Industry veterans predict major changes for the practicing optometrist

Primary Care Optometry News gathered members of its Industry Council during the American Academy of Optometry meeting in Seattle for a frank discussion on the issues facing optometrists today: the Affordable Care Act, technology, performing refractions, prescribing to and advising patients, and the future practice of optometry. Participants represented manufacturers in the areas of contact lenses, therapeutics, technology and spectacle lenses. Here we present the first part of this provocative discussion that was moderated by PCON Editor Michael D. DePaolis, OD, FAAO. Watch next month’s issue for the second half.

DePaolis: Let’s kick off with the 800-lb. gorilla: the Affordable Care Act. To what degree do you think this will really impact us? We all hear there will be 30 million uninsured people flooding eye care practitioners’ offices. Will that really happen, or have many of them traditionally been seen as fee-for-service patients?

John Hawley: Everybody knows there might be more patients available, yet some optometrists who practice the medical model can’t even get on panels, so they won’t have access to these patients. A lot of optometrists are afraid that they’ll be locked out of it completely. I don’t think anybody in Washington really knows what’s going to happen.

DePaolis: You make a very good point. You look at accountable care organizations (ACOs), and it’s clear that primary care physicians are going to be graded according to how well they shepherd care of the masses. And part of that involves annual diabetic exams, for instance. The one thing that could play out here very quickly is primary care physicians looking for networks of eye care practitioners to whom they can refer patients to ensure annual eye examination compliance. Do you have a sense that through all of this vertical integration practitioners could really get left out?

Michael Pier, OD: If the person driving the bus is an MD, then I would venture to say that history will repeat itself and a majority of referrals will go to other MDs as opposed to ODs.

DePaolis: I would agree. But when you look at how taxed ophthalmology is now, do they have the time to do annual diabetic exams? Do you think otherwise?

Pier: I think realistically they probably will have difficulty footing the burden. But the interest is more in where the referrals stay. With regard to patient care, optometry has always been at its best when it’s in an area that’s not competitive with the ophthalmologist. In areas for referral, MDs are more likely to refer to MDs than they are to ODs, unless there is no MD available.

DePaolis: Does it behoove optometrists to strategically align themselves with MDs?

Hawley: I think that’s happening around the country. If you look at some of the groups in Los Angeles, they have referral networks of 1,500 to 2,000 doctors. I’ve been to some of their meetings. So I think that’s starting to happen. If you have a patient with diabetes or age-related macular degeneration and you do testing and refer that patient to a retina specialist, they will do the same testing again – because at the moment there is no way to share all of that information. So if you talk about affordable health care, keeping it in the optometric office is the affordable alternative. If every person with eye disease went to an ophthalmologist’s office, they’d never be able to see them. It has to be optometry. There are fewer fellows going into subspecialty training in ophthalmology. The residencies are diminishing. Optometry is increasing, but they have to get together as a profession so they’re not locked out.

Cristina M. Schnider, OD: I see the issue, also, at the other end of the spectrum with the children. We will have a lot more opportunity to examine youth who are well patients, not typically the group that is sought by ophthalmology, for all the right reasons. So I think there’s a huge opportunity. Sadly, eye care right now is a low involvement category, so we, as the profession and the industry, have an opportunity to step up and engage more people. I think a huge problem is going to be that they won’t know they can access the care, and they will absolutely not know how to access the care unless someone stands up and shows them the path.

DePaolis: Should that leadership come from our professional organizations, speaking as a single voice? Or should it be local groups of clinicians in their own backyard – more of a grassroots effort?

Schnider: I would love to see the two major organizations in our profession work more closely together, but it’s absolutely a huge opportunity for our profession. I also think that payors, like VSP and EyeMed, have a lot of the covered lives now in vision care and I suspect that they won’t let it go by. So it could be a payor who steps up. I would personally prefer to see our profession do it.

Steve Reiman: You’re hearing about some of these groundswell efforts occurring. Some optometrists understand the dynamic and see this opportunity for children’s eye care, so they are contacting parent-teacher associations and getting involved in the community with the grassroots approach.

With respect to your first question, which is the numbers, everybody is playing around with these numbers – 30 million and 9 million new kids – I don’t think it’s going to be anywhere near that, certainly at the beginning. But there will be a flood of patients coming into eye care, which I hope is a positive thing for business.

Dave Hansen, OD: I’ll take a different approach. I think it has changed from an 80/20 rule to a 90/10 rule; 90% of the work is done by the 10% who understand how to manage patient care. I believe there will be a sifting-out period for those who figure out the rules of the game, and 10% will own 90% of the patients. Private practices will have their niches, as Mike stated, in certain rural or urban areas. The major health meccas have already established the efficient and comprehensive model. The government should have used the Mayo Clinic in Rochester, Minn., as the model. The Cleveland Clinic, Johns Hopkins and others will survive; however, Mayo has a system with integrated patient care that works. These systems will dominate in the next 3 or 4 years.

Reiman: It’s a scary proposition, too. I don’t know if it’s 90/10, but when I talk to our partners, clearly there’s confusion and fear. And I think, yes, confusion about what this all means to them. They are not sure how to latch on to make sure they’re not left behind. I think that should concern everybody. Because I don’t think it’s within the spirit of this rule that 10% of the people absorb all these new patients. To make it work, it’s got to be a broader audience.

DePaolis: I would agree, Steve.

Hawley: Then does it make it affordable when you’ve got these huge institutions and we know how they are generally run? So, they might be getting all that money, but is that a savings for us? And does that come at the expense of optometry because they’re excluded completely?

Hansen: The optometric joint model has been established in St. Louis and Indianapolis. Practitioners who are in their late 50s up to 70s and want to retire have joined other practitioners to build networks with 60 to 70 practices. I think that will increase across the country. These model groups will make up the 10% that will own 90% of the patient care business.

Hawley: You don’t get as many single practitioners in ophthalmology anymore. Do you see optometry more and more falling into groups like that to keep overhead and costs down?

Sean Clark: The other phenomenon we’ve been seeing is more and more joint MD and OD practices. Do you think that will continue to accelerate?

DePaolis: It’s interesting you mention that, Sean. In New York we are finally entertaining legislation that will allow MDs and ODs to have joint ownership of a professional practice. This may very well be the foundation for joint practice expansion.

On to another topic: What do you see happening to reimbursement?

Hawley: I think it’s going to go down. My personal premiums are going up, but all the doctors I know are facing a 20% cut across the board in Medicare. The reimbursement for testing is going down. So, where’s all this money? I think it’s with the insurance companies. I think they’re the ones who will control everyone’s destiny now, and no one seems to be addressing it. The doctors, whether it’s MD or OD, are being pinched in the center of this, and they’re the ones who will be hurt. And we’re going to be hurt as members of the public. But the insurance companies are ruling the hill.

DePaolis: The reason I wanted to bring this up is because I have the sense that a lot of our colleagues are just riding the tide right now. The aging Baby Boomers have been very good to optometry, affording many practices the opportunity to be busy and profitable. I think many are just looking at the Affordable Care Act (ACA) as icing on the cake, another 20 million lives tumbling into our offices. I just don’t see the reimbursement structures remaining at their current level. Does anyone have a sense either way?

Schnider: If you look at the words “affordable” and “accountable,” those words are critical to understand. Affordable will mean that they have to drive costs out of the system. And the accountable means that we will be more accountable. Outcomes will be looked at and we, as a profession, have not had to think about that. We, as manufacturers, need to know how to differentiate a product and get it on a formulary. I think we will see both “affordable” and “accountable” implemented.

The future of the private practitioner

DePaolis: What do you think the practice of optometry looks like going forward, considering what we’ve been talking about: shifting demographics, ACA, cost containment constraints and vertical integration? Is the solo, independent, private optometric practitioner an endangered species?

Rod Tahran, OD: I think the solo independent practitioner is an endangered species. I believe the future is what Dr. Hansen was talking about where a group will swallow up, or buy up, smaller practices in a geographical area and bring them under the networks and share overhead, costs and staffing. I really believe what’s happening in the Indianapolis area is the future.

Pier: I believe the costs of being a solo independent professional today outweigh the advantages of being in that modality because of the constraints that are put upon a practitioner with regard to medical records, with regard to ACA, with regard to reimbursements, with regard to patient confidentiality. Quite honestly, those costs are hard to bear for a single practitioner working as hard as that person can 6 days a week. It doesn’t make fiscal sense to a bottom line of the practice. I don’t see it as an endangered species. I see it as one that’s going toward extinction.

Steve Jeffords: I think one of the other factors that supports what you all are saying is that private equity is now entering the arena here and has been for a couple of years. And that’s a leading indicator. The money people are best to anticipate what’s going to happen.

Pier: And they are not putting it into private, solo practices.

DePaolis: That’s a very astute observation. So, do you think the way in which practices are morphing is generational? Do you think the 55-year-old optometrist is motivated differently than their son or daughter who is now entering the profession at 25 years of age?

Schnider: Optometrists haven’t historically learned as a group. We’re trained to do everything ourselves. We’re not good at delegating. We don’t learn how to really use staff. We haven’t historically worked in collaborative practices. Whereas in medicine, they grow up always delegating, always practicing as a community. So I find it interesting to look at our generation, how we were trained, and then look at the millennials who do everything socially. I think they’re better equipped, just by the way they grew up, to share and collaborate. I think we are producing the right generation of people to grow into this model. I think those of us who are already out there maybe are not as well equipped.

DePaolis: I’ve worked with ophthalmology residents for 20 years, and they’re different today. They are brilliant, young individuals, but I don’t see that entrepreneurial yearning quite as frequently as I did 20 years ago. I think they’re coming in with different expectations, and maybe that’s their training — maybe more of a “hospitalist” approach.

Tahran: Plus, the trend in optometry schools is more of an intraprofessional setting with the physician assistant and the pharmacy schools and the dental schools sharing space with optometry. I think in the next 10 to 20 years you’ll see a lot more of that.

Hawley: Will optometry be almost divided into two schools: the refractive person who does most of the eye glasses and the medical optometrist? I know optometrists who don’t have an optical shop.

ACA 1 year later

DePaolis: John, that’s huge. And it moves us in the direction of my next question. Say it’s January 2015. What is the optometrist who currently now sees 15 patients a day — most of whom are refractive and maybe 11 of them buy their glasses and/or contacts from the doctor — what does their practice look like now?

Pier: They have basically 25 patients a day, not 15.

DePaolis: Are they kids? Are they diabetics?

Pier: Partially. I think the patients who migrate into a practice are going to be a more varied presentation than what an optometrist sees today. And the ACA is going to be able to provide that.

I also believe that there will be some pent-up demand over the first few years of people who always wanted to get their eyes checked but didn’t, and now have the opportunity to. And I believe that is a big portion of the people who are going to sign up for a subsidized program through the ACA, which happens to be that 30 million. Whether you get five or 10 or 15, those are all patients who will be coming into a practice.

Hawley: I think it has to be a mix. Ten percent to 20% of that new business will buy their contact lenses and eyeglasses over the Internet, and that will grow. So then that very lucrative part of an optometric practice goes away. But where will the diabetics go? We always feel like the one disease that can break Medicare completely is diabetes. If the optometrist doesn’t embrace those patients, then primary care physicians will. And if they don’t look after the dry AMD patients, who will? The retina specialist doesn’t do this. I think if optometrists don’t take that opportunity, they will lose out in the long term.

DePaolis: Let’s consider the colleague who sees 15 patients a day. (I’ve never lived those days.) So, now they are up to 25 patients a day. How do they do that without working 15 hours a day?

Pier: Change their habits.

Carey Reynolds: Optometrists must have a really firm grasp on practice efficiencies so that when the glaucoma or dry eye patient calls, they know exactly where to slot them into the schedule and have established protocols for follow-up. Beyond that, optometrists also need to fully understand how to get reimbursed for these medical visits and stop giving away services for free.

DePaolis: Thank you, thank you, thank you.

Schnider: I’m sure business people are looking at this potential pool of patients. Wal-Mart, some of the pharmacies, they are developing health care centers. So I’m not sure they are going to wander into those offices.

Clark: I couldn’t agree with you more. I think that everybody’s looking at this opportunity and, whether it’s 10 million or 30 million, there are a lot of people out there who are very astute at going after those folks.

Hansen: I’ll take a different approach. With an escalating patient population, you need to incorporate technology. We talked about diabetic retinopathy. Diabetic care will be a primary entry point in optometry. Advanced ocular technology will be utilized for earlier diagnosis and treatment of these systemic conditions. Our optometry schools/colleges are developing technology to assist with detection from 7 to 10 years prior to retinopathy. Indiana University and the University of Houston College of Optometry are two of the institutions looking at the cellular level of pre-diabetics for earlier care. This technology will be affordable.

DePaolis: To me, either optometry steps up and accepts that role or we very rapidly become a mid-level practitioner, with literally decades of legislative efforts gone by the wayside. From a professional standpoint, that’s not a very favorable place to be.

So, with this anticipated increased demand, do we need more optometrists or do we need a really smart optometrist who delegates well?

Pier: How long does an average patient have to wait to get an eye examination? If I have to wait 2, 3, 4 weeks or days or whatever, then I need more optometrists. If I can get in tomorrow, then I don’t know that I need more optometrists.

Schnider: But where do you need them? That’s always been the issue.

Hansen: It will be the issue regardless of the volume of patients.

Tahran: I spoke to an optometrist in a community of 30,000 people in Texas last week, and he was frustrated because he has always sent follow-up letters to his family physicians, and he thought they weren’t reading them. Now all of a sudden they need the follow-up letter, like with diabetics. All of a sudden he’s the friend of the family physicians. And now he says it’s just created a boon in his practice. I don’t know if that’s going to happen everywhere. But for him, it’s wonderful. And he’s talking about hiring a scribe and doing other things to try to increase his efficiencies.

DePaolis: Rod, I think it really has the potential to happen in a lot of places, if you do nothing more than look at the prevalence of diabetes.

So, young optometrists are graduating with substantial debt at the same time veteran practitioners are starting to formulate practice exit strategies. Maybe now both parties can have what they’re looking for.

Pier: Do you think that horse is already out of the barn? We’ve been talking about that for the last 15 to 20 years. There have always been older practitioners and there have always been younger practitioners. But I don’t know if the economics make sense anymore. With the debt of a new graduate and the reimbursement they need to manage that debt, and with the older practitioner who, in your example, possibly hasn’t kept up, I don’t know that there’s enough there to fund his practice sale and 401k and provide enough income for a new graduate to service debt and make a living. I don’t see those numbers working as they used to.

DePaolis: I think you’re right. I think that the horse has left the barn as it relates to, “My practice sale will be my 401k.” But for the vitality of the practice and to maybe have some legacy that goes forward, I think the opportunities are there.

Schnider: There is a great business opportunity in training. It will be different. You will have to do things differently if you have any hope of being part of Dave’s 10%. How are we training our new students? We don’t have anyone from academia here, but it will be a whole different skill set: delegation, use of advanced technologies, working with colleagues, referrals, writing referral letters. I don’t know that everyone knows how to do that right now.

Clark: That may be an opportunity for us as manufacturers to help, right? And when that training might not be there coming out of school, what can we do to supplement that?

DePaolis: Let’s talk about technology, because, clearly, this goes nowhere unless practices embrace it. What sort of technologies do you think you need, for instance, above and beyond what you would see in a standard examination? And this can include the dispensary.

Rod, what can doctors do in their practices to embrace technology and to differentiate themselves? For instance, to demonstrate value in the eyes of the patient who might otherwise purchase eye wear online?

Tahran: The biggest change that’s happening in eyeglasses is that with technology, we can now produce lenses that were designed years ago that couldn’t be produced until now, because we have the machinery and the facilities and labs to produce them. One of our latest products was designed 30 years ago, but couldn’t be produced until today.

And the other part of that is the fitting, the personalization. We have all these new devices in the dispensary that make the fitting much more precise, much more high-tech, which we hope gives the practitioner an advantage and makes it a reason for the patient to be there in person.

Reiman: The interesting thing there is that the same technology that enables that to occur in practice can be leveraged to the Internet. So it’s kind of a conundrum.

Performing the refraction

DePaolis: When will we change the way we perform refraction?

Hansen: Soon. I predict it within the next 5 years.

Schnider: The technology is there. You look at many of the other refractive techniques, and humans don’t do a whole lot better these days, from a technical perspective, at least.

Hansen: It’s not refractions or automated refractions. It’s aberrometry. It’s optics. It’s advanced optics. It’s already there.

Tahran: Regarding refraction, I do have to take another side. For the general refraction, I tend to agree. But I see more practitioners dealing with traumatic brain injuries, post-concussive patients. You know that segment is growing. In that case, it’s more of a combination OD-ENT, exam which is more of an observation-type exam. You can’t really do that with equipment. That’s the other side of it. It is estimated that about 5 million people need that type of an exam. And I think we’re just hitting the beginning edge.

Hawley: Could one of the friends of optometry be the geography of America? There is a reason why Tennessee and Kentucky have therapeutics way ahead of California, where most of the optometric practice there is retail-oriented. In the rural states, you may be the only doctor within 50, 60, maybe 100 miles. Those practice scopes grew out of necessity. Maybe in every state you’re going to have the big centers. But no one wants to drive 2 hours to get care that he could get in that private practice. So, do you make your glasses more affordable because you will be making up that difference by seeing patients with diabetes and AMD? Your income is growing, but you are just changing the distribution.

The schools should be teaching business as one of the last courses. Optometry has to think about where it will be in 10 to 15 years. If it doesn’t, it will be dictated to.

DePaolis: So, Dave, do you think traditional optometric refractions are gone in 5 years?

Hansen: Absolutely, not the traditional refractions as we know them today.

DePaolis: You don’t think the patient will expect their optometrist to fine tune that refraction?

Hansen: Those that want to “bless with a hands-on approach” will be outside of the normal standard of care utilizing advanced technology.

DePaolis: That’s a huge savings in time.

Hansen: Yes.

Pier: I would say that there was a capability for that, but I don’t know if that will become a reality.

DePaolis: We’re building a new office, and we’ve entertained the idea of putting tablets loaded with a Fournier refractive app in our exam rooms for patients to use while they are waiting to be seen. We’ll let them have a go at refracting their own eyes, and then transfer that to the phoropter. The idea would be to see just how close they can get.

Schnider: It will be interesting to see as we move into more and more of a managed care situation whether people will stay in a rigid system that may not provide that personal interaction or go to the boutique practices that choose to exist outside of the system.

Pier: I believe that there is some truth in that. But self-medicating is done. And for other problems that are serious enough to me, I would like to have a doctor review the chart and help make that decision. I believe it’s no different in eye care.

With regard to refraction, I may be able to go on that iPad and do wonderful things, but I want the doctor to review it and help me and give me their recommendation. I want my financial analyst to give me a recommendation. And I want other people who have expertise to help me along my way. I don’t think the doctor is going to be moved away from refraction. I think you’re going to be more important in the interpretation and the recommendation than you ever were before using the new technologies.

Tahran: I’m like you, Mike. I mean, I want the blessing, but I’m not sure today’s 15-year-old patient needs that.

Pier: They may not need it, but they want it. And I also believe today’s 15-year-old patient will be 30 or 40 and will also want it even more then.

Uniform education, licensure

Hansen: In order for the ACA to happen, in optometry specifically, you will need uniform education and universal licensure in all states; that provides better patient care. If optometry does not change their individual practice act laws for universal mobility in all states, the government will change it. You mentioned this, John. And it’s going to happen in a very inappropriate way. Mobility to practice in any state is critical for our profession.

DePaolis: I agree.

Refractive vs. medical services

DePaolis: Let’s now drill down to those things that are important for providing services to your patients. Eye wear, contact lenses and what I call the “big four” in medical eye care: dry eye, cataract, AMD and glaucoma.

What amazes me is that, despite the advances in contact lenses and refractive surgery, a majority of people still wear glasses. Is that changing any time soon?

Schnider: Glasses are, I think, increasingly becoming a fashion accessory. So I think the question you need to ask is: Is it really glasses “and” vs. glasses “or” something else? And, as contact lens manufacturers, are we packaging options to meet a person’s lifestyle needs? And, as a contact lens manufacturer, we often go in saying, “They must wear it full time.” Maybe not. Maybe we need to be more flexible.

DePaolis: You mean daily disposables are changing things, Cristina?

Schnider: I certainly hope so.

Clark: It doesn’t have to be an “or” question. It can be an “and” question, right? And I think that’s the piece that we’re missing.

It’s also interesting that the vast majority of people who end up in contacts actually do it because they are requesting it of their doctor, right? And when you think about the pressure that might come on the practice from all sorts of other things – lower reimbursement, Internet eye wear suppliers, everything else – I think it’s an opportunity for contact lenses to become a bigger part of the practice because it could help maybe offset other areas of pressure. And maybe there are things the doctor could be doing in their own financial best interest to stimulate that conversation rather than sitting back and waiting for the patient to come to them.

DePaolis: Those are great comments because, as we all know, those profit margins are getting squeezed and are not going to rebound anytime soon.

Schnider: The box sale puts coins in the pocket. That person sitting in your chair puts dollars in your pocket. For the moment, selling eye wear puts dollars in your pocket, but I think those days may be leaving.

So the advice I would give to the young professionals is, first of all: What gives you joy? That should be the first thing you care about. And the second thing is: What is the value stream? Worry about the things you can control better, and put dollars rather than coins in your pocket. I think the days of relying on devices as a significant source of revenue are going very quickly.

DePaolis: Do you think we should give it up?

Schnider: If I were honestly advising my son or daughter, I would say yes. Rely on what you do best, which is providing health care services to your patient, and refractive services, vision care services.

DePaolis: There’s still a possibility to have it all. Devote your time to providing eye health services and delegate the other to ancillary support; in essence, meeting all of the patient’s needs.

Pier: I don’t know if we like it or not, but I think that’s what defines the profession. This whole idea of being able to be a source for vision care with regard to a device, with regard to an examination, with regard to a contact lens. That’s what defines optometry. So to advise the future of the profession to move away from manufacturing, or fitting, or advising, or recommending the appropriate type of device is to really change the definition of what the public believes optometry is.

Schnider: Recommending or selling?

Pier: Either, or both.

Tahran: We encourage them to prescribe everything. The patient comes to the doctor to get advice and to hear what they need. So we tell them, “Hey, look. It’s not glasses or contact lenses. It’s not glasses or a drug. It’s all of the above.” And the doctor should prescribe everything that patient needs.

Schnider: The dentist’s treatment plan.

Pier: They have to have an understanding of what it is, and knowledge about it, and be able to recommend what is going to help the patient. What is the recommendation if you leave that to someone else?

Schnider: That’s not what I’m saying. For example, if I have a keratoconic patient and I believe it’s time for a corneal transplant, I’m not just going to tell them to go to the Yellow Pages and find a surgeon. I’m going to shepherd them through the process. So I think Rod and I are in agreement: we need to have full understanding of the options and we need to prescribe, down to the over-the-counter ocular lubricant. We should be prescribing everything. It’s the “power of the pen.” We must put the power of the prescription behind everything we do. So I think I’m in agreement with you. I’m just not sure that you should rely on the profit from the device as driving your 401k.

Pier: I don’t think there’s anything wrong with that. I believe that optometry has always had pretty much one foot in retail and one foot in medicine. The combination of that is what defines our profession. I don’t know that moving away from that is going to be better or worse, but it will redefine our profession.

Tahran: And I don’t mind that we keep one foot in each.

Hansen: No, I have no problem with that whatsoever. And I think that the public, the consumer, has that anticipation and expectation of optometry.

Tahran: When someone draws a pie of an optometry practice, it’s usually split in half. About half goes toward products and half toward health care. My stepdaughter is a second-year optometry student. She’s being pressured toward disease. She asked me for my advice, and I said, “I would keep my fingers in both.” I feel like the circle should increase in all directions, not dissuade in terms of the segments of the pie.

Changes in contact lens market

Hansen: Mike, your original question asked whether there will be an increase in the contact lens category. In 2011 there were 36 million contact lens patients in the country. Last year there were 34 million. That’s a 16% drop. That’s the first time in 30 years we’ve had a change from the traditional 7.3% entering and 7.3% leaving contact lenses each year. During that time we’ve had more clinical complications with synergy between contact lenses and solutions. We’ve had an aging presbyopic population. Are these patients not selecting multifocal and bifocal options? The laser vision correction business hasn’t increased. Something is changing. Until we determine these dynamics, the category will have challenges.

DePaolis: Yes, when do we get to the point when we don’t have three going in, three going out?

Clark: We’ve been thinking a lot about this lately. It’s the leaky bucket syndrome, right? It’s not getting filled any faster than it’s coming out the bottom. Again, I think the tension in the system is that patients don’t get treated holistically when wearing contact lenses today. You have to think about the entirety of their experience. There’s the ocular surface. The doctor’s first thought before somebody puts a contact lens on, or if they are having a contact lens issue, should be: Are we really looking at everything that’s going on with that patient? People don’t wake up one day and just decide to stop wearing contacts because they look better in glasses.

DePaolis: So the Baby Boomers have done more to grow the industry. Unfortunately, at their ages, there are many reasons to “exit” contact lens wear – dry eye, cataracts or even excessive work-related near point visual demands. Admittedly, sometimes it pains me to see the 63-year-old emmetropic pseudophake who no longer needs contact lenses. Fortunately, on the other end of the spectrum, kids are entering contact lens wear at earlier and earlier ages. In the past, contact lenses were a privilege for a 10-year-old; now they’re a rite of passage.

Schnider: The age has certainly gone down. Some years ago we did a large study looking at fitting 8-year-olds to 12-year-olds, and that was anathema. It wasn’t that many years ago. And now it seems to be commonly accepted. But today we don’t have as many children as we used to have, and there are a lot more mature contact lens wearers. So, the bucket is still leakier because they’re dropping off at a faster rate at the top end and they are coming in at the bottom end, even though we’re pushing the bottom end down.