Phyllis Rakow, COMT, NCLM, FCLSA(H) is a JCAHPO-certified ophthalmic medical technologist, at a large three-location group practice in central NJ. She has almost 40 years of experience in the contact lens field and has written numerous journal articles, a
These tips have helped doctors reduce chair time, see more patients, and develop a reputation as a state-of-the-art contact lens practice.
Contact lens technicians wear many hats-including medical assistant, educator, interviewer, salesperson, arbitrator, and right-hand to the doctor. As technicians learn, grow, and interact with patients, they are building practices.
As a technician with 42 years in the eyecare profession, I would like to share tips and skills that will enhance a technincian’s value to the practice. These tips have helped doctors reduce chair time, see more patients, and develop their reputations as state-of-the-art contact lens practices.
A good contact lens history is a critical skill. Every patient has a story, and technicians must convey these stories in the patient’s own language. If technicians interpret patients’ words and enter their histories on the chart in technical terms, something important may be lost in the translation.
A thorough contact lens history not only helps doctors select the right contact lens candidates, it helps them select the best lens modalities, materials, and care systems for each patient.
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These questions will guide the doctor in the decision-making process:
• Many patients look younger than they appear. Technicians need to know the age of patients to find out if they are presbyopic. However, asking for a patient’s age may be uncomfortable. It is best to ask, “What is your date of birth?”
• Is the patient under treatment for any medical problems? Allergies, arthritis and other collagen diseases, diabetes, and thyroid problems are associated with dry eye disease. Antihistamines, decongestants, diuretics, Accutane, oral contraceptives, and MAO inhibitors also contribute to ocular dryness. Patients on immunosuppressing drugs may be more susceptible to infection.
• Has the patient ever had a corneal abrasion or other injuries to either eye? Which eye, and how did it occur?
• Has the patient ever had a serious eye infection or corneal ulcer?
• Has the patient had eye surgery?
• Does the patient have any other eye disease (e.g., keratoconus, corneal dystrophies, macular degeneration, cataracts, or glaucoma)?
• How does the patient use his eyes at work and for leisure activities?
• Is the patient involved in contact sports (soccer, football, basketball)?
• What motivated the patient to want contact lenses? The motivating factor is the desire to see and be seen without glasses. Patients with frivolous reasons, such as, “My glasses tend to slip down my nose,” or “I’m always forgetting where I left my glasses,” are not motivated enough to assume the responsibilities of contact lens wear and care.
• Is the patient currently wearing contact lenses, or has she tried them in the past?
• If contact lenses are currently being worn, are there problems with vision, comfort, dryness, deposit buildup, or lens slippage?
• Is the patient currently wearing contact lenses lens part time or full time? How many hours on a typical day?
• If contact lenses were tried and discontinued, “Why did you stop wearing your contacts?”
• What is on the patient’s contact lens “wish list” (e.g., daily disposables, lenses for astigmatism, multifocals, lenses that are better for dry eyes)?
When testing visual acuity, it is important not only to record the near and distance acuity but to record how the patient reads the letters (20/20 easily vs. 20/20 with effort) or at near (J1 easily vs. J1 with effort).
Many practices use automated refractor/keratometers, making it impossible to evaluate the quality of the mires. For practices performing manual keratometry, any mire distortion or doubling should be recorded.
The gold standard for corneal curvature is topography, which will show the contour of the cornea over a much wider area and indicate irregularities. Contact lens technicians who master the techniques of keratometry and topography will increase their skills and save time for the doctor, thus increasing their value to the practice.
A good history of how the “emergency” occurred, followed by a check of visual acuity and inspection of the lenses for buildup, damage, or warpage is essential. Questions to ask the patient include:
• Tell me how your eye feels?
• Is there pain, redness, discharge, or swelling?
• When did the symptoms start?
• Was the onset gradual or sudden?
• Did you try to treat them in any way?
• Did you go to your primary-care physician or the emergency room first?
• Did you sleep with your contact lenses last night, wear them in a smoky environment, or wear them longer than usual yesterday?
• Are your eyes unusually sensitive to light?
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Routine follow-up visits should be scheduled late in the day (except for patients wearing extended wear lenses) because redness, dryness, and other problems tend to show up after lenses have been worn for several hours. Visual acuity should be checked, and keratometry or topography repeated if indicated.
Questions to ask include:
• How many hours have you worn your contact lenses today?
• How many hours do you wear your contact lenses on a typical day?
• What lens care solutions are you using? Patients may have switched from the recommended care solution to a solution that is incompatible with their contact lenses or to which they are sensitive.
• Tell me what you do when you remove your contact lenses at the end of the day? Patients may have switched solutions, may not be rubbing their lenses prior to disinfection, or may be “topping off” the lens case without rinsing their cases and refilling them with fresh solution each day.
• Let me see your contact lens case. Cases harbor harmful micro-organisms. Besides nightly rinses, it is good practice to wipe the case with a cotton ball dipped in alcohol weekly and replace it every time a new bottle of disinfecting solution is started.
When extended lenses are dispensed, it should be emphasized to the patient that “extended wear means extended care,” and they should be told to:
• Instill saline or rewetting drops in each eye upon awakening
• Ask themselves:
• Do I look well?
• Do I feel well?
• Do I see well?
• Instill saline or rewetting drops at bedtime and as needed during the day.
Extended wear follow-up visits should be scheduled early in the day because most problems appear upon awakening. Patients should be asked whether they have experienced episodes of redness, pain, discharge, unusual light sensitivity, or blurred or foggy vision on awakening since their last visit.
Most telephone shoppers are looking for price, rather than quality of care. Many regard contact lenses as a commodity, rather than a medical device that requires careful fitting, thorough wear and care instruction and regular follow-up visits.
When prospective patients inquire about price, the technician should inquire about previous lens wear, including problems with vision, comfort, and handling; satisfaction with current lenses; and whether the patient is interested in a different modality, such as lenses for astigmatism, multifocals, or daily disposables.
The fitting skills of the doctor and the quality of care should be emphasized, as well as the many choices of lenses and care systems that would provide the optimum fit and comfort. Fees should be discussed last, with an explanation to the patient that fees vary according to lens type, prescription, and lens-wearing history.
Some practices offer a reduced fitting fee for previous contact lens wearers. While these patients may save time by not needing instructions on lens application and removal, some patients will require added doctor time due to poorly fit lenses, irregular astigmatism, dry eye syndrome, giant-cell papillary conjunctivitis (GPC), a history of corneal infections and ulcers, or a corneal dystrophy.
Other patients may need more technician time in wear and care education because of a history of non-compliance. It is best to let the doctor determine the fitting fee after all information has been gathered.
Not all patients are successful candidates for contact lenses. They may not achieve the level of comfort or vision that they anticipated, or they may not master lens application and removal. Some patients may have severe corneal irregularities that make them impossible to fit.
A refund policy should be established based on material cost and time spent. Generally, fitting fees are non-refundable because a great deal of time has been spent with an unsuccessful patient.
If diagnostic disposable lenses were used, no material costs are involved. However, if several pair of custom toric or gas permeable lenses have been ordered and tried, there are mailing costs and restocking fees to factor into the refund.
On the other hand, think about future referrals and remember that a rigid refund policy may hurt the practice more than a small refund to an unsuccessful patient. It helps to maintain patient goodwill by applying part of the retained fitting fee to a future contact lens trial.
According to Public Law 108-164, signed into law in December 2003, contact lens fitters must provide patients with a copy of their contact lens prescriptions. The patient should receive the copy when the contact lens fitting is complete so they can obtain lenses from their supplier of choice, even if patients don’t ask for it.
“Fitting” is described as “the process that begins after the initial eye exam and ends when a successful fit has been achieved.” In the case of renewal prescriptions, the fitting is achieved when the prescriber determines there is no change in prescription.
If a third-party supplier requests a prescription, the prescriber must confirm its accuracy by direct communication with the sellerÃ or inform the seller that the prescription is not correct and provide the accurate information. A reason must be given for an invalid prescription (e.g., “expired”).
Non-confirmation is confirmation! If the prescription is not confirmed within eight business hours, the supplier is legally permitted to fill the prescription.
It is important for the contact lens technician to ensure that every request from a third-party supplier is confirmed in a timely manner. Non-confirmation of an expired or invalid prescription could expose the technician and/or the fitter to malpractice.
Prescriptions are valid for a minimum of one year, except in cases in which the prescriber thinks that the ocular health of the patient is at stake such as keratoconus, giant-cell papillary conjunctivitis (GPC), recurrent infections or ulcers, and therapeutic lenses or bandage lenses.
Short expiration dates must be supported by accurate records of medical necessity. The prescriber must include the original prescription and expiration dates and can limit the quantity of even ordinary lenses to be purchased if the expiration date is near.
The scope of practice for contact lens technicians is extensive. On-the-job training, journals, interaction with contact lens and solution sales reps, and conferences (e.g., American Optometric Association [AOA], Southeastern Council of Optometrists [SECO], American Academy of Ophthalmology, and Vision Expo East and West) offer courses to help technicians expand their knowledge base and develop skills that will enhance their value, increase their professionalism, and turn their jobs into careers.