Offer all contact lens options, but make specific recommendations

LASIK has been a vision correction option for 10 years. But patients have heard the recent negative press. Some who previously considered refractive surgery are having second thoughts. They’re hearing about complications and possibilities for improved technology in the future.

In today’s optometric practice it’s easy for clinicians to lose focus on something near and dear to their hearts: contact lenses. With this discussion we hope to bring clinicians up to date with respect to contact lens options for patients interested in refractive surgery.

Roundtable Participants
Jane Beeman, COA, FCLSA, is director of professional relations for Bausch & Lomb North American Lens and Lens Care, Rochester, N.Y.	Nikki Iravani, OD, is director of clinical research and professional relations for CooperVision Inc., Lake Forest, Calif.
Michael DePaolis, OD, FAAO, Editor of Primary Care Optometry News, is in private practice in Rochester, N.Y.	Howard B. Purcell, OD, FAAO, is director of professional affairs for Vistakon, Division of Johnson & Johnson Vision Care Inc., Jacksonville, Fla.
Richard P. Franz, OD, FAAO, is vice president of professional relations for Ocular Sciences Inc., Concord, Calif.	Richard E. Weisbarth, OD, FAAO, is executive director of professional services, North America, for CIBA Vision, Duluth, Ga.

Michael D. DePaolis, OD, FAAO: If a patient presents for a refractive surgery consultation, what sort of obligation do we have both ethically and medicolegally to at least discuss contact lenses? To me, informed consent is not just discussing the risks and benefits of surgery, but also discussing the other options.

Howard B. Purcell, OD, FAAO: It is important that we present patients with options. We don’t need to present every option that has been available since 1930, however. At some point, I think we need to say what we think is best for that patient. That’s the piece that is often missing.

If we’re going to compete, we need to present options fairly and not allow our own biases to get in the way. Patients want maximum vision. They are really appreciating getting better than 20/20 vision. We’ve been doing that for a long time with contact lenses, and I think it’s important that patients understand that.

Richard P. Franz, OD, FAAO: One of things that we as a profession do not do well is make a recommendation. People don’t come to our offices to make a decision. They come to get a recommendation. You need to provide options, but this whole idea of throwing the decision back at the consumer is one that has not really served a lot of practitioners well at all.

Nikki Iravani, OD: It goes back to spending time educating your patients and getting to know their visual goals. For example, if a 36-year-old engineer who works on the computer all day long comes in and says, “I’m thinking of refractive surgery because I’d like to have convenience and super vision,” you need to spend the time and tell this patient: “In a couple of years, you’re going to be a presbyope, and you’re going to be back in glasses again.”

Jane Beeman, COA, FCLSA: You’ve hit on two very fundamental issues. The first is that we have to educate contact lens patients that wearing contact lenses is not a compromise of anything. With today’s technology and today’s products, they should demand the same level of performance that they would demand from their spectacles or from refractive surgery.

The second thing is presenting options. From a practice management standpoint, there are so many good options that it’s eating up chair time. Do you present every option to every patient?

Dr. Purcell: We don’t really have the time to present those options. All of us in the contact lens industry are challenged to create a more proactive approach at presenting contact lenses. The day the practitioner becomes more proactive in presenting contact lenses is the day we can back off in spending as much as we do on consumer advertising and can invest that money in other places.

Dr. Franz: We need to understand that our patients are educated and savvy. We often hear from patients that if their practitioner didn’t present them with an option, they assumed the practitioner doesn’t play in that area.

Delegate, delegate, delegate

Dr. DePaolis: Practitioners need to educate patients, but they have time constraints. What is your recommendation to clinicians?

Dr. Purcell: I think delegation is the key to that. We have to be more comfortable with delegating. We don’t have to spend hours with patients to make them feel that they’re getting quality time. If we can delegate, it gives us more time to sit in front of patients and talk to them about their options.

Dr. Franz: In addition, there’s so much technology available today to assist the office personnel in delivering a very consistent message of patients’ available options. Practitioners need to be willing to take the time to train the staff to use this new technology.

Ms. Beeman: Practitioners can use teaching tapes and training videos. They can go over the key points a second time to make sure that the patient understands everything.

Dr. Iravani: E-mail is an excellent communication tool, and practitioners should take advantage of this tool to routinely communicate with their patients and keep them aware of the latest and the greatest updates. E-mail blast or bulk e-mail is another way to communicate with and educate patients.

Dr. Purcell: This is a good way to mask waiting time. You can have something positive happening during that down time.

Richard E. Weisbarth, OD, FAAO: The best practices have an integrated type of approach. At the time that the patient calls for an appointment, the staff is already asking questions, such as, “Are you a contact lens wearer? Are you interested in contact lenses? Have you heard about the latest and the greatest?”

If a practitioner has a sign out front, he or she may put on it, “We now offer the latest in this contact lens technology.” When patients walk in the door, there’s something on the reception counter. When they go into the pre-test room, there are posters on the wall.

By the time patients get to the practitioner, they have already been primed. They’ve been exposed to a variety of different sources, and they can ask more intelligent questions.

Daily disposables

Dr. DePaolis: Let’s talk about daily disposables. They provide an alternative for certain patients that optimizes vision and comfort, and they are quite convenient. What are market trends telling us in terms of daily disposables? What percentage of new fits do they make up? What percentage of overall lens wearers are wearing daily disposables?

Dr. Purcell: There hasn’t been a lot of growth in daily disposables. It represents about 3% of new fits right now.

Dr. Weisbarth: The trend has changed over years. As the cost of daily disposables has come down, we’ve gone more from a part-time type of modality to a full-time modality. At $2.00 a day, a certain number of patients are interested. At $1.75, it goes up. At $1.50, it goes up a little more. Once you hit about $1.00 day, it is viewed as a very affordable lens.

Patient profiling

Dr. DePaolis: Can we profile a daily disposable patient?

Dr. Weisbarth: Patients who have had any kind of problems with reusable lenses are going into daily disposables to eliminate solution preservatives. Additionally, anyone who has had allergies — seasonal allergies or solution-related allergies — is going into these lenses. Another one of the growing trends is children and teens. Practitioners present it as the easiest way to wear contact lenses.

Dr. Franz: I would challenge that to some degree. The daily disposables seem to have been very market-specific in their acceptance. In the United Kingdom, for example, 40% of all new fits are going into daily disposables. In Japan, there is a huge daily disposables market. Now, is the profile of people in the United Kingdom different than patients here?

Dr. Purcell: Vision and health are most important to these patients. Michael Jordan was said to wear a different pair of shoes for every game he played. Why? He wanted to perform at his best all the time. A key advantage to this modality, aside from the health advantages it brings, is performance. You are going to perform at your best all the time.

It’s a little dangerous to categorize that optimum patient, because I always hear the story of the person who pedaled his or her bike to the office and found value in this modality. So, as much as I think it’s important to know who is the low-hanging fruit, I think it’s also important to understand that you’re going to be surprised on occasion to see who appreciates the true value of this modality.

Staff education

Dr. Weisbarth: We really need to talk about staff education. The first person who the patient comes in contact with is a staff member.

Dr. Purcell: One practitioner I know encourages his staff to promote the doctors in his practice. They’re ambassadors for the doctors they work for. They carry the doctors’ business cards and give them out. It seems like such a simple thing, but not many clinicians really encourage their staff to boast about them. There’s nothing wrong with that as long as they truly believe it. They’ve seen the successes in the office.

Dr. Iravani: Include your staff members when the pharmaceutical and contact lens company reps come to visit. When the rep is educating you about the latest launch and the latest contact lens materials, include your staff in that educational process so that they learn about those things, too.

Dr. DePaolis: Does a successful practice build phone scripts?

Ms. Beeman: While it’s helpful for learning some new words, I don’t think scripting is a good idea. It can be demeaning to the staff. It gives them the impression that they’re not smart enough to understand what they should say. Maybe we’re doing it because we feel like we haven’t communicated well to them.

If you cannot get beyond the point that the people working in your office are just employees, then it won’t ever work the way you want it to. You have to have a vested interest in them succeeding if you want them to have a vested interest in you. If you can create the idea that it’s a group practice and that they’re members of this group, then they will be your best ambassadors.

Dr. Purcell: I’ve never been a big scripting person. I don’t particularly like when I call an office and feel like I’m getting a script read to me. However, I do think education is important.

Extended wear

Dr. DePaolis: With the advent of silicone hydrogels, do you think the major impediment to extended wear is clinician mindset? Do you think the patients view extended wear as an alternative to refractive surgery now?

Dr. Weisbarth: I think the average patient is very much interested in the concept of continuous wear, but for the past decade, we’ve told them not to sleep in their lenses. People would be interested in it, but they’re not educated to know that something’s different now.

Dr. DePaolis: Is it safe to say that wearing contact lenses overnight is a relatively safe modality if you consider laser surgery a relatively safe modality?

Ms. Beeman: A refractive procedure, even one that’s as safe and effective as today’s LASIK procedures are, may not be some patients’ ultimate choice. You have to balance the choice of refractive surgery with another option, and they’re asking you for 24-hour vision correction. That’s what they want.

Dr. Franz: The information that patients rely on the most is basically what their practitioner tells them. If people have negative feelings about extended-wear lenses, it’s probably because we have directly or indirectly relayed those negative feelings to those patients. This modality is going to grow and become a viable vision correction device. We need to educate practitioners about the safety issues.

Dr. DePaolis: You really can’t look at the overnight wear of contact lenses in 2002 as you did in 1982. Just like you can’t look at toric soft lenses in 2002 as you did in 1976. Technologies mature, and practitioners need to keep up with the times and the recommendations.

Dr. Purcell: Patient selection is critical. When extended wear was early in its development, some practitioners wanted to put non-compliant patients in extended wear lenses. This is a very scary reason for implementing extended wear. I think we have to be cautious about that. We’ll, again, find ourselves getting some negative press about a modality that clearly has moved us to the next level.

Silicone hydrogel gives us a wonderful opportunity to address patients who have demonstrated some issues with lack of oxygen transmissibility. It’s a great option to go to. I salute the companies who have made that step. However, I believe we still have some things to do to convince the clinician and the patient that we’ve really solved the extended-wear dilemma.

Dr. Iravani: It goes back to educating and presenting all options to patients and advising them about the modality that best suits their profile. Like everything else, extended wear is not for everybody.

Dr. DePaolis: What pre-existing conditions contraindicate patients wearing lenses overnight?

Dr. Weisbarth: Being a smoker.

Dr. Purcell: We have to be extremely cautious with patients who have had a prior complication as a result of overnight wear.

Dr. DePaolis: What percentage of people who start wearing silicone hydrogels for 1 week or even a month at a time, are successful?

Dr. Purcell: It is as high as 60%.

Dr. Weisbarth: That’s based on one base curve. With a second base curve it obviously increases.

Ms. Beeman: While 30 nights has been a goal, patients need to understand that these products can be worn up to 30 nights — that doesn’t mean there’s anything wrong with taking them out at 25 nights or 28 nights or 2 nights. It’s an individual patient tear chemistry issue. Every patient reacts to lenses differently.

Extended wear follow-up schedule

Dr. DePaolis: How often should patients wearing extended-wear lenses be seen?

Dr. Purcell: You must see the patient at his or her worst. Seeing him or her at 1 week, 2 weeks or 3 weeks is fine, but if the patient is going to go a full 30 days, you’d better see him or her at the full 30 days.

Dr. Weisbarth: Most practitioners realize that seeing the patient the morning after the first night of overnight wear is totally worthless because you’re not going to see anything. The eye is going to be clear, and everything’s going to look fine. So, the typical follow-up schedule is starting to shape up to be at the end of 1 week, at the end of 1 month, possibly at the end of 3 months, definitely at 6 months and then every 3 to 6 months thereafter. That depends on the practitioner’s philosophy.

Ms. Beeman: This can confuse patients. Practitioners are concerned about going back to an overnight wear modality, so they want to see patients more frequently. So, you tell patients that you’re giving them new improved technology that’s actually safer for their eye but you’ve got to see them more often.

That happens only in the beginning. Once you get comfortable with the technology and with the patient selection, then you drift back into a regular schedule.

Dr. Weisbarth: You can’t let a new patient go beyond 30 days without seeing him or her. We are still talking about leaving a lens on the eye. Things could potentially go wrong, and the key is that the patient has to know how to get that lens in and out. If it’s 3:00 in the morning, I want that lens out before the patient even calls me. Patients still have to make sure that their eyes look good, see well and feel good. Nothing has changed. We have lenses that breathe better and provide a better physiological response, but oxygen is just part of the equation.

Dr. Purcell: That’s an important message. Clinicians may think that they put the lens in, and the patient is done. That’s a dangerous premise.

Dr. Iravani: Due to these reasons and concerns, practitioners should consider all options and not necessarily prescribe continuous wear for every patient with every profile.

Reversibility, adjustability

Dr. DePaolis: We have so many good options, whether we are talking about continuous wear, daily disposables or torics or bifocals. What are the issues of reversibility and adjustability, and how can they be conveyed to patients, particularly those who are comparing this with refractive surgery?

Dr. Purcell: When handled appropriately, these new modalities can create some real flexibility for patients, but we do need to understand that most of the potential complications that take place, even with historic extended wear, are reversible. Those horror stories that we hear about ulcerative keratitis are very rare.

When you hear the stories about contact lenses, you tend to hear the horror stories. It gives you this idea that half the patients wearing lenses are having these kinds of problems. What you’re observing today is the beginning of a trend — we need to stop considering the risks that contact lenses carry and look at their advantages. The future of contact lenses is not about risk, but about advantage.

Dr. Iravani: Patients want clear vision and comfortable and safe lenses, as well as convenience. There is no barometer or standard way to measure convenience, because a lot of it is subjective. Present your patient with options, and explain that refractive surgery is irreversible, and complications and regressions are concerns. However, comfortable contact lenses are safe, and if any complications arise they are reversible.

For Your Information:

• Howard B. Purcell, OD, FAAO, can be reached at Vistakon, 7596 Centurion Pkwy., Jacksonville, FL 32256; (904) 443-1019; fax: (904) 443-1252: e-mail: hpurcell@visus.jnj.com.
• Jane Beeman, COA, FCLSA, can be reached at Bausch & Lomb, 1400 N. Goodman St., Rochester, NY 14603-0450; (716) 338-6462; (800) 344-8815; fax: (716) 338-5776; e-mail: jbeeman@bausch.com.
• Nikki Iravani, OD, can be reached at CooperVision Inc., 21062 Bake Pkwy., Suite 200, Lake Forest, CA 92630; (800) 341-2030, ext. 3354; fax: (949) 597-0663; e-mail: niravani@coopervision.com.
• Richard P. Franz, OD, FAAO, can be reached at Ocular Sciences Inc., 1855 Gateway Blvd., 7^th Floor, Concord, CA 94521; (800) 972-6724, ext. 7006; fax: (925) 969-7128; e-mail: rfranz@ocularsciences.com.
• Richard E. Weisbarth, OD, FAAO, can be reached at CIBA Vision, 11460 Johns Creek Pkwy., Duluth, GA 30097-1556; (678) 415-3560; fax: (678) 415-3151; e-mail: rick.weisbarth@cibavision.novartis.com.