16 December 2024
The scenario
As a locum optometrist, the time I have to get to know a patient is condensed – I may never return to the practice again – so I want to ensure the conversations I have and the recommendations I make are meaningful. Can you share tips on getting the right information from patients regarding their current lenses to ensure they are as comfortable in their contact lenses as possible?
Rebecca, locum optometrist
The advice
Clair Bulpin, optometrist and Johnson & Johnson Vision team faculty member
Meaningful conversations are essential to getting the best out of an interaction with a patient when it comes to contact lens wear. We need to be able to confidently make tailored and personalised recommendations that suit the specific and individual needs of the patient. There is a person behind those eyes, and everyone is different. Being ‘routine’ about your ‘routine’ is not in anyone’s best interests.
I have several roles within education and quite often adopt the petulant toddler approach of repeatedly questioning why. I try to help my students understand that to add value, you need to understand exactly why you have posed a question to the patient, or exactly why you have looked for something on your slit lamp. It is not enough to simply ask the right question, we need to understand why it is the right question to ask.
We often fall into set lists of questions and similar conversations on repeat – maybe these are guided by computerised record systems, maybe it’s the comfort of a routine you are settled into, but it is important to remember that a series of closed questions does not feel like a conversation. Consider what you really want to know to be able to give great advice.
There is a person behind those eyes, and everyone is different. Being ‘routine’ about your ‘routine’ is not in anyone’s best interests
Yes, it is important to understand a patient’s contact lens wearing patterns, and I’m not suggesting that finding out how many days a week they are worn and for how long they are worn for is not important, but I could controversially argue that this is far less relevant these days than in years gone by. That is part of a set of questions I was taught at university, when soft contact lens material choice was limited to high or low water content hydrogels, and we were arguably allowed to be concerned about oxygen transmission.
In 2023, silicone hydrogels accounted for almost 90% of the soft fits in the UK,so we may need to reconsider which questions now add the most value.
The key is in the questions
I may prefer to start by asking whether a patient is using their contact lenses as much as they would like to these days, or I may reference a previous record and comment that last time they were using the contact lenses for x,y and z – is this still the case? It can also be useful to find out if there are any times when they would like to wear their contact lenses but don’t. Referencing a previous appointment, which as a locum optometrist, is unlikely to have been with you, can make for a more personalised encounter.
In most cases the shift from being a happy contact lens wearer to unhappy contact lens wearer is a slow one. There will be subtle and small changes initially. These may be so subtle in fact, that the patients themselves may have not yet realised that they are adapting to a new regime. This gives us a real opportunity to intervene ahead of bigger changes.
It is not enough to simply ask the right question; we need to understand why it is the right question to ask
A lot of practitioners are fond of rating comfort out of 10. For example, wearing time hours and wearing days. This is another ‘number’ to record, but only has real value if we seek to explore and understand it further.
Where are we setting our benchmarks of acceptable on this number scale? If a patient responds eight or nine, is that good enough? Getting the right information from a patient has to mean being in a position to act or recommend options if applicable.
Ratings of comfort are without a doubt subjective. We will all know of someone who can stub a toe and move on seemingly unaffected, whereas someone else may howl with pain and hop unnaturally for a period of time afterwards. This number on its own doesn’t add value to the interaction and certainly doesn’t help guide the conversation unless it is explored further.
Dry eye discomfort is not exclusively in the realm of the contact lens wearer and to add context, I’d recommend an additional starter question. It can be quite insightful to understand what their comfort rating may be on a non-contact lens wearing day. Consider asking how they would rate the comfort of their eyes overall. Having treated many dry eye patients over the years, the biggest wakeup call I received from a grateful patient was when they commented that they didn’t realise they weren’t supposed to ‘feel their eyes.’ Now this was an extreme, but it made me reflect that we shouldn’t necessarily attribute discomfort to the contact lens, if we haven’t also explored their general comfort without them.
If a patient describes their typical comfort without contact lenses as seven and in contact lenses as seven, this is a very different pathway of discussion to someone who describes the same elements as 10 and seven.
Historic comfort is valuable too. If the lenses are now a seven, but previously were five, it doesn’t mean we can’t seek to improve, but it may indicate what changes have already helped.
Ensuring that the patient remains comfortable in contact lenses for the long term means we need to not just ask the right questions, but fully explore the answers
The full story
The comfort ‘score’ in isolation doesn’t tell the full story. How about a scenario where the patient is using their contact lenses five days a week, 10 hours a day and rates comfort as 9 out of 10, even at the end of the wear? At first glance, this all seems pretty good. But if further conversation reveals that they used to wear the contact lenses seven days a week, comfortably for 14 hours a day, but changed because they noticed that the longer wearing times now make them less comfortable, this is information that might not have been readily apparent without the delving deeper.
In an ideal world, what would the patient’s contact lens experience be? That’s what we are striving to provide. But this is malleable: their needs will change, their environment may change, and their eyes will change. Ensuring that the patient remains comfortable in contact lenses for the long term means we need to not just ask the right questions, but fully explore the answers. Most of the jigsaw pieces will give you an overall view, but you will miss the intricacies in the detail. Consider what you really want to know and ask the questions that will give you those answers.
