Article Date: 3/1/2010

<i>There's An</i> “App” <i>For That</i>
premium spectacle lenses

There's An “App” For That

Here's a blueprint for prescribing premium lenses based on your patient's visual requirements, and equally important, occupation and history.

PETER SHAW-MCMINN, O.D., AND VANESSA SHAW-MCMINN, O.D.
Riverside, Calif.

Through the years, I've worked with 20 or more optometrists in my practice, and I'm constantly amazed at how different their prescribing practices are. Many optometrists, although dedicated to providing the best care, are reluctant to present premium lens options to all patients, even though the best spectacle solution for most patients is usually premium lenses. As an assistant professor at the Southern California College of Optometry, I am reminded of this every year during the graduation ceremony when doctors and graduates recite the optometric oath. We pledge to: “… advise my patients fully and honestly of all which may serve to restore, maintain or enhance their vision and general health.” That usually translates to prescribing premium products.

Whenever we bring a new O.D. into the practice, we remind him of this responsibility and give him the tools to fulfill it. This year, my daughter, Vanessa, joined the practice, so I've asked her explain how we identify patients who would benefit from premium spectacle lenses and how we match our prescription to their needs.

Peter Shaw-McMinn, O.D.

An important skill I learned from my dad is how to look at a patient's history and begin to formulate possible solutions. Here are some key indicators that prompt a prescription for premium lenses.


ILLUSTRATION BY NICK ROTONDO

Entering complaint

Patients don't think about their vision and vision correction in specific terms as we do, and they sometimes have difficulty communicating exactly what may be bothering them. Our questionnaire is designed to draw them out. Their answers usually lead us to the type of lens that will address their concerns. For example:

Do you ever have problems with glare interfering with your vision? Patients who answer yes to this question would benefit from antireflective (AR) coating and polarized sun lenses.
Do you have problems with glare when driving at night? Antireflective coating and lenses that correct higher-order aberrations (HOAs) may be indicated for patients with this problem.
How many hours a day do you use a computer at work and at home? How long before your eyes feel tired or irritated? Patients who use a computer 8 to 12 hours a day and report their symptoms start after 2 or 3 hours should be wearing variable focus lenses. In my opinion, computer users should never have symptoms. People may think there is no remedy for this problem because everyone at work has eye fatigue from computer use, so they believe this is normal. These two questions allow us to educate patients about products that can give them relief and improve their productivity.
Do your eyes ever feel dry or irritated? Dry eye causes photophobia, so polarized sunwear or photochromic lenses are indicated. Although we may not immediately think of prescribing a specific indoor lens, the new anti-fatigue lenses may help patients who report dry eye because this condition can exacerbate fatigue symptoms.
Do you have allergies? We prescribe polarized sun lenses or photochromic lenses for these patients for the same reasons as we do for dry eye patients.
Do you notice reflections on the lenses of your glasses? Antireflective coating is a must for these patients.
Are your glasses easy to keep clean? For those who answer no, premium AR coating is the solution.

Premium Is Not Necessarily Costly

Any hesitation I had about prescribing premium lenses was eliminated when I reviewed our price list with our optician. I learned that with most insurance plans, the difference in a patient's cost for a PAL that corrects HOAs and one that does not was insignificant. If a patient is a good candidate for premium lenses, I show him the aberrometer readings and relate the custom computerized lens benefits to his vision and symptoms, then I prescribe the premium lenses because I have my patient's best interests at heart.

By spending a few extra minutes to explain the premium options to my patient and relate how those products relate to her lifestyle, I not only improve the patient's quality of life, I gain her respect and appreciation, which translates into loyal patients, future referrals and increased profit.

Vanessa Shaw-McMinn, O.D.

Patient's medical history

Educating patients about the vision-related consequences of their medical conditions will motivate them to comply with your recommendations for premium lenses. Medical indications for premium lenses include:

Cataract. Patients with cataracts have increased HOAs and problems with light transmission, so they benefit from HOA-correcting lenses with AR and UV400 blocker for indoor and nighttime wear and HOA-correcting, polarized sun lenses with AR coating and UV400 blocker for outdoor wear.
Age-related macular degeneration (AMD). Research suggests that exposure to the blue wavelengths of light contributes to AMD progression,1,2 therefore, we prescribe a brown tint on polarized sun lenses with AR coating for these patients. Offering these patients the best possible option for the best possible image is important. We prescribe premium progressive lenses with AR coating and UV blocker.
Glaucoma. One of our goals when prescribing spectacles for glaucoma patients is to enhance contrast sensitivity.3 That usually means lenses that correct for HOAs, have AR coating and possibly a UV400 blocker or amber tint. Because glaucoma is a risk factor for cataracts,4 and beta-blocker therapy for glaucoma has also been implicated,5 we prescribe HOA-correcting polarized sun lenses with AR coating and UV400.
Progressive or high myopia. Recent evidence indicates we can slow myopia progression with an add,6 so we often prescribe progressive lenses for these patients. At the very least, high index (1.74) would be indicated to improve cosmesis. With the higher index, however, reflections increase, so AR coating is necessary.
Monocular patients. These patients should be prescribed polycarbonate or Trivex lenses to protect the remaining eye from trauma.
Patients at risk for ocular trauma. Patients whose occupations or hobbies put them at risk for trauma also need polycarbonate or Trivex lenses.
Diabetes, post-RK, macular edema, pre-presbyopes. Diabetes is out of control in many of our patients. A progressive lens, even in a pre-presbyope, will give them an increased chance of adequate vision. Other patients with variable acuities such as post-RK or macular edema patients can also benefit from a progressive lens.

Family medical history

Even if a patient has no entering complaint or specific ocular disease or condition, one of our responsibilities is preventative care. Just about everyone has a grandma or a parent who had cataracts, macular degeneration or glaucoma. Use this risk factor as a way to educate patients about the need for appropriate spectacle lenses. A 2006 survey, conducted on behalf of Transitions Optical, found that only 9% of the U.S. population knows that protecting the eyes from the sun is important to protect vision. If a patient indicates a family history of cataract, AMD or glaucoma, be sure to discuss the benefits of sun lenses, photochromic lenses, UV400 blocker and AR coating.

Occupation

Many occupations require being out in the sun, driving at night, or prolonged near work. Patients employed in these occupations need premium lenses. For example:

► Professional drivers and people who commute long distances need premium sun lenses, as well as night-driving lenses with AR coating or HOA correction.
► Construction workers need premium sun lenses or photochromic lenses and impact-resistant materials.
► Computer users will be more comfortable with variable focus lenses. Even people who do a lot of near work not requiring a computer will be more comfortable with anti-fatigue lenses.

Offer High-Def Vision

In an era when consumers often pay $900 to $2,000 for a new television because it's HDTV, our patients can understand the benefits of premium lenses that essentially allow them to view their world in high-definition. They simply need to be educated about the technology that will give them superior resolution all day, every day for about 68 cents a day ($500 lenses for 2 years), which is less than the cost of a cuppa joe at the local convenience store.

Vanessa Shaw-McMinn, O.D.


This patient routing slip is an important tool in our practice. The doctor checks off the features as he presents his findings to the patient, then he hands this form to the optician with instructions to demonstrate the prescribed treatment to the patient. One advantage is that it shows the need for multiple pairs. The patient may not purchase them all at once, but the treatment plan can extend over 2 to 3 years, similar to a dentist's or physician's long-term treatment plan.

Recreation

Many hobbies and sports are played during daylight hours and also at night or in dim light or cloudy conditions. If your patients enjoy the following activities, be sure to prescribe lenses that are appropriate for the conditions.

Golf. Polarized sun lenses when there is no “grain” in the greens, photochromic lenses when “grain” is present. Brown tint for hazy conditions, gray for blue skies.
Tennis. Sun lenses, possibly with amber tint, or photochromic lenses; AR coating for night games.
Hunting and shooting. Tint varies with shooting conditions; AR coating.
Baseball. Sun lenses for day, clear lenses with AR coating for night.
Fishing. Polarized sun lenses to see deeper into the water.
Swimming. Swimming goggles with UV blocker and a tint to protect eyes and eyelids.

Medications

Approximately 90% of patients presenting for an eye examination are using some form of systemic medication, herbal or nutritional product.7 Many drugs dilate the pupil and reduce the pupil constriction response, others photosensitize tissue, and many are associated with cataract formation. Here are a few medications your patients may be using that require a spectacle intervention:

► Antiarrythmia agents
► Antidepressants
► Antihistamines
► Antihypertension agents
► Antipsychotics
► Chemotherapy drugs
► Erectile dysfunction agents
► Herbal products
► HIV/AIDS agents
► Nonsteroidal anti-inflammatory drugs
► Oral contraceptives
► Oral diabetes agents
► Statins
► Tetracycline

Patients should be advised of the need for polarized sun lenses with AR coating to prevent future problems and clear lenses with AR coating, UV blocker and HOA correction to improve night and indoor vision. Remember that other factors may come into play, such as a need for anti-fatigue lenses, photochromic lenses, high-index lenses or Trivex lenses.

Educating your patients

I reinforce the benefits of high-quality lenses to my patients throughout their examination. This begins when I review their history form, confirming their responses and investigating their needs. During this discussion, I introduce the idea of premium spectacle lenses. For example, I might comment, “I understand how working on a computer 8 hours a day can cause your eyes to become tired and uncomfortable. Fortunately, there are new advanced lenses available to help alleviate this problem. I'm going to do some tests to see if you would benefit from these special nonglare computer lenses, and then I'll tell you more about them.”

While testing near vision, I ask the patient how far she sits from the computer monitor and where her reading materials are. This is important information for me to know because the variable focus or computer lens is prescribed based on near working distances. The “degression” is based on the distance of the computer screen and the distance of reading material and the possible need for some distance vision. At the end of the examination, I summarize the significant findings and the correction or treatment I am prescribing. For the computer user, for example, I might say:

“As I explained earlier, you are nearsighted with astigmatism, and your eyes need extra help with focusing up close. Your eyes have been fatigued and your neck has been sore at work because your current glasses do not give you sufficient viewing area for the computer. I'm pleased that I can help you experience enhanced vision with the computer lenses I am prescribing. This lens is specially designed to allow your eyes to relax and give you the most comfortable vision during your long work day. The advanced nonglare technology will allow 10% more light into your eyes, giving you sharper vision while eliminating unwanted glare from the computer screen and overhead lights. An extra benefit of these lenses is that when people look at you, they will see your eyes and not the reflections on your lenses.” OM

In reviewing a patient's complete history, it becomes obvious that premium lenses will best meet his needs for vision correction and to help prevent future vision problems. As eyecare experts, we are in the best position to ascertain a patient's specific needs. Communicating the risk factors to the patient and explaining the benefits will result in enthusiastic patients, happier opticians and the fulfillment of the oath you took on graduation day.

Peter Shaw McMinn, O.D.

1. Algvere PV, Marshall J, and Seregard S. Review Article: Age-Related Maculopathy and the Impact of Blue Light Hazard. Acta Ophthalmologica Scandinavica. 2006; 84:4-15.
2. Reme CE, Wenzel A, Grimm G, Iseli HP. Mechanisms of Blue Light-Induced Retinal Degeneration and the Potential Relevance for Age-Related Macular Degeneration and Inherited Retinal Diseases. SLTBR Annual Meetings Abstracts 2003.
3. Wilensky JT, Hawkins A. Comparison of contrast sensitivity, visual acuity, and Humphrey visual field testing in patients with glaucoma. Trans Am Ophthalmol Soc. 2001;99:213-217; discussion 217-218.
4. Kanthan GL, Wang JJ, Rochtchina E, Mitchell P. Use of antihypertensive medications and topical beta-blockers and the long-term incidence of cataract and cataract surgery. Br J Ophthalmol. 2009;93:1210-1214.
5. Harding JJ, Egerton M, van Heyningen R, Harding RS. Diabetes, glaucoma, sex, and cataract: analysis of combined data from two case control studies. Br J Ophthalmol. 1993;77:2-6.
6. Cheng D, Schmid KL, Woo GC, Drobe B. Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results. Arch Ophthalmol. 2010;128:12-19.
7. Bartlett JD, Jaanus SD. Clinical Ocular Pharmacology. Portsmouth, NH: Butterworth-Heinemann; 2007.

Dr. Vanessa Shaw-McMinn, a 2009 graduate of Southern California College of Optometry, practices at Woodcrest Vision Center in Riverside, Calif. Her most recent project was co-producing a training video, “The Anti-Reflective Prescribing and Selling System,” for the Vision Council of America.
Dr. Peter Shaw-McMinn is an assistant professor of clinical studies at the Southern California College of Optometry. He is the senior partner of Sun City Vision Center. Dr. Shaw-McMinn has received honoraria from AR Council, Essilor of America and Transitions.


Optometric Management, Issue: March 2010