One or Two: Which Would You Choose?

Scenario #1: Amy purchases another supply, but her contact lens wear reduces over the next few years until she drops out.

Scenario #2: Amy purchases another supply and remains a happy contact lens wearer for many years to come.

We need to ask our patients the right questions, rather than expecting them to tell us what is wrong when they don’t, in fact, realise anything is wrong to begin with

What series of events lead to scenario #1 as apposed to scenario #2?

In Scenario #1, Amy went to optometrist A and, when asked if she had any problems, responded “No”. Amy was sold another box of contact lenses and was put on an annual review. Over the course of the next three years, she began to have more difficulty at near, which she could resolve by simply taking her spectacles off, but this was less practical when her contact lenses were worn. Her eyes became increasingly dry, especially with contact lens use, so spectacles became the more practical, simpler option.

In Scenario #2, Amy went to optometrist B who asked how she was doing with her contact lenses. Amy responded, “Great, no problems”. Optometrist B then delved deeper, asking if she experienced fatigue or difficulty at near. Upon reflection, Amy said she did experience fatigue after prolonged screen use – but assumed this was normal.

Optometrist B further questioned, asking when her eyes became dry. Amy reported that her eyes could be a little dry at the end of the day, but that was when she was needing to take her lenses off anyway.

Optometrist B then suggested that Amy try a lens that could reduce eye fatigue; a daily disposable multifocal lens.

Amy didn’t see herself needing multifocal lenses as she had heard negative things about them, perceived daily disposable lenses to be too expensive, and she was not really having any problems. However, Optometrist B explained that a fresh lens every day is a far safer, healthier, and more comfortable way to wear contact lenses. They also reassured her that the recommended lenses were very different to the multifocal spectacles Amy had heard negative comments about, in terms of cost and difficulty with adaptation; they just had a little ‘boost’ to relieve eye strain. Either way, she could trial the lenses at no cost – if she didn’t like them, she could dispose of them and continue with her present contact lenses.

Amy returned after a week of trialling the new lenses, reporting her eyes not only felt more comfortable, but she felt far less fatigued at the end of the day. She had not realised she had been experiencing problems – these symptoms had come on gradually and she had normalised them.

Amy upgraded to these lenses, and returned religiously each year, as she trusted her optometrist to provide the best solution for her.

TAKING CONTROL

As a child, I loved Choose your own adventure books. However, as someone who has always hated suspense but loved winning, I would read the endings, then work my way backwards. Some may see this as a problem and label me a ‘control freak’, however I would argue that we optometrists are all the same, especially when faced with a patient who, if left untreated, unmanaged and/or unmonitored, could be at risk of developing ocular diseases such as glaucoma, macular degeneration, or even contact lens complications. Being in preventative health care, we perform tests on healthy eyes to ensure we are not missing the unhealthy ones, and we educate our patients of potential ocular complications, especially those at risk. Some may argue we are over-zealous with the barrage of tests we do and the questions we ask to identify symptoms. Yet the reality is that most patients don’t know they have elevated eye pressures, visual field defect, or the beginning of contact lens intolerance or early presbyopia. They silently suffer without knowing it and, if left unchecked, without us knowing it either.

Yes, it is crucial for us to preserve our patients’ ocular health, however it is also imperative that we ensure they can see well and comfortably. So why are we hesitant about discussing contact lens ‘problems’? Why don’t we have conversations with patients, even when they say they are ‘not having problems’? Why don’t we modify management when they say they are ‘fine’, just as we would to best protect our ‘at-risk of disease’ patients?

We need to ask our patients the right questions, rather than expecting them to tell us what is wrong when they don’t, in fact, realise anything is wrong to begin with.

Achieving the best outcome may mean prescribing multiple solutions – but why should we be shy about that, when vision is our most precious sense? After all, how many of us run in our work shoes? Or butter bread with a cook’s knife? We use multiple tools that are ‘the same but different’ because some are excellent for one task, but lousy for others.

Patients will rarely feel compelled to come in and tell us when they stop wearing their contact lenses – or why – they simply stop. By the time we find out, it is too late. And then, another contact lens patient ceases to exist, and another contact lens fairy loses its wings.

THE BUSINESS ARGUMENT

Many practitioners perceive that contact lenses are a waste of time because spectacles drive higher margins per sale, but studies have shown that contact lens patients are in fact, more valuable to a practice. They return more frequently, spend more per consultation – and surprise, surprise – also purchase and wear spectacles, resulting in more revenue per patient.1

This is particularly true of our current presbyopic population, which encompasses all the Baby Boomers and earlier generations who generally have more wealth and can afford multiple solutions. What many people don’t realise is that most of Gen X is also now presbyopic… a generation that includes Beyonce, Britney and Serena.

We’ve all heard ‘forty is the new thirty’ and that these patients aren’t ready to slow down – presbyopia has traditionally been associated with aging, and many in the presbyopic population are living like they’re ‘forever young,’ and certainly don’t want to be labelled ‘old’. Giving them vision and freedom from spectacles can enable them to appear and feel younger, and keep them involved in sports and activities that are inconvenient to perform in spectacles.

However, many of these patients have been told they’re not suitable for presbyopic contacts – or they’ve tried them and found them blurry. I am amazed by the number of patients who tell me this after wearing contact lenses for only a few minutes.

What many patients fail to realise neuroadaptation is required for any presbyopic lens solutions – be it contact or spectacle lenses in multifocal, monovision, extended depth of focus or a combination of various modalities. Neither do they realise that neuroadaptation takes time.

Contact lens manufacturers have been generous enough to supply lenses at no charge, so that patients can ‘try before they buy’. I believe this has been to their detriment as many patients are quick to discard them if they’re not immediately visually comfortable.

Spectacle lens manufacturers have not been as generous. I doubt whether there are any optometrists or patients who are quick to remove their new specs and throw them in the bin when they ‘don’t work’ at handover. Cost alone compels them to persevere through the adaptation period and return for tweaking if the prescription is not quite right.

I often ask, “how much do you value something if you get it for free?”… I’ll admit, there are many pairs of free sunglasses (thank you manufacturers) that I have been sad but not devastated to lose, and many more I’m sure I don’t even recall owning. I am a firm advocate of charging for your services – this forces the patient to buy in, and put their faith in you. It also shows you have confidence in your skills and abilities.

THE REWARDS OF RECOMMENDATION

Contact lenses for presbyopia can be very rewarding – you can dramatically improve a patient’s quality of life with these magical pieces of plastic.

Patients will reward you, not only with their gratitude, but also with their loyalty. Their friends will see your patients not wearing spectacles yet able to see, and they’ll visit you asking to be afforded the same freedoms.

I’m not going to sugar coat it, presbyopic contact lenses can be time consuming, and sometimes they simply do not work for a patient. The same goes for progressive spectacles. What I can guarantee, is that you will miss 100% of the shots you don’t take.

So, spoiler alert. You know the two endings. Now you also know the way to get there. It’s your adventure, it’s your path to choose.

Jessica Chi is the director of Eyetech Optometrists, an independent speciality contact lens practice in Melbourne. She is the current Victorian, and a 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, a member of Optometry Victoria Optometric Sector Advisory Group and a Fellow of the Australian College of Optometry, the British Contact Lens Association and the International Academy of Orthokeratology and Myopia Control. 

References 

1. Gullege M. Contact lens patients are more valuable than eyeglasses-only patients. Rev Optom Business. Nov 2016.