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The roundtable

Offering the opportunity of contact lenses to everyone

ECPs from the UK, Sweden and Norway discussed the needs of presbyopic patients with astigmatism and how they are introducing Bausch + Lomb’s ULTRA® Multifocal for Astigmatism into practice, in a recent roundtable hosted by the contact lens company and OT 

For many optometrists, fitting presbyopic astigmats with contact lenses has seemed a daunting task and might even have been a conversation they opted to steer away from. As the lifestyles of presbyopic patients increasingly change, becoming more active in their social and working lives, so the demands on their vision have changed.

This January, Bausch + Lomb introduced its new contact lens for presbyopic astigmats, aiming to meet the needs of this patient group.

Expanding the monthly contact lens family, the Bausch + Lomb ULTRA® Multifocal for Astigmatism features MoistureSeal® technology, a 3-Zone Progressive DesignTM for seamless vision, and OpticAlignTM Design to offer stability.1,2,3

Six eye care professionals from the UK, Sweden and Norway met for a virtual roundtable, hosted by Bausch + Lomb and OT, to discuss the needs of this patient group and how they are using the Bausch + Lomb ULTRA Multifocal for Astigmatism in practice.

Bausch + Lomb Ultra multifocal for astigmatism

A video of highlights from the roundtable discussion can be viewed on OT’s YouTube channel
 

The patient group

The roundtable began with an exploration of the needs of presbyopic astigmats and Joseph Seaman, from Claudine Ickeringill Optometrists in Chichester, suggested these have changed dramatically in the last 30 years.

“From the thought of the person sitting in their chair and knitting, or reading a book whilst watching television,” Seaman compared, “now we think of someone doing a range of different outdoor and dynamic tasks; driving and driving at night, sports, alongside all the close-up hobby tasks and the digital devices we are all using much more.”

While the astigmatic presbyope might have similar challenges to any presbyope when it comes to contact lens wear, Seaman suggested: “Historically, especially within the contact lens market, we haven’t had the same tools to deal with those challenges.”

David Barker, of Rawlings Opticians, Croydon, agreed that presbyopes are living more active lifestyles, suggesting that traditionally when they reach the 40–50 age range, “it is suddenly monovision or glasses over the top, and that doesn’t really work with most presbyopes now.”

Describing their need for both middle distance, and distance vision, for a range of tasks from working on computers to driving, Barker summarised: “It’s balanced vision that they want, and that is the stumbling block we’ve always had up until now.”

Michelle Beach, from Park Vision in Nottingham, shared: “When I first qualified, if you had astigmatism, it was almost a ‘no’ for soft contact lenses; you went into a rigid gas permeable lens (RGP). Now, with the market for single vision toric contact lenses, there’s very little that you say ‘no’ to with the range and the axes available.”

Considering how he approaches patients emerging into presbyopia, Barker shared: “I think I'm almost planning in my mind the presbyopic discussion about three or four years before they become presbyopic, warning them that we're going to have to start getting used to some compromise here and there.”

The needs of presbyopic patients have recently shifted again. Pointing at the experience of the past year, Seaman suggested that with a large proportion of presbyopic patients working and likely used to face-to-face meetings where their current visual solutions might have worked well, “a lot of those meetings are now online and will continue to be, so I think there’s a lot more concern about intermediate vision and balanced, comfortable binocular vision at intermediate.”

Beach suggested this forms a conversation that optometrists are having with presbyopic patients around the potential benefits contact lenses could offer. “This is the beauty of contact lenses because with the multifocal contact lens, you can look straight ahead and see what you are doing,” she said.

Navigating the conversation

When introducing the idea of multifocal contact lenses to presbyopic patients, particularly those with astigmatism, some practitioners noted a reluctance born of past experiences or conversations about suitability.

Sarah Smith, of Page and Smith Opticians, Harrogate, shared that when she prompts the conversation with patients about the option of contact lenses, often, patients believe they are not suited for them, have been previously told that it is not an option for them, or dropped out of rigid gas permeable lens wear.

Despite this, she said she had found the contact lens trialists of the Bausch + Lomb ULTRA lens to be a “really enthusiastic bunch.”

When it comes to managing patient expectations, Smith explained: “I generally tell them the contact lenses will do 95% of what you want them to do, so they have always got in mind that, maybe if I’m doing a really long distance drive, I might not wear them, or if I’m threading a needle, they might not quite do that.”

Barker shared that in the past, “I’ve probably tried to undersell them,” but with newer technologies available, he has aimed for a more “positive” approach whilst managing patient expectations.

The different expectations existing daily or monthly contact lens wearers might bring to multifocal wear is also an important factor in managing those expectations, Seaman said. While a daily contact lens wearer might have specific tasks they would want to wear the lenses for, Seaman suggested that monthly wearers might feel their contact lens option needs to work across their visual tasks.

Compromise or balance?

A key phrase brought up throughout the discussion was that of ‘compromise,’ and ECPs questioned if this term should still be used.

Reflecting on this language use around presbyopic patients, Barker pointed out that even varifocal spectacles have a form of compromise, commenting: “They all compromise somewhere but we don’t talk about this with multifocal spectacles, so maybe we should get out of this talk about compromise and start looking at it more positively.”

Seaman suggested: “I think patients often respond well to compromise if they are in charge of that compromise.”

As well as talking about the freedom contact lenses can offer, he advised drawing the patient into the decision-making process of what they want from their vision.

Smith agreed, adding: “I’ve even written it on the boxes – these are the reading options, this is a distance option, tell me which you like.”

She added that she is consciously trying not to talk about compromise but instead discusses “balanced vision.”

I think we do need to open that concept out to our patients around there being options for the different tasks you do, even when it comes to your vision

Dimple Zala, professional affairs manager UK/Ireland & Nordics for Bausch + Lomb

Stefan Skjöld, Skjöld/Skjöld & Grönvall, Sweden, also found that patients are used to a degree of compromise, even within their spectacles and the directions they are able to read or view through their lenses, particularly noting that they get more freedom in vision from their contact lenses.

Co-chair of the roundtable, Dimple Zala, professional affairs manager UK/Ireland & Nordics for Bausch + Lomb, commented: “It’s great to hear that we are moving on from the word compromise” with the available technology moving forward, adding that, “of course that little compromise is still there, but it’s nowhere near as much as what it was.”

Sharing the analogy of a ‘wardrobe of options,’ like having a range of shoes for different activities, Zala suggested: “It is the same with vision correction.”

“How are we limiting ourselves and our patients with just one pair of varifocal spectacles, or just one multifocal contact lens? I think we do need to open that concept out to our patients around there being options for the different tasks you do, even when it comes to your vision,” she explained.

A true multifocal

Following the launch of the Bausch + Lomb ULTRA Multifocal for Astigmatism earlier this year, practitioners discussed their reactions to the lens and how they are using it in practice.

Sharing his satisfaction with the new contact lens, Skjöld felt a key factor in the success of the lens has been its stability3. He suggested this is particularly important for this group of patients, where a lot of lens movement could be distracting.

Describing being “pleasantly surprised” by the contact lens, Smith shared that with an older core patient base at her Harrogate practice, “the challenge there is do we go straight into a high add?”

Giving the example of patients who had been using modified monovision, she shared that though initially concerned about putting them into a high add and whether this would “completely kibosh the distance vision,” she found that they had much better reading vision without taking too much off the distance vision.

When the lens became available, Beach explained that she already had a list of patients she was keen to try it with and described seeing several ‘wow’ reactions from patients.

“We can’t climb inside their heads and see what they are seeing,” Beach explained, “so although sometimes we think they are seeing well – it’s a 6/6 – but it’s not a clear 6/6 perhaps, or there is a distortion.

“I think sometimes we don’t quite understand that they are compromising,” she added. One trick Beach found was that, in some instances, the axis can be a few degrees off centre and still work effectively: “Advice that I would give is don’t worry if you are not quite on the axis.”

She highlighted her initial nervousness around moving some patients out of their premium material, high water content daily lenses into the monthly lens, but shared that nobody had complained of discomfort or dryness, or felt they were taking out their lenses more.

A benefit of the new lens for Barker has been the blended design, and being able to offer what he called, “a true multifocal,” receiving positive feedback from patients. “I’ve had a couple of patients say: ‘I’ve never seen as good as this with any option you’ve given me before’,” he said.

Simplicity is another key feature of the fitting process for the new contact lens, Barker shared. “It’s not a complicated fitting process and you can tweak it here and there but it is relatively straightforward. I’m not juggling two or three adds like I have done in the past.”

Geir Kjolberg, of Lillestrøm kontaktlinse-institutt, Norway, also described the product as easy to work with. He offered positive examples of patients who reported being “fantastically happy” with the lenses and their vision.

ECPs also explained that the available stock and speed of orders has been an influencing factor in their positive reaction to the lens.

Beach shared: “I’m finding it really easy to order and the lenses are coming in a couple of days. Patients are booking in and we have already got the trials in place for them. If there is a tweak that needs to be done then they are coming through so quickly – in two or three days.”

Problem solving with presbyopic patients

Key to communicating with patients about contact lenses is asking the right questions and considering how the lenses might benefit different aspects of their lives.

In Beach’s Nottingham practice, contact lenses are discussed with every patient. “We always have a big discussion about patients’ social lives, activities, the sort of things they want to do,” she said.

For patients who aren’t sure or haven’t previously had an interest in contact lenses, communicating ideas of when contact lenses would work for them can help, Beach said: “I think that is when they start to get their heads around the idea that, ‘This could be quite a good thing for me.’”

“All my staff are very on board as a team and are suggesting contact lenses as well,” she continued, highlighting: “I think if you can discuss your own personal experience, that really helps.”

Kjolberg also noted the benefit that a passionate team can bring to promoting the benefits of contact lenses, sharing that his team members are “very keen on contact lenses and they are very glad to share all the opportunities and positive things about contact lenses.”

When it comes to fitting a patient with multifocal contact lenses, Skjöld shared that he explains the differences they can expect from their glasses to the lenses.

“I put the lenses on and then I go on talking, so they can adapt to the lenses,” he shared, emphasising that often he won’t start with the reading chart. “When they are tired of listening to me, they start looking. Even if I go on talking. They will say, ‘Now I can see better.’ Then it’s explaining, ‘Well, this is just a trial lens, we go from here and we can make it even better.’”

I think we always want our patients to know that we’ve got their best interests and their best eye care and health at heart

Michelle Beach, founder and optometrist Park Vision, Nottingham
 
Smith, too, doesn’t opt for a reading chart when patients first experience multifocal contact lenses, but asks them to look at their phone instead, adding: “There is always a bit of a ‘wow’ when they look at their phone.”

She agreed that a key aspect of the conversation is to say, “this is good, this is our initial vision, but it’s only going to get better from this point on.”

Really getting to know patients and what visual solutions might suit them, Seaman described, is “just about problem solving.”

Asking the patient about their hobbies isn’t always the best approach, Seaman cautioned, as people will immediately think of hobbies, even if they are occasional, over their day-to-day activities. Instead, he suggested asking questions to understand what is important to the patient, and what is important to their vision, such as ‘what do you use your eyes for?’ and ‘how do you spend your time?’

Judging when to make an intervention is important, Seaman suggested, and while some patients know they are having an issue and might attend the practice with this in mind, “sometimes it’s not necessarily a problem they know they are having.”

“You can find out by listening initially, by asking follow-up questions and ultimately by measuring,” he said, suggesting that putting up a reading chart or holding up their phone and introducing a boost over what they have could be a way to provoke the discussion. He added: “There is always a limit to what people will give in terms of communication, so you can elicit a response by showing them.”

Agreeing, Beach shared: “I think we always want our patients to know that we’ve got their best interests and their best eye care and health at heart.”

She highlighted the importance of keeping patients informed and up-to-date on new technologies: “I think if you’re passionate and excited about these new developments, your patients get excited about it too.”

Getting the team involved, seeking the opportunities and finding creative approaches

With the new lens available, practitioners discussed how they plan to introduce the Bausch + Lomb ULTRA Multifocal for Astigmatism to more patients in the future.

Finding that patients have been keen to try the lenses, Smith shared plans to identify any patient that might be suitable for a trial of the new lens, suggesting that patients who have previously dropped out of contact lens wear represent particular areas of opportunity.

She said: “They might have been quite happy wearing their RGPs or soft torics until they hit 40, some dry eye issues crept in and then a bit of presbyopia and so they may have had a good 10 years out of lenses.”

Just being able to inform the patient of how much the technology has changed in this time, Smith shared, gets patients excited that they might have the opportunity to get back into contact lenses.

Kjolberg also described his intention to use the lenses a lot more, adding that discussions with other practitioners, such as the roundtable, “make me also want to try to use it more.”

It’s just about being creative and trying to efficiently use your chair time as much as you can

Joseph Seaman, practice owner and optometrist, Claudine Ickeringill Optometrists, Chichester
 
Barker described his plan to “get the whole practice team involved,” sharing: “Previously I think, most of us have probably been a little bit reluctant to talk to these astigmatic multifocal spectacle wearers about contact lenses.” He added that now the options are available, “we will start looking at our patient base and being proactive with looking at those parameters we can fit.”

He continued: “I think we should be getting that message out there to patients that we have got answers for you now where perhaps we didn’t before.”

Beach related to the past concerns around fitting presbyopes, sharing: “It’s nice to have an option now that is probably going to be quite successful if you’ve got the right prescription with the right parameters.”

One member of the team at Beach’s practice is a designated ‘contact lens buddy’ who follows up with contact lens patients, and who patients can contact via email.

“She’s gone through every single contact lens patient to see who’s compromising or who would be suitable who’s dropped out of lenses,” Beach explained. The practice has also asked a patient who has benefited from the new contact lenses to write a blog post testimonial which will be sent to patients via a newsletter.

For many practices, high numbers of bookings might be a challenge in balancing how proactive they can be about contacting patients for a trial, Seaman identified, but added: “Even if you’re fully booked for five weeks, it doesn’t mean to say you can’t be proactive and think, that person is booked in two weeks, they’ve got astigmatism and might be interested in contact lenses, maybe I’ll just order a trial in their prescription so it’s sitting in their card.

“That way I can have a conversation with them at that appointment and if they want to try it, it is there,” he said. “It’s just about being creative and trying to efficiently use your chair time as much as you can.”

Skjöld, meanwhile, suggested that a successful contact lens fit can be positive for promoting the contact lens further, noting: “We can get a lot of ambassadors out in the community.”

Concluding the roundtable, Zala suggested that while the product could be a “practice builder” it could also be important for patient loyalty as an “opportunity to really offer the benefits of multifocal contact lenses to these patients.”

Highlighting the comments around proactively and confidently introducing the benefits of the contact lenses, Zala shared: “I think that’s fundamentally where we can all start.”


As an optometrist how would you advise an ECP who might be struggling with the astigmatic multifocal fit? Why should they be confident?

Dimple Zala, co-chair of the roundtable, and professional affairs manager UK/Ireland & Nordics for Bausch + Lomb

I think it is about offering the opportunity to everyone and being proactive. We know that everyone will have a time when spectacles are inconvenient. If we can have that broader thinking around ‘one solution doesn't fit all tasks and activities within a person's day,’ then we can really open our eyes and those discussions with our patients around the opportunity of having a vision correction option that actually works for them for that particular task, and giving that patient the confidence of not having to compromise.

We’ve talked about compromise around fitting multifocal contact lenses, but that is a thing of the past now, with advanced technology, materials and designs. It’s also a part of our obligation as optometrists to be in a position to offer whatever we see as the right thing for the patient and have that open discussion.

Multifocal contact lenses may have been shied away from in the past because there’s this myth around them being really tricky to fit and involving a lot of chair time. But I think what the group actually brought to the forum is that it isn't that difficult. Providing practitioners follow the fitting guide that’s associated with the particular lens, we’re not spending any more chair time.4

We’re also reducing the inconvenience of the patient having to come back for repeated visits, which was another thing that we as practitioners really hated because it could feel like the practitioner was losing credibility in the eyes of the patient when they had to keep coming back for these small tweaks. With the new technology, it’s a thing of the past now.

By using the fitting guide, we’re ensuring that first fit success rate with the 3-Zone Progressive Design,4 and the opportunity to give the patient that instant feeling of ‘wow.’

References

  1. Karpecki, P., Wesley, G., Epstein, A., Giedd, K., Brujic, M. and Gaddie, I., 2019. Capturing the Presbyopic Astigmatic Patient Opportunity.  Reviewofoptometry.com [Accessed 16 June 2021]
  2. Bausch + Lomb, 2019. Bausch + Lomb ULTRA® Multifocal for Astigmatism Patient Evaluations Survey
  3. Bausch + Lomb, 2018. Bausch + Lomb ULTRA® Multifocal for Astigmatism Stabilisation Study
  4. Wright, M., Hoyle, K., Smiley, C., Mitchell, B. and Bazan, J., 2016. Capturing the presbyopic opportunity. Reviewofoptometry.com [Accessed 28 May 2021]
  5. Reindel, W., Mosehauer, G., et al, 2018. Patient comfort, vision and cleanliness over 12-months of Samfilcon A Lens Wear. Poster presented at AAO.