Article Date: 7/1/2004

exam time
Contact Lenses vs. Surgery
With so many choices available, doctors must find the time to engage patients in a detailed conversation on vision correction options. Here's how to begin.
BY SARAH A. MAROSSY, O.D.. Coeur d'Alene, Idaho

 

ILLUSTRATION BY PHIL HOWE

Most of us have a specific patient flow agenda that we follow to stay on schedule. This schedule allots a specified amount of time for each patient visit from the beginning of the day to the end. But does our schedule allow us enough time to conduct a detailed discussion of available vision correction options?

I'm envisioning a proactive, interactive conversation where you actually spend chair time explaining options and then give patients an opportunity to ask questions and decide on their visual correction preference based on the given information.

Setting aside discussion time sounds nice, but in reality, many doctors run behind or are bound to a tight schedule. To stay "efficient" with chair time, we must keep conversation to a minimum and we must keep moving between rooms. So how can we initiate a discussion of visual correction options and still stay efficient with chair time? Also, how many options are appropriate to present to a patient? Do you have to mention refractive surgery if you specialize in contact lenses? Let's discuss further.

Delegate to improve care

Thanks to modern technology such as autorefractors, nerve fiber analyzers and digital handheld tonometers, we now have the ability to gather data more efficiently and delegate the operation of this technology to staff members. The technology, or equipment, is almost always technician-friendly and many companies now offer on-the-job training for staff.

In a high-tech office, technicians can easily and efficiently perform autorefraction, tonometry, retinal imaging, topography and visual fields with the help of technician support. This approach should equate to improved patient care because the doctor has more time to actually analyze collected data and promote patient discussion rather than simply using valuable chair time to collect data.

Evaluate your situation

Let's suppose that every eyecare professional reserves five minutes of his exam process for patient discussion. What options should he present for alternative vision correction? Is there a specific hierarchy of options? See "Presenting Options" for more on this. Every doctor probably has biased opinions for a variety of reasons.

For example, let's suppose Dr. X has a profitable and specialized contact lens practice. It's without a doubt that Dr. X most likely will discuss contact lenses and possibly even Corneal Refractive Therapy (CRT) as "alternative options" to eyeglasses. Dr. X will be enthusiastic and motivated to make these recommendations because of personal experience with contact lenses and the fact that his entire staff is also well-educated in that department.

Would Dr. X offer LASIK in an equal and unbiased manner when discussing alternative correction options with patients? What about corneal Intacs or other surgical-based procedures? Is Dr. X obligated to inform every patient of all alternative vision correction options besides contact lenses in an evenly weighted format?

Dr. Y practices in a neighboring town and works with a group of ophthalmologists. Dr. Y is also an optometrist, but the practice he's associated with is a high-volume refractive surgery center and does little contact lens fitting. The office doesn't even have an optical department within the building. Dr. Y spends time educating his patients at the end of each exam about their options for vision correction.

Does he first suggest contact lenses, CRT, glasses or LASIK to the patients he encounters? As you can see, Dr. X and Dr. Y have different practice modalities that ultimately may influence how they discuss corrective options with their patients.

The question remains whether both Dr. X and Dr. Y have an obligation to discuss all alternative corrective options in an equal and unbiased manner with each patient. What if Dr. Y has no experience doing CRT? Is he still obligated to discuss this option within the context of the conversation? What if Dr. X has little experience with LASIK and feels uneducated concerning the latest information on the subject? Is he still obligated to offer this option to all patients?

Follow your comfort level

I think it's best to say that there's no "right" answer to the above questions, although they do force us to think seriously about what we say, persuade or dissuade in the exam room.

In my opinion, most of us base our recommendations on personal experience. The more knowledgeable and skilled we are in a specific area, the more comfortable we are offering our expertise to patients. It's certainly not realistic to expect every optometrist to be an expert in every vision correction option available.

The ideal referral situation

In our profession, we can refer patients not only to each other, but to any other primary care provider we choose.

What if Dr. X referred patients to Dr. Y for LASIK consultations and Dr. Y referred patients to Dr. X for contact lenses and CRT? This would certainly make for a win-win situation for both doctors. But guess who else wins? The patient.

We all seem so referral-biased toward ophthalmology, yet within our own profession we have a variety of specialized doctors willing and able to handle everything from vision therapy to CRT. We should also feel comfortable referring to fellow colleagues who happen to offer a certain specialty or own a specialized piece of diagnostic equipment that we don't. So how do you refer a patient to a fellow optometrist without losing that patient forever?

Refer and keep your patients

Referring to fellow colleagues within our own optometric community seems foreign to many optometrists. Through the years, we've remained programmed to refer to ophthalmology when a second opinion or specialized piece of diagnostic equipment is sought for monitoring a disease process such as glaucoma. With increased levels of technology, combined with more broad-based optometric training, many optometric practices are now modeling or even exceeding many general ophthalmology practices in terms of equipment and array of services offered.

Unless you're strictly setting up appointments for surgical consults, why not send patients over to fellow optometric practices and use each other's resources? Patients, in my experience, are impressed and often surprised that optometry offices have so much to offer besides just glasses and contact lenses. The approach our office uses is to fax or to send a formal "referral report" to one of our fellow optometric offices. They only bill the technical procedure code -- without interpretation. When the photos or other diagnostic test information arrives back at my office, I set up a follow-up appointment to review findings with my patients and then bill for the interpretation/report portion of that procedure. I know I'm getting that patient back because it's a referral-based relationship and I can trust that these fellow optometrists are on the same "team" promoting goodwill and synergy instead of belittling the optometric profession.

Putting it all together

We should embrace new technology and welcome the opportunity to discuss as many of these new vision correction options as possible with every patient we encounter. Give patients the opportunity to make informed decisions about their vision correction options. It's our job to take the time to inform and educate them correctly.

 

Presenting Options

Let's say a 27-year-old female patient presents to your office for a new comprehensive eye exam. She works and is married with one child. Her prescription is OD ­2.00 DS, OS ­2.25 ­0.25 x 180. Keratometry readings are: OD 43.50/43.75 @ 092, OS 43.25/43.50 @087. She has no history of any eye trauma, infection, surgery or disease. Her pachymetry readings are: OD 568 mm and OS 570 mm. You find no ocular pathology.

Supposing this patient has worn nothing but eyeglasses since she was 13 years old, she would be a good candidate for the following vision correction options:

  • eyeglasses
  • Corneal Refractive Therapy (CRT)
  • daily disposable soft contact lenses
  • extended wear soft or GP contact lenses
  • frequent replacement, planned replacement or conventional soft contact lenses
  • conventional GP contact lenses
  • LASIK
  • PRK
  • Corneal Intacs
  • other surgical procedures.

But asking a few more detailed questions could change our option list.

Q: "What activities do you enjoy?"

A: "I'm a swimmer and also enjoy scuba diving and boating."

Because of this patient's level of involvement with water sports, I'd think twice about placing her in contact lenses as a primary alternative to eyeglasses. The risk of infection would be my main concern with the soft contact lens modality. With GP lenses, I'd be more afraid of her losing them with water/eye contact. CRT and laser vision correction options would rise to the top of my list at this point.

Q: "How old is your child?"

A: "Three weeks. My husband and I are up most of the night caring for her."

Imagine this 2.00D myope stumbling to the crib for feedings every night. Also, babies tend to touch and grab things. I'm sure this patient's glasses are a constant chore to keep both clean and on her face. With this history in mind, I would place extended wear contact lens options on the top of the list. Daily disposable lenses might be another top choice. LASIK and PRK would not be options. (Many refractive surgeons won't consider operating on a mother who recently gave birth and/or is still breast feeding because of the potential prescription instability, altered tear film composition and undue trauma on the new mother.)

With additional lifestyle information, we can quickly establish and rank refractive correction options. Patients have a right to be informed of their options just as we have a right to recommend appropriately.

 

Dr. Marossy is in private practice and lives in Coeur d'Alene, Idaho. In addition to clinical duties, she also lectures on a national level, has been featured in several optometric magazines and is a contributing writer to the American Optometric Association's contact lens e-newsletter. E-mail her at sm@visionsource.xohost.com.

 

 



Optometric Management, Issue: July 2004