No exam is more important than the first time the patient is being fit in your office; however, the importance of a comprehensive contact lens evaluation can easily get overlooked by busy practitioners. In addition, optometrists often miss a valuable opportunity to both improve patient satisfaction and increase revenue by not initiating the contact lens conversation.
Many patients don’t mention contact lenses because they assume their eyecare provider would tell them if they were candidates; therefore, ODs must proactively bring up contact lenses with more patients.
This first visit sets the stage for the doctor-patient relationship and is important for maximizing future success in contact lens fitting, patient retention to the office, and retention of the patient in wearing contact lenses.
This article outlines a step-by-step process to get new patients and new wearers happily into contact lenses.
Initial patient discussion: Gauging goals
Start by simply discussing what got the patient interested in trying contact lenses. Oftentimes, patients come in with either preconceived notions about contact lens wear that might not be accurate for them, or they may come in as a completely blank slate.
The most essential step when matching and prescribing the right contact lens for the right patient is to first establish goals. Patients also don’t know all of the contact lens options—modalities, materials, and optics—that exist. Contact lens evaluations should be a goal-oriented exam, starting with a series of straightforward questions.
For a comprehensive article and cheat sheet on contact lens modalities, check out The Contact Lens Cheat Sheet: Multifocals, Dailies, Sclerals, and More!
Questions for each type of contact lens wearer
New contact lens wearers:
- How many days a week do you want to wear your contact lenses? Every day, alternate equally with glasses, just for special occasions, or sports/hobbies?
- What kind of work do you do?
- Are you planning to sleep in contact lenses?
- How much time do you spend on screens?
- How important is cost to you?
- How often would you prefer to change your lenses? Daily or monthly?
Presbyopes:
- Are you okay with wearing reading glasses over your contact lenses?
- Do you want contact lenses that allow you to see distance and near without the constant need for reading glasses?
Existing contact lens wearers:
- What brand do you currently wear?
- What solution do you use?
- How often do you discard your contact lenses?
- How often do you sleep in your contact lenses?
- How often do you discard your contact lens case?
- Is there anything that could be improved about your current contact lenses—comfort or vision?
These questions already give us a good idea of what kind of modality we should consider.
Download the Contact Lens Decision Flowcharts here!
📚
Contact Lens Modality and Troubleshooting Decision Flowcharts
These two flowcharts outline the steps to selecting the optimal lens for new contact lens wearers and tips for troubleshooting contact lens fits in existing wearers.
Clinical evaluation of contact lens patients
A current refraction is critical
Prior to discussing any options, acquire an up-to-date manifest refraction! It doesn’t matter if the patient was seen just a few months ago by you or they brought in an outside refraction from an exam yesterday, this step is absolutely crucial.
Without a current refraction, we risk starting the contact lens evaluation on poor footing and losing out on first trial lens success, which all could increase chair time. Also, an accurate refraction dictates what contact lens we can fit to the patient. If the patient has -3.75D of astigmatism at an oblique axis, that definitely affects what options we have for the patient.
Slit lamp exam
The next step before we can discuss lens options with the patient is performing a slit lamp exam. Look for anything that would make fitting contact lenses more difficult. Ocular surface disease, corneal irregularities, eyelid issues, and history of corneal refractive surgery can all affect how a contact lens behaves.
Conditions that can be treated prior to contact lens wear, like dry eye and meibomian gland dysfunction, should be addressed to ensure patient comfort and clarity in the contact lenses. Some issues—such as post-refractive corneas, keratoconus, high or irregular astigmatism—may require specialty contact lenses to solve, which can limit options that we bring up to the patient.
Avoiding common pitfalls when fitting contact lenses
To bypass later confusion and disappointment, refrain from discussing options before examining the patient, completing their refraction, and talking to them in-depth about their expectations. For example, with one of my patients, the discussion centered around the benefits of daily disposable contact lenses, which resulted in the patient becoming very excited about trying daily disposables.
However, their refraction revealed 3.25D of oblique astigmatism. This discovery meant dailies were not an ideal option because there weren’t parameters available in his exact prescription. This required a pointed conversation.
Similarly, upon completing a contact lens evaluation on a different patient, they asked at the end of the exam, “What color can I get these in?” Sadly, this meant completely restarting the fit with the new consideration of a lens available in colors, which could have been avoided had the patient been asked about color contact lenses at the beginning of the evaluation.
These are prime examples of why it’s important to get as much information as possible prior to lens selection.
Selecting the right lens
Once the practitioner has gained a complete picture of what the patient wants to get out of contact lens wear, it is time to start discussing different contact lens options that will accomplish the patient’s goals.
For a part-time wearer (i.e., less than 5 days a week on average), a daily disposable is almost always preferred due to the following factors:1,2,3
- Convenience for the patient
- Lower risk of complications like microbial keratitis or giant papillary conjunctivitis
- Better patient wear-and-care compliance
Key considerations for choosing a contact lens
Cost
Of course, cost can be a limiting factor. However, when the patient is a part-time wearer, the annual cost of daily disposables becomes equal to or less than the cost of reusable contact lenses, so there is really no good reason not to opt for daily disposables at that point.
For those patients who want to wear contact lenses every day, discuss the pros and cons of daily disposable over reusable contact lenses, as well as the annual supply cost difference after accounting for rebates and the estimated cost of solutions.
Daily disposable contact lenses have become more affordable and are available in silicone hydrogel, which may work well with their lifestyle, allowing patients to decide which option works best for them.
To learn more about the impact of contact lens materials, read Do Differences in Contact Lens Materials Matter?
Lifestyle
A patient’s occupation also plays a critical role in the lens selection process. Patients, such as firefighters, have three 24-hour shifts per week where they sleep on site and need to wake up and get going at a moment’s notice to respond to a call.
They cannot waste time putting in contact lenses when responding to a call, and often have a hard time wearing glasses under their protective mask. These patients have often told me that no matter what, they are going to sleep in their contacts.
With that knowledge, it is logical that they be fitted with a lens approved for continuous wear. Because these patients work 24 hours on, 48 hours off, I have them only sleep in their lenses when they are on duty and remove the contacts nightly when they are not. This way, we limit the amount of risk of microbial keratitis by limiting how many nights they sleep in their contacts.
As an aside, patients should not routinely sleep in their contact lenses, as it always increases the risk of complications. However, sometimes it’s unavoidable and, therefore, important to put those patients into an appropriate lens.
Table 1: List of contact lenses and the associated length of time they can be worn.
| Lens | Brand | Approved Duration of Wear |
|---|---|---|
| Air Optix Night and Day | Alcon | 30 days continuous |
| Purevision | Bausch + Lomb | 30 days continuous |
| Biofinity EW | CooperVision | 6 nights/7 days |
| Ultra | Bausch + Lomb | 6 nights/7 days |
| Oasys | Johnson & Johnson | 6 nights/7 days |
Many occupations require extensive screen use; with these patients, present a contact lens with specific optics, such as DigitalBoost Technology, to help reduce visual symptoms of digital device use or HEVL (blue-light) filters.
Don't forget to check out the Contact Lens Modality and Troubleshooting Decision Flowcharts!
More reflections on refraction
When looking at the patient’s refraction, there are a few decisions that will be based on the findings.
Astigmatism
With astigmatism, any refraction with 0.75D of cyl or more can possibly benefit from a toric contact lens.5 I demonstrate to the patient in-phoroptor the difference with and without the astigmatism correction to see if they would benefit from correcting it in the contact lenses.
If they say the vision is clearer with the astigmatism correction, go over the differences in design, fit, and cost of a toric lens, and let the patient decide if they want to proceed with a toric design or a standard spherical lens.
Then, determine what brands come in their prescription. Not all lenses have around-the-clock axes, and some non-custom brands only go up to -1.75 cyl in certain parameters, while others go up to -2.75 cyl.
When fitting toric lenses, monitor their settling time. Oftentimes, it will be obvious right away that a particular brand is a good fit for that patient based on how long the lens takes to settle accurately. Ideally, the lens should have ample time to settle, but don’t allow an excessively long time, as that could negatively impact the patient’s experience in contact lenses.
Presbyopia
When fitting presbyopes, go over distance-vision-only vs. multifocals vs. monovision.
There are pros and cons to every modality, and no single option is the best for every patient. If the patient only wants contact lenses for sports like golf, tennis, baseball, or anything else with small and/or fast-moving objects, maintaining crisp distance vision, depth perception, and contrast sensitivity can be important to these patients, which can be reduced with monovision and multifocals.6,7,8
Alternatively, if the patient spends 10 hours a day working on a computer and reading, they may love a multifocal that provides good binocular near vision and not mind losing some crispness to their distance vision.
Also, as many presbyopes are first-time contact lens wearers, it is critical to spend an ample amount of time training them on the insertion, removal, and care of their specific modality.
Tips for training first-time lens wearers
For new contact lens wearers, success depends largely on understanding how to insert, remove, and care for their lenses. Some reasons for early dropout among new patients include discomfort and difficulties handling contact lenses.9
When training patients on inserting and removing contact lenses, ensure they practice proper hygiene by washing and drying their hands with a lint-free towel. Teach patients the correct orientation of a contact lens, which should resemble a bowl.
For those using biweekly or monthly lenses, emphasize that tap water should never be used, and storage cases should be replaced every 1 to 3 months, or as recommended by their eyecare professional, to maintain lens hygiene.
Download the Contact Lens Decision Flowcharts to share with your patients. Focus on providing strong early support for new wearers and follow up early to see how they are coping at home.
5 key takeaways
Lastly, there are some things I’ve learned over the years that make my contact lens evaluations go more smoothly that I’d like to share:
- Always discuss options with the patient and let them make the final decisions. When the patient has some autonomy in their medical decisions, they are more likely to commit to them.
- Don’t assume the patient always wants the most cost-effective option. Determine what’s most important to the patient; people are often very willing to pay the premium to accommodate their goals/desires.
- When putting patients in lenses for the first time, have them look down and to the side opposite the eye you are inserting the lens. The temporal conjunctiva has the most “real estate,” and having the patient look down allows them to not see you coming at them, so they won’t squeeze/resist as much.
- Utilize the auto-refractor as an over-refract estimator to help guide Rx changes. This greatly improves the efficiency of finding the absolute best Rx for the patient in the least amount of time.
- If the contact lenses aren’t “behaving” like they should or over-refractions come out looking odd, get a corneal topography. Post-refractive and irregular corneas don’t always respond predictably to standard soft contact lenses. Don’t waste time spinning your wheels trying lots and lots of different trials on a patient before investigating further.
In conclusion
These clinical pearls are meant to allow you to maximize patient satisfaction when being fit into contact lenses for the first time, while still maintaining an efficient office flow with minimal chair time.
As contact lenses can provide an amazing improvement in a patient’s quality of life, it is important to share the latest available options with as many individuals as possible.
