CONTACT LENSES

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Are You Fitting What is Best?

Don’t be “Doctor Status Quo”

CHRIS SMILEY, O.D., COLUMBUS, OHIO

As clinicians, we have a tendency to develop fitting philosophies based on past successes and failures. Though these experiences can be invaluable to our overall contact lens success, many times our failures lead us to develop failure biases. Too often, these biases influence our contact lens choices, prompting us to swear off fitting a particular lens type in similar cases, even if the lens may be what’s best for the patient.

Herein lies the difference between “Doctor Status Quo” and “Doctor Contact Lens Pro.” Doctor Status Quo takes the quickest, easiest route that just fixes the problem for the patient while evidencing his or her failure bias. Doctor Contact Lens Pro, on the other hand, strives to try new things, looks for ways to upgrade the contact lens-wearing experience for each patient and is rarely discouraged by occasional fitting failures. In addition, Doctor Contact Lens Pro feels that the contact lens practice is extremely profitable and generates strong word-of-mouth referrals.

Here, I illustrate the benefits of becoming Doctor Contact Lens Pro vs. Doctor Status Quo in the cases of low astigmatism (0.75D to 1.00D) patients and presbyopic patients.

Torics vs. spherical lenses for low astigmatism

Depending on the population type, roughly 50% of eyes have an astigmatism of 0.75D or greater, reports Eye Contact Lens. However, according to Contact Lens Spectrum, toric contact lenses make up only about 25% of the contact lens market. Clearly, there is an opportunity to increase toric lens utilization, primarily with the low astigmatism population.

Lets look at two different approaches to handling low astigmatism patients:

► Doctor Status Quo: I fit most low astigmatism patients in spherical contact lenses unless they complain of vision issues. Spherical lenses take less chair time, are comfortable and work for most patients.

► Doctor Contact Lens Pro: I recommend toric lenses for almost all my low astigmatism patients. I demonstrate the difference between the cylinder being corrected and uncorrected in the phoropter. When patients notice a difference, I advise them that a toric lens will offer sharper vision.

The Doctor Contact Lens Pro approach may not be 100% successful in fitting every patient who has low astigmatism; however, with this strategy, the O.D. can upgrade these patients into an aspheric spherical design knowing it can mask unwanted residual cylinder and, therefore, convert a relative “failure” into a resounding success.

Improvements in lens materials, edge design, reproducibility and the ability to manufacture rotationally stable lenses without dramatically increasing lens thickness all contribute to modern toric lenses being as comfortable as spherical lens designs. Numerous studies show that patients have improvements in visual acuity with toric lenses vs. spherical lenses. Furthermore, patients with 4mm or larger pupils tend to have more marked improvements in vision with a toric lens, reports Optometry & Vision Science. Larger pupils let in more off-axis rays and are more susceptible to blur caused by radial astigmatism. Patients tend to notice this blur with night driving and other low-lighting tasks. With a toric lens, these off-axis rays and induced radial astigmatism can be corrected, resulting in clear, crisp vision.

Keep in mind, providing an overall higher quality of vision and correcting astigmatism may be a key element in preventing contact lens dropouts. Though data suggest that discomfort is the No. 1 reason for contact lens dropout, Ophthalmic and Physiological Optics reports that 65% of contact lens dropouts have 0.75D or more of astigmatism in one eye. A practitioner cannot ignore or mask low astigmatism and maintain a successful contact lens practice. Also, O.D.s should not make financial decisions for patients. Although toric contact lenses do cost a bit more than spherical lenses, the pricing is reasonable and economical overall, and the potential better vision toric lenses provide is well worth the difference in price.

Monovision vs. multifocal contact lenses

Recent studies suggest that multifocal contact lenses are preferred by patients. According to a 2008 Gallup poll, eight of 10 contact lens wearers older than age 50 were interested in multifocal contact lenses. In my experience, interest has not waned. Yet in 2011, only one-third of contact lens visits for patients older than age 40 was for a multifocal lens, reports Clinical and Experimental Optometry. Is your practice missing out on this opportunity?

Again, lets look at two different approaches to handling presbyopic patients.

► Doctor Status Quo: I gradually add plus to the non-dominant eye on most of my emerging presbyopes to enhance near vision. It takes little chair time and works great. Patients are happy. Every year I add more plus, patients completely lose binocular vision, but very few complain.

► Doctor Contact Lens Pro: I recommend a multifocal contact lens to most of my emerging presbyopes, especially when I hear complaints of end-of-the-day fatigue, or when I begin to measure some degradation of near vision. I recognize that patients with stellar distance vision may initially resist the multifocal softening of the distance vision. However, I have developed strategies to handle those issues, such as using lower adds on the dominant eye when necessary. Multifocal lenses are not for everyone, but my success rate is very good.

According to multiple studies, in comparison with monovision, multifocal contact lenses provide enhanced stereo acuity, improved range of near vision, improved balance of vision between eyes, improved intermediate and computer vision, particularly in advanced presbyopia, and little differences in contrast sensitivity. Also, multifocal contact lenses offer better designs and optics in reducing higher-order aberrations than their predecessors and monofocal wear. Furthermore, Eye & Contact Lens reports that, on average, multifocal contact lenses are preferred by patients 3:1, and that starting a multifocal fit in emerging presbyopes is preferred and successful.

Contact lens specialists have a long-term plan for patients outside of gradually increasing plus on the non-dominant eye. There will always be an occasional patient better suited for monovision, and that is expected. However, in today’s technology-driven world, multifocal contact lenses should be your first choice for your presbyopic patients.

Prescribing the best

Opportunities to advance our patient care and contact lens practice exist every day. As doctors, we should be in the business of recommending the best option, which is one that addresses concerns and provides the best vision technology.

Success for your patients and your practice is found by becoming Doctor Contact Lens Pro rather than Doctor Status Quo. Fit the best! OM

Dr. Smiley is owner of Vision Professionals, a two location multi-doctor practice in Columbus, Ohio, and is a clinical assistant professor at The Ohio State University College of Optometry. He serves as a consultant and clinical investigator for numerous companies including Bausch + Lomb, CooperVision, Alcon, Synergeyes, and Blanchard Contact Lens, Inc. Send comments to optometricmanagement@gmail.com.