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Catch up on the top stories in optometry during the week of September 8-September 12.

Takeaways from this week in optometry: September 8- September 12

Articles

Long-term atropine use to treat myopia associated with increased risk of ocular complication in schoolchildren in Taiwan

A total of 293 optometrists, practice owners, and managers were involved in the survey.

Myopia treatment trends outlined in The Vision Council's recent report

Researchers conducted this study to determine how often and why spontaneous soft drusen regresses without atrophy in patients who had intermediate or atrophic age-related macular degeneration.

New study examines soft drusen regression without atrophy and drusen ooze

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Walmart and Sam's Club plan new initiatives in 2013, including a private-label contact lens brand, an online and phone contact lens program, and lower prices on contact lenses.

Walmart, Sam’s Club launch new CL initiatives for new year

Alden Optical launches Alden On-Demand series, with the first a NovaKone training and certification

Alden Optical debuts on-demand online learning

Nearly one-half of patients requiring vision correction are significantly astigmatic in at least one eye and could benefit from advances in toric contact lens technology, according to a study published in Eye & Contact Lens: Science and Clinical Practice.

About 50% of patients severely astigmatic, study says

Prefer to listen on the go? You can follow the podcast on 

Follow Dr Korik on social media:
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One of the 15 clinics Miriam Korik, OD, works at is an optical boutique. She shares her expertise on exam personalization and how to realize these tweaks as sales.

You and Eye: On contact lenses, personalization, and boosting optical sales

 assistant managing editor, Emily Kaiser Maharjan, to discuss custom fitting contact lenses as a business model.

 This transcript has been lightly edited for clarity.

Hello and welcome to Optometry Times On Air. My name is Emily Kaiser and I'm the assistant managing editor of Optometry Times. I'm here with Dr Luis Rojas, custom contact lens fitting extraordinaire. Welcome to the show, Dr Rojas.

Hi, how are you? Thank you for having me.

I'm good. Happy to have you here, really excited to really dive into it. So first, can you please describe what custom contact lens fitting means to you? What sets it apart from a standard lens fitting?

Yeah, that's a great question. When I think about custom contact lens fitting, I truly mean it in a tailored type of way. You're tailoring it to the needs of the patient [and] the visual demand of the patient. When I think about custom contact lens fitting, I really refer to it in terms of soft lens customization and tailoring to the patient's needs. The visual demand of the patient, any particular hobbies, their day in and day out from morning till night, and I'm tailoring it to their life. 

Whether or not I have full control over the material, the aspects of the size, the prescription, I'll do my best to do that. But, I really want to listen and take the time to listen to the patient, and really address all their concerns, their visual demands, [and] come up with the solution. More importantly, just have the realistic expectations of how to tackle all those issues.

Fantastic. How can optometrists give their patients the custom fitting experience? Do they need any equipment to level up, is that pretty approachable?

You don't have to have the fancy equipment. I will say, if you have a typographer that has a pupillometry, that will kind of explain some types of designs out there. So if you can explain to the patient, "hey, I'm measuring your your corneal shape, and on top of that, I'm measuring your pupil size in different light settings, whether it's nice optics go topic." You can explain to the patient, I'm selecting a type of lens that has a certain type of power profile that's tailored to the patient's pupil size. So, you can use that instrumentation to help. 

I'm very visual in my office. We have a lot of technology, we have screens to show them all the tech and scans that were that we're doing. So do you have to have these fancy toys? You don't, you just need to listen. You need to have a really good case history. Most of the equipment that optometrists will have in their office should be sufficient to tailor to their needs. But, I think that one of the biggest things is finding the time clock and trying to take that time to really listened to the patient. 

And I think that, going back to your original question, it's more of that custom contact lens fitting approach, where you're just taking the time to really tailor that suit to them. In regards to vision, this ends up being that tailor contact lens.

So, it sounds like you know patient communication is a huge part of the custom contact lens fitting experience. It's not just about getting the lens to fit the eye. It's also getting the patient to understand why it fits the eye or why you're doing the steps that you're taking to make sure that this is what fits.

Yeah, that's correct. I mean, we're in 2023. Moving forward, almost every contact lens has an amazing perk or some type of technology that's just fresh. There's a lot of leaders in the space as well. So in regards to what you're saying, that's absolutely right. The fitting process in itself, the actual physical fitting, ends up not being the hard part. It's trying to select which awesome lens is out there that can better fit the patient's visual needs.

So nearly every type of contact lens on the market has a fitting guide or calculator. How can optometrists leverage these tools to get the best possible outcome?

These are offered by companies as guardrails. They want you to have first time fitting success and they want it to be easy, especially when we're talking about multifocal. [It's] one thing fitting a spherical product, but a multifocal is like fitting a progressive lens with so many corridors. If we're talking about glasses, we're talking segue height and power profiles [and] how fast you get into the different zones in the progressive. Well, if we change that conversation to contacts, we also have different power profiles. 

Every manufacturer has some proprietary thing, so they have a different transition into that multifocal or bifocal segment. You have to understand what the limitations are and the guardrails of these calculators. Ultimately though, you're the doctor.

So yes, it's telling you stick to this, stick to that, but if your experience and understanding the patient's working distance, the expectation and again, going back to visual demand, you can go off those guardrails. That's something that we do all the time, we call it off label. I would say more than half of what we do is considered off label.

Right and once again, that's kind of feeding into the customer experience is fitting what fits the eye in front of you rather than this "fantasy eye" that we're working off of with the fitting guide.

It's not a schematic guy. This is a living breathing person and whether they had previous surgery or other medications that they're taking, maybe some trauma, you have to take in all of that. When you're looking at a calculator, it's giving you that perfect example, perfect patient. Let's be honest, there's not like a perfect patient.

For sure. So when sitting down to fit contact lenses, you aren't just looking at correcting visual acuity. You're looking at the patient's entire visual system, and you're considering their preferences. How do you usually factor in considerations for dry eye, for contact lens materials, for filtering for blue light, and stuff like that?

It all plays a big role, and it's just a big puzzle piece. You're collecting these pieces of the puzzle throughout the case history, throughout the examination process, whether you take photos of the cornea, whether you notice that there's a reduced tear breakup time. Perhaps they have very sensitive eyes or photophobic. So, you're considering whether we're trying to reduce glare and halos or light scatter. There's so many factors to consider. 

As I'm doing the exam, I'm taking mental notes of where am I going with my contact lens selection [and] how can I leverage that? By the time I get to my contact lens room, I have all these products in front of me and you quickly, in a matter of seconds, whether you call that muscle memory or not, you have to go and select the right product, usually just trust your gut. You know the perks, you know the high points of every lens. Like I said, it's a puzzle piece, but you need to address the patient. For example, [the] patient has dry eye, but they also have light scattering at night. Well then, what lens is out there that can give you that? How can I reduce the evaporation rate of the eye? If I place this contact lens with a certain type of material will I exacerbate the underlying dry eye? Will I enhance the vision by preventing the evaporation of the tear film? 

You have to consider all of these pieces and then explain it to the patient. Going back to communicating with the patient, if you have the mindset of, okay, this patient is going to leave my office and they're going to know exactly why I fit them in a particular product. I think a lot of us can do better about that. Sometimes we just, again, go muscle memory, grab a contact lens, here you go, here's your minus two lenses. The patient has no idea of why you chose it. Vocalizing everything that you're doing is so, so important. I tell the patient as they're washing their hands, "hey, you have this product it has a pupil optimized design. It's tailored to your pupil size, by the way it cuts evaporation rate." Some of them may or may not get that, but I do have a lot of engineers, and they ask those particular questions. 

So it's a very, it's very helpful to explain that. But, I want them to know [they were] not just fit in a contact lens, it was tailored to [their] visual needs, [I] listened to [their] needs, and [I] selected a product and [they] know exactly why.

I'm sure that that helps a lot with patient satisfaction. And even the patients who maybe go home and try out their lenses, and they don't like them for whatever reason. They can come back and have a more informed discussion with you about, "I know that you fit me in this for this reason, but my dry eye is still really bothering me. Can we do something about that?"

I let them know you're not married to the product. At any point in time, we can make changes. That's part of that tailoring process. We have up to, at least in my clinic, 60 days to do that. I'm not going to take the full 60 days, but it's nice and comfortable for the patient to know [they] can come back and re-tweak this and just give it a shot. Again, that perfect patient, you think they're gonna do great in this power profile, this material is gonna be great for them. Or, maybe they have a high prescription [and] they need a breathable lens so they don't have any corneal pathology that develops later. Then they come back, they say it's too stiff, or it's too difficult to use. So, you just have to keep an open mind. In our office, we are about 90 to 92% Johnson and Johnson. 

I am a consultant for Johnson and Johnson, but I feel like their products are very tailored to the patient. We have a wide variety of lenses in our office that we can help [fit]. We fit every type of brand, there is no brand that we don't fit. But, I do feel like the moving forward and the technology aspect of Johnson and Johnson's lenses have have really pushed the boundaries, especially with the new blue light filter that they're incorporating in the max lens and that pupil optimized design. So I do feel like that is the next level of tailoring a prescription and a contact lens that almost matches the tailoring approach that you're doing in a progressive glass. So I think that's pretty unique.

Yeah, absolutely. Going back to our conversation earlier about how you never really have the perfect patient in front of you. Part of that also comes down to patient behaviors. Maybe they aren't always following the correct timeline of how long you should be wearing their contacts or the correct cleaning protocols and stuff like that. 

So, how do you address those issues as they come into the clinic? If they come in and they say, "oh, man, my contacts feel like they don't fit well." And you [say], "Well, how long are you wearing them?" And they [say], "like 14, 16 hours." Do you bake that into your workflow, or do you adjust for that when you're prescribing these contacts?

I listen to the patient. I'm understanding, I sympathize with the patient. I've been practicing for almost eight years. When when I first graduated, I'm wanted to be the people pleaser. So I said, "oh, don't don't worry you can continue doing that." That's a very bad approach just to win a patient over and just go along with their habits. I also, over time, have learned if you are really, really strict, you may rub somebody the wrong way. So there is something right in the middle where you understand their their habits, and you start making some micro changes over time. You don't have to instill a lot of fear, or show them acanthamoeba or an ulcer in a cornea and say this is what's going to happen to your eyes. 

Some of them do need that. But, I'm very frank with them and said, "hey, you only have one pair of eyes, so daily disposable contact lenses are going to be the healthiest [and] the most hygienic." We always start off with daily disposables in our clinic. We don't even, how should I say this, ask what do you prefer? That's not the type of prescribing psychology and philosophy that we follow. 

What we do is we just assume that they're going to be a daily disposable contact lens where unless proven otherwise, you have to give me a reason why you need to downgrade to a different type of lens. We're in a market now where daily disposables today, there's just so much benefit towards them. Let's face it, we don't want to be cleaning, buying solutions and cases, etc. If I can just give you a lens, that's one less thing for you to worry about. At the end of the day, you just toss it. But I do listen, and I try to sympathize with them as well.

Yeah, absolutely. So part of the challenge of providing a customized contact fitting experience is finding a lens with enough power profiles. Do you have any favorite lenses for this particular workflow?

Yeah, absolutely. When it comes down to power profiles, like we said, there's a lot in the market that offer a low and a high example, and we're just referring to multifocal here. You can have a low and a high, you can have a low, mid, high. That's about 2 or 3 power profiles. There's another brand. I know biofinity offers more power profiles as well, with a distance lens and the near lens, etc. You get to up to several. 

But, another reason why I've kind of stuck with a maximum multifocal, [is] we have 183 power profiles, 183. Not just the low to mid and a high. Now the cool thing here is you don't have 183 drawers in your fitting kit, that would be crazy, that's a lot of real estate. 

Let's say I go to a low drawer and a multifocal. I grabbed the low drawer and in between all those power profiles, I know that if I grab a minus one and I compare it to a minus five, I'm getting a different power proof [and] I'm getting a different optical zone. That pupil size of a given patient is going to match that optical zone a lot better. If I can customize that in such a way where I'm now matching the patient's pupil size to the obstacles under the contact lens, you get this perfect marriage of distance, intermediate and near. Now getting everything perfect, we know perfection is hard to find, and some of them might fall out of this range. But, I've had really good success with that lens. Just understanding how this lens was made, understanding the mechanics and how they reengineer the curing process, and how to make this lens more breathable. 

To answer your question, that goes back to knowing how to fit the lens, listening to the patient, and then selecting a lens that's going to match the power profile of that lens to the patient's pupil. So, a patient's pupil size from from a 14 year old versus a 6 year old is going to be completely different. We know that the pupil size gets smaller as we age. We know that myopic patients or nearsighted patients are going to have larger pupils versus farsighted patients. So again, going back to my kit, instead of having 183 drawers, I don't have to think twice. I grab a mid or a low, whatever I'm going to grab, and I know that has a unique tailor to power profile to the patient's pupil.

Yeah, that's such a fantastic option. So we've talked a lot about the clinical side of fitting things. Obviously, that is what you're here to talk about. But, I also want to touch on the practice management, the business side of things. Do you use customized contact fittings as a marketing tool? Do you use that as part of your business model?

That is 100% of what we do. In fact, most of our patients are referral based because of that model. So, our entire business model and philosophy of fitting contact lenses has been in the specialty niche, in the customized and tailored niche. This has led to a lot of referrals from ophthalmology as well, where they said, "hey, I did such surgery and now they're stable from an anatomical perspective, but can you fix their vision because we're not there yet." 

Sometimes the patient and I feel bad for these retina specialists because they'll do scleral buckles and they'll do these amazing retinal surgeries to get them the foundation of vision, and then they're left with a lot of cylinder or a lot of other things that they just can't see. At the end of the day, they might not see the benefit of that retinal detachment surgery, but ultimately just want to drive or they want to see. So they come to me with, "hey, they fixed me, but I still can't see, so what solutions do you have?" That has led our practice to grow and thrive, just focusing on that. Other colleagues around the areas, fellow ODS that said, "hey, I don't have the expertise to fit a gas pump lens or a scleral lens." Or even if it's [a] simple soft lens, "hey, I don't have the availability or the lenses in stock, so can you take care of this patient's needs? Okay, great." So, we do that. It's basically what we do. So, it's embedded in my DNA. This is what we do, it's all about that tailored approach.

That's so great. I know a lot of people these days love a tailored approach, especially in the days of online shopping and influencing and all that kind of stuff. It's so easy to take the stock option, but getting something custom fit, especially for your one set of eyes is so huge.

We all want a one size fits all approach, and that would make our life a lot easier. But you really have to dig deep, especially now there's so many great ones. So again, explaining to the patient why you're selecting such product is so, so crucial.

Absolutely. Do you have any lingering advice for people who maybe want to get into the custom contact lens game?

One would be [to] have the time to listen to the patient's visual demands. Listen to their hobbies, what do they do? Maybe just not ask those simple questions, but "hey, Ken, do you have time to explain to me day in and day out? I mean, are you at your house working remotely? Are you outdoors a lot? Are you going in and outdoors? Do you drive a lot at night? Do you have dry problems? Do you have allergies?" Asking all of these questions, not just to put it in your medical record for thoroughness, [and] really listening to the patient, going out there, and just telling the patient, "I understand where you're coming from, I actually have a product or solution for you." Whatever brand that's going to be, and voicing that out. So that's number one. 

Number two would be the psychology of how confident you are. They're going to listen to you, they're going to read your body language. I would say one of the biggest pitfalls for most practitioners [is] when they're troubleshooting a contact lens, or maybe it's not coming out as they expected, they sort of give up [and say], "oh, it's I'm another multifocal, these are going to be quite difficult." Your body language will show a lot. If you're doing over-refraction and the patient doesn't say wow, then you kind of start losing the confidence. I would say this, be super confident about the changes you're making about the lens selection that you're prescribing. They read it, they feel it, you just have to be super confident and always know there's another option if you can't fix it. We haven't given up on any patient. We always find a solution. Whether it's A, B, or C, you can end up finding a solution for a particular patient.

All right. Well, thank you so much for taking the time to join us On Air today, Dr Rojas, this has been a fantastic discussion. I've really enjoyed it. So thank you.

Thank you for the opportunity. Thank you so much.

Luis Rojas, OD, shares his tips and tricks for getting the best fit for multifocal contact lenses, as well as how to leverage custom fittings as a service as a marketing tool.

How to implement a custom contact lens fitting model into your practice

Chandra Mickles, OD, MS, FAAO, FSLS, the North America professional education lead on myopia with Johnson & Johnson Vision, sat down with 

® to debunk some of the common orthokeratology (ortho-k) myths.

Before diving into the debunking, Mickles described ortho-k as “a fitting process of specially designed gas permeable lenses” that “reshape the cornea” of a patient’s eye—all while they sleep—promoting correction-free, clear vision.

I think most [individuals] think of the freedom, the flexibility, that having correction-free, clear vision provides. But ortho-k does so much more than that. Many studies have shown that it slows the progression of myopia …. Patients who wear [ortho-k lenses] have better vision-related quality of life than patients who wear soft contact lenses and spectacles. [Ortho-k] has also been shown to improve self-esteem. I even hear from parents of children who wear these lenses that one of the great benefits is that they don’t have to worry about their children losing their glasses or breaking them or losing their contact lenses.

The biggest [expectation] is having that clear vision. But to be honest, it’s not that they’re going to have it 30 minutes after the exam is over. What we typically expect is, by the next day—depending on how their prescription is—or after a couple of days, their vision will be clear during the day. It does take some time. It’s not like soft lenses: You put them on during the exam, and now you have clear vision. It does take a little time for that shaping to happen.

[Ortho-k] is kind of like a retainer; I use that analogy a lot…. It does take a little time to really shape it and make it semipermanent. But unlike surgery, this isn’t permanent. After you say, “Well, I don’t want to have this anymore,” a patient can stop wearing the lenses and then their eyes go back to their original shape.

What are some common misconceptions of ortho-k that might be keeping doctors from fitting these lenses?

It amazes me that despite these benefits, there are very few doctors who are fitting ortho-k lenses—less than 8% of doctors in the [US] …. The literature shows that the key myths holding them back from fitting are that they believe that parents aren’t interested, they think that ortho-k may not be safe, and they think it is complicated and time consuming.

Ortho-k is safe. If you think about anything foreign that you’re putting on the eye—like a contact lens—of course it’s going to increase the risk for infection, but that risk is very low.

If we look at the risk of microbial keratitis [MK], which is what most doctors are concerned about, it is 1 in 5000 patient-wearing years for daily disposable soft contact lenses, and then approximately 1 in 1000 [patient-wearing years] for reusable soft
contact lenses and ortho-k.

Essentially, what that means if I turn that around, is that if a patient wears an ortho-k lens every day for 1000 years, they have 1 chance of probably having [MK] or having an infection. If you think of it that way, that’s a really low risk.

If we just look at children, there are studies—[including] 1 study that I was a part of—looking at children [aged 8 to 12 years]; they have a lower risk of developing infections compared with adults and teens. That’s probably due to better [adherence to] care and wear with a parent’s supervision.

Overall, yes, ortho-k is a very safe contact lens option that doctors should recommend for their patients.

And I think another piece [is] that a lot of times doctors think soft lenses are safer than ortho-k lenses. But when we compare a daily wear of soft reusable lenses and ortho-k [lenses], based on the latest studies, they essentially have the same risk.

And it may be now that even ortho-k has a lower risk of MK than daily wear of soft, reusable contact lenses.

Is ortho-k complicated and time consuming?

There are doctors my age or older—when we think back to being in school—we went through this long process of trial and error of fitting these lenses.

But now, ortho-k fitting has come a long way, where there have been advancements that make it not so complicated [or] time consuming, such as the designs.

There has also been an improvement in the technology that we use to fit the lenses, such as topography. Also, now there is computer-based software available to help with designing the lens. All of this has helped [ortho-k] become not as complicated [or] time consuming as we originally thought when they came out on the market.

Yes. And the crazy thing is that when I looked at literature on this—and all of this
is just published this year and in 2021—[uninterested parents are] a top reason holding doctors back.

A few years ago, I was [a] lead investigator on a multicenter study looking at parents’ knowledge and perception of myopia and myopia management. What we found was that 70% of the parents in that study were interested in myopia management; they just need to be educated about it.

And then when we dive in a little further, the top choice of the treatment options for myopia management was ortho-k, which I’m sure [was] surprising for a lot of practitioners. So [parents are] interested, and when I ask my peers, they’re like, “Yeah, Chandra, most of my patients, once I ask them about it, they jump on board, for sure.”

The education is a huge piece. I did an event [recently], where I brought in a parent of a patient, and she’s just surprised that more doctors aren’t sharing with patients and parents about these lenses [and] all the great benefits.

It’s been so helpful for her twin boys who are wearing ortho-k lenses during the evening, and she’s like, “I tell all my friends about it.” I think we just need to do a better job at educating our patients.

Yes, it is cost-effective. Considering that parent again, she opened my eyes to something I didn’t always think about. But when you think about it, especially children—and they’re constantly breaking their glasses—then it makes ortho-k a lot more cost-effective. And then if you even compare it to surgery, ortho-k is more cost-effective …. All the benefits outweigh any of the costs. When I think about all the specialty lenses out there, [ortho-k] is right in line with the cost of those lenses, and I think it’s well worth it for sure.

What do you hope our audience takes away from this discussion?

Now [that] we know that ortho-k lenses have all these benefits, I think all doctors—or as many as possible—should jump on the opportunity to utilize these lenses to help their patients. Because their misconceptions aren’t true. Yes, parents are interested, ortho-k is safe, and it isn’t as time consuming or complicated as we originally thought.

Financial disclosure: Chandra Mickles, OD, MS, FAAO, FSLS, is an employee of Johnson & Johnson Vision"

Black Eyecare Perspective

Eyecare practitioners' top misconceptions just may surprise you.

Debunking common ortho-k myths

Marc Bloomenstein, OD, FAAO, and Editorial Advisory Board member for 

 outlines what attendees can anticipate from the greatest anterior segment disease and medical management of contact lens complications course ever at 

Vision Expo West

Podcast: The greatest anterior segment course ever at Vision Expo West, with Dr. Bloomenstein

Andy Pawson, president and general manager of Alcon global vision care, talks with 

 Editor in Chief Gretchyn Bailey about the company’s plan to launch a new contact lens in early 2022—Total 30 is a monthly lens incorporating water-gradient technology. Pawson discusses plans for line extensions of Total 30 to toric and multifocal lenses and comments on the status of Precision 1 for Astigmatism, which launched in late 2020.

New launch is scheduled to release in early 2022

Podcast: Total 30 contact lens coming in early 2022, says Alcon prez

Acuvue Theravision with Ketotifen from Johnson & Johnson Vision is the first entry into an anticipated category of drug-eluting contact lenses. This lens was recently approved in Japan for vision correction and allergy symptom relief. Brian Pall, OD, MS, FAAO, director of clinical science at Johnson & Johnson Vision Care, discusses the lens and its technology.

Click here to read this interview's transcript

Click here to watch this interview's video

Acuvue Theravision with Ketotifen from Johnson & Johnson Vision is the first entry into an anticipated category of drug-eluting contact lenses.

Podcast: First drug-eluting contact lens approved in Japan

Danielle Richardson, OD, shares her experiences in fitting Johnson & Johnson Vision’s recently launched Acuvue Oasys Multifocal with Pupil Optimized Design contact lens. Dr. Richardson also offers two key points to ODs remember when jumping into fitting.

Podcast: Tips on fitting new Johnson & Johnson Vision multifocal contact lens

Contact lenses have more to offer than only refractive error correction, according to Lyndon Jones, PhD, FCAHS, FCOptom, FAAO, director of the Centre for Ocular Research & Education at the University of Waterloo School of Optometry. Jones is lead author on a recent 

 published in the British Contact Lens Association’s journal 

 outlines other applications for contact lenses, and Jones discusses these with 

® Editor in Chief Gretchyn M. Bailey, NCLC, FAAO.

The full paper is open access and available to all: 

https://www.contactlensjournal.com/article/S1367-0484(21)00021-7/fulltext

Contact lenses have more to offer than only refractive error correction

Contact Lenses

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