Optometric Management sat down with Vitto Mena, OD, MS, to discuss strategies for keeping patients in their contact lenses, including risk factors for dropout, suggestions to combat challenges with wear from the initial fitting, and strategies for practice management.
Optometric Management: How do you identify patients who are at risk of dropping out of contact lens wear before they actually stop wearing their lenses?
Vitto Mena, OD, MS: The biggest factor is dryness. Especially when the pandemic happened, we saw a lot of mask-induced dry eye symptoms, which led to a lot of dropouts. Many of those people are wondering whether they should get back into contact lenses now. Others actually started wearing contact lenses because their glasses were fogging up with their masks.
When dryness is an issue, we need to make sure we check the tear film. You can use your meibographer if you have one to check the status of the patient’s meibomian glands and determine whether they’re a good fit for different types of lenses. We all know that daily contact lenses are the best for hygiene and to decrease the risk of infection, for example.
Dryness can also be caused by medications a patient is taking or by lifestyle factors like screen time. You have to ask about a patient’s hobbies and make sure you understand the visual demands in their school or work environment because the patient’s answers determine whether they’re potentially going to drop out of contact lens wear or not.
I went into optometry for sports vision, so every patient in my chair is considered an athlete. Whether they’re driving a vehicle or they go out and play pickleball or tennis or just shoot some hoops outside, every patient is an athlete. So I always present the opportunity of contact lens wear to everybody who comes across my chair, and I give them all the options. I say, “To be comfortable in your contact lenses, you have to have proper hygiene when it comes to your eyes. You need to keep them lubricated by blinking more often and drinking more water.”
OM: Do different demographics require different retention strategies?
Dr. Mena: With new wearers, I always bring up the conversation first, personally. I’m always saying, “Hey, are you willing or open to trying contact lenses?” especially if they play a sport as well. When I have that conversation, I’m always going to give them the best modality first and I worry about price last because you want to start them with the better option. If they talk about dry eye symptoms later and I say, “There’s another lens out there that exists,” the patient might think, “Well, why didn’t you start me off on this one first?” That would be something that I would tell practices: Always start with your best quality lens, because it’s going to minimize dry eye symptoms and minimize dropout as well.
If a patient is nearsighted—let’s say they have a –1 D or a –2 D—and we know their contact lenses are going to dry out if they’re on a computer screen because they don’t blink as often as they should, I might make a suggestion that’s a bit outside the box. I might suggest that they remove their contact lenses when they’re working on the computer screen because they can see up close. If you minimize that wear time, it’s going to minimize near-point stress on the visual system and it’s not going to lead to dry eye symptoms. If a patient is able to take off their contact lenses, that is something that I would tell them to try to minimize dropout from happening.
Every population obviously has different tear films and different visual tasks, but we all have similar fluid dynamics, so it’s really the approach for everybody to make sure they’re blinking, staying hydrated, and keeping the ocular surface lubricated.
OM: Do you have strategies to get people to blink more?
Dr. Mena: It’s really hard because you’re so focused on your task when you’re at work or you’re studying unless you’re actually putting something on your phone to remind you. We always hear about the 20-20-20 rule, but I like to suggest having, say, a bottle of water next to you while you’re on your screens because that’s going to remind you to grab your water and look away from the screen. It might even be a cue to remember to blink. The more you stay hydrated, the better you’re going to feel and the better you’re going to see.
Ergonomic Tips for Computer Use
- Stretch out your hand an arm’s length away. This is how far away your computer screen should be from you
- Make sure your monitor is positioned slightly below eye level so your upper eyelids cover more of your eyes
- Adjust the brightness and contrast of the screen
- Do conscious slow blinks: Close slowly for 1 to 3 seconds and then reopen and repeat for a few seconds during your break to help with incomplete blinks that lead to dryness
- Keep a water bottle near your computer to remember to blink more and keep your body hydrated
OM: Do you have other go-to solutions for patients who experience end-of-day discomfort or other barriers to contact lens wear?
Dr. Mena: Sometimes patients think they can’t wear contact lenses if they have an astigmatism, for example, or if they’re a new presbyope, they don’t know that there are contact lenses that exist for them. They might have also tried at another office and it didn’t work out for them. That doesn’t mean that they’re out of luck when it comes to contact lenses though, so no matter what, I always introduce contact lenses and let them know that all the options that are available, depending on their prescription. There’s a vast variety of lenses that exist. Barriers to wear can be mental sometimes. If the patient thinks that they can’t wear contact lenses, for whatever reason, that can make it hard for them to adapt.
Other times it’s just a convenience factor, or price can be a barrier to entry because they have both glasses and contact lenses. You just have to give patients everything you have in your arsenal so they decide what’s best for their visual outcomes and demands.
When we see a new patient, for example, we’ll tell them to bring their glasses, their old contact lens prescription if they have it, and the solution they use because another barrier, or something that could cause discomfort, is the solutions that patients use. If they use a generic version vs a name brand, that can cause discomfort and eventually lead them to dropout because people can have sensitivities or allergies to ingredients in generic solutions. In my opinion, price is the biggest barrier and discomfort is number 2.
OM: How often do you see people who are uncomfortable touching their eyes and how can you help them overcome that?
Dr. Mena: Let’s say a kid’s in my chair. I’ll usually ask them, “Do you play any sports? Cheerlead, dance, karate, anything like that?” Whatever the answer is, I’ll say, “All right, fantastic. Would you be interested in contact lenses?” Even if their answer is no at first, I’ll ask more open-ended questions to understand why they don’t want to wear contact lenses. If it’s because they don’t know how to put them in, I can say that we can teach them and they often accept wear from there.
If a patient is hesitant because they don’t want to touch their eye, they think insertion and removal or even wear might hurt, or they’re afraid the lenses might get stuck in their eyes, we can have a longer discussion where I can reassure them and dispel myths they might have heard or fears they might have. I might say it’s similar to learning to ride a bike for the first time or another analogy to help put them at ease. I can also explain that if they do the right thing with their contact lenses—meaning they don’t sleep in them, they don’t shower with them, them don’t swim with them—then everything is going to be okay. It doesn’t work every time, but for some, they appreciate the extra discussion and they’ll say they want to try. If a patient can touch their eyelid, I’ll know that they’re more of a candidate for contact lenses.
OM: Do you have a protocol in your practice for following up with patients who have dropped out of contact lens wear? How can practice staff get involved in identifying patients who are struggling with wear?
Dr. Mena: It’s going to depend on the practice obviously, because sometimes people might see it as time-consuming if they see patients back for a short visit. They think it’s not the best return on investment in a way. But studies show that if you can keep patients happy in their lenses longer, especially in daily lenses, the revenue stream of that practice grows immensely. So it’s very important that you care for those contact lens patients; you don’t want to lose them.
Because patients can also buy lenses elsewhere, including online, the contact lens evaluation becomes crucial. You set your price for the evaluation and certain types of follow-ups. For example, the patient comes back after a week or a month and you evaluate how they’re doing and whether any adjustments need to be made. They might have ordered their supply by that point, but this is where we can try to tweak and keep them engaged.
You can also use text message reminders to check in and see if they have any issues that require a switch to another lens. If you keep that engagement with the patient, if you can use that as a tool, then that’s going to show them that you care, and it reminds them to maintain their eye health in the way you taught them.
Like I mentioned before, I like to use analogies with patients. In my practice, we compare changing daily lenses to changing clothes every day to show patients how their contact lenses can become part of their regular routine, and to illustrate the hygienic benefits of using dailies. If we need to switch someone from dailies to another lens, we go to what’s more affordable for them. But if we can keep that message going, the better it’s going to be for not only the patient, but also for the practice.
OM: What impact has improving contact lens retention had on your practice from a patient care perspective and a business perspective?
Dr. Mena: Daily lenses are obviously a bigger return on investment, but the other thing is, as I mentioned before, every patient in your chair is an athlete. They may not be able to wear glasses for the activities they do, and wearing contact lenses helps minimize the risk of potential eye injury that we would worry about with athletes wearing glasses.
For kids, I’m able to start some patients as young as 6 years old. Other practices might not start until 12, which can be another barrier to entry like we discussed earlier: Sometimes we as the doctor can actually be a hinderance if we’re not considering younger kids as potential candidates. Because we now have an FDA-approved contact lens to slow the progression of myopia, we have so many lens options for our pediatric patients who would do well in contact lenses. We can give patients the best of both worlds when we fit them for both glasses and contact lenses because they get to decide what they want to wear in each situation. That naturally brings more revenue to the practice if you’re giving them 2 different options as well. That’s how it’s been helpful in our practice.
I’ve found that it’s valuable to have that conversation about contact lenses, because when you have a contact lens patient who’s also a glasses patient, that’s really where the money is.
The other thing is because the contact lenses are a class 2A medical device, they have to be renewed on a yearly basis. I’ll say to patients, no matter if it’s a daily or monthly lens, at the end of the day, it’s still a piece of plastic on your eye. You want to give it some breathability, so you have to make sure you’re staying hydrated. You have to blink more often. That’s why dailies are the better option. Those are the conversations I’m having and the little nuances that I tie into my exam chair with my patients.
OM: If an optometrist wanted to improve their contact lens retention starting tomorrow, is there a first change that you would recommend that they make in their practice? And what’s a mistake or more than one mistake that you would suggest that they avoid?
Dr. Mena: The number one mistake I’d be cautious of is avoiding having these conversations with patients because of age. Starting that conversation with those young children and their parents is key. If a child can make their bed and do other chores easily, as well as touch their eyelid without flinching, they’re a great candidate for contact lenses. Start by asking the child about their interest level, and once you’ve confirmed they’re interested, you might be surprised that the parent was actually thinking about contact lenses for their child themselves, but didn’t know they could wear them.
I also like to point out that starting patients in habits like this when they’re young can lead to more success in the future because they can be more receptive to their parents’ instruction, compared with young teenagers who may be less receptive.
Also, always start off with daily lenses to keep them in retention because studies are showing that their eyes are getting drier and they’re overwearing their lenses and things of that nature, so that’s what’s going to lead to dropout. You can tell patients that you’re starting with the best option for the health of their eyes so they understand how dailies can help them.
In addition to removing contact lenses when doing near work for patients who can, I also suggest patients use their glasses as they’re winding down at night before they go to bed to give their eyes more breathability. Start those conversations, but don’t think in people’s wallets. You have to present them with the best possible lens option, whatever lens option that may be for that individual practice, but start them off and then they’ll decide whether they can afford it or not.
I’ll tell a brief story about one of my patients who was an all-star cheerleader. I think she was 15 at the time. She always wore glasses, but her mom would tell me how much she hated wearing them. I suggested that she try contact lenses, but her mom said they had been to 3 other doctors and she hadn’t been able to put the lenses in at all. I asked my patient if she wanted to wear contact lenses and she said yes, so I was confident that I could get her into wear.
When I tried to insert this patient’s lenses for her, I realized she was a blinker, and that was why she had such a difficult time previously. So, I kind of cheated in a way. I used proparacaine so she could get used to the feeling of touching her eye. And once I did that, I was able to put the lens on her eye. It ended up taking her 2 hours to do her training for the insertion and removal, and she was ultimately able to insert and remove them on her own without further assistance from the proparacaine. Most practices are not going to have time for that. But I like to think about it this way: If you were to pay someone as an athletic trainer and you were struggling with lifting weights, would the trainer say, “Hey, you know what? Lifting is not for you”? No, they wouldn’t, right?
Sometimes doctors will say, “I guess contact lenses aren’t for you” when a patient struggles with insertion and removal. But I always try to go above and beyond like that because I know that this patient and her mom could tell other people about this experience and that could encourage someone else who’s struggling with their contact lenses to come in. I look for the level of enthusiasm from the patient, and then we go from there. I know if the patient does not want contact lenses, there’s nothing that I could say. I might be able to persuade them a little bit, but it really comes down to their mindset.
I always look at it in a positive way because we want them to see the board in their classroom. We want them to have a backup if they break their glasses. We want them to have the tools they need to succeed in all areas of their life.
So again, don’t be afraid to have the conversation. Start them early with dailies, make price secondary, and you’ll start to see more referrals from other patients telling their family and friends, which will increase your revenue.OM
