- From the Publisher: A New Vision for AOC
- EyetubeOD in 2013 and Beyond
- Navigating the Retina: Imaging for the Optometrist
- Considerations for Patients on Anti-VEGF Therapy
- Incorporating Imaging Into Practice: The ‘3 Ps’ of Premium Eye Care Delivery
- The Boom from the Inside Out: Novel Approaches to Nutrition and Retinal Disease
- Creating a Center of Excellence for AMD
- Highlights from Cataract & Refractive Surgery Today
- Bilateral Contemporaneous Posner-Schlossman Syndrome With Advanced Chronic Open-Angle Glaucoma
- An Overview of Contemporary Contact Lens Practice
- Innovations for Improving Contact Lens Designs
- Presbyopia-Correcting Contact Lenses: Is Their Time Now?
- Experts Weigh in on How to Ensure Success With Contact Lenses
- Addressing Patients’ Needs With Specialty Contact Lenses
- Your Eye Care Website: Get in the Game!
- A Novel Approach to Patients’ Assessment
Six Tried and True Pearls
By Melissa Barnett, OD
No. 1. Treat Dry Eye Early and Aggressively
When evaluating a new or existing contact lens wearer prior to a fitting, it is important to examine him or her for the signs and symptoms of dry eye disease (DED). Patients will have better vision and improved comfort with contact lenses if their DED is treated successfully, and this is especially true in the setting of multifocal or specialty contact lenses. Examine the tear meniscus, tear film quality, and tear breakup time. Evaluate the cornea and conjunctiva using both lisammine green and sodium fluorescein for any signs of staining. If staining is present, treat the patient aggressively. For example, cyclosporine 0.05% (Restasis, Allergan, Inc.) is the only prescription medication approved to increase tear production. This twice-aday drop can be instilled prior to contact lens insertion and after removal. If the patient has a healthy tear film, consider inserting punctal plugs. Temporary collagen plugs may be used first to determine if they are effective, then silicone plugs are indicated for long-term relief. Contrary to some beliefs, cyclosporine 0.05% and punctal plugs may be used synergistically with great success.
No. 2. Switch To Daily Disposable Lenses
When specifically asked, many patients will report that their contact lenses do not feel comfortable, and they experience reduced vision toward the end of their replacement schedule. Daily disposable contact lenses offer a clean lens with crisp vision each day and now come in a variety of parameters: single vision, toric, and multifocal. These lenses also reduce costs because the use of solutions is not needed. Happy daily disposable contact lens wearers are also great to grow the practice. For environmentally conscious patients, inform them that most blister packs are made of polypropylene and are #5 recyclable at Whole Foods Markets and Preserve Products (www.preserveproducts.com). A recycling program can also be set up in the office.
No. 3. Review Contact Lens Solutions
Recommend specific contact lens solution(s) and include this information on the contact lens prescription. At every patient visit, make sure to review contact lens solutions and how they are used, and change the solutions if needed. For soft lenses, consider a multipurpose solution or hydrogen peroxide system. For gas permeable lens wearers, consider changing the cleaning regimen if there are problems. Hydrogen peroxide and nonpreserved sodium chloride 0.9% inhalation solution have been very successful with scleral lens wear. An additional cleaner may be needed on occasion as well.
No. 4. Have a Variety of Lenses
Different patients have different needs; therefore, it is essential to have a variety of lenses. Each modality has a different material and design, so it is essential to have a go-to lens for the patient with DED, the patient who has trouble handling contact lenses, and the patient with an irregular cornea. Offering many modalities is beneficial for fitting a diverse patient population.
No. 5. Think Outside of the Box
Be creative: consider multifocal or monovision for patients with irregular corneas. Not only do these lenses offer patients good distance vision, but they also eliminate the need for reading glasses. These end up being the happiest patients and will refer their friends and family to the practice. To obtain premium vision for patients, consider fitting scleral, hybrid, or soft daily disposable multifocal lenses. I have found this new technology to be remarkable. Consider using multiple pairs of contact lenses depending on the needs of the patient. For example, daily disposable lenses for certain situations can be helpful, and the patient’s additional pair may be a different type of contact lens altogether. Scleral lenses to treat ocular surface disease are valuable to rehabilitate the cornea as well as improve vision. Consider a soft lens for keratoconus—this technology has greatly improved in recent years. Be sure to ask patients about their visual needs at work and for hobbies and sports as well.
No. 6. Try New Technology
This is an exciting time for contact lenses, and new ones are being developed all the time. Because innovation in this area is constant, a new lens may be ideal for a patient. Reading the trade publications, attending continuing education meetings, and speaking with colleagues can help optometrists stay up to date on the latest developments. Make sure to visit the exhibit hall at scientific conferences to see and handle lenses at each company’s booth. It is also useful to seek out courses from different speakers to get various opinions about contact lenses. When a new lens is released, try it in the practice. Experience with the lens is crucial to see if the technology will benefit your patients.
Melissa Barnett, OD, is a principal optometrist at the UC Davis Medical Center in Sacramento, California. She is a consultant to Alcon Laboratories, Inc., Allergan, Inc., and Nidek, a spokesperson for the California Optometric Association, and is on the board of the Scleral Lens Education Society. Dr. Barnett may be reached at firstname.lastname@example.org.
Focus on the Contact Lenswearing Experience
By Jason R. Miller, OD, MBA
New technologies are important to the bottom line of a contact lens practice, and they are most profitable early in the product’s life cycle. Early adopters will typically reap larger benefits with respect to many products including contact lenses. In addition, many eye care practitioners say that contact lens wearers are important to their business model, but how many of us optometrists actually focus on maximizing comfort and take the time to discuss these new technological advances in the industry with our patients?
Contact lens comfort may be difficult to predict in that contact lenses introduce a unique challenge to the ocular surface. They are a foreign vector placed on the ocular surface and can illicit symptoms of dry eye in individuals who might otherwise have virtually none. In fact, literature states that more than 50% of patients who wear contact lenses complain of discomfort.1,2
We practitioners have a number of strategies to increase contact lens comfort including treating underlying ocular surface disease, supplementing lens wear with contact lens rewetting drops, optimizing the contact lens solution, and optimizing the contact lens material and design.
Treat Underlying Surface Disease
An underlying ocular health issue may be the root cause of patients’ discomfort. Subtle changes in the way patients are questioned about their contact lens wear may give the practitioner valuable insights into patients’ comfort concerns while wearing their contacts. Instead of simply asking patients, “How are your contact lenses doing?” consider asking more detailed questions like, “What percent of your contact lens wearing hours are comfortable wearing hours?” or “What time of the day do you usually take your lenses out?” These questions may reveal surprising answers and a potential contact lens dropout symptom that needs to be addressed.
The eye examination is the opportunity for the eye care practitioner to educate the patient on how to best wear and care for their lenses. This is the critical moment during a patient encounter where we practitioners incorporate all of the findings and combine that information with our knowledge and experience to give the patient the best recommendation. But what information resonates with patients, and what factors should optometrists be focusing on to maximize contact lens compliance efforts?
For patients with comfort complaints, create a strategic approach to better achieve comfort. First, optimize the ocular surface and mitigate any effects that suboptimal health would have on contact lens comfort. Next, focus on contact lens care and look for ways to modify the regimen to optimize comfort. This entails getting a true account of the patient’s care routine and making sure that he or she is using the solutions that will most likely improve the wearing experience. If the patient has strayed from prescribed wear and care patterns, take the time to review proper care techniques or refit the patient in an option that better matches his or her preferences. Finally, review the patient’s contact lens prescription. Remember that we practitioners have a number of contact lens materials and designs that can improve patients’ comfort. Silicone hydrogel or SiHy lenses, in particular, have been designed to maximize oxygen permeability while maximizing comfort through significant technological advancements in surface chemistry.
Take What you have Learned
Daily disposable lenses may be the best choice for patients with comfort concerns. One-day contact lenses are very useful for patients who are part-time wearers, and they are often ideal for the population with DED. The option of daily disposable lenses offers the potential to add contact lens wearers to the practice. This mode of contact lens wear offers many advantages, of which convenience is by far the biggest.
From single-use daily disposable contact lenses to 2-week, 1-month, and the less-common, quarterly and/or yearly replacement schedules—today’s contact lens wearers have many options to consider when choosing a lens modality. Ultimately, the eye care practitioner is responsible for selecting a proper contact lens modality, material, and solution combination to ensure lens wear success. In the end, the best lens to use is the one that maximizes patients’ comfort and matches their preferences.
Jason R. Miller, OD, MBA, is a partner in a three-doctor private practice at EyeCare Professionals of Powell, Ohio, and an adjunct faculty member for The Ohio State University College of Optometry. In addition, he is currently in multiple leadership roles within the Ohio Optometric Association. Dr. Miller may be reached at email@example.com.
- Nichols JJ, Ziegler C, Nichols KK. Self-reported dry eye disease across refractive modalities. Invest Ophthalmol Vis Sci. 2005;46(6):1911-1914.
- Guillon M, Maissa, C. Dry eye symptomatology of soft contact lens wearers and nonwearers. Optometry Vis Sci. 2005;82(9):829-834.
Increase Your Patients’ Satisfaction
By Margie R. Recalde, OD
Throughout our careers as optometrists, we have all come across clinical pearls that have helped us grow as clinicians and guide how we practice. Some of the most challenging cases are the ones that give us the most rewards. We learn from both the good and the bad, but through it all, we become better doctors for our patients. The following are some contact lens clinical pearls that may benefit your practice.
Patients’ noncompliance with prescribed therapies is a universal problem that occurs across the board with all health care practitioners. When it comes to contact lenses, we have all spent a significant amount of chair time educating patients on proper hygiene and lens care, the importance of adhering to regular replacement schedules, and warning them about the risks of overnight wear. Yet, after all these efforts, some patients continue to not adhere to our advice.
It is important to note that despite our best efforts, patients only remember about 50% to 60% of what we tell them in the examination room. At my colleagues’ and my practice, we utilize a patient education form to ensure that patients remember all of our instructions. The form also acts as a contract that the patient must sign before leaving our office, therefore holding the patient responsible for knowing the information. When we release a copy of the contact lens prescription, it contains detailed information on the type of contact lens solution to use and the replacement schedule. Education is one of the best ways to improve compliance.
Dry Eyes and Contact Lenses
When a patient is suffering from chronic DED, it gradually becomes extremely difficult for him or her to wear contact lenses. It is up to us to figure out the problem before the patient drops out of contact lenses permanently. It may take some detective work to figure out the problem. It is important to take a step back to review patients’ medical history including their over-the-counter and prescription medications. A careful case history, thorough slit-lamp examination, and a dry eye workup would be next on the list.
Treating DED may take some time depending on its severity. Make sure that you discuss with your patient the chronic nature of DED and that treatment will help manage the condition but not cure it. It is important to set reasonable expectations.
Even after the medical treatment of their DED, some of my patients have had to switch to daily disposable lenses to help improve comfort. 1-Day Acuvue TruEye (Vistakon Division of Johnson & Johnson Vision Care, Inc.) is an excellent lens for patients with DED. Some patients may need to stop wearing contacts for a short period to get their DED under better control before restarting contacts. Your patients will appreciate the time and effort that you are investing to ensure that they can wear contact lenses successfully. Overcoming the DED obstacle can be challenging, but in the end, you will gain a loyal patient.
Fitting multifocal contact lenses does not need to be challenging. If you perform a proper overrefraction, then it becomes easier to finalize the contact lens prescription.
Overrefract at distance first and have the patient keep both eyes open. Place a +0.25-D power over the dominant eye in free space, then increase the power if needed to obtain the patient’s best binocular visual acuity. Try to push the plus power without compromising the visual acuity. If the patient prefers minus power, double check to make sure that it improves his or her distance vision.
Once finalized, leave that lens over the patient’s dominant eye while overrefracting the nondominant eye for distance. Once the nondominant eye overrefraction is also achieved, then test the patient’s near vision while leaving the distance overrefraction lenses in place. Make sure to use the patient’s cell phone to test his or her near vision. If you were able to push plus at distance, that extra plus power will also help near vision. If the near vision is still not satisfactory, then add +0.50 to the nondominant eye.
Keeping up to date by talking to your peers, contact lens representatives, and reading journals are just some of the ways we keep our practices moving forward. The essential part of improving is to take what we hear and act upon it. Being open to change is how we grow as clinicians.
Margie R. Recalde, OD, is in a group MD-OD practice at Eye-Q Vision Care in Fresno, California. She is a consultant to Allergan, Inc. and has received past honoraria from Alcon Laboratories, Inc., and Bausch + Lomb, Inc; however, she acknowledged no financial interest in the product or company she mentioned. Dr. Recalde may be reached at firstname.lastname@example.org.
Do Not be Afraid to Try Scleral Multifocal Lenses
By Keith Wan, OD
Scleral contact lenses work well for patients who cannot wear traditional soft contact lenses. These patients include individuals with keratoconus, corneal ectasia, and corneal transplants. Also, during the past year, I have had success fitting dry eye patients with scleral lenses. The lens vaults the cornea, and it has a saline moisture barrier that stays intact throughout the day. These features enhance the lens’ comfort, and the high oxygen permeability of today’s designs make them very safe as well. The latest technology also gives me the ability to fit multifocal scleral lenses.
Optimizing Vision With Multifocals
I have been using the iSight scleral multifocal lens from GP Specialists, Inc. for many of my patients. This scleral lens has five curves including the central area, two curves that vault the limbus, and two curves in the periphery that land on the sclera for stability (features of any scleral lens). Like with a soft, multifocal lens, there are two designs of the lens with a center-near and a center-distance zone. With regard to the multiconic sections of the lens, the center of the center-distance lens provides optimal distance vision, and the 2 mm outside the center will provide the best near vision. The opposite is true with the central-near lens model: the central 2 mm provides optimal near acuity with best distance acuity found just adjacent to this zone. Of note, the eye care specialist can control the size of this central zone in either model.
The key to fitting these lenses is obtaining the patients pupillary size in both dark and light conditions. These measurements dictate how the optometrist will control the center optical zone. The specialist must determine the patient’s dominant eye, which in turn will determine if the lens needed is a center-near or a center-distance model. If a patient says that he or she needs great vision at distance and wants to see a little better up close, then I might use two center-distance lenses. If he or she needs better near vision, I generally use two center-near lenses, and I can change the size of the center zone.
The belief that scleral and multifocal lenses are difficult to fit has been a barrier to their use. For beginners, however, fitting software helps in determining the near and distance zones. Having a fitting set can also be very beneficial; many labs like GP Specialists offer loaner fitting sets.
Emerging presbyopes are easy to fit with multifocal scleral lenses. These patients require a low add, and many of them have never worn any type of contact lens. When they present with complaints about their near vision, I will fit a soft contact lens first. If the optics of a soft lens do not provide the visual outcome the patient desires, then I will jump right to a scleral lens because the optics are great, and the comfort is there.
A key to success with introducing a new technology to the practice is the staff. Staff members need to know how to explain the product to patients both on the phone and in the office, because they will be responsible for teaching and training patients on these new lenses. The optometrist can be the very best, but if the support team does not have confidence, then the technology will not be successful.
Keith Wan, OD, is in practice at Scripps Poway Eye Care and 4S Eyecare & Optometry, San Diego, California. He acknowledged no financial interest in the product or company he mentioned. Dr. Wan may be reached at (858) 530-2800; www.sp-eyecare.com.
Tips for Prescribing Contact Lenses for Astigmats
By Denise M. Whittam, OD
“Hi, my name is John, and I have astigmatism.” How many times has a patient announced his or her astigmatic condition within the first minute of your examination? They may not remember to change their lenses on time or schedule an annual checkup, but somehow the fact that their eye is shaped like a football stays top of mind. Beyond this basic physiological detail, however, most patients do not really understand the impact of astigmatism on visual function, which is what should matter most.
I see a lot of low astigmats who do not see as clearly as they should because they are wearing spherical lenses that mask their astigmatism. Their vision is “good enough,” so most do not come in complaining about it. When I ask targeted questions—like: Do the letters and spaces in a string of words kind of blend together? Do you have to squint to see the difference between an 8 and a 3? Do you have better vision with your glasses than your contact lenses?—it is easy enough to elicit that not all is well with their visual world.
With modern toric lens designs, we optometrists have the opportunity to fully correct these patients without sacrificing comfort. My go-to lens for astigmats is the 1-Day Acuvue Moist for Astigmatism (Vistakon Division of Johnson & Johnson Vision Care, Inc.). By moving patients into the daily disposable modality and giving them a fresh, clean lens every day, we can improve comfort, further enhancing the “wow factor” that comes from improving their vision.
Today’s toric lenses are easy to fit without extra chair time. We no longer have major problems with lens translation or rotation that so often resulted in failure with earlier generations of toric lenses. To successfully fit torics, it is important to keep your trial lens sets well stocked. Although it is impossible to have every possible sphere/axis combination on hand, the major brands’ largest toric fit sets can accommodate about 90% of patients, so you can be fairly confident that the right lens will be there if they are restocked regularly.
For both spheres and astigmats, I prefer the daily disposable modality because it dramatically reduces the buildup of lipids and proteins that can lead to lid irritation and giant papillary conjunctivitis.
Everting the lids during every contact lens examination is the best way to appreciate the impact of overwear on the lids. Using an iPad (Apple, Inc.) in the office, I show patients photographs of their own lids alongside images of severe giant papillary conjunctivitis and healthy, nonirritated lids. The photographs help patients immediately grasp that fresh lenses every day contribute to their ocular health, even if they have not yet felt any consequences of overwear.
Addressing value is really the secret to overcoming the biggest barrier to new modalities. It does cost more to switch from a monthly or 2-week lens to a daily disposable lens or from a spherical lens to a toric, and practitioners should absolutely be prepared to discuss the cost differential. When patients ask about cost, what they are really asking is, is it worth it? Do the benefits of switching justify the cost?
Our job is to convey the value of what we are prescribing for patients ocular health, vision, and comfort and to convey that with practical examples that make sense to them. When you factor in being able to eliminate solutions and rewetting drops, reducing the chances of an unscheduled office visit or ocular allergy drops, and the availability of rebates and discounts, patients are often surprised to see that the cost differential of a toric daily disposable is less than they expect it to be.
I think it is also important to reassure patients who are changing to a new and more expensive type of lens that they will not be stuck with something that is not right for them. A commitment to service is what sets us apart from Internet ordering. I strongly encourage an annual supply, but I tell patients that if for any reason we decide at their 1-week follow-up visit that this lens is not right for them, I will exchange the boxes.
If a patient is overly hesitant to order an annual supply— perhaps unsure that daily disposable lenses are worth it—I will suggest trying them for 3 months. If the patient does not see the value of daily disposability after one 90-day pack of lenses, I say we will go back to a 2-week toric lens. I have never had a patient take me up on that offer.
The reality is that the combination of two great technologies—the health and comfort of the daily disposable modality and the stability and ease of fit of modern toric lenses—is great for patients. This combination lets us be the hero, by meeting patients’ comfort, safety, and visual needs all at once.
Denise M. Whittam, OD, practices at Cohen’s Fashion Optical of 47th Street in New York City. She has no financial interest in the products or companies she mentioned. Dr. Whittam may be reached at (212) 697-9299; email@example.com.