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HomemipatientDiscuss, Recommend, Understand

Discuss, Recommend, Understand

We cannot force our patients to do what they are not willing to do, even if we believe it’s the best thing for them.

CK, a 33-year old female, was referred to the practice for contact lens fitting by her corneal specialist. She had been diagnosed with bilateral keratoconus R>L at age 17 and had tried rigid gas permeable (RGP) contact lenses at age 21. CK found the RGP lenses uncomfortable to wear and had trouble handling them. With a motivation to be spectacle free when playing sport, she persisted but soon lost them while skiing. The experience made her averse to trying them again.

For the most part CK manages well with her spectacles. She reports itchy eyes and admits to rubbing her eyes but tries not to. She has been monitored for progression of her keratoconus for the past two years by her corneal specialist, but fortunately has not exhibited any. Should progression be documented, cross-linking would be offered.

Vision with spectacles was R 6/15=, L 6/9= with prescription, R -7.00/1.75×100, L -6.50/-1.75×5.

if my efforts to get CK into contact lenses fail, then at least she has two pairs of fabulous spectacles

Subjective refraction gave R -5.25/-2.75×104 (6/12-), L -6.25/-1.75×170 (6/9).

External eye examination revealed moderate corneal thinning R>L consistent with keratoconus. The corneas were otherwise clear. There was no staining, but there was grade two papillary conjunctivitis. Tear break up time was reduced to six seconds in both eyes.

Videokeratoscopy revealed moderate sagging cones R>L (Figure 1).

No Life Without Spectacles

When CK made an appointment with my practice, she stated that she did not want contact lenses. At the beginning of the examination, she reported that her ophthalmologist had wanted her to try contact lenses, but she was adamant that she was not interested, given her prior negative experience.

Being a high myope, and a young, active female, I believe that CK would benefit dramatically from contact lenses. I discussed (praised!) the benefits of contact lenses, using emotive descriptors such as ‘life-changing’ and ‘gives you freedom’ – all the phrases I tout enthusiastically because of my own love of this technology.

Unfortunately, and despite having described a number of scenarios I personally could not imagine without wearing my contact lenses, CK was opposed. She couldn’t imagine the same scenarios without her spectacles. In her mind she had closed the door to contact lenses at age 21. She simply wanted prescription sunglasses.

Eventually I obliged, though I did reiterate the importance of avoiding eye rubbing, as this has been shown to promote progression of keratoconus.1 It is a message I give to every single one of my keratoconic patients. CK was aware that eye rubbing could worsen her keratoconus, but she struggled to avoid it because of itchy eyes.
I recommended Zaditen eye drops to be used twice daily to control her ocular allergies.

During frame selection, CK told me she could not see herself well enough to choose spectacles. I offered contact lenses for the purpose of frame selection, promising that I wasn’t pushing her towards them for future use. CK agreed, the lenses went in, and she remarked on how comfortable they were compared to prior experiences. We ended up prescribing Face à Face spectacles, and prescription Gucci sunglasses. After she had chosen her frames, the contact lenses were discarded, and there was no further contact lens discussion.

Two weeks later, CK’s spectacles were dispensed, and she loved them.

When to Concede

Being an avid contact lens practitioner with a keen interest in keratoconus, and a happy myopic contact lens patient myself, I assumed I could convince CK to pursue contact lenses. I discussed the options – RGPs, offering hybrid or mini-scleral contact lenses for enhanced comfort and improved vision; and soft contact lenses which also offered enhanced comfort, convenience and a relatively low cost. Mini-scleral lenses were too much of a commitment in terms of cost and effort for a patient who was not keen on contact lenses, but I explained that soft contact lenses were fitted using diagnostic trials which would be at no cost to her until they were trialed successfully… try before you buy, with nothing to lose. Despite my efforts, CK could not be convinced.

Contact lenses have significant advantages over spectacles, especially for keratoconus and high myopic astigmats. For example, spectacles induce aberrations, which are more noticeable as the degree of prescription increases. In high prescriptions, the lenses are thicker, aesthetically unpleasing and can be physically uncomfortable due to their weight. In keratoconus, the predominant optical aberration is coma, which leads to monocular diplopia, ‘ghost’ images and flaring around light sources.2 Patients with keratoconus who wear spectacles will often complain of distorted vision, and a ‘fishbowl’ effect. Rigid contact lenses or similar can dramatically reduce these aberrations.

EASE

When I am involved in dispensing, I remind myself of the EASE (Enhancing the approach to selecting eyewear) study. The study included patients with no prior contact lens wear, divided into a test group and a control group. The test group was offered contact lenses to enable them to see themselves during frame selection, whereas the control group was not. Of the test group, 88 per cent agreed to contact lenses as an aid for frame selection. The test group spent on average 32 per cent more on their spectacles compared to their control group, and also reported a subjectively superior dispensing experience. Following, 33 per cent of the test group went on to purchase contact lenses compared to only 13 per cent of the control group3 (Figure 2).

Offer the Option

Those who suffer from significant ametropia will understand how difficult frame selection can be when not visually corrected. Offering a contact lens trial during frame selection can give the patient the confidence to choose their spectacles, and enable them to commit to spending more because they can see. It saves time for patient and dispenser alike, as the patient is able to make an informed decision of how they look in their new frame, and it prevents any unforeseen shock upon spectacle collection.

As practitioners we cannot force our patients to do what they are not willing to do, even if we believe that it’s the best solution for them. Just because you believe something is better for a patient, does not mean they think it is better for them. 20/happy for a patient may be more appealing than 20/20 and having to stick things in their eyes. We can discuss the options and recommend. So I will continue to recommend, and recommend to CK, until the unfamiliar becomes familiar and the idea of contact lenses is no longer negative. And if my efforts to get CK into contact lenses fail, then at least she has two pairs of fabulous spectacles.

Jessica Chi is the director of Eyetech Optometrists, an independent specialty contact lens practice in Melbourne. She is the current Victorian and past National President of the Cornea and Contact Lens Society, and an invited speaker at meetings throughout Australia and beyond. She is a clinical supervisor at the University of Melbourne, and has served on the continuing education committee for the Australian College of Optometry and the Therapeutics Advisory Board for the Optometry Australia

References
1. McMonnies CW, Boneham GC (November 2003). “Keratoconus, allergy, itch, eye-rubbing and hand-dominance”. Clinical & Experimental Optometry. 86(6):376–84.
2. Pantanelli S, et al. “Characterizing the wave aberration in eyes with keratoconus or penetrating keratoplasty using a high-dynamic range wavefront sensor”. Ophthalmol. Nov 2007. 114(11)2013-21.
3. Atkins NP, Morgan SL, Morgan PB. Enhancing the approach to selecting eyewear (EASE): a multi-centre, practice-based study into the effect of applying contact lenses prior to spectacle dispensing. Cont Lens Anterior Eye. 2009 Jun;32(3):103-7

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