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HomemistoryLuke Skywalker, Yoda, the Dark Side and… Contact Lenses PART II

Luke Skywalker, Yoda, the Dark Side and… Contact Lenses PART II

In the October issue of mivision, optometrist Margaret Lam described corporate optometry’s increasing hold over Australia’s contact lens landscape.Likening the contact lens market to the Death Star from Star Wars, independent optometrists to the rebel spaceships and corporates to the Empire’s ‘sinister agents’, she wrote, “I would encourage all rebel independents to mount a hostile takeover of the Death Star. It’s time to reclaim that clever little innocuous plastic medical device called a contact lens, and repurpose it as a cause for good in practice rather than ignoring its presence”.In this second instalment, Margaret presents recommendations and strategies from the leading specialty contact lens Jedi.

Luke Skywalker stands in front of Yoda as a young man and asks if he is suitable for Jedi training. Yoda rejects him saying he is too old, there is far too much innate fear and hence too much of the dark side in him to become a Jedi.

Having experienced and worked in both corporate and independent optometry, I don’t think it is impossible for a corporate optometrist to become an exceptional contact lens optometrist. However, I concede it would be a challenge – I imagine time structures for eye exams in a corporate practice model and its negative impact on conversion rates (number of eyetests conducted as a ratio of spectacle sales) as well as lack of recognition for these specialty services may necessitate more of a self-directed learning path.

While there is no one singular path to contact lens Jedi awesomeness, independent practice models make it a little easier to develop specialty skills. Just as well really, because quite simply, you can’t dabble in Jedi training and get the best outcome for the patient.

…co-management should not be hampered by the fear of losing your patient but governed by making a decision in the patient’s best interests.

From my personal experience, I can credit my passion for contact lenses to my excellent mentors at uni in my undergraduate optometry course at UNSW. There I was fortunate enough to be taught and inspired by CL gurus including Fiona Stapleton, Brien Holden, Eric Papas, Debbie Sweeney, Narelle Hine, Helen Swarbrick, Wendy Ho, Robert Terry, and Lauren Richard, among others.

Looking back, I had no idea how fortunate I was to learn from these experts. I later discovered that I had been particularly fortunate that Brien Holden was able to turn up to deliver his lectures in our year – with the immense number of great projects he works on and gives his time too, most undergrad optometry students hear of him as an urban myth but don’t get to meet the man in person.

Fifteen years ago, Sydney’s Emmanuel Calligeros signed my uni lab coat in a self-fulfilling prophecy, labelling me a ‘Contact Lens Supernerd’. I was unabashedly an optometry supernerd way before it became cool to be nerdy.

I Wasn’t Alone

Every optometrist with a special interest in contact lenses tells a similar story. Something inside them triggers inspiration… that inspiration triggers an intense interest in learning… and that learning allows you to identify strong mentors. Those mentors inspire a little bit of personal bravery to master prescribing and fitting challenging cases… and the mastery of challenging cases feeds immense satisfaction for being the person responsible for completely changing someone else’s life. All via these small, tiny bits of floating, highly bespoke plastic that get custom made – to the nearest micron so that patients get to see the big picture, more clearly.

Speaking of his journey to becoming a contact lens Jedi, Lachlan Scott Hoy from Innovative Eyecare in Adelaide said, “As a second generation optometrist, anisometropic hyperope, keen sportsman, and someone who grew up hating wearing spectacles, I had a keen interest in contact lenses as soon as I could get my hands on them.

“Fitting specialty contact lenses is by far the most rewarding part of being an optometrist. The spine tingling feeling you get from fitting a keratoconic, a child with OrthoK, or a severe dry eye sufferer with a scleral contact lens, and seeing the difference you make to someone’s quality of life is what gets me out of bed in the morning,” he said.

Jess Chi, who recently purchased Eyetech Optometrists from fellow contact lens expert Russell Lowe, said she recognised the life changing potential of contact lenses at a young age. “I have been fascinated by contact lenses since I began wearing them at the age of 13. As a teenage girl at the time,

I gained so much confidence and freedom.

“Contact lenses was my favourite subject during optometry school, and I was fortunate enough to land a graduate position at one of the leading contact lens practices in Australia. Day-to-day work involved providing people with vision who had previously had their vision impaired from various eye conditions. I know how much contact lenses impacted my life, and I am just a myope. Being able to correct vision for people with irregular corneas, high ametropia and paediatric aphakia is extremely rewarding and has further grown my passion for contact lenses,” said Jessica.

Developing your contact lens practice

The contact lens Jedi see contact lenses as one of the key exclusive strengths of our profession – not a weakness to be ignored. They don’t get obsessed about contact lens margins, they just work with them.

I like what Heath Davis, formerly from Optomeyes and now from OPSM, had to say about the decision he made long ago to move into specialty contact lens fitting.

“It was a case of either skill up, or refer long standing patients elsewhere. I felt in order to do the right thing by my patients, it was my duty to skill up,” he said.

In the wise words of optometrist David Stephensen from Marooka in Queensland, “Any practice activity that generates a healthy profit is worthwhile. I’ve never seen the logic in pursuing specs but not contact lenses. Each dollar of profit in a practice is the same as another. I don’t think that profit margins in spectacles are likely to remain at current levels in the longer term either, so the changes in contact lens profit margins are part of the new normal trading conditions for our profession,” added David.

Jim Kokkinakis, from Sydney’s The Eye Practice, believes contact lenses are a great way to strengthen ties with ophthalmologists and complement their services. Jim describes to me his experience in purchasing a practice that had pre-existing keratoconus patients, and then working in a role as an educational liaison in a leading refractive eye surgery centre. As a result of those close ties working with corneal ophthalmologists, he began to manage severe corneal irregularity cases in which rigid gas permeable contact lenses were the only possible successful visual solution.

From my own experience at theeyecarecompany, being fortunate to be referred work with general practitioners, leading ophthalmologists and neurologists, I couldn’t agree more: contact lenses are a skill subset that dovetails nicely with other health professions, particularly ophthalmology.

So how do you develop your contact lens practice?

Mark Hinds at Brunswick Optical in Queensland sums it up well. “Firstly, the disposable contact lens market is easy to develop through proactive consulting and patient management – We simply recommend and prescribe contact lenses to each patient that is suitable. This organically grows this sector of my business that would otherwise be dormant or lost. We then manage and subsequently maintain those patients in the sector by proactively arranging their re-ordering with consultation recall.”

In a moment of some irony, and with a little self-consciousness, he quotes my own words printed in an earlier mivision article (mivision April14, Issue 89): “This has been called ‘bundling’ by some contact lens advocates like Margaret Lam. It has the potential to work well by keeping prices competitive and it keeps the ‘convenience’ box ticked for the patient.”

Mark continues. “Secondly, our large specialty contact lens business. We have worked hard to develop trusted relationships with fellow optometrists, ophthalmology and industry. We let them know we are happy to help them with complex fits, corneal issues and therapeutic care – whether that be by fitting the patient up and sending them back, evaluating the patient and sending them back or simply discussing a place to start.”

Mark describes a great system of co-management between himself and referring optometrists. “If there is a patient that would benefit from a contact lens that requires specialty expertise, we design the contact lenses, but general and follow up care is maintained from the referring optometrist, and the patient ends up with optimal care they may not have received otherwise.”

Mark, with his down to earth way, is one of my favourite supernerds. His casual nature has me perpetually underestimating his immense wisdom.

If anyone deserves to be titled ‘too cool for school Han Solo’ in this article, it would be tough to go past Hindsey.

On the impact of corporate optometry in the contact lens space, Mark is already ahead of the game. “With the way optometry has developed, some optometrists find themselves in a framework of practice that does not allow them to optimally cater for these specific cases. This is where we can be of service for these clinicians. By having this philosophy we have grown our specialty contact lens base and have hundreds of complex patients in a growing shared care arrangement – everything from orthokeratology to scleral RGP lenses. We are also fortunate to work closely with some of Australia’s best corneal specialists.”

Indeed, specialty contact lenses is admittedly a time consuming and also an expensive model to maintain if you just dabble in specialty fitting.

At theeyecarecompany, we stopped counting when we’d acquired over 15 different types of specialty contact lens fitting kits to optimise our offering to suit different patients’ conditions. That means if you’re in a corporate optometry model, or if you are just starting out in practice, or if you’re not serious about specialty contact lenses, it may not be financially viable to go down this track. And this is where we have to start realising that for the benefit of our patients, our profession is going through a maturation process and recognising within optometry we have colleagues that have special areas of expertise that can be referred to in much the same way as you would refer a patient to a subspecialty ophthalmologist.

For those who choose not to upskill and invest in specialty contact lens fitting, co-management should not be hampered by the fear of losing your patient but governed by making a decision in the patient’s best interests. Patients referred to our practice from other optometrists are strongly encouraged to maintain their general care with their main optometrist and see us just for their contact lenses. It’s a great relationship built on mutual respect.

Online and Other Pressures

On the topic of competition from the internet, Mark Hinds, again with his typical Queenslander eloquence sums it up nicely.

“Wow, are we still banging on about this?

“The disposable contact lens market is a key indicator for where the spectacle frame market is heading… a successful business model has to reflect the market place.

“The globalisation of the contact lens market place, thanks to the internet, has dictated the price. That means the 1990s model margin is not applicable. It is 2014, where the TV is 5cm thick and 150cm across, a robot vacuums, groceries are delivered, we can buy almost anything online including anything optometry, and this year’s optometry graduates will be younger than the internet as we know it. My point is – move on and embrace this market. Make it work for our practice. If we don’t we will be pondering where all of our contact lens patients went while we are trying to return our video to where the video store once was,” he said.

So how do we embrace this new market? Mark again. “My answers are to fortify our practice with products and a service that a set of patients cannot get anywhere else, and for the reusable products, keep them premium and convenient, and keep prices competitive,” he said.

I am certain Kate Gifford (nee Johnson), from Gerry and Johnson Optometrists is my Princess Leia. She redeems the Queenslander contingent with true class and eloquence. “The future of contact lenses is challenged by unregulated sales, practitioner motivation to fit, and public attitudes.

“Contact lenses are medical devices of high technological complexity but they have been devalued by their own developers, in the chase for dollars, to a commodity in the eyes of the public. This attitude permeates to optometrists, and no doubt affects motivation to open the door to the financial and health risks of offering contact lenses to patients who can end up prescribing and dispensing their own powers, materials and wearing schedules.”

Kate shared the story of a colleague’s despair at seeing a woman in her 80s who had self-prescribed contact lenses from the internet for four years before running into trouble and seeking professional care.

“If we neglect contact lenses as part of our optometric toolkit, we won’t be doing the right thing by a number of our patients who don’t achieve their best correction with spectacles,” said Kate. “We need contact lenses and our patients do too.”

Maintaining Viability

Kate believes that in the face of heavy competition, it will take partnerships between prescribers and industry to ensure disposable lenses remain a viable product that can be safely and economically supplied to our patients through regulated channels.

“The fact that contact lens dispensing is unregulated in this country is ridiculous. This poses an enormous public health risk. But before this is addressed, in your own consulting room, you can deal with the elephant in the room, by discussing why these medical devices should be valued and explaining the very real risks and dangers involved in purchasing from platforms other than an optometrist.”

“Specialty contact lenses enjoy far less market competition than disposable lenses, and there is potential for market growth for these as well as disposable lenses. These do require investment in optometrists’ skills and access to required technology, by both the individual and their employer. For these and many other reasons, there are interesting times ahead, but there will always be a place for contact lens fitting in optometric practice,” she said.

Richard Lindsay from Lindsay Associates in Melbourne believes continued viability requires practitioners to charge a realistic fee for service. “Although we may realistically lose 10–20 per cent of contact lens business to online competition, we have the advantage of providing personal service – and the internet driven culture loves good service. As a whole, optometrists have shown a strong reluctance to charge for their time and that especially goes for CL services. Performing our CL fittings at no charge is quite ridiculous. The problem is, this standard is now part of life for some of our colleagues. As time goes on and dispensing income is eroded, it is even more important to generate that CL consultation to cover the cost of time and remain profitable.”

At Boyce Optometry in Queensland, John Boyce agrees, “You could say the contacts are merely a ‘bonus’ to the practice. Certainly the margins with soft disposables have been eroded in recent years, but if we charge a fee commensurate with our training and skill, and can venture into the specialty contact lens areas where ‘bargain basement’, ‘cut-price’ and low cost internet prices cannot have an impact, then it is still financially rewarding”.

In the End, Why Bother?

One of my all-time favourite contact lens Jedi heavyweights is Alan Saks – a third generation optometrist whose father and grandfather were also amazing, forward thinking contact lens pioneers.

Alan is pretty clear on why we should all be bothered to understand and promote contact lenses.“Optometrists that neglect the contact lens part of their offering are misguided. They are reactive. They don’t think it through. Theirs is an emotional reaction to the changes in the market. They are their own worst enemy – they turn patients away who buy online and lose ALL their business. Time and time again it is shown that CL patients are the best! They also have spectacles, sunnies, solutions, accessories – it is how you handle them!”

So, Let’s Repurpose the Death Star

My contact lens supernerd colleagues and I have successfully repurposed the contact lens Death Star as a practice builder to be used to create thriving practices that work in harmony with the corporate optometry model.

Perhaps surprisingly, despite coming from diverse practices, each of the members of this impromptu Jedi council have demonstrated uncanny parallels in optometric practice and our belief in the role of contact lenses into the future.

It strikes me that all of these thriving practices have a healthy portion of their income from traditional optometry income streams – consultations, spectacle frames, lenses, sundries, and sunglasses. Yet, supplementing this, they happen to have a thriving contact lens income stream.

Reading between the lines, one of the unanimously resounding points was that contact lens practice viability is a great reflection of the financial health of your optometry practice in general. In this regard, contact lenses can be a useful ‘canary in the coal mine’ to represent how well you can personalise and optimise your patient offering to meet a tailored solution for your patients’ needs.

Looking more broadly at the subject of contact lenses, it’s exciting to read about a collaborative project between those bright engineers in Google X labs in Switzerland and the corporate contact lens company Alcon. Their plans are to develop a contact lens that will monitor blood sugar levels via a nanomicrochip sandwiched between two layers of contact lens material. These innovative, non-invasive lenses will then be able to measure the glucose levels of the glucose intolerant and diabetics through completely non invasive means, without having to draw blood samples. This will be a great complement to the Triggerfish contact lenses that measure diurnal intraocular pressure via clever micro-circuitry. In the words of Yoda, ‘Do. Or do not. There is no try’. I think we can safely say, in the world of contact lenses, the future is bright and full of promise.

8 Steps to Repurposing the Death Star

1. Invest in the skills and knowledge required to successfully prescribe and fit contact lenses
2. Commit to service excellence
3. Recommend and prescribe contact lenses to any patient that is suitable
4. Educate patients on the risks and dangers of buying CLs from non-optometric platforms
5. Maintain premium lenses at competitive prices
6. Proactively arrange the patients’ re-ordering and consultation recall
7. Create a customer loyalty program
8. Offer contact lens patients preferred pricing on other eye health products. If you’re offering specialty contact lenses:
Don’t dabble in this space – commit or refer on
Develop relationships with other optometrists and health providers who will refer patients on for co-management.

Margaret Lam BOptom UNSW, OA, CCLSA, OSO, IAO President of the Cornea and Contact Lens Society of Australia (NSW). Margaret Lam graduated from the University of New South Wales in 2001. She started theeyecarecompany in 2005, a small group of successful independent optometry practices that focus on professional eyecare and designer eyewear across four locations in greater Sydney and Sydney CBD. She practises full scope optometry, but with a passionate interest in specialty contact lenses, retail aspects of optometry and successful patient communication. Her experience includes working in independent practices, chain practices and corporate multinational optometry practices and as a locum optometrist. Margaret has also worked in an advisory role with several leading contact lens companies, is a public speaker on topics spanning contact lenses, specialty contact lenses, practice building, successful patient communication, and retail aspects of optometry.