Article Date: 11/1/2000

Recently, I've shared with you some of the knowledge I've gleaned during my years in practice. This month, I'll share more mind-vitamins to help you in your own quest for contact lens nirvana.


Takes these every day:

         There are a lot more cones out there than we think. Is it just me, or is it the CLEK study -- or, are we really finding more keratoconus? Any first-year optometry student can find a cone that's ready to explode. The real trick is finding the subtle ones.
One of the best reasons for dilating a patient's eyes is to evaluate the cornea. Topographers are great, and there's no substitute for a good slit-lamp examination, but I think that the best way to find a sub-clinical cone is with a direct ophthalmoscope and a dilated pupil. Any disruption in the homogeneity of the corneal optics will beam through in the red reflex.

         Base curves should be a little flatter than you think, and peripheral curves should be a little steeper. I've found that a little apical touch and very little edge clearance add up to stable acuity and better lens comfort. Yes, I know we want to align the cornea, and there should be enough edge clearance to promote good tear exchange, but -- and be honest with yourself -- haven't you dispensed a lens that had peripheral curves that you thought were "too tight," but the patient loved it?
I'm not advocating extremes. Be subtle, but be flat in the middle and tight around the edge.

         Bigger lenses are better than smaller ones. I've said that rigid gas permeable (RGP) lenses will be acceptable to patients only if you make them comfortable. In addition to flattening the base curve and lowering the edge clearance, the other key to RGP lens comfort is to increase the lens diameter.
Larger lenses that are flatter are more difficult to prescribe because you can have trouble with alignment and tear exchange. The answer is to try toric base lenses at the first hint of misalignment. With today's manufacturing processes, there's no reason to shy away from them.
Finally, a larger lens with a lower edge clearance means a thicker edge. Everything you do to make an RGP lens more comfortable is blown right out of the water if the edge thickness increases. Lenticulate, lenticulate, lenticulate!

         Patients discontinue lens wear because of redness, dryness and presbyopia. The great Brien Holden presented a paper at the Academy a few years ago, concluding that patients wouldn't drop out of their lenses if the lenses didn't make their eyes dry and red. I'd also add that we don't need to lose contact lens patients because of presbyopia either.
Specialize in solving the bifocal issue, and you'll only gain patients. Dryness and presbyopia are the "special friends" of our aging contact lens patients. Learn how to deal with dryness, and most of the redness will take care of itself. No one likes complaining patients, but our kids wouldn't eat without them.

         Doctors quit because of a lack of experience and patience. Patients quit wearing lenses because of dryness and redness. Doctors quit prescribing lenses because patients complain. Doctors lack patience when dealing with complaining patients because they lack the knowledge to solve their complaints, leaving them feeling helpless.
When it comes to doctorin', a thirst for knowledge is essential. A fellowship-trained glaucoma specialist who's 15 years out uses practically none of the therapies or diagnostic criteria he or she learned in training.
Everything's new. Everything's in flux. The same goes for a contact lens practice. If you aren't busy keeping up, you're busy falling behind. So find the time to read those important journal articles. Who knows, you might learn something!

Dr. Newman is in solo practice at the Plaza Vision Center in Dallas, Texas. He's a Diplomate in the Section on Cornea and Contact Lenses of the AAO.

Optometric Management, Issue: November 2000