STRATEGIC SKILL BUILDERS: Continuing Education
The Proactive Therapeutic Approach
Taking control of your optometric practice.
By S. Barry Eiden, O.D., F.A.A.O., Chicago, Ill.

We are all aware that some contact lens and drug companies directly market to consumers via television and magazines, which can lead to patients asking for specific prescription products. Also common is the request for refractive surgical procedures based on direct-to-consumer advertising that guarantees outcomes we know are outside of expected results.

This "pull-through marketing" has been effective for these companies, so I'm sure we'll see more of it. The good side of this for us is that it builds awareness of eye care and puts people in our exam chairs -- but the challenge is how to respond to patients who want a product that may not be in their best interest.

This trend could put us in either a defensive position of reactively capitulating to consumer demands, or an adversarial role that risks losing patient confidence. What can you do to cope with this dilemma? Read on to find out.

THE PROACTIVE APPROACH

An alternative approach is possible and results in superior doctor-patient relationships, practice growth and financial success, as well as overall improvement in professional satisfaction. The approach is proactive. First you gather historical and subjective information. Then you analyze the data based on clinical findings. Finally, you present the patient with treatment options.

Patients come to you for your expertise. Otherwise, they'd see a practitioner who offers the cheapest and most convenient source of eye care and materials. By educating a patient about his condition and treatment, you take a strongly proactive approach. The result is a more compliant patient who understands his eye health status and the effects of treatment.

By educating a patient about his condition and treatment, you take a strongly proactive approach.

ADDED BENEFITS

The added benefit of this approach is improved practice productivity. Patients are more willing to pay for services and materials they perceive as valuable. Your referral rate will rise when your patients believe your practice provides a higher level of care.

Our practice isn't the least expensive or the most convenient in our area, yet we're in the top 5% to 10% of American optometric practices in revenue generated. We show sustained growth in all aspects of practice at a time when the productivity of many private practices and corporate vision centers is stagnating or declining. I believe we owe our success to our patients' belief that our quality of care, expertise, experience and value exceed our competition's. Proactive treatment is the cornerstone of our success.

CASES IN POINT

The following cases illustrate the difference between reactive and proactive approaches to care.

Case #1. A 27-year-old woman presented for a routine contact lens examination. She was wearing 2-week disposable spherical contact lenses and reported comfort with adequate vision. Visual acuity measurement revealed 20/30 acuity at distance in each eye with binocular acuity of 20/25- with contact lenses. Assessment of lens fit and physiological response was normal and acceptable for each eye. Our manifest refraction gave findings of OD -2.25 -0.75 x 100 20/20, OS -2.50 -1.00 x 80 20/20.

The reactive approach

If you took this approach, you'd simply duplicate her existing contact lens prescription and continue the 2-week daily disposable schedule. The patient wouldn't object, and she'd find her experience at the office adequate and unremarkable.

The proactive approach

Proactively, you could address the presence of against-the-rule astigmatism. With the number of excellent toric disposable designs available, we can now correct vision to levels matching best corrected spectacle acuity while maintaining the convenience and ocular health response of frequent replacement lens systems.

The critical element in success with soft toric disposable lenses is obtaining the optimal lens fit for excellent, stable vision and comfort. Many practitioners find themselves compromising vision in order to use a disposable lens. In the past, we ignored low cylinders so we could fit a patient with disposable lenses. Now we can both correct the astigmatism and use disposable lenses, but we must still insist that the toric disposable lenses provide stable and excellent vision and comfort. We can achieve this goal in a much higher percentage of cases today than ever before.

Case #2. A 32-year-old man presented for a routine eye examination and annual contact lens evaluation. The patient wore disposable contact lenses on a daily wear basis and his records indicate that we prescribed them on a 2-week replacement schedule. The patient had no complaints and was in good general health. His stated purpose for the visit to our office was to obtain a new supply of contacts.

The exam revealed healthy eyes, except for a slight injection of the conjunctival blood vessels under the slit lamp. Corrected visual acuity was 20/20 OU, at far and near with contact lenses. The contact lens prescription was unchanged, and the patient's eyeglasses were close to the new refraction.

At the patient's last visit 1 year earlier, he'd purchased two multipacks of lenses for each eye. His records showed no other lens purchases since.

Reactive approach

You could advise the patient that all is well and that he may purchase additional boxes of disposable lenses at this time.

	Fitting the dominant eye in a multifocal contact lens for distance and the non-dominant eye in a multifocal lens for near is especially helpful for patients who work at computers.

Proactive approach

We would ask the patient how often he discards his lenses and indicate that our records show that he's using the 2-week lenses for about 1 month. We'd then use the opportunity to educate the patient, in a friendly way, about the importance of compliance with the prescribed disposal schedule.

We would mention the early sign of inflammation that we see in the blood vessels under the microscope, and that this can lead to further complications. It's important to realize that patients may not think of contact lenses as a medical device, but that they will respond in a positive way when they realize that their eye doctor notices a break in compliance and has genuine concern about eye health issues.

We cautioned our patient not to stretch his wearing time because this lens type and the lens care system was designed for a 2-week period of use. The patient purchased a full year's supply of eight multipacks at this visit.

Case #3. A 53-year-old man presented for a routine eye examination, expressing the need for a new reading spectacle prescription. His last eye exam was performed more than 4 years ago. He reported no eye problems beyond reduced vision clarity with his reading glasses. Fur-ther history revealed he was being treated for hypertension and that his mother had been treated for elevated IOP for the past 5 years.

Unaided visual acuity was 20/20 at distance OD and 20/25- OS. Refraction found a manifest of OD +0.25 sphere and OS +1.00 -1.25 x 70 with an add of +1.75 OU. Intra-ocular pressures as measured by applanation were OD 24 mm Hg and OS 27 mm Hg at 10 a.m. Optic discs exam revealed asymmetric cupping of OD 0.45 and OS 0.70 with an apparent inferior temporal notch OS.

The reactive approach

You could begin glaucoma treatment, spending minimal time on patient education about glaucoma, its natural progression and treatment issues. But patients who don't understand their disease are much less likely to comply with your recommendations unless they experience definite symptoms, which isn't common in primary open angle glaucoma until the end stage.

The proactive approach

We suspected primary open angle glaucoma. Our success in diagnosing and managing glaucoma patients is greatly enhanced when our patients are properly informed about the disease.

We begin by stating that glaucoma is a disease of the optic nerve that's often associated with elevated intraocular pressure. We emphasize that typically glaucoma doesn't cause subjective symptoms (pain, redness, blur) until the end stage where treatment is often unsuccessful. It's an insidious disease that slowly and painlessly causes severe vision loss and ultimately blindness.

Only by regular eye health evaluations can we diagnose the disease. And only with frequent and regular follow-up exams can we monitor the effectiveness of treatment or the progression of glaucoma.

With this introduction, our patients better understand the need for sensitive testing and objective study of the optic nerve (with computed tomography, for example) to find glaucoma in early stages. They also understand that only by complying with treatment and follow-up schedules can they preserve the vision that they have. Printed materials indicating the prescribed do-sage and potential complications of medications, as well as instructions on drop administration and basic information on glaucoma are helpful in encouraging compliance, too.

Poor compliance with medications and follow-up are common when patients aren't fully informed about glaucoma. This often results in needless vision loss. Our confidence in diagnosing and managing glaucoma, with our dedication to educating suspect patients and their families has resulted in a growing and successful glaucoma practice.

Case #4. A 54-year-old woman is wearing bifocal glasses in a round segment design. She's become interested in contact lenses after speaking with a co-worker who wears rigid bifocal contact lenses. Because her eyes are very sensitive, she's concerned that she couldn't wear rigid lenses. She expresses more interest in soft lenses if they could provide the vision that she needs for distance, near and intermediate visual tasks. Manifest refraction is OD -3.50 -0.25 x 170 20/20, and OS -3.75 -0.50 x 180 20/20 with an add requirement of +1.75 OU.

All diagnostic testing and therapeutic procedures are covered by medicare and secondary insurance; patients are responsible only for unmet deductibles.

The reactive approach

You could fit her with monovision soft contact lenses, tell her that soft bifocal lenses won't work well enough for her vision needs or perhaps suggest fitting distance soft contact lenses and reading glasses over the contacts.

The proactive approach

We recommended soft bifocal contact lenses and proceeded with an in-office trial with diagnostic lenses. Diagnostic lenses in the correct distance and add powers are a wonderful screening tool, yielding valuable information after about 15 minutes of wear.

Our experience has shown us that equal binocular visual acuity of 20/20 for both distance and near in each eye with current soft multifocal contact lens designs is difficult to achieve because of the magnitude of the required add power. However, modified monocular vision correction works very well in most cases.

We fit the dominant eye in a multifocal contact lens that provides excellent distance and intermediate vision, and fit the non-dominant eye in a multifocal lens that provides excellent near and intermediate vision. Under binocular vision circumstances, patients fitted with this modality experience very good distance, intermediate and near vision. This approach is especially helpful for patients who work at computers. You can achieve this fitting modality with a variety of soft multifocal lenses including aspheric and concentric designs (in disposable, frequent replacement and conventional formats).

Case #5. A 42-year-old woman expressed interest in laser-assisted in situ keratomileusis (LASIK) because a co-worker had the surgery at a local "laser center" for a very low price ($799 per eye) after responding to a radio advertisement. The patient wore glasses to see distant objects and usually removed them at work as well as around her house. She'd worn contact lenses for about 10 years, but discontinued use because of chronic dryness and the inconvenience of contact lens care.

Her manifest refraction was OD -1.50 -0.50 x 180, OS -2.00 -0.25 x 175. Best visual acuity was 20/20 for each eye; uncorrected acuity was 20/40 OU. At near point, the required add power was + 1.00 OU, and uncorrected near acuity of course was 20/20 for each eye. This patient's ocular health assessment was unremarkable and ocular and systemic health histories were also unremarkable.

The reactive approach

The reactive response would be to tell the patient that she fell within the approved parameters for LASIK and that most patients with her level of nearsightedness had excellent results. LASIK is the procedure of choice for myopia of more than 3.00D. Intacs (intrastromal corneal ring segments) are indicated only for myopia up to 3.00D with minimal astigmatism. The reactive practitioner might mention that he handles postoperative LASIK care with a local laser center, and that although their LASIK fee was more than $2,000 per eye, they were probably better surgeons than the ones at the discount center.

This patient would probably ultimately go to the discount laser center to undergo LASIK. She'd probably end up regretting her decision when she was left with blurry near vision and the realization that many of the things she formerly did without glasses now required her to wear them.

The proactive approach

Our patients realize we're directly involved with refractive surgery. We're sure to inform them with our on-hold message that they're invited to schedule an appointment. We also have refractive surgery pamphlets available in our office, and our technicians ask them about their interest in refractive surgery during the pre-exam work-up.

For this patient, we'd review our clinical findings with her candidacy for surgery in mind. We'd advise her that many people her age with similar refractive errors are dissatisfied with their vision when fully corrected for distance in both eyes by LASIK because of its influence on uncorrected near vision during daily living activities.

We'd also discuss monovision and strongly advise a contact lens monovision trial before refractive surgery. We'd present alternatives to LASIK, such as Intacs, which are reversible and have excellent clinical outcomes for her refractive error. We also would present non-surgical alternatives such as contemporary multifocal disposable contact lenses.

Our patient would understand the difference between our refractive surgical practice and the discount laser center. We'd emphasize:

• our long experience
• our involvement in research
• our positions as advisory board members and consultants to surgical companies and organizations
• our comprehensive care program (extended follow-up care and complimentary enhancements or modifications) versus the limited post-operative care and charges for enhancements at discount centers.

Most of all, we'd emphasize our unbiased viewpoint. We provide all types of refractive care (glasses, contact lenses and refractive surgery) with equal expertise and emphasis. Our recommendations are based on what we sincerely feel is in the patient's best interest. Most of our patients who want refractive surgery decide to come to us.

Case #6. A 67-year-old-man presented with chronic gritty eye symptoms, worse when waking in the morning and toward the end of the day. Biomicroscopy revealed bilateral inferior "smile" pattern corneal staining, positive lissamine green conjunctival staining, and a phenol red tear volume measurement of 9 mm OD and 11 mm OS (normal values are above 20 mm). Clearly, this patient had dry eyes.

The reactive approach

A reactive practitioner might have diagnosed based on the symptoms, without the tests that helped us find aqueous deficient dry eye, related to involutional degeneration of the accessory lacrimal glands.

The proactive approach

Our closer observation revealed mild chronic blepharitis. We ex-plained the function of the tear film and the effects of blepharitis and aging on tear function. Then we recommended a short-term antibiotic and steroid combination ointment, with regular lid hygiene (daily lid scrubs with warm compresses) and punctual occlusion. These treatments usually give consistent relief beyond the temporary effects of artificial tears.

We suggested diagnostic trials with collagen punctal plugs, which reduce tear loss by reducing outflow, followed by application of permanent silicon plugs. All diagnostic testing and therapeutic procedures are covered by Medicare and secondary insurance; our practice participates in these programs. Our office will directly bill Medicare and the secondary provider. Therefore, patients will only be responsible for any unmet deductible.

Here, we made the appropriate diagnosis, educated the patient, prescribed the most effective treatment and addressed concerns about costs and insurance coverage. Patient compliance given these conditions has been excellent.

Case #7: A 33-year-old male presented wearing conventional soft spherical contact lenses, which were about 9 months old. His complaint was a progressive decrease in contact lens comfort and wearing time over the past month.

He'd been a contact lens wearer for the past 8 years and had worn conventional soft lenses. He followed a peroxide-based disinfection system with prescribed weekly enzymatic cleaning (perhaps every 3 to 4 weeks when the lenses seemed "dirty"). He typically replaced the lenses every year or two, depending on how comfortable he found them.

Lens evaluation revealed moderate protein and lipid depositing. Slit lamp examination revealed mild contact-lens-associated papillary conjunctivitis (CLPC) of both superior tarsal conjunctivas (grade 1+), with hyperemia and mild mucus production. All of the other aspects of the slit lamp examination were unremarkable.

The reactive approach

You could issue a fresh pair of conventional lenses and encourage the patient to use enzymatic cleaning more frequently and regularly.

In our experience, however, improved compliance on a long-term basis in cases like this one would be unlikely. Typically, most patients start off very compliant with their cleaning regimens but over time return to their old "bad habits."

The proactive approach

We suggested a refit into single use soft disposable contact lenses. We've seen even the most severe cases of CLPC respond excellently when fresh lenses are used every day. Daily disposable lenses address both the physiological needs of the eye and the convenience and compliance issues that are so important to people today.

YOU'RE THE EXPERT

The key elements of a proactive therapeutic practice include diagnostic skills, patient education and a confident recommendation of treatment strategies.

You're the expert. By establishing a practice based on these elements, you make your patients see you as a healthcare professional, not as a commodity provider.

Dr. Eiden is president of North Suburban Vision Consultants, Ltd., a private group practice. He's also an assistant clinical professor at the University of Illinois at Chicago Medical Center in the Department of Ophthalmology, Cornea and Contact Lens Service.