lenses because I have astigmatism.”? I’ve been in practice long enough to remember when toric soft lenses were referred to as snowflakes, because no two were alike. Thankfully, those days are long gone. Even so, it seems that more times than not, patients have to ask for contact lenses rather than wait for a recommendation from their practitioner. Why is that? It should not be the case for modern toric lens designs.

Today’s toric soft lenses are comfortable, stable, reproducible, and available in a plethora of parameters. They work so well that even small degrees of astigmatism can be corrected for optimal vision, and much higher degrees of astigmatism can be managed like never before.

Remember, too, that GP lenses have value for these individuals. The quality of vision that a rigid lens provides can help patients who have more critical vision requirements.

DRY EYE MANAGEMENT AND
 IRREGULAR CORNEAS

If you look at any eyecare journal these days, you’re bound to see at least one article on dry eye. It’s well documented that our reliance on electronic devices has changed our normal blink habits to the point at which dry eye has become a prominent problem for many people.5 It is estimated that meibomian gland dysfunction plays a significant role in nearly 90% of cases.6 Just as addressing dry eye disease is critical before referring a patient for cataract surgery, so too should we address it with all potential and current contact lens wearers. When treated, most patients who have dry eye can enjoy the many benefits of contact lens wear.

Patients who have severe dry eye, as well as those who have keratoconus or other irregular cornea conditions, may benefit greatly from scleral lens wear. While scleral lenses have been available for a long time, they have enjoyed a resurgence in recent years with the development of highly permeable materials. Many laboratories and manufacturers are now producing high-quality scleral designs that make this modality conducive for everyday practice. Getting comfortable with one or two scleral lens designs will enable you to address the needs of most patients who have these ocular surface conditions. As a bonus, scleral lenses are also available in multifocal and front-surface toric designs that help manage not only dry eye and irregular corneas, they also provide excellent visual outcomes.

MYOPIA CONTROL

Research tells us that individuals who have myopia are more prone to developing ocular conditions such as myopic macular degeneration, retinal detachment, glaucoma, and cataract.7 The higher the degree of myopia, the greater the likelihood of developing these conditions.

Approximately 40% of the U.S. population is myopic (up from about 25% in 1972), and by 2050, it is estimated that half of the world population will be myopic.8 The number of myopic individuals is expected to double between 2000 and 2050, and the number who have high myopia will quintuple.8 It is postulated that the reasons for this dramatic increase of myopia are both hereditary and environmental, the latter owing to increased near-point activity and inadequate time spent outdoors.8

It is well documented and generally believed that peripheral defocus, as occurs with conventional myopia correction, promotes elongation of the eye and, thus, progressive myopia.9 Some specialty contact lens options have shown promise in decreasing the degree of myopia progression by up to about 50%.

Distance-center soft multifocal designs can promote peripheral defocus and reduce the rate of progression of the condition. The first soft contact lens specifically designed for this purpose was recently approved in the United States. Orthokeratology with reverse geometry GP lenses may have a similar effect. A contact lens specialty practice should now include myopia control as part of its realm of services.

WHAT THE FUTURE HOLDS

The contact lens industry continues to evolve, with the development of ever better and healthier materials and optical designs. In the last year alone, we have seen the introduction of a photochromic contact lens that can transition from light to dark and vice-versa to reduce glare, light sensitivity, and blue light transmission. Soon, we’ll likely see contact lenses designed to deliver ocular drugs and to monitor critical health measurements, such as intraocular pressures and glucose levels.

The future of contact lenses is bright and intriguing, and it should offer great opportunities to create happy patients and successful practices for practitioners who are willing to embrace this exciting specialty. CLS

REFERENCES

  1. Rumpakis JM. New data on contact lens dropouts: an international perspective. Rev Optom. 2010 Jan;147:37-42.
  2. Efron N. Daily soft lens replacement. In: Efron N , ed. Contact Lens Practice, 2nd ed. Oxford: Butterworth‐Heinemann, 2010. p 209-216.
  3. Sulley A, Dumbleton K. Silicone hydrogel daily disposable benefits: the evidence. Cont Lens Anterior Eye. 2020 Feb 22. [Epub ahead of print].
  4. Duffin E. U.S. mean disposable household income by age 2018. Statista; November 18, 2019. https://www.statista.com/statistics/980324/us-mean-disposable-household-income-age . Accessed April 1, 2020.
  5. Golebiowski B, Long J, Harrison K, Lee A, Chidi-Egboka N, Asper L. Smartphone use and effects on tear film, blinking and binocular vision. Curr Eye Res. 2020 Apr;45:428-434.
  6. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016 Mar;100:300-306.
  7. Holden B, Sankaridurg P, Smith E, Aller T, Jong M, He M. Myopia, an underrated global challenge to vision: where the current data takes us on myopia control. Eye (Lond). 2014 Feb;28:142-146.
  8. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016 May;123:1036-1042.
  9. Berntsen DA, Barr CD, Mutti DO, Zadnik K. Peripheral defocus and myopia progression in myopic children randomly assigned to wear single vision and progressive addition lenses. Invest Ophthalmol Vis Sci. 2013 Aug;54:5761-5770.