OPTOMETRIC OPINIONS
Colorful Optometric Viewpoints
Practitioner responses on the role of opaque lenses and on fitting keratoconic patients with contact lenses.
By Amber Gaume, OD, and Jan Bergmanson, OD, PhD

The authors conducted two separate practitioner surveys during the 19th annual Cornea, Contact Lens and Contemporary Vision Care Symposium, held by the University of Houston College of Optometry. A state-of-the-art computer program (Com Tec 2000) asked questions of the attendees, and each question typically generated 30 to 38 responses. The Com Tec 2000 instantaneously compiled and displayed these responses for the presenters to discuss. (The results were strictly a sampling, as each keypad that attendees used to enter their responses to questions could record only one response per question.)

Two-thirds of the audience was male, so it's important to recognize that our small, male-dominated sample will limit the impact of these surveys because optometry schools are graduating more and more females. Nevertheless, several interesting revelations about practitioner attitudes came to light in analyzing the responses. We'll review the details of the two surveys as well as the revelations that became apparent.

Survey Number One

Of the attendees questioned for the first survey, 65 percent replied that greater than one-third of their patient base wears soft contact lenses. This is a remarkable finding because the national average is approximately only 10 percent to 12 percent. (However, perhaps the nature of this particular symposium attracting practitioners who have a greater interest in contact lenses and anterior segment has elevated this figure.)

When asked about general attitudes regarding opaque contact lenses, 63 percent of the practitioners surveyed believe that they already use this opportunity to its fullest potential to grow their practices. This was an interesting response as well, because two-thirds also reported that less than 10 percent of the lens wearers in their practices wear opaque tinted lenses, even if just for occasional wear. Also, when asked how often they (or their staff) initiate the suggestion of a cosmetic tinted lens trial to prospective wearers, 50 percent of respondents replied that they never do (they believe that patients will ask them if they're interested). A lack of promotion of opaque contact lenses seems apparent, yet the majority of practitioners surveyed feel as though they're doing a good job. It's well known that patients are more likely to consider a product if their eyecare provider recommends it, however, only 17 percent of respondents seem to take advantage of this notion. So why then, do ODs avoid suggesting to their patients one of the most profitable lenses on the market today?

Finding a Reason Interestingly enough, more than one-fifth of the practitioners seem to have difficulty combining sales and health care, believing that promoting cosmetic tinted lenses makes them less of a doctor. Of those remaining who don't endorse these lenses, 15 percent replied that the process requires too much time. Of those who do promote tinted lenses, nearly 20 percent replied that they only mention the option half of the time, depending on how far behind schedule they are, while 14 percent suggest cosmetic lenses only if the patient has a medical or cosmetic need. Some practitioners don't wish to promote cosmetic opaque lenses because they believe that these lenses have no place in health care. At the same time, they're opposed to the sale of such devices on the open market. Such an approach is likely to create a demand without a supply.

Could this resistance to promoting opaque tinted lenses be the catalyst for the increase in sales of such lenses on the black market or for the recent attempt to deregulate the sale of "cosmetic" lenses? Can we expect to have it both ways -- no doctor promotion and no one else to sell the option? We have an obvious dilemma on our hands that we must reconcile. We don't have an answer on how best to address this issue, but our survey appears to confirm its existence.

Survey Number Two

The second survey discussed keratoconus. In general terms, practitioners indicated a strong familiarity of the condition with 97 percent agreeing to its classification as a corneal disease. With regard to the incidence of this condition, the responses were diverse and ranged from 1/100 to 1/1,000,000 (perhaps because literature reports such a wide range of values [generally 1/2,000 to 1/20,000]).

When asked whether rubbing of the eyes caused keratoconus, the responses were again diverse. Greater than two-thirds of the doctors believe that no scientific reason exists to indicate that eye rubbing results in this disease, and that perhaps the disease leads to eye rubbing. The notion that vigorous and excessive mechanical rubbing causes keratoconus most likely stems from observations that many clinicians have made with keratoconus patients during office visits. The literature, however, hasn't provided any scientific basis for this correlation -- especially when mechanical irritation of the skin, to which the cornea relates, leads to thickening rather than thinning.

Digging a Little Deeper The authors also asked practitioners to report the origin of keratoconus in terms of corneal layer. Forty-four percent perhaps correctly stated that the true origin of the condition is not known. (According to the literature, essentially two theories regarding the etiology of keratoconus exist -- one believing the starting point is in the epithelium and the other that it all begins in the stroma.)

Nearly 30 percent of respondents reported having fit 20 or more keratoconus patients, but this high figure could again stem from the fact that this symposium attracted practitioners more interested in contact lens challenges. On the other hand, 45 percent replied fitting five or fewer cases and eight percent reported never having fit a keratoconic cornea.

Gauging Enthusiasm In this group, no less than 41 percent love the challenge of fitting keratoconic patients with contact lenses and only three percent were unenthusiastic, claiming that they're never successful. Eleven percent indicated that they probably stay away from fitting these types of patients because they lack proper training. Only 11 percent reported that this area of contact lens practice isn't profitable, while 76 percent felt it was good for practice economy. (Maybe a more knowledgeable clinician achieves a fit more efficiently, reducing chair time and increasing profitability. Or maybe practitioners were over optimistic or simply poor assessors of the time and costs involved.)

GPs and Keratoconus Finally, the survey asked practitioners whether they thought GP wear causes corneal scarring in keratoconus. A literature review indicates that this is an unresolved issue, which may explain why there was no consensus. The responses were nearly even, with 44 percent believing that this relationship exists and 56 percent rejecting the idea. Our own histopathological investigations suggest that anterior scarring is a result of the disease process itself rather than the mechanical trauma induced by the constant presence and friction exerted by a GP lens.

Proceeding with Open Eyes

Although our small sample size reduces the impact of these surveys, we hope they illuminate clinical attitudes regarding specific issues of current interest to optometry. Certainly, we encourage larger, better-controlled surveys that would more accurately portray true practitioner trends, perceptions and misperceptions.