contact lenses

Are Specialty Lenses for You?

They can be if you have or are willing to obtain what's needed for success.

Frank Celia, Contributing Editor

Converse long enough with optometrists who operate thriving specialty contact lens practices, and you will likely notice a recurring story. It involves a patient with a challenging underlying condition (frequently keratoconus) who goes from clinician-to-clinician, sometimes for years, searching in vain for a contact lens that will bring him relief. When this patient finally receives satisfactory care, a semi-emotional scene of gratitude follows, often in the presence of an incredulous spouse who cannot resist asking why on earth the outcome took so long.

This scenario's prevalence suggests two things. First, a big market exists for under-treated specialty lens patients. And second, they are very difficult to treat successfully.

Practitioners interviewed for this story agree with both these statements, and add that for those willing to make a foursquare commitment to tough contact lenses cases, the rewards can be substantial. Higher professional fees (as much as ten times higher or even more—although admittedly for patients considerably more time-consuming), higher profits on contact lens materials and the total absence of big box or online competitors are among the perquisites of specialty lens care, they say. But these experts also say the true economic benefit is patient retention. Patients that you fit in custom/specialty lenses are generally yours forever. Additionally, those who succeed in this field gain the satisfaction of helping patients overcome serious conditions.

So, what exactly is required to establish a successful specialty contact lens practice? The answers are provided here, courtesy of the experts.

Clinical experience

It is not enough to have a successful conventional lens practice and then simply tack on specialty cases. Practitioners who succeed in this field must have a background and experience in specialty fits, according to established clinicians.

“You can't just all of a sudden one day say you're a contact lens specialist,” explains S. Barry Eiden, O.D., F.A.A.O., of North Suburban Vision Consultants in Deerfield, Ill.

At the outset of his career, Dr. Eiden says he spent two years working and studying under the tutelage of an optometrist who had decades of experience fitting challenging cases.

“That, in essence, was a contact lens residency. My actual residency was in disease,” Dr. Eiden says. “So my advice to someone wanting to get into this field would be to take a contact lens residency. But if you can't do that, you have to work in a place where there are enough difficult cases to learn by trial and error.”

The other option is the “build it, and they will come” strategy, says Dr. Eiden. To do this means making a commitment to taking on these complex cases and learning as you go. Using the expertise of laboratory consultants and joining professional contact lens organizations, such as the AOA Contact Lens & Cornea Section or the AAO Section on Cornea, Contact Lenses and Refractive Technologies, fosters interaction with others with similar interests and experience, who can then function as “consultants.” Further, Dr. Eiden recommends attending contact lens specialty meetings, such as the Global Specialty Lens Symposium or the San Diego Specialty Contact Lens Symposium. Reading the various contact lens journals (e.g. Contact Lens Spectrum—a sister publication of OM—the CLAO Journal, the BCLA Journal, etc.) is also a must, he adds. “With hard work, you can do it on your own,” says Dr. Eiden. “However it takes time.”

Equipment

Fitting sets are must. Experts say a wide range of lenses is necessary to accommodate as many patients as possible, probably a minimum of four or five brands for each lens type. Manufacturers often allow a practice to borrow a fitting set for a short period of time, but eventually they must be purchased. Fitting sets cost between $1,000 to $1,500 each. (No incentive exists to keep the actual lenses themselves in stock since each is special ordered.)

Brent G. Ostoich, O.D., of the Sullivan-Ostoich Eye Center in Chicago, believes that those treating keratoconus patients should keep fitting sets for at least three main lenses, including RGP and scleral lenses.

Specialty contact lens patients almost always have some underlying medical condition, making certain diagnostic equipment, not usually found in the average practice, a necessity, say those interviewed. How much equipment appears to vary depending on the levels of data required by the doctor to achieve the best outcome for the patient.

Dr. Ostoich says that in his practice, corneal topography is indispensable.

“My main concern is the surface of the cornea,” he says. “As long as I can tell what the surface of the cornea is like, I'm good. Other than keratoconus and scleral lenses, probably the biggest part of my practice is ortho-K. And corneal topography is my life-line for that.”

Other practitioners say they see the need for a greater range of diagnostic tools. Dr. Eiden, for instance, says he's dedicated four rooms of his office to specialty contact lens equipment storage alone. He says he documents his patients' anterior segments with photos and videos, measures corneal aberrometry and tracks endothelial cell morphology via specular microscopy

“You need to manage the underlying problems, such as dry eye, appropriately, and these diagnostic tools will tell you what is going on,” Dr. Eiden says. “For example, let's say I see a patient who has been wearing lenses for many years. If I do a specular microscopy and realize the endothelial cell layer is abnormal, I know this was probably caused by low oxygen transmission to the cornea over many years. Now, I have reason to use high-oxygen transmission lens materials on this patient.”

Even when nothing appears amiss, new technologies can identify incipient problems before they become serious, he adds.

Referral relationships

To access the volume of patients required to make a specialty lens practice successful, you must establish referral relationships with ophthalmologists and fellow optometrists, authorities say.

“Most of these patients will come from ophthalmology practices,” says Gregory W. DeNaeyer, O.D., F.A.A.O., of Arena Eye Surgeons in Columbus, Ohio. Dr. DeNaeyer, like many specialty lens providers, works in a multi-specialty practice among several ophthalmologists.

“At a minimum, sending local corneal specialists a letter of introduction with a CV would be helpful,” he says. “Visiting their office would be even better. Getting them to refer a few cases is the difficult part, but once you demonstrated how you have helped their patients, they will see the value in referring their patients. Building a relationship with them is paramount.”

A specialty lens staff

Because the chair time involved in fitting specialty lenses exceeds that required for conventional lenses, you must rely heavily on support staff to handle a great deal of the hands-on fitting tasks to make specialty fits worthwhile, experts say.

“I direct every aspect of contact lens evaluations, but have my staff perform diagnostic tests, such as keratometry, insert and remove lenses, and make minor changes, such as over-refractions,” says Jeffrey Sonsino, O.D. F.A.A.O., an associate professor of optometry at the Vanderbilt Eye Institute in Nashville, Tenn. “Utilizing well-trained technical staff allows for a much more effificent operation.”

He says most of his staff have been with him for nine years and have received the majority of their training on the job. That said, he stresses it's essential to remain up to date on the wide range of complicated problems associated with specialty fits.

“. . .Nowadays, a lot of this stuff [up-to-date training] can be done on the web,” Dr. Sonsino says. “Our staff do a lot of webinars.”

He cites the Scleral Lens Education Society (www.sclerallens.org) and the Gas Permeable Lens Institute (www.gpli.info) as two organizations that offer useful webinars.

Dr. Sonsino estimates that an optometric or ophthalmic technician requires at least six months of training to become proficient in specialty contact lenses.

Dr. Ostoich says he also trained his staff personally. Specifically, he says he supervised the training of his technicians one case at a time, adding that it took about two-to-three years for each of his staff to learn the ropes.

Trade shows, seminars and certified training courses are also recommended, not just for the expertise they provide, but for motivation as well, say those interviewed. “Staff members get excited about the field when you send them to these kind of events,” says Ann Laurenzi-Jones, O.D., F.A.A.O., who performs specialty fitting for the Northshore University Health System in Glenbrook, Ill. “They feel inspired that you are supporting them and their education. I think it's a good idea all the way around.”

Out-of-pocket pay patients

The general consensus seems to be that the specialty contact lens practice is mostly comprised of out-of-pocket pay patients. The reason: Many of those interviewed say that while they do accept vision and health insurance, the reimbursements often don't cover the high labor and material costs involved in treating the conditions that require specialty contact lenses.

So, these patients often have to chip in their own money. In fact, those interviewed say some specialty lens practitioners have gone so far as to completely opt out of accepting insurance.

Dr. Ostoich says he requires new patients to sign a contract stipulating they are responsible for any costs insurance fails to cover. In addition, he says he's careful to warn patients that this a far from rare occurrence.

Dr. Sonsino adds, “Our policy—and the policy of a lot of my colleagues at other academic medical centers—is that this is a fee-for-service model. We certainly provide all the documentation patients need for reimbursement by their insurance company, but ultimately the responsibility is theirs.”

These specialty contact lens practitioners are quick to point out, however, that patients are often willing to spend their own money to receive outstanding care. Like orthodontics, the benefits are so tangible that patients frequently consider the costs well worth it, they say.

In the case of keratoconus patients, for example, a successful lens-fitting outcome is often the only barrier between them and a corneal transplant. The key to garnering out-of-pocket pay patients is to explain the specific benefits of the specialty lens to the patient's condition. Once the patient understands the benefit, cost isn't as important.

Summing it up

The economic outlook of the specialty contact lens field is rosy, say those interviewed. “If you are a specialist in any area, you are never going to be out of a job,” says Dr. Sonsino. “If you have a practical skill that few other people have, there is always going to be an opportunity for you to make a living.”OM