THE TERM “CONTACT LENS FITTING” is ingrained in our industry. Nonetheless, the meaning to consumers and eyecare practitioners may differ. These disparate understandings are on course for more collisions as technology increasingly subsumes pairing eyes with contact lenses.

Without a coordinated industry paradigm shift to “contact lens prescribing,” consumers will increasingly question why they cannot purchase whatever contact lenses they want, perceiving the eyecare practitioner not as a subject-matter expert but as an obstacle to their desired transaction. In response, contact lens professionals will spend more time unwinding narratives promoted by online contact lens retailers, and educating patients on why professional services are necessary and desirable.

THE CONSUMER MINDSET OF “FITTING”

Among consumers, “fitting” connotes determining size and shape. A web image search of “fitting” returns photos of plumbing fixtures for connecting different pipes and clothing with measuring tape to match different body sizes. While the services for pipe fitting and wardrobe fitting can involve professionals, it is not unusual for consumers to turn them into do-it-yourself projects.

Similarly, U.S. consumers often feel that they can fit themselves with disposable contact lenses. Online contact lens retailers support and condone this sentiment, letting consumers shop for them as if they were purchasing other consumer goods, eliminating the eyecare professional as an intermediary.

THE PRACTITIONER MINDSET OF “FITTING”

The eyecare professional’s definition of contact lens fitting is more expansive, multifaceted, and dignified, encompassing the following:

• Matching the geometry of the eye with appropriate lens parameters considering keratometry, palpebral aperture size, lid laxity, horizontal visible iris diameter and, increasingly, ocular sagittal depth and scleral contour. At a minimum, lens parameters that should be considered for soft lenses include base curves, overall diameters, and materials.
• Lens selection considering refractive needs, suitable replacement frequency, physiology including the ocular surface and tear film, lifestyle, and patient expectations.
• Over-refraction and modification of refractive power considering binocularity.
• Assessment of ocular health and its response to contact lens wear, with modification as necessary.
• Training in lens care and handling and reeducation on proper practices.

COLLISIONS OVER INTERPRETATIONS OF “FITTING”

As an example, take the patient who has contact lens discomfort and requests fitting into a direct-to-consumer advertised contact lens. During the contact lens evaluation, the practitioner detects epithelial basement membrane dystrophy and determines that corneal erosions underlie the discomfort. After escalating treatment from ocular lubricants to phototherapeutic keratectomy, the patient successfully returns to wearing the same contact lens that was previously uncomfortable.

If patients’ walk-out statements show “contact lens fitting fee,” patients may question whether a “fitting” was performed because they ended up in the same contact lens. Instead, the practitioner performed evaluative and prescribing services, falling within the practitioner’s understanding of “fitting.” This misalignment of understanding manifests in other instances when contact lens discomfort has causes such as meibomian gland dysfunction, papillary conjunctivitis, or infiltrative keratitis. The consumer does not interpret “fitting” to include assessing ocular health or contact lens over-refraction.

Simply put, the consumer notion of “fit” is often at odds with what the practitioner means by “fit.” This manifests as conflict between consumers and eyecare practices as to why additional services and their corresponding fees are necessary.

Consumers commonly do not understand why a spectacle prescription cannot be converted into a contact lens prescription. Likewise, consumers generally do not understand that the power specifications of a toric or multifocal lens, when applied to another type of toric or multifocal lens, may produce very different outcomes.

Finally, consumers usually do not realize that power is just one component of a contact lens prescription, and that power and prescription are not synonymous with one another. It falls on eyecare professionals and industry partners to educate consumers in these situations. However, explaining comes at a cost. As the political pundit George Will famously said, “If you’re explaining, you’re losing.”

Prior to the 2003 enactment of Fairness to Contact Lens Consumer Act (FCLCA),¹ the patient’s cost of contact lenses often included professional services. But since FCLCA went into effect, most eyecare clinics separate the costs of the lenses and professional contact lens services. While this is a welcome change, it also leads some patients to question the legitimacy of a “fitting fee,” particularly in cases in which their contact lens prescription remains unchanged.

As an example, consider a Redditor who asked, “Do all vision clinics charge a ‘contact lens fitting’ fee?” The leading user-voted response was, “You have to pay extra because you live in North America, where contact lens dispensation is legalized thievery and straight up abuse of the prescription system. It has little to do with medical safety and eye health, and a lot to do with revenue.” The responder continued, “The one way around the cartel is to pay their fee—once—and then buy online for later orders. The online stores are supposed to check your prescription, but they never do.”²

Although the Reddit response may cause consternation among U.S. eyecare professionals, it is worth contemplating. It is true that the contact lens market is regulated differently in different countries. In the U.S., a valid contact lens prescription is required for purchase. However, in the European Union, contact lenses are deregulated in 25 of 27 countries so that a consumer may purchase contact lenses without a prescription.³ Furthermore, a literature search using PubMed shows no compelling evidence that the incidence of microbial keratitis in contact lens wearers is significantly different in Europe than in the U.S.^4,5

While the incidence of the worst complication of contact lens wear seems no different between a regulated versus unregulated market, this may not apply for other complications and the overall success of lens wear. Practitioners can validate the Redditor’s last point about online retailers filling contact lens prescriptions without verification, as several retailers operate with impunity.

In seemingly sparse situations, the online contact lens retailers get caught, as with Hubble: the Federal Trade Commission sanctioned Vision Path, its parent company, for not verifying prescriptions and substituting lenses without a valid prescription.⁶ Nonetheless, the plethora of online contact lens retailers, including offshore operations that ignore regulations, creates a de facto deregulated U.S. marketplace.

At the same time, U.S. practitioners anecdotally observe more consumers attributing successful contact lens wear to the brand of contact lenses rather than professional expertise. It’s no surprise that online retailers support a strong patient-product relationship, as it diminishes the role of the eyecare professional and smooths away their major friction point for selling contact lenses. In the process, the eyecare practitioner is painted as a burdensome obstacle to the consumer getting what they want.

The opposite and time-tested approach is a strong patient-practitioner relationship in which the practitioner’s experience and expertise bring a desired outcome and the contact lens plays a secondary role. The growth of remote online contact lens prescription renewal, accelerated by the COVID pandemic, is tilting the disposable contact lens market toward a patient-product relationship in which any eyecare practitioner is irrelevant as long as a prescription is generated.

Emerging technology for contact lens fitting embraced by online retailers will continue solidifying a de facto deregulated U.S. marketplace. Yet if these same technologies are embraced and leveraged by eyecare professionals, they can bring opportunities to better serve our patients and strengthen the patient-practitioner relationship.

EMERGING CONTACT LENS FITTING TECHNOLOGY

Mass marketed disposable contact lenses today embody a one-size-fits-most approach, where a particular line of contact lenses—with one or two available base curves and a shared lens diameter—accommodates most patients. For this reason, matching a disposable contact lens to most ocular geometries requires minimal expertise and is formulaic.

For example, one contact lens manufacturer’s lens prescription calculator determines the initial lens power selection of their disposable multifocal to a claimed high degree of success, based solely on refraction, add power, vertex distance, and eye dominance.⁷ Naturally, some consumers may wonder if they can use these lens calculators to “fit” themselves.

Initial lens selection will get further enhanced with narrow artificial intelligence (AI), perhaps an AI-powered “fitting chatbot.” Already with diabetic retinopathy screening, one narrow AI system has demonstrated higher sensitivity than either general ophthalmologists or retinal specialists in detecting more than mild diabetic retinopathy.⁸ Whereas image detection is not the same as initial contact lens parameter selection, the prospect is that these technologies will improve and rival what a practitioner can do.

Unlike disposable contact lenses, scleral lenses do not drape the corneal surface, so their shape and landing on the conjunctiva/sclera is key for a desirable outcome. While on-eye diagnostic scleral lens evaluation is commonplace today, look for technology-enabled measurements to increasingly determine scleral lens parameters. Topography beyond the limbus with scleral profilometry, while still novel with limited widespread clinical adoption,⁹ offers a look at what may become commonplace someday.

With three scleral profilometers now commercially available, measuring between 100,000 and 1 million points of data from the ocular surface depending on the instrument, the collected data guides scleral lens parameter selection, promising to reduce chair time and improve outcomes. Two of the current scleral profilometers collect data that enables fabrication of free-form scleral lenses.

In general, the collection of these data with scleral profilometers is unwieldy, requiring lid manipulation and stitching image data from the subject looking in different fields of gaze. Future refinements may ease these constraints, increasing adoption of profilometry. In addition to facilitating scleral lens design, profilometers may aid in fitting corneal GP, hybrid, and custom soft lenses.

SMARTPHONE FITTING

Several eyewear companies use a smartphone or tablet to scan the wearer’s face, allowing the selection of suitable frames from a defined inventory with virtual try-on,¹⁰ or even to create custom-tailored eyewear.¹¹ The technology leverages the TrueDepth camera Apple used for its biometric FaceID and augmented reality applications, which projects thousands of invisible dots on the user’s face and captures them with an infrared camera.¹² While this technology may not yet have the fine granularity to measure the ocular surface for custom contact lens fitting, one can presume that efforts are underway to use consumer smartphones to scan the ocular surface for disposable contact lens fitting.

Improvements and increased use of light detection and ranging (LiDAR) scanners in mobile devices can concurrently aid in establishing the test distance to measure visual acuity with a smartphone app. At least one study showed that at-home visual acuity measurements, including with a mobile app, were comparable to and within one line of acuity of in-office visual acuity measurements.¹³ Expect mobile technology to continue advancing to enable data-driven diagnosis and treatment.

Perhaps the mobile technology poised to advance assessing the ocular surface the most is photogrammetry (Figure 1), in which serial, overlapping photographs are used to create three-dimensional models.14 In combination with cloud computing to offload data processing from the mobile device, it is conceivable that the smartphone will become an effective screening tool for keratoconus and other corneal irregularities, while also serving as a technology-based contact lens fitting tool.

Expand

There are challenges to surmount, however, as photogrammetry is limited in modeling reflective and clear tissue. As with some of the commercial profilometers, fluorescein in the tear film may aid this technology in detecting the ocular surface.

Even in situations in which the one-size-fits-all approach of disposable soft lenses fails on outlier eyes, custom contact lens prescribing is becoming technology-driven. Rather than the clinician determining how to modify the base curve, optical zone, or peripheral curve radii or widths, look for technology to increasingly assume this role.

REMOTE CONTACT LENS SERVICES

While de novo contact lens prescribing does not yet lend itself to online service, online prescription renewal of existing eyeglass and contact lens prescriptions is already common. There is even a U.S. Food and Drug Administration (FDA)-approved online vision test,¹⁵ used for online prescription renewal. Expect more to come.

In addition to the efforts to advance self-administered care at home, there are hybrid efforts like the tele-optometry systems deployed in a growing number of optical establishments, which allow a technician to administer elements of a traditional optometric examination with a remote physician supervising.^16.17 This model of eye care allows for evaluation of diagnostic contact lenses on the eye and ocular health since the technician can assist, including the possibility for de novo contact lens prescribing. A review of patent activity reveals a contemplated prescribing system based on assessing a reference contact lens on the eye using an image sensor that a prescriber can access remotely.^18,19

Like it or not, COVID has accelerated technological advances for online contact lens prescription renewal. De novo contact lens fitting is the next frontier, with tele-optometry systems and a technician to aid a remote practitioner in providing contact lens services. Furthermore, while it may seem improbable, self-administered 3D scanning with smartphones and sophisticated AI-powered apps enable self-administered de novo contact lens fitting.

Combined with a U.S. contact lens marketplace that is effectively deregulated due to minimal enforcement and online contact lens sellers who operate with impunity, our profession can expect technology to increasingly assume the role of contact lens fitting. The question is whether practitioners will supervise technology-assisted fitting and retain prescriptive authority, or whether online retailers will exploit a permissive environment in which lens selection is completely self-directed with the assistance of technology without a prescription.

THE DISTINCTION BETWEEN FITTING AND PRESCRIBING

“Contact lens fitting” is a deep-seated industry term and an unfortunate selection, as it leads consumers to believe that desirable outcomes with contact lenses do not require professional expertise or prescriptive authority. Development of technology-driven parameter selection tools exacerbates this misunderstanding.

Manufacturers, vision plans, and regulators, among others, use the parlance of “contact lens fitting” commonly without elaborating that it is not just determination of size and shape. Meanwhile, manufacturers continue making contact lenses “easy to fit” with good intentions of reducing professional chair time to help eyecare practitioners improve efficiency. But the “easy-to-fit” paradigm brings more consumers to wonder: If it is so easy, then why can’t they fit themselves? Arguably, a better aspiration for manufacturers is prioritizing successful patient outcomes, even if this requires professionals to expend a reasonable amount of chair time.

Practitioners identifying as “fitters” may suffer an existential crisis when AI-assisted technology surpasses their capability to select disposable contact lenses and to align the scleral haptic with the patient’s ocular surface. Enlightened practitioners who place parameter selection technology under their purview—analogous to harnessing autorefraction to expedite arriving at the endpoint of subjective refraction—will gain improved efficiency and elevate their role to include more clinical decision-making and patient communication versus data collection. This embrace of “contact lens prescribing” holds an inherent implication of expertise and medical authority, which encompasses fitting, anterior segment evaluation, and refractive adjustment.

ELEVATE FROM “FITTING” TO “PRESCRIBING”

Semantics shape the culture surrounding our services (Table 1). “Contact lens fitting” implies trying “free trial contact lenses” and “tweaking” the prescription during “follow-up visits.” In contrast, greater value is suggested by “contact lens prescribing and evaluation,” using “diagnostic lenses” with “prescriptive refinements” during “progress visits.” However, it may be too late for our profession to course correct.

The use of contact lens “fit” and “fitting” is already adopted in such high concentration that it could be a Sisyphean task to find leadership and coordination by the industry players—manufacturers, vision plans, eyecare professionals, regulators, key opinion leaders, and consumer and industry media. Meanwhile, online sellers of contact lenses do not share the same imperative and may in fact purposely confuse fitting and prescribing.

Practitioners must also consider the resources required to change our industry lexicon, as we could apply those resources to other beneficial initiatives such as scope expansion, third-party reimbursement, and public relations. As with any initiative, there are opportunity costs to consider.

LEARNING FROM PODIATRY

It is worth noting that podiatrists avoid using the terms “fit” and “fitting” to describe their services of dispensing custom orthotics. David B. Alper, DPM, a member of the board of trustees of the American Podiatric Medical Association, noted that podiatrists instead prefer to discuss measuring and evaluating the function of custom-prescribed orthotics.²⁰According to Dr. Alper, this is done to differentiate their services from those of a shoe salesman, who may recommend off-the-shelf shoe inserts.

He also noted that this semantic choice by podiatrists did not come from a formalized and coordinated effort within their profession. Rather it was a necessary shift made by podiatrists in response to retail arch support franchises promoting “fittings” with technology that scans the feet and assesses gait.

Calling someone a “fitter,” while not derogative, has an uncouth undertone. Analogous to podiatry, contact lens professionals should differentiate their prescribing services from the lower-level and limited fitting concept. In essence, contact lens prescribing is to contact lens fitting as a comprehensive eye examination is to standalone refraction.

While it may be difficult to coordinate a semantic shift on an industry level, practitioners can start within their own practices by mindfully selecting their language during patient interactions. Their reward is smoother practice operations and added value for professional contact lens services.

Manufacturers and laboratories can likewise adopt a prescribing-ahead-of-fitting paradigm by distributing “prescribing guides” instead of “fitting guides” and designating their “fitting consultants” with the more appropriate title of “prescribing consultants.” The use of preferred semantics will benefit manufacturers and laboratories by underscoring their practitioners’ expertise and prescribing authority. Their payoff is differentiation from the competition and gaining the support of physicians who identify with the prescribing paradigm. In this fashion, what is good for individual practices, laboratories, and manufacturers helps to drive common prosperity for the entire contact lens industry.

ACCEPTING RATHER THAN DENYING CHANGE

Over the last few decades, the optometric profession has faced numerous threats—from autorefractors, to laser vision correction, to online eyewear; each time, pessimists claimed doom to the profession. However, in each instance, the optometric profession has adapted and grown by incorporating autorefraction in its practice to improve efficiency, providing pre- and post-operative laser vision correction services, and using virtual eyewear selection technology and e-commerce to bring patients an enhanced experience. Against this backdrop of repeatedly turning perceived harm into help, changes in contact lens delivery may follow a similar rhythm.

The movement toward remote prescription renewal by online contact lens sellers suggests that early-adopting practitioners could likewise provide prescription renewal to certain patients. Contact lens professionals and their patients may also benefit by incorporating tele-optometric services, including future consumer-administered mobile fittings, with practitioner oversight and prescriptive authority.

The evolution from in-person, practitioner-performed contact lens fitting toward technology-enabled remote fitting, and eventually self-administered fitting, may follow the trajectory of automobiles moving from completely manual driving to fully self-driving. As such, it is a work in progress that will involve collisions as part of the territory. Even if the days of fitting by the eyecare practitioner are numbered, prescribing will endure and convey a level of medical authority and expertise. CLS

References

1. U.S. Congress. Fairness to Contact Lens Consumer Act. 2003 Dec 6. Available at congress.gov/108/plaws/publ164/PLAW-108publ164.pdf . Accessed on Nov. 1, 2023.
2. Soupdeloup. Do all vision clinics charge a “contact lens fitting” fee? Reddit. Available at reddit.com/r/halifax/comments/rlul3z/do_all_vision_clinics_charge_a_contact_lens . Accessed Nov. 1, 2023.
3. Chou B. Contact Lens Prescribing Now and in the Future. Contact Lens Spectrum. 2021 May;36:27-30,32-34.
4. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999 Jul 17;354:181-185.
5. Ting DSJ, Ho CS, Deshmukh R, Said DG, Dua HS. Infectious keratitis: an update on epidemiology, causative microorganisms, risk factors, and antimicrobial resistance. Eye (Lond). 2021 Apr;35:1084-1101.
6. Tressler C. What to know about Hubble’s $3.5 million settlement with the FTC. Federal Trade Commission Consumer Advice. 2022 Jan. 28. Available at consumer.ftc.gov/consumer-alerts/2022/01/what-know-about-hubbles-35-million-settlement-ftc . Accessed Nov. 1, 2023.
7. CooperVision. OptiExpert Contact Lens Prescription Calculator. Available at coopervision.com/practitioner/tools-and-calculators/optiexpert/optiexpert-web#/calculator . Accessed Nov. 1, 2023.
8. Lim JI, Regillo CD, Sadda SR, et al. Artificial Intelligence Detection of Diabetic Retinopathy: Subgroup Comparison of the EyeArt System with Ophthalmologists’ Dilated Examinations. Ophthalmol Sci. 2022 Sep 30;3:100228.
9. Legerton J. No-Fee CE: Future-Focused CLs. Contact Lens Spectrum. 2023 Nov;38:27-35.
10. Gartenberg C. Warby Parker’s new app uses AR and face scans to try on virtual glasses. The Verge. 2019 Feb 4.
11. Topology. 2023. Available at topologyeyewear.com . Accessed Nov. 1, 2023.
12. Apple Inc. About Face ID advanced technology. 2023 Aug 22. Available at support.apple.com/en-us/102381 . Accessed Nov. 1, 2023.
13. Bellsmith KN, Gale MJ, Yang BS, et al. Validation of home visual acuity tests for telehealth in the COVID-19 era. JAMA Ophthalmol. 2022 May 1;140:465-471.
14. 3DSources. Photogrammetry Guide 2023 – Definition, Advantages and Uses Explained. Available at 3dsourced.com/guides/photogrammetry-guide . Accessed Nov. 1, 2023.
15. Visibly. Visibly Becomes First FDA-Cleared Online Vision Test in the United States. 2022 Aug 16. Available at https://www.prnewswire.com/news-releases/visibly-becomes-first-fda-cleared-online-vision-test-in-the-united-states-301606088.html . Accessed Nov. 1, 2023.
16. 20/20Now. Ocular Tele-Health Exams In 30 Minutes or Less. 2023. Available at for2020now.com/how-tele-optometry-exams-work . Accessed Nov. 7, 2023.
17. Eyoto. Explore Aetheia’s Unique Features Vs A Traditional Slit Lamp. 2023 May 4. Available at https://www.eyoto.com/theia-vs-traditional-slit-lamp . Accessed Nov. 1, 2023.
18. Legerton J, Marsh J. Automated contact lens design through image capture of an eye wearing a reference contact lens. Patent Wo202122216504A1. 2022 Oct 13. Available at patents.google.com/patent/WO2022216504A1 . Accessed Nov. 1, 2023.
19. Legerton J, Marsh J. Automated contact lens design through image capture of the eye. U.S. Patent US20220313081A1. 2022 Oct 6. Available at patents.google.com/patent/US20220313081A1 . Accessed Nov. 1, 2023.
20. Alper DB. Interview with Approval. 2023 Aug.
21. Polycam. 3D Capture, For Everyone. Available at poly.cam . Accessed Nov. 1, 2023.
22. Chou B. How to Escape the “Insurance” Trap. Optometric Management. 2004 Feb;39.