Article Date: 4/1/2011

“You Truly Change Lives”
contact lenses

“You Truly Change Lives”

Experts reveal how to reap the rewards of fitting patients with specialty contact lenses.

Robert Murphy contributing editor

Many optometrists have found tremendous personal rewards and ongoing challenges—not to mention ample remuneration—by devoting their practices largely or entirely to specialty contact lenses. Sure, it takes an up-front investment in fitting sets and equipment, such as a high-end corneal topographer. You'll have to adjust your schedule to accommodate long fitting sessions and multiple return visits. It'll require that you network among your optometric peers as well as corneal surgeons and other ophthalmologists to attract referrals, not to mention those who will come from patients' word-of-mouth referrals.

Most of all, you'll need to appreciate and enjoy fitting challenging corneas. In that context, a successful fit is very rewarding.

“When fitting specialty lenses, you truly change lives,” says Thomas Quinn, O.D., M.S., F.A.A.O., a private practitioner in Athens, Ohio. “People who couldn't function visually are able to function because of your intervention. When we allow ourselves to appreciate the positive impact we can have on people's lives by fitting specialty contact lenses, it's pretty thrilling.”

Why specialty lenses?

Practitioners who specialize in tricky contact lens fits say that while the financial incentives to fit specialty lenses are attractive, the main focus must be on the patient. (See “Conditions for Specialty Contact Lenses,” at the end.) Satisfy the patient's needs, and everything else will fall into place, they say.

“There are people wrapped around the eyeballs,” says Christine W. Sindt, O.D., F.A.A.O., associate professor of clinical ophthalmology and director of the contact lens service at the University of Iowa, in Iowa City. “And ultimately, the best thing that we can do for the patient is to address their lifestyle and their activities of daily living. Because if you can't bring quality to life, then there's no reason to do anything.”

Satisfying your patient's needs may be paramount, but there is more. Many doctors say they fit specialty contact lenses to serve an unmet need. You might be in a position to save your local patients the time and hassle of traveling a long distance to find a specialty contact lens fitter. It works the other way too. For example, some patients drive up to eight hours to visit Dr. Sindt, she says. A reputation for excellence can travel far.

Bill for your services

No doubt, specialty contact lens fits usually take more time than other types of visits, and patients may return many times until the fit is right. If you take an antiquated approach and bundle your fees into one up-front lump sum, you'll be giving away your time and services, along with your practice's profitability. Instead, consider adopting the medical model, and charge for every patient visit and every procedure you perform.

“The first thing you need to learn is how to code and bill for medically necessary contact lens prescribing,” says Clarke D. Newman, O.D., F.A.A.O., who practices in Dallas.

Those interviewed agree: If you don't get paid for your services, you will lose your motivation, enthusiasm and ultimately, your financial ability to provide specialty contact lens fits.

Equip your practice

Specialty lens fitting requires that you invest up front in certain necessary instrumentation as well as fitting sets.

A top-quality corneal topographer is considered de rigueur for specialty contact lens fitting. When dealing with an irregular cornea, you need a detailed assessment of its hills and valleys and unique shapes, says Dr. Newman. He says he also advocates a specular microscope as well as an aberrometer.

“An aberrometer is like an autorefractor on steroids,” says Gary Gerber, O.D., president of The Power Practice, a practice management consulting firm in Franklin Lakes, N.J. “Instead of just giving you sphere, cylinder and axis—these are only three of the reasons why your vision is blurry—there are other things that make a prescription.”

Specialty contact lens practitioners also recommend that you obtain an anterior segment optical coherence tomographer (OCT). With OCT, you can acquire scans of the anterior segment, including the corneal back surface. And don't forget anterior segment photography, which can be useful for monitoring patients through time.

Getting the right fit

More than anything, it is fitting sets that separate the devoted specialty lens fitter from the dabbler. These may run from $200 up to $1,000 a set, although some companies will give you credit toward your first five or so lens purchases.

“I think if you're going to use a lens any decent amount, you really need to have a fitting set,” says Jason R. Miller, O.D., M.B.A., a private practitioner in Powell, Ohio, and an adjunct faculty member at the Ohio State University College of Optometry. “If you don't have a fitting set, you're ordering things empirically based on what you think is going to fit.”

Dianne Anderson, O.D., F.A.A.O., who practices in Naperville, Ill., recommends investing in a few very versatile diagnostic lens sets, including:

► aspheric keratoconus
► semi-sclera
► hybrid
► corneal reshaping

Education and training

Fitting specialty contact lenses requires specialized expertise, say those interviewed for this article. In some of the more difficult cases, even the most experienced lens fitters find successful fits ultimately come down to trial-and-error. Yet, numerous resources exist from which you can gain tons of information on scleral lenses, hybrid lenses, rigid and soft multifocals, torics and more.

For example, live meetings will often offer workshops where you can get hands-on training in fitting some of the newest lenses available. In addition, you get to network and trade notes with your fellow specialty contact lens fitters.

Numerous websites offer education and training as well. The Scleral Contact Lens Education Society website (www.sclerallens.org), for example, offers a message board where you can post cases, and the Society's 400-plus members can log on and make fitting suggestions.

“That's an opportunity for people to learn more and understand more,” Dr. Sindt says. “You're not truly a specialty contact lens fitter unless you fit scleral lenses.” These are especially useful, Dr. Sindt says, for keratoconus patients, penetrating keratoplasty (PK) patients, dry eye patients and Sjögren's syndrome patients, as fitting these patients is especially challenging.

Wish to learn more about keratoconus? A good place to start is the National Keratoconus Foundation's website (www.nkcf.org).

“The National Keratoconus Foundation has a listing for preferred providers,” says Loretta Szczotka-Flynn, O.D., Ph.D., an associate professor and director of the contact lens service at the University Hospital, Case Medical Center, Department of Ophthalmology, in Cleveland.

In addition, fitting consultants from the GP contact lens labs can provide expert advice on the lenses they represent, say those interviewed. For example, you can send the patient's topography map to consultants for suggestions, lens parameters and troubleshooting advice, says Dr. Anderson.

Finally, it pays to contact the latest corneal surgeons regarding their procedures, as they may then refer the patient to you post-operatively.

You can do this by keeping up with the surgical journals, logging on to the relevant websites—or simply speaking now and again with a friendly surgeon.

Establish a workflow

Aside from overcoming the learning curve for specialty lens designs, it's critical to establish an efficient work pattern for these visits, says Dr. Anderson. She recommends integrating the following steps into all specialty contact lens visits:

1. During pretesting, along with autorefraction, autokeratometry and corneal topography, have your technician uncover the patient's corneal or refractive condition at the first visit with a complete ocular and contact lens history.
2. Perform a subjective refraction, if possible, to determine the patient's best-corrected spectacle acuity. An unstable refractive endpoint, progressive myopia, hyperopia or unusually increased astigmatism are clues the patient may need specialty lenses.

“For example, increased hyperopia with increased astigmatism is indicative of radial keratotomy (RK) regression,” Dr. Anderson says. “Unusually high with-the-rule astigmatism with poor acuity indicates keratoconus, while unusually high against-the-rule astigmatism is characteristic of pellucid marginal degeneration (PMD). The observation of scissors reflex with retinoscopy or an inferior shadow on retroillumination also indicate these conditions.”

3. Perform a thorough slit lamp evaluation. Look for Fleisher's ring in the epithelium and stromal striae or scars. Also, stain the cornea, and look for tear-layer insufficiency and superficial punctuate keratitis.
4. Study the corneal topography map. “The map will tell you if the cornea is prolate or oblate, and will qualify the astigmatism as normal or irregular,” says Dr. Anderson.
5. Use the diagnostic contact lens fitting set to determine the optimal fit and power of the lens, even if you are confident with the patient's refraction.

Marketing and referrals

Okay, so you've committed to fitting specialty lenses. Now what? If you build it—that is, a specialty lens practice—will patients come?

They will if you get your name out there. Here are several marketing strategies provided by those doctors who were interviewed for this article:

Surgeon referrals. Post-PK patients may be among your best patients. Try to get to know ophthalmologists in your area who do corneal surgery, and let them know that you have the tools and expertise to fit their patients successfully.
Optometrist referrals. Many O.D.s refer patients who require a challenging contact lens fit. Notify the optometrists in your area that you specialize in difficult to fit contact lens patients. Assure both surgeons and your fellow O.D.s that you will return the patient to their care after fitting. Emphasize that you will work with these doctors as a team, and that you're not out to steal their patients.
Patient referrals. Once you fit patients successfully, encourage them to tell their friends about your good work. (Keratoconus patients are famous for networking with each other, especially on websites, social media, and e-mail.
Professional meetings Make up a new business card indicating your specialty, and hand it out at local and state optometric meetings. Give a talk at a community meeting. (Then, go shake some hands and distribute some cards.)
Traditional media. Dr. Miller says he arranged for a nine-year-old girl in whom he successfully treated with orthokeratology to record a radio ad describing how well she was doing following treatment. “She talked about the process and how happy she was,” He says. The ad generated a response.

Your time for a specialty?

If fitting specialty contact lenses seems too much of a stretch for your practice, consider this: Hungarian immigrant Adolph Zukor quit the fur trade and later exhibited the first feature-length film in 1912, before becoming chairman of Paramount Pictures in 1935. In 1980, a former actor named Ronald Reagan won the first of two U.S. Presidential elections.

The point: If you're looking for a new challenge and an entirely new mode of practice—and possibly an expanded revenue base—consider fitting specialty contact lenses.

Speak with a colleague who already fits specialty contact lenses. Discuss the opportunity with your staff. Look at your town or region—is there an unmet need for specialty contact lenses? The answer may provide you with a valuable new direction for your practice. OM

Conditions for Specialty Contact Lenses
Dianne Anderson, O.D., F.A.A.O., Naperville, Ill.

Who are the patients best suited for specialty contact lenses?
Consider patients who have common corneal dystrophies and degenerations—keratoconus, pellucid marginal degeneration, lattice degeneration, Terrien's marginal degeneration and anterior (epithelial) basement membrane dystrophy—who experience poor visual acuity with spectacle lenses or soft contact lenses. They require specially designed rigid optics to provide a smooth and stable refractive surface.
Those with high refractive errors, such as myopia, astigmatism, hyperopia and aphakia, benefit from thin, high Dk GP materials with well-centered, rotationally-stable optics. Post-surgical conditions, such as radial keratometry (RK), LASIK and penetrating keratoplasty, fare best with high Dk, large diameter designs to cover the incisions, treatment zone/flap bed and graft host junction, respectively. Post-RK, myopic LASIK corneas and sunken grafts are oblate in shape and are, therefore, best fit with reverse geometry designs.
Hyperopic LASIK and proud grafts are highly prolate in shape and, therefore, do best with high Dk, large diameter aspheric designs. Severe ocular surface disease caused by conditions, such as graft vs. host disease, exposure keratitis and lagophthalmos can benefit from semi-scleral or scleral GP designs, which vault the entire cornea and rest on the sclera or bulbar conjunctiva. This produces a liquid bandage effect to constantly hydrate the cornea and protect it from the environment.
Lastly, orthokeratology lenses for myopia control or as a LASIK alternative is an untapped market. Fitting lenses for orthokeratology requires certification. This process is the best way to learn the intricacies of reverse geometry designs, which can be applied to the aforementioned surgical conditions as well.
By becoming well-versed in diagnosing the aforementioned conditions and understanding the specific lens designs and materials, which result in the best lens-to-cornea relationship, you'll streamline the initial fitting process and decrease chair time for future visits.

Mr. Murphy is a freelance editor to Optometric Management based in the Philadelphia area. Send comments to optometricmanagement@gmail.com.


Optometric Management, Issue: April 2011