It is not easy to establish a specialty contact lens practice. I have started two of them: one in an ophthalmology group and the other in an optometric private practice. The good news is that there are many patients who truly need and desire our services in this area. The potential is there for anyone who has a love for contact lenses and is willing to work. Here are some tips to help you make it happen for your practice.

DEVELOP THE EXPERTISE

Many specialty lens patients have been to several practices seeking care for their condition.¹ They immediately know who can help them and who cannot. There are some Doctor of Optometry (OD) programs in which students gain great experience treating and fitting these types of patients. Students can gain additional training in cornea and contact lenses through a master’s program. Some people dedicate an entire postgraduate year to a cornea/contact lens residency. They are ready to hit the ground running. But if you are one of many who did not develop advanced competency in this area during your training, there are still many opportunities to do so.

Utilize your laboratory. This includes both the account managers and the individuals on the consultation line. They want you to succeed. Ask them questions regarding the nuances of fitting their lenses as well as practice management. Many laboratories host excellent webinars, which have become even more prevalent since the COVID-19 pandemic began.

Spend some time observing an existing specialty lens practice. If you have not seen a high volume of specialty lens fits, the hands-on learning gained from observing even a half-day of these fits will be invaluable. Seek out someone who fits specialty lenses all day, every day. Those of us who do this for a living are happy to help.

Invite a specialty contact lens expert to your practice. Often arranged through a laboratory, I have enjoyed visiting my colleagues’ practices to help them troubleshoot some of their most difficult fits.

Read every journal article on specialty contact lenses that you can.

Spend an entire continuing education conference attending contact lens courses. Many of the larger meetings (e.g., the American Academy of Optometry [AAO] annual meeting or Optometry’s Meeting from the American Optometric Association [AOA]) offer several days of contact lens courses. The Global Specialty Lens Symposium (GSLS; held next on Jan. 19 to 22, 2022 in Las Vegas) is another great place to start, as it covers all types of specialty lenses—all in one conference. The “hands-on” workshops at conferences can be especially helpful. Many laboratories provide these as well. If you do this for several years, you too will be an expert in fitting and troubleshooting these lenses.

Have a textbook or two on hand. Comprehensive texts discuss all types of specialty contact lenses.^2-4 Keep in mind, however, that the field is changing so quickly that newsletters often provide the most up-to date information. They provide updates on the latest research by providing summaries of, or links to, articles as well as news about current products and technologies.

For the most advanced competency, pursue a higher certification. Although peer evaluation may be daunting at first, learning and becoming your very best as a practitioner are rewarding endeavors. For overall excellence, pursue the Fellowship of the AAO. For scleral lenses, a great place to start is Fellowship in the Scleral Lens Education Society (SLS). For the most comprehensive specialty lens excellence, join the Diplomate process of the AAO Cornea, Contact Lenses and Refractive Technologies section. An added benefit of all three is the opportunities that you will have to meet colleagues who are equally as passionate about specialty lenses as you are.

LOCATE THE PATIENTS

It is not enough to just know the material; to build a specialty contact lens practice, you must also demonstrate your expertise to others. Referrals are the lifeblood of this type of practice.

Good referral sources include optometrists, cornea specialists, general ophthalmologists, oculoplastic surgeons, neuro-ophthalmologists, oncologists, endocrinologists, rheumatologists, hematologists, otolaryngologists, pediatricians, primary care providers, opticians, and colleagues and patients from your own practice.

Do not forget to communicate back to referring providers once fittings are complete. Let them know, in general terms, your gratitude for the referral as well as the results of the new contact lens fitting.

To promote your practice, utilize word of mouth, practice visits, letters, emails, phone calls, texts, your website, and social media (for example, posting on a local Facebook page). Consider advertising via print media, television, and radio. Get listed on the practitioner locator page of organizations such as the GP Lens Institute (GPLI), SLS, and the National Keratoconus Foundation (NKCF); the former two also provide practitioner education, and the latter provides patient education.

Besides being able to meet and learn from other practitioners, the aforementioned network of colleagues has another benefit as well. Because you will now have a built-in network of experts from throughout the country and world, when patients move to another location, you will always know a good colleague in that area who can help them.

What patients will you be serving? Most have irregular corneas; others have healthy corneas, but a mass-produced soft lens does not meet their needs for other reasons. Their diagnoses may include keratoconus, keratoglobus, pellucid marginal degeneration, corneal dystrophies, corneal degenerations, corneal scarring due to prior trauma or infection, post-corneal transplantation, dry eye disease, ocular surface disease, post-refractive surgery, irregular astigmatism, high astigmatism, presbyopia, exposure keratitis, high ametropia, anisometropia, childhood myopia, and iris anomalies (aniridia, coloboma, etc.).

BE PREPARED

You need to have all of the tools in your toolbox to properly serve these types of patients. To fully treat and manage all specialty lens patients, you should have expertise with, and possession of, at least one trial lens set in each of these categories:

• Corneal spherical GP
• Corneal keratoconic GP
• Corneal reverse geometry GP (Figure 1)

  

• Scleral GP (Figure 2)

  

• Multifocal corneal GP: aspheric
• Multifocal corneal GP: translating
• Multifocal soft: center-distance
• Multifocal soft: center-near
• Multifocal soft: myopia management
• Orthokeratology GP (if recommended by your lab)
• Keratoconic soft
• Hybrid

CONFIRM PRACTICE ORGANIZATION

It is important that your practice is willing and able to support a specialty contact lens service. There must be adequate space and staffing to ensure success. The practice needs to understand that these are far from routine patients. Some may have anxiety regarding their vision loss. Many of them suffer from severe ocular conditions and cannot see well with glasses—only with their specialty contact lenses. For example, if they call to replace a lost or broken lens, their request must be attended to immediately.

Schedule These visits are neither simple nor routine. They take longer, and more attention must be devoted to their scheduling.

For the initial patient evaluation, we book 30- to 45-minute slots, with the understanding that between the testing, fitting, and lens settling period, the patient may be in the office for up to two hours. This visit may include the following:

• A complete history of contact lens wear (prior records detailing current parameters are particularly valuable)
• A thorough history of contact lens care; sometimes it is poor care and compliance rather than a poor fit that led to discontinuation of contact lens wear
• Corneal topography/tomography (Figure 3)

  

• Refraction
• Pachymetry/specular microscopy
• External ocular photography
• Visual acuities and entrance testing
• Slit lamp examination with sodium fluorescein and lid eversion
• Measurement of horizontal visible iris diameter (HVID)
• Contact lens trial fitting
• A comprehensive education about the patient’s condition, including handouts

Other testing that may be utilized includes keratometry, aberrometry, optical coherence tomography (OCT), axial length measurement (for myopia management), and scleral profilometry.

For scleral lens dispensing visits, a 30-minute lens settling period must be built into the schedule. In my practice, all such patients are given an appointment time 30 minutes prior to when they will see me—that means overlapping appointments to ensure maximum efficiency.

Layout/Supplies Ideally, your office should possess a comfortable, clean, and well-lit room dedicated to contact lens application, removal, and education. Necessary supplies include:

• Both stand-up and flat mirrors; the latter is for applying scleral lenses
• GP and soft lens rinsing and soaking solutions
• Preservative-free solution for scleral lens filling
• Large and small contact lens suction cups/applicators (Figure 4)

  

• Handout explaining application, removal, and care
• Sodium fluorescein
• Extra contact lens cases
• Scleral lens application stand
• Hand-held cobalt blue light
• Chairs for the patient and staff member
• Gloves and plexiglass shield (post-pandemic)
• GP lens daily cleaner and hydrogen peroxide for the disinfection of reusable trial lenses

Additional important pieces of equipment for an advanced contact lens practice include a radiuscope, lensometer, hand magnifier, laboratory-strength contact lens cleaner, and a modification/polishing unit including polish, suction cups, and/or spinner tools.

Staff Often, what separates the great practices from the good ones are the staff members. When interviewing, select them for their positive personality and their enthusiasm for helping specialty contact lens patients. Almost everything else can be trained.⁵

1) Your staff members are an extension of you. Make sure that you and your staff are on the same page. For example, it is important that you share the same philosophy on contact lens care and follow-up visits so that patients receive the same message no matter whom they are interacting with in the practice. During the case history, a staff member should ask patients how they clean their lenses “from the time that they start until the time they finish” and then correct them immediately if they are not complying. A technician who is afraid to offer instruction at this point reinforces poor care. Despite being embarrassed by their noncompliance, most patients are ultimately grateful that we care.⁶

2) A good staff member is critical to performing the contact lens application/removal/education visit. It may be the patients’ first-ever experience applying contact lenses (or a different type of lens, such as a scleral) to their eyes, and they are understandably apprehensive. If it does not go smoothly, they are more likely to drop out of contact lenses, even though the fit and vision may be perfect.

Application and removal of contact lenses is not easy at first; this is especially true for specialty contact lens patients, as their acuities without contact lenses may be quite poor. A good technician utilizes a positive attitude, patience, contact lens knowledge, and a good sense of humor to put patients at ease. A successful dispensing visit can set the stage for years of healthy contact lens wear.⁵

Often, a close bond will form between technicians and patients during the application/removal session, which is beneficial to both parties as well as to the practice. Similar to a dental hygienist in a dentist’s office, your technicians may spend more time with patients than you do, so an upbeat personality is an important trait for this job. As a result, patients will form a good impression of the practice and a positive attitude toward contact lenses in general.^6-8

3) Designate at least one staff member to be familiar with both medical and vision insurance plans, because staff members are often the ones to verify benefits and obtain pre-authorization for potential coverage of medically necessary contact lenses. This is particularly important for vision plans, with which materials are more likely to be completely or partially covered. Initially, you will have to train him or her. I provided my specialty contact lens coordinator access to videos, articles, courses, and webinars. The information may be daunting at first, but a capable and intelligent staff member will shine. The goal is for the staff member to be more familiar with coding and billing for medically necessary contact lenses than the practitioner is. Once that is reached, it is of enormous benefit to your practice.

4) Specialty contact lens designs contain many more parameters compared to spherical soft contact lenses. Additionally, the terminology for these lens specifications may differ from laboratory to laboratory. A meticulous staff member must understand the terms and abbreviations well enough to order the lenses accurately.

A large practice may have four separate individuals performing each of these important functions. In a smaller practice, the same person may perform all four, sometimes with help from the physician. Regardless of how many staff members perform these tasks, close attention to detail is vital to the success of the specialty contact lens practice.

Once staff members obtain more experience, begin to include them in the process. Ask if they have any recommendations or ideas for improvement; some of their innovations may impress you (Figure 4).

THE BENEFITS

The rewards of providing specialty contact lens services are intellectual, financial, and emotional. We can restore sight, correct vision, enhance comfort, improve appearance, and prevent myopia progression. Specialty lenses, when carefully fit and combined with the necessary follow-up care, may bring great satisfaction not only to the patients but also to their practitioners. CLS

REFERENCES

1. Gromacki SJ, Seligson V. Diagnosing Keratoconus Without a Topographer. Optometric Management. 2014 June;49:47,49-50.
2. Bennett ES, Henry VA. Clinical Manual of Contact Lenses (5th ed.). Wolters Kluwer, Philadelphia, 2020:808-832.
3. Bennett ES, Weissman BA. Clinical Contact Lens Practice (2nd ed.). Lippincott, Williams & Wilkins, Philadelphia, 2005:827-842.
4. Hom MM, Bruce AS. Contact Lens Prescribing and Fitting with CD-ROM. Butterworth-Heinemann, Boston, 2006.
5. Gromacki SJ. Want to Build a Top CL Practice? Contact Lenses Today. 2015 May 17.
6. Gromacki SJ. A Good Tech Means Good Care. Contact Lens Spectrum. 2004 Oct;19:25.
7. Gromacki SJ. Instructions for Scleral Lens Application. Contact Lenses Today. 2013 Nov 3.
8. Gromacki SJ. Contact Lens Training Today. Rev Optom. 2011 May;148:73-76.