Almost all businesses are changing at a rapid rate, and the eyecare field is no different. Disruptive technology is ubiquitous, from online ordering of spectacles and online and kiosk eye examinations to soft lens self-evaluations combined with quick ordering from mobile apps. How can eyecare practitioners compete in this environment?
The most obvious strategy is to find ways to continually connect with your current patients, because they have already experienced you, your staff, and your office. Building your marketing efforts through social media is another method.
How will you attract a continuous flow of new patients, contact lens wearers in particular, to the practice? Organic growth is possible through internal marketing efforts that raise awareness of everything you offer to patients. Another way to attract new patients is through referrals of friends and family members by that same group of current patients or through direct referrals from other eyecare providers in your community.
Let’s look at how positioning your practice as a Specialty Contact Lens Center of Excellence could impact your surviving and thriving in the future. Patients who wear specialty contact lenses are typically loyal to the practice, and they rarely price shop for their care, making your specialty lens practice a profit center that is not price sensitive. Not to mention, fitting specialty lenses is intellectually stimulating — and fun!
First, let’s define what specialty contact lenses are and are not.
There are multiple ways to define specialty lenses. A definition could be design-related, meaning spherical, toric, multifocal, etc., or it could be associated with specific ocular conditions, such as high refractive error, presbyopia, irregular cornea, meibomian gland dysfunction, and contact lens-induced dry eye. A definition could even be material-based, such as soft versus GP versus hybrid. Some practitioners might differentiate them as fee-based or reimbursement-based.
My definition of a contact lens specialist is this: An eyecare practitioner who is aware of all of the lenses available in a given category, knows when to use each one, and most importantly, understands what techniques are necessary to accurately use them.
So let’s get started along the path of positioning you and your practice as contact lens specialists.
1. MAKE THE COMMITMENT
If only you could simply anoint yourself a contact lens specialist. If you happen to be one of the 20 to 25 cornea and contact lens residents who are trained annually, that is one thing. The rest of us need to make a strong commitment to take the time to learn the designs and products, invest in special instrumentation, develop relationships with lens manufacturers (in particular the consultants), read the latest publications, participate in pertinent webinars, and attend the important conferences to begin networking with peers in the specialty lens field. This transformation will not occur overnight, but if you develop a structured path, you will be positioned as a contact lens specialist relatively quickly.
2. INVEST IN INSTRUMENTATION
Hands-down, the key instrument for the contact lens specialist is one that measures the ocular surface. Of the numerous instruments on the market, some are more “contact lens friendly,” while others are oriented more toward the surgical setting. Keratometric measurements have historically been the basis for contact lens design, but actually they supply very little information about the corneal surface. It is nearly impossible to expect measurements taken at points approximately 2 mm to 4 mm in the central cornea to tell us much about the corneal shape. Therefore, you must have access to a corneal topographer, and you must learn all of the functionality of that particular instrument, including the differences between axial, tangential, and elevation maps. Note that difference (or subtractive) maps are critical to compare the before and after effects of a lens on the eye (Figure 1). In addition, corneal topography is often used clinically to detect and evaluate the severity of keratoconus. In essence, you must become skilled at corneal topography to become a contact lens specialist.
Anterior segment optical coherence tomography (OCT) is playing a more prominent role in specialty contact lens fitting today. This is mainly because the use of scleral lenses has been reintroduced to North American eyecare practitioners along with the importance of sagittal height fitting relationships, which can only be estimated — not calculated — with topography. Additionally, OCT images combined with built-in calipers can measure posterior tear-film thickness behind contact lenses, evaluate lens bearing, examine lenses for thicknesses at different points, provide cross sections of design profiles, and demonstrate possible lens flaws, along with the possibility of evaluating pachymetry and corneal edema (Figures 2 and 3). OCT is quickly becoming an important tool for contact lens specialists.
3. DILIGENTLY ACQUIRE OTHER OCULAR DATA
Refractive error is important in contact lens design, as is the ocular surface data discussed previously, but numerous other measurements differentiate the contact lens specialist.
First, there is cornea size, typically referred to as visible iris diameter (VID) or horizontal visible iris diameter (HVID). This measurement should be taken into consideration for every lens whether you are prescribing a stock soft, custom soft, corneal GP, scleral GP, or hybrid lens. Approximately 20% to 30% of corneas are larger or smaller than “average,” indicating that the fit of these lenses could be improved with the proper lens-to-cornea size relationship.
Next is pupil size, which is critical in most lenses but of particular importance in presbyopia-correcting designs. Noting the patient’s photopic and scotopic pupil size, then employing the proper coinciding optical zones will decrease halos, glare, and other visual disturbance in different lighting conditions. Pupil position and visual axis along with line of sight are also important to note.
Last but not least, you should note the patient’s lid configuration, position of upper and lower lids, distance from the center and lower portion of the pupil to the lower lid, and completeness of the patient’s blink.
4. USE VARIOUS METHODS TO CAPTURE ON-EYE IMAGES
Everyone in eye care is employing more imaging than ever before, mainly because today’s slit lamps have photo capabilities along with the relative ease of storing images in the patient’s electronic health record. A specialty contact lens practice must be able to acquire numerous types of images in white and cobalt blue light with and without fluorescein and utilizing many different types of illumination. Diffuse and retro illumination as well as the use of optic section provide images that document various lens fitting characteristics.
High quality video is also important, particularly if you want to participate in venues where you can share interesting cases with your peers. Imaging is an excellent method for sharing difficult cases with your lens laboratory to allow them to weigh in with possible answers to fitting challenges. Video can be captured with HD cameras or simply by holding or attaching your mobile device to the slit lamp oculars.
5. BECOME A LENS DESIGN EXPERT
To develop your specialty lens presence, you must first understand lens design. This is best achieved simply by asking your laboratory consultant many questions about the various lens parameters. You should know the optical zone sizes and whether they use radius or angles in the lens periphery and what the overall thickness profile is. While some laboratories treat this information as proprietary, most are willing to share it with you, because they realize the more you understand a particular product, the better chance you and your patient have of being successful.
Visiting your laboratory to watch how lenses are fabricated is also extremely helpful. You will gain an appreciation of how well contact lenses are manufactured today. In addition, you will gain insight into how surface treatments, such as plasma and PEG (polyethylene glycol), are applied. You will also learn the differences in the manufacturing processes for corneal and scleral GPs as compared to the extra steps necessary when making soft lenses.
If you are really keen on differentiating yourself, consider becoming familiar with lens design software, which will enable you to custom-design your own lenses (Figure 4). There are different options of these programs. Some are built into a topographer, others can download the topography files into the design software, and still others stand alone. Regardless of the program you choose, knowing how to use this software puts you in the driver’s seat for determining what is best for your patient’s ocular situation.
6. TAKE THE QUICKEST PATH TO BECOMING A SPECIALIST: PRESBYOPIA
Frankly, I believe you could position yourself only as a presbyopia contact lens specialist and be as busy as you want to be. It is the largest specialty lens category, yet one where many patients have remained somewhat dissatisfied, particularly with the visual results. To do this correctly, you need to have access to a multitude of lens products and be aware of the different optical principles applied with each one.
In the soft lens arena, you will want to have every major brand of disposable soft lenses available, as each one has its place, and you will need to understand the optics of the individual designs. Are the lenses center-near or center-distance? Are multiple add powers available? Are the optics spherical or aspheric (Figure 5), or are they in the newest category, extended depth of focus? Which design works best for distance, intermediate, or near vision? When should you consider mixing brands to achieve the best visual result? Remember, there is no rule that states a patient must wear the same brand or even the same add power on each eye. In fact, the creativity of certain combinations can often be the difference between visual success and failure.
Do not forget about GP and hybrid lenses for presbyopic patients. Both provide the sharp acuity that will meet the needs of certain patients. GP bifocal designs offer the most flexibility in that they can be designed with the optics in the right place at the right time, and they are not so dependent on pupil size and dynamics. Translating, segmented type lenses (Figure 6), which are often a go-to design for higher add powers, should be considered for early presbyopes as well. Once these designs are successfully fit, a simple power change is usually all that is needed as the patient ages.
Stay tuned for a new approach, decentered optics in presbyopic lens designs. It is well established that a patient’s visual axis does not coincide with the geometric center of the cornea or that of a well-centered, rotationally symmetric lens. Thus, the patient’s line of sight does not match the location of the lens optics, particularly in varying lighting conditions. We are relying on decentered optics to improve visual results significantly and expect these designs to become available in the near future.
7. APPRECIATE TORIC SOFT LENSES (YOUR PATIENTS DO)
Most eyecare practitioners feel quite comfortable prescribing toric soft lenses, but they are usually reserved for eyes with refractive astigmatism of 1.25D or more. Consider a toric soft lens for residual astigmatism of 0.50D or more when spherical.
Also, consider offering custom soft lenses for patients with astigmatism, and not just for the power. Being able to prescribe a specific amount of ballast or to alter the base curve/diameter combination is helpful to stabilize toric lenses. For patients with astigmatism and presbyopia, custom-made soft designs are an excellent alternative.
8. BE FAMILIAR WITH CONTACT LENSES FOR MYOPIA CONTROL
Over the next few years, myopia control will begin to come of age as the first products are cleared by the U.S. Food and Drug Administration. While pharmaceutical agents such as atropine will likely play a role, contact lenses will be used primarily to provide the necessary optics to slow axial elongation.
Multifocal soft lenses are demonstrating success for myopia control, but we are still not absolutely sure of the best optical configuration or add power to prescribe for varying levels of early myopia combined with the age of the patient.
Orthokeratology lenses are a consideration as well (Figure 7). The optics provided to the central and peripheral retina by the reshaped cornea after orthokeratology appear to be ideal based on what we know today.
Sophisticated new instrumentation in this area will allow us to accurately measure peripheral refractive error. This will enable us to finally be able to document what is occurring refractively in this area of the retina to control axial growth.
9. START FITTING (MORE) SCLERAL LENSES
Today’s contact lens specialists usually have a high level of interest in scleral lenses. Over the past 8 to 10 years, this field has evolved rapidly, with more than 40 designs available from 20+ lens manufacturers in North America alone.
Most often, practitioners consider scleral lenses as devices for managing irregular corneas after disease, injury, surgery, or extreme ocular dryness. Candidly, they have been life-changing for thousands of patients who have struggled with previous contact lens fits.
Keep in mind that scleral lenses have other uses. Patients with poor vision who have been unsuccessful with soft lenses can see better while still achieving all-day comfort. Patients with soft lens-induced dry eye can benefit from scleral lenses as well, and these lenses continue to show promise for presbyopia.
10. UNDERSTAND THE ROLE OF TINTED LENSES FOR MEDICAL INDICATIONS
Contact lens specialists may encounter patients who need specially tinted lenses for various reasons, including cosmetic correction, artificial pupil, matching the fellow eye’s iris pigmentation, and so on. The use of these lenses is a life-changing event for patients. Prescribing tinted lenses requires in-office diagnostic sets, color swatches, or digital photography to determine the best possible color match. Figure 8 shows the right eye of a teenage patient whom we treated in our office. She had a history of ocular toxocariasis at age 4 and was self-conscious because of the difference in the appearance of her two eyes. Note the much more natural appearance of her eye after being fitted with a cosmetic tinted lens.
All that’s left is to build a close relationship with your contact lens laboratory (in particular, their expert consultants), start attending training sessions offered by associations and at major meetings, and begin to build your internal and external referral network. You will be well on your way to establishing your practice as a Specialty Contact Lens Center of Excellence. CLS