How to Keep Up With the Changing Times

To adapt to today's competitive contact lens practice environment, you must become more efficient. Here's how to save time while increasing the quality of your care.

BY KEITH S. AMES, OD
DECEMBER 1998

We're accustomed to basing our fees on cost. If you believe that fitting a contact lens will require an hour of your time, cost-based pricing dictates that you charge for your time. Today, we're confronted with a different paradigm. The mature market doesn't care how long it takes you to fit a contact lens. It establishes and supports a fee through competitive forces, so you must reengineer your practice to be able to deliver services within its fee range. This price-based costing means that you must set your costs of delivering a service according to what the market place will support.

This fundamental shift affects all aspects of your practice, particularly your contact lens practice. To be profitable today, you must deliver contact lenses with maximum efficiency. If you're conducting business as usual, competition will continue to impact you adversely. However, if you can adapt to today's changing, competitive health care environment, you may be pleasantly surprised. Becoming more efficient in fitting contact lenses can not only save time and reduce costs, but enhance patient outcomes and overall satisfaction as well. The following approaches have helped me reduce chair time associated with my contact lens practice and produce better outcomes for my patients.

Know Your Starting Point

Establishing accurate baseline refractive, keratometric and biomicroscopic data is essential. My experience has shown that precise and carefully considered refractions promote successful contact lens wear. While this may seem like a given, refraction is as much of an art as a science, and therefore varies from practitioner to practitioner. Confidence in your refractive findings will allow you to make better initial lens recommendations and to better troubleshoot visual performance problems.

For example, it's fairly common to underplus or overminus refractions. This is often appropriate and can enhance acceptance of spectacle correction, but contact lens wearers will accept the full plus or minimum minus correction more easily. For this reason, latent hyperopes are excellent contact lens candidates and presbyopic patients will excel with a refraction that's been carefully considered to avoid overcorrection. Another example is the toric soft lens patient. When I have a contact lens wearer with low degrees of refractive astigmatism (0.50D to 1.00D) and poor soft toric acuity, I reconsider my refraction. Often, the significant cylinder I thought existed becomes borderline on retesting, and the patient will see better with a spherical lens.

Proper Lens Selection

Avoiding problems is much easier than correcting them. As a general rule, I fit only hydrogel lenses that can be replaced regularly to enhance physiological performance and minimize patient frustration with lost or damaged lenses. Monthly lens replacement is very cost-effective and convenient for most patients, and compliance has been high in my experience. More frequent lens replacement can be beneficial, but the truth is that most patients will not maintain a more aggressive replacement schedule. I start with a cycle that most patients will follow and select a lens that performs acceptably in that cycle.

I prefer non-ionic materials or ionic materials with lesser propensity to spoil. Myopic patients can wear either low or high water content lenses, but hyperopic patients need the higher water content to maximize permeability. I discourage extended wear whenever possible and do not permit it with thicker designs, such as soft torics.

I also utilize RGP contact lenses when appropriate. For patients with exacting visual demands and moderate to high refractive errors, especially with-the-rule astigmats, RGPs are the lenses of choice. For presbyopes, current RGP multifocal contact lenses provide great success.

Dispense Your Trial Lenses

Take advantage of warrantied fitting and free trial contact lenses. Lens companies want your business and are providing the perfect opportunity to increase practice efficiency. I rarely perform non-dispensing trial fitting for cosmetic RGP and soft lens fits. Judging the fit of a lens after a few minutes of wear on an unadapted, anxious patient with excess tearing and abnormal blinking is misleading. Frequently, changes in lens design are made unnecessarily and prove counterproductive, especially for soft toric and RGP fitting. Lens-lid interaction is critical in establishing the final fitting characteristics of these lenses. Wouldn't it make more sense to judge the fitafter blinking has normalized?

Dust Off the Retinoscope

We all know how important the biomicroscope is in contact lens fitting. Well, I believe that the retinoscope is equally important. Correlating visual acuity with the crispness and degree of overrefraction can be very helpful in fine-tuning a refractive correction. You can assess the quality of the optical system you have created with a quick, objective over-retinoscopy.

I have lens flippers in 0.50D increments that allow me to perform this test in free space. This test is especially helpful when evaluating soft toric lens performance. If I scope cylinder with an axis in the same direction as the contact lens, I know I've undercorrected the cylinder. Conversely, if the scoped axis is perpendicular to the contact lens axis, I've overcorrected the cylinder. If the scoped axis is oblique to the lens axis, I know that rotational forces are creating cross-cylinder effects. Compensating for small degrees of rotation can be helpful, but design changes are generally indicated when rotation is excessive or unstable.

I perform over-retinoscopy in free space for most of my contact lens and spectacle wearing patients, and I have learned to appreciate the effects of instrument accommodation. Don't be surprised to find 0.25D to 0.75D of more plus, less minus than you typically see behind a phoropter. This information alone has allowed me to fine-tune many corrections and solve subtle vision problems.

Listen to Your Patients, But Not Too Carefully

It's important to listen to your patients. Their perception of how well the lens is performing can often identify and help correct fitting problems. However, subjective complaints can be misleading and may represent failure of the lens to meet patient expectations, rather than an objective technical problem that can be corrected. Be careful not to make multiple changes in the contact lens correction in an attempt to solve an elusive problem reported by the patient. If objective results correlate with patient complaints, I'll work tirelessly to solve the problem. However, I'm not afraid to tell the patient that the contact lens fit is as good as it's going to get. It's amazing to me how many patient problems become a non-issue when the patients are advised that the situation can't be improved.

Dr. Ames is in private practice in Chillicothe, Ohio and is a technical and marketing consultant to the contact lens industry. He served five years as a U.S. Army Optometry officer and has held senior positions in the contact lens industry for Bausch & Lomb and Polymer Technology Corporation.