Making the right recommendation at the right time for presbyoes

The scenario

As a locum optometrist, I often don’t have the opportunity to see patients more than once. I want to ensure that I am making the right recommendations to the right patients at the most suitable times, as well as making the most appropriate lens selection during trials to ensure first fit success. Can you share advice?

Sam, locum optometrist

The advice

Clair Bulpin, optometrist and Johnson & Johnson MedTech faculty member

Life as a locum often means a single patient interaction rather than the opportunity to build long-term relationships with patients. It also means that we need to stay knowledgeable and informed about an array of products and services to best meet the needs of the patient.

The right patient can be any patient. There is a huge discord between presbyopes interested in wearing contact lenses and those wearing contact lenses. This almost certainly exists because we are not having the right conversations. A motivated patient may ask if they can use contact lenses, but many more are assuming that if they were an option, we, as eye care professionals, would mention them.

Maybe our approach at the end of each eye examination should be simply to explain that there are several options available: contact lenses, spectacles, and in some cases, more permanent surgical options, and to ask the patient which one they would like to discuss first? Even if they still head down the spectacle route, at least they know that contact lenses are a viable option.

A knowledgeable clinician can advise on options that really suit the patient, a modality that works for them, all in conjunction with material properties which meet their anatomical and physiological needs, rather than generic recommendations

 

What is the right recommendation?

When it comes to contact lenses, we are blessed with choice. There are ever-increasing ranges of different contact lens designs, modalities and materials. Making the right recommendation is a delicate partnership of balancing the specific needs of the patient alongside the properties of the available contact lenses.

In my early days, we were taught to ask new patients how often they’d like to wear their contact lenses. This question is often futile in a new wearer – they neither understand what the contact lenses can do, or really appreciate when they may wear them until they experience life in contact lenses.

It’s far more useful to enter the conversation understanding their typical day. Is there a long drive to work? Are they working at a screen? Is there air conditioning? How do their eyes feel currently at the end of their typical day? What do they usually do in the evenings? Are they going to a gym, walking the dog, or dozing off on the sofa? And then what about their weekends or days off – how do these pan out? Once we have this information, we are well placed to discuss how contact lenses would fit into their lifestyle needs. These conversations should also seek to understand whether there is a preference for convenience when thinking about suggesting a modality.

Combining the information uncovered about the patient’s lifestyle needs with ocular health assessment allows us to then make an informed and more effective recommendation. We must remember that the presbyopic eye is undergoing more than just refractive change. Pupil size is changing, media clarity is changing and perhaps, most importantly in contact lens wear, so is the tear film. A knowledgeable clinician can advise on options that really suit the patient, a modality that works for them, all in conjunction with material properties which meet their anatomical and physiological needs, rather than generic recommendations.

There is a lot to be said about managing patient expectations – some of this, I think, goes both ways. I feel that optometrists are more forgiving of the limitations of varifocal spectacles. For example, if a patient commented that they couldn’t read in bed in their varifocals, it’s unlikely that the practitioner would suggest abandoning varifocals. It’s far more likely that there would be an open discussion about the position of the near portion and the limitations that varifocal spectacles may have, with the suggestion, therefore, of a separate pair of near spectacles for this task. Lots of varifocal spectacle lens wearers have separate pairs of spectacles for driving. Yet applying the same logic to contact lens wear is less often seen.

There are many patients who can do everything they want in their varifocal spectacles or multifocal contact lenses, but we also have to identify those patients where we may need to offer a range of solutions. This should not be seen as a failing of the product in question, but more that a bespoke recommendation for the individual is needed. I’m fairly sure that most patients own more than one pair of shoes. They may have a favourite that do the job most of the time, but they will have the others for specific requirements. An analogy such as this really helps in conversations.

I would recommend viewing every contact lens appointment as an opportunity to discuss options. A patient may be very happy with their current contact lenses, but this may simply mean that they don’t realise there is anything else available that would benefit them

 

When is it time to make a recommendation?

I would recommend viewing every contact lens appointment as an opportunity to discuss options. A patient may be very happy with their current contact lenses, but this may simply mean that they don’t realise there is anything else available that would benefit them.

I would suggest that eye care professionals are always asking themselves ‘what would I fit this patient with today?’ If the patient is already wearing this option, then tell them and provide that reassurance. If not, explain why you think an alternative contact lens may be a better option. The patient relies on us to keep up to date with new technologies and we should feel comfortable enough with our knowledge to share this with the patient. Any presenting symptoms or signs also provide an obvious starting point for those discussions.

Make sure that the patient’s first experience in multifocal contact lenses has the potential to be as positive as possible for you both

 

Aiming for first fit success

Use the fitting guide. The manufacturers have put a significant amount of time and energy into making it easy for us to select the first trial contact lenses. The guides will often include enhancements – on occasions, as well as ordering the main trial contact lenses for a patient, I have also ordered the distance and near enhancement options so that if something does need to be tweaked, these are available at the time of collection rather than requiring another visit.

Make very clear notes within your records so that future practitioners understand the conversations you have had and why you are recommending that trial contact lenses. It serves as a useful reminder to the patient should they have questions at a later date, but also supports the continuity of patient care, helping to eliminate the impersonal journey that sometimes arises from seeing a different person at each appointment.

In a trial appointment, you may not have a range of trial contact lenses available, and I would approach fitting the next best thing with caution. I personally find that more time spent understanding the patient leads to a more successful fitting in the long term. You wouldn’t suggest someone tried varifocal spectacles for the first time by giving them a prescription or lens design which was ‘close’ to what you’d suggest and then see how they got on. Make sure that the patient’s first experience in multifocal contact lenses has the potential to be as positive as possible for you both.