The roundtable

Support, support, support: proactively engaging contact lens wearers

How can practitioners prevent contact lens dropout, and what methods are they using to achieve this? OT  sought to find out

glasses and contacts
Getty/Svetlana Monyakova

The world of optics has changed over the past 12 months – from increased use of remote consultations to greater numbers of contact lens fits for those tired of finding their glasses impossible to manage alongside a mask or face covering. How can optometrists navigate these new challenges, and what tools are at their disposal to help them do so?

In a roundtable discussion hosted by Alcon and OT, three experienced eye care practitioners (ECPs) discussed contact lens dropout, managing the expectations of and supporting the journeys of patients, how the contact lens side of their business has weathered the storm of the previous year, and the place of future technology in contact lens management.


Dropout: tackling discomfort, vision and handling

Sandip believes that, with better products, discomfort has become less of a problem. “My philosophy is to optimise your ocular surface and tear film in order to maximise comfort,” he said. “And that, combined with better products, tends to give me fairly good results.” He also cited regular communication with the patient as a key way to reduce dropout.

Irish optometrist Fiona Kavanaugh finds that, for her patients, comfort is a greater concern than vision. She told the group: “I sometimes put in a lens that I know is not as comfortable first, and then I follow it with a lens that is much more comfortable, and it gets rid of the price issue because they realise the value of comfort.”

She finds that explaining her own experience as a new user of multifocal daily contact lenses, which she now uses for the majority of her daily tasks, helps her patients with any vision issues. She is also aware that there is no magic bullet when it comes to confidence in handling, and has brought patients back as many as four times for coaching sessions, as well as utilising videos to demonstrate insertion and removal.

Like Sandip, she has also found that good management of the ocular surface is a “huge” factor, and that encouraging patients to use ocular lubricants in the morning and evening has been helpful, “so that you're putting the contact lens onto a good surface.”

She explained. “When they see the image on the screen, and they can see the red areas and orange areas that are drying, they completely understand why they have to do something. That has been a great help.”

Providing patients with heat bags, eye masks and lubricant drops, and encouraging them to think about omega-3 levels, has also been positive, Fiona added. After a couple of weeks of these actions, she has found more success when they have returned to practice.

Former British Contact Lens Association president Keith Tempany agrees that “sometimes you need three or four coaching appointments, especially with kids.” He added: “We do a lot of contact lenses, and sometimes the first visit is just chatting, and showing them the videos, getting to feel a lens, maybe having a go. But then, maybe just let them think on it and watch the videos at home.

“In COVID-19 times, the videos are really useful. We email them out to patients before they come in for a teach, so they've already got an idea of what's expected, then we play them again at the start of the session.”

He also emphasises the importance of having a quiet area in the practice for the coach, where no one is watching.

Ultimately the most important thing, Keith believes, is to “make sure that the patient is confident and competent before they actually take the lenses home.”

“If we aren't doing the job properly when coaching,” he said, “we're going to have handling issues. If they're really comfortable and confident with putting them in, taking them out, and the hygiene aspect, that's surely one of the easiest issues to get rid of.”

Managing expectation

For vision, pre-empting any issues is also essential for Keith: “You need to talk to the patient, to tell them that contact lenses will do probably 80-90% of what they want, near vision-wise,” he said.

“We call it a visual wardrobe, where you have different balances and prescriptions for different uses. We have different shoes for different outfits and for different things that we do, and it should be very simple with daily disposable lenses to just explain to patients that one pair of lenses can't do everything that you want them to.”

Keith also pointed out that, for a variety of reasons, patients may not actually tell you that they're suffering from discomfort. Acceptance of discomfort as normal (“that's what contact lenses do”), or worries about the lenses being taken away, should be considered.

“I think you've got to really use your probing question technique at the aftercares,” he said. “That's where we pick up most of the challenges. You've got to choose your questioning carefully to establish the true wearing time.”

I do believe that there is a tendency to brush comfort issues aside, and perhaps not address them as well as we should do, based on the fact that it's another problem that'll need solving

Dr Sandip Doshi, optometrist and clinical consultant

He added: “I ask them to explain what they do at the end of the day. What's their routine? What do they do with the case? We check their cleaning habits and their case hygiene, because that can influence the culture of reusable lenses towards the end of their lifecycle.”

Sandip believes that there can be a tendency to prioritise vision over comfort, and that this needs to change: “I think we don't address it enough. I tend to ask patients: ‘Are you getting enough hours of comfortable wear? Do you feel you need more?" We need to be much, much more proactive in asking those questions.”

Fiona asks her patients to score their comfort out of 10, and is dissatisfied with any rating below a seven – something that the other practitioners agree with.

Keith reiterates that, when it comes to dropout, “you've just got to take every patient as they come, with their own problems, their own wearing times, their own workplace, their own hobbies. You've really got to know your patients. To actually show patients, visually on the screen, what their eyes are doing, helps with an awful lot of things, mostly with dry eye. It’s the old adage that a picture paints 1000 words.”

Providing support

Keith reiterates that effective follow-up is key to reducing dropout, especially among new patients, who “need a little bit more TLC, whether it's in sorting out dry eye issues, or just investing the time.”

New wearer support programmes, he believes, can be useful in highlighting problems, “so that patients can then contact you for an appointment to then sort them out. This can help focus on what the issue is, and potentially save time.”

For patients, he finds that the journey is a vital factor in whether dropout will occur. He added: “I always think it's better to under promise and over deliver. You do get patients where they don't need that TLC, but it's good to make sure they're aware that you're there for them at any point.”

It is important that you don't rush them at the teach. I see it as an investment in time that will be rewarded by loyalty and long-term contact lens wear in the future

> Keith Tempany, contact lens practitioner and former president of the BCLA

Sandip’s focus is also on “support, support, support” – before the fitting to ensure suitability and that the lenses aren’t too difficult to handle, and during the wearing, particularly with new wearers.

He said: “We've set up communication that allows patients to get in touch with us. We use WhatsApp Business, because everybody has WhatsApp on their phone. They can ping a message to the practice, and one of three practitioners will pick it up. We've been able to support patients literally round the clock with this. The fact that people know that this service is there inspires a lot of confidence.”

He emphasises the importance of support continuing as wearers become more experienced, too, so that they know that they can come back regularly for aftercare, to discuss any concerns, “and, in time, to discuss better and newer products as well.”

Sandip adds: “We do make a point of letting patients know that there will be discussion going forward: that things change, including products that may be more appropriate for their prescriptions or their requirements.

“The key in my opinion is to offer support at all levels throughout that journey, in order to make sure that they know. We've got their back.”

Contact lens business: staying robust through national lockdowns

For Fiona, the contact lens side of her business “has held up very well” through three national lockdowns.

“Contact lenses got us through the first lockdown, in terms of turnover, because we weren't seeing patients,” she said. “We did emergencies only. We had a lot of contact lens orders the first two weeks of lockdown.” New fits, she has noted, include those struggling to wear glasses with a mask.

Sandip also found that his practice’s contact lens scheme and direct debits brought in vital income.

He said: “We made a point to get in touch with our contact lens patients to reassure them that, if we were to go into a national lockdown, there would be no issues with getting contact lenses to them.”

The key in my opinion is to offer support at all levels throughout that journey, in order to make sure that they know. We've got their back

Dr Sandip Doshi, optometrist and clinical consultant

Practice staff also contacted infrequent wearers, and asked if they would like lenses to be ordered in case a lockdown did take place.

“We found a huge uptake on that,” Sandip said. “Lots of people really appreciated the fact that we were being proactive in making sure that they had ample supply to see them through. It was certainly financially a saving grace for us.”

He’s also taken on contact lens work “with people who are getting fed up with the fact their glasses steam up all the time, particularly those habitual spectacle wearers who are struggling to get out and about.”

Contact lenses and the future

Keith has begun considering how he may be able to carry out a contact lens fit remotely. He believes that new technology, with the ability to video call and assess red eye, “could be quite an interesting development later,” but that it's currently too early to consider it as a replacement for an in-person contact lens check.

Sandip also believes that new technology has its place in the future: “It adds a new dimension, when we are doing virtual consultations with patients, in order to stay in touch, or for them to upload images to be analysed with the software, or to have a virtual consultation. I think digital technology will probably change how we work going forward. I don't believe it will replace face-to-face consultation, but I think it will help us identify those patients that need a face-to-face consultation, and perhaps prioritise them.

“Ultimately, I think COVID-19 has really made us realise that there are different ways to do what we do, and perhaps it doesn't need to be always face-to-face. It may not be in the best interests of the patient; it might not be in our best interests to be seeing patients face-to-face all the time.”

I think this has really made us realise that there are different ways to do what we do, and perhaps it doesn't need to be always face-to-face. It may not be in the best interests of the patient

Dr Sandip Doshi, optometrist and clinical consultant

Sandip would like to see flexibility from the GOC to allow virtual fittings and virtual consultations to continue, particularly with asymptomatic patients, giving the practitioner the ability to make decisions on whether a face-to-face appointment is necessary.

He said: “I believe the blue-sky situation would be that virtual consultations will become a real reality in the future. But obviously, with the proviso that the practitioner is ultimately responsible for making that final decision as to whether or not that patient can be signed off virtually or whether or not a virtual consultation is just the means to suggesting the patient needs to be seen in practice.”

Keith questions whether, if remote fitting becomes a more permanent reality, a rise in dropouts will be seen as a result of missed nuances that can be more easily picked up during an in-person consultation: “There is that little look when you ask them, “Do you ever sleep in your lenses?” And you know they do by the way they just answered you.”

Sandip believes that “it could swing either way… I think really the key to this is going to be the practitioner’s skill in deciding, ‘is that patient really giving me the fullest picture of what's happening to them?’ And if there's any element of doubt, let's not forget that there will always be the opportunity to get that patient in.”

Alcon and OT host the roundtable discussion with three experienced ECPs