Hybrid care and evolving contact lens need for myopic and presbyopic patients

In a roundtable discussion, hosted by OT and CooperVision, four eye care practitioners reflect on the results of the survey – lifting the lid on the opportunities and challenges they have found in contact lenses in their own practice in recent years, both for myopic and presbyopic patients, and the potential of hybrid care.

Opportunity and challenge in the hybrid contact lens journey

With OT’s Insight survey highlighting that 47% of practitioners predict the contact lens patient journey will become increasingly hybrid over the next five years, OT is interested in how eye care practitioners are experiencing these changes as they take shape.

Simon Callaghan, optometrist at Rawlings Opticians in Banstead, feels that the turning point for hybrid care came during the COVID-19 pandemic, where through necessity remote contact lens aftercare became the norm.

The pandemic highlighted that many patients would rather utilise a hybrid model than return to practice several times, Callaghan believes.

However, he emphasised that remote contact lens care must still follow regulatory rules.

With this in mind, the move to a full hybrid contact lens journey is not something Callaghan feels comfortable with currently, he explained.

“Some patients would like the idea of more of a remote system, but I’m not sure how I feel about signing off a contact lens [fit] without actually seeing it,” Callaghan said.

Getting to know your patients also means knowing which of them should not be given the leniency to be signed off remotely, Callaghan emphasised.

“I need to feel comfortable from the clinical and medical side of it before I’d be happy to do consultations remotely,” he said.

Krupa Mistry, optometrist at Burnett Hodd & Tam Optometry in Central London, likes to keep “an open-door policy” with patients.

“When I see patients for a contact lens fitting, I tend to give them my email address and ask them to keep in touch and let me know how the lens feels,” Mistry said.

“If you have built that trust with your patient, making sure that we’re not crossing the line on the legal side of things, I think that’s a good way of doing it,” she added.

Having an open-door policy, where patients know that they can get in touch with any issues without necessarily having to come into the practice, could also reduce patient dropout, Yasmin Ahmed, optometrist at Central Vision Opticians in Finchley, noted.

Sejal Patel, clinical performance consultant at Specsavers in Hertfordshire, Oxfordshire and Berkshire, emphasised that patients’ lives are increasingly busy.

“I find that patients, especially contact lens patients, don’t want to keep coming back in,” Patel said.

“Remote follow-ups have really worked well after COVID-19,” she added.

Sending videos for contact lens teaches beforehand, so patients are prepared and know what to expect when they do come into practice, has helped a lot in terms of reducing follow-up visits, Patel noted.

We’ve got opportunities, including convenience for the patient, and reducing drop-out rates. It encourages compliance, if you’ve got regular touch points

Adding value with remote care

OT is interested in where practitioners feel remote care can add the most value within the contact lens patient journey.

“Overall, I see major opportunities when it is used appropriately,” Ahmed said.

She explained: “We’ve got opportunities, including convenience for the patient, and reducing drop-out rates. It encourages compliance, if you’ve got regular touch points.

“But also, you’ve got the challenge of making sure safety is thought about, and if there are any red flag symptoms, they don’t get missed. Regulations and professional accountability are really important.”

Callaghan told OT that his practice has completed an audit on the number of contact lens dropouts, and that the numbers were higher than expected.

“Sometimes it might be that the patient can’t get the lens in or can’t take it out properly, and they may blame themselves and think it’s not for them, and then cancel their appointment,” Callaghan said.

He added: “But if you have those remote touch points where they know that they can phone or send an email, you will reduce those dropouts. Having that remote care would make them feel more comfortable.”

Another area where remote care can add value is in terms of practice loyalty, Ahmed noted.

“We’re in an era where people are self-prescribing, because contact lenses are easily available on the internet,” Ahmed acknowledged.

She added: “If you could have the added incentive of having an open, remote system where they can call in whenever they want, it might add value to being on a direct debit, for example, and you then retain the patient.”

OT asked how effective practitioners are finding pre-appointment digital communication tools, such as online questionnaires and handling videos, in preparing and supporting contact lens patients.

Callaghan uses handling and hygiene videos, alongside written instructions, referring patients to them during the initial fit and framing them as ‘homework’ that should be completed before their next appointment.

“They’ll come back in the second time and say, ‘Oh, yes, I read those points and watched the videos.’ By the second visit, it should have become easier,” he said.

Patel noted that “everything is on the phone nowadays, and everybody is used to learning things online.”

Digital symptom questionnaires can work well, especially with new contact lens patients who might be at risk of dropout due to handling, and in checking compliance with hand hygiene, she believes.

Patel added: “Also, we use email and SMS reminders, which helps a lot with check-ins, and so that they don’t forget their appointments.”

With the subject of clinical safety and regulation in mind, how can practitioners be sure that these remote care tools – useful as they might be in increasing efficiency in practice – are utilised safely, without compromising clinical standards?

“I think there should be a framework for which patients can have remote care, and which ones should be coming in – for example, children, diabetics, and those with medical conditions. It [remote care] may be not for everyone,” Ahmed said.

Patel emphasised: “Efficiency is really good, but you need to make sure you’re not lowering your clinical threshold. Improving accessibility and communication, whilst also maintaining clinical governance, is really important.”

In terms of safeguards or guidance that might be needed in order for remote care to become more widely adopted in contact lens practice in the future, Callaghan believes that the most important thing is being clear with the patient what symptoms to look out for, and to ensure that they understand when contacting the practice is required.

“You’d like to think patients would know what to look out for, but not all patients do, so you have to make it clear what might be okay, and what isn’t okay, so shouldn’t be left too long. [Be clear that] if this does happen, then yes, it means a face-to-face,” he said.

It is important to have a clear system so that the patient knows that they can contact the practice via a certain route and be booked back in straight away, so they are not waiting for their routine remote aftercare that might be scheduled two weeks ahead, Callaghan advised.

Without this system, the practitioner might risk “finding a major problem that should have been sorted two weeks earlier,” he warned.

Callaghan added: “Making them aware, and having the information out there, is the main thing.”

Clear, professional guidelines on suitable remote practice would be helpful for practitioners, Mistry added.

Remote care might be particularly helpful for new contact lens patients, where vision has been checked and a successful contact lens fit has taken place, and touch points around questions or extra help with the teach are the priorities, Callaghan believes.

“From a new patient point of view, those remote touch points would work well,” he said.

In terms of the limitations of hybrid and remote care, Ahmed notes that “often, you see things on the cornea that the patient has no symptoms of.”

“We can’t rely on self-declaration of symptoms,” she warned.

Mistry also noted that hybrid consultations are unlikely to be appropriate in the case of complex contact lens fittings.

“If you’ve got patients who are in sclerals or rigid permeable gas lenses, or with myopic control lenses in children, you might be a more inclined to see them more routinely, rather than your soft lens patients, who are quite straightforward,” she said.

“In these cases, we are happy to probably say, after the first initial fitting, that we could touch base in a hybrid way. But with specialist contact lenses, we would want to see them back a little bit sooner.”

Growth opportunities with presbyopia and multifocal contact lenses

OT’s Insight survey found that improved multifocal performance was viewed by practitioners as the development likely to have the greatest impact on contact lenses in UK optometry practice. With this in mind, OT asked how advances in multifocal lens designs have changed our practitioners’ approach in fitting presbyopic patients.

Callaghan believes that evolutions in lens design have helped practitioners in remembering that contact lenses are an option for presbyopic patients generally.

“There are a lot of practitioners out there who can have a good in-depth conversation about presbyopia, including what it actually is. But maybe we’re too geared towards spectacles, in terms of single vision readers or varifocals, and are maybe not giving the patient the option of multifocal contact lenses,” Callaghan shared.

“There are a lot of patients out there, and we might miss that there are opportunities,” he added.

Mistry noted that new technologies in multifocal lenses mean greater opportunities to fit different types of presbyopic patients – patients with different needs, different lifestyles, and different visual demands.

This “makes it easier as a practitioner to fit different types of presbyopia contact lenses,” Mistry believes.

“Maybe 10 years ago, we had limitations as to what we could fit for those patients,” she added.

Another factor that practitioners no longer need to worry about is having to change material when moving patients from a soft to a multifocal lens, Ahmed noted.

Patel believes that improved technology has lessened dropout rates for presbyopic patients.

“Stable optics in a lot of the newer designs makes vision a lot better, and comfort-wise, the materials have improved hugely,” she said.

“Presbyopic patients generally get drier eyes, so we used to have dropouts because of that. But design and technology have helped that significantly.”

With OT Insights findings also revealing that 85% of respondents see multifocal contact lenses as ‘critical’ or ‘important’ to future category growth, what improvements in multifocal contact lens design do our practitioners feel would make the biggest difference to patient satisfaction and clinical outcomes?

Patel identifies improved low light performance, to assist with nighttime driving, and neuro adaptation of the lens, in order to reduce adaptation time and improve retention, as the key developments that she would like to see.

Neuro adaptation would also be helpful for patients who regularly use screens, Patel believes.

She would also like to see manufacturers making sure that there are more options available for higher astigmatic patients.

Presbyopic patients generally get drier eyes, so we used to have dropouts because of that. But design and technology have helped that significantly

Mistry notes comfort as an area that she would like to see improved.

“A lot of these presbyopic patients, often women in their 40s or 50s, tend to have dry eyes. A lot of dropouts are because they can’t tolerate that contact lens after a few hours,” she said.

Ahmed noted handling as a potential improvement area.

“A lot of hyperopic patients can’t see the lens in front of them, so it’s quite tricky handling them, especially as they are maybe not as dexterous as they reach an older age,” she shared.

In terms of introducing multifocal contact lenses to presbyopic patients, Ahmed explained that having a trial bank of lenses has been invaluable in her practice.

“While the patient is with you, instead of having a really long conversation around ordering specific contact lenses, you can get the patient to try them. Quite often they just want something that works, rather than having to make a decision about which one they should go for,” she told OT.

Callaghan explained that planning ahead is useful in his practice: “We do a similar thing, where we might look ahead at the diary and try and pick out those potential candidates for complex lenses.”

He advised: “Have the trial banks and the lenses ready. Sometimes you have the conversation, and it’s an extra effort to come back, or we have to order lenses in, which ends up being a negative thing, and the patients ends up saying ‘no thank you.’

“But if you have them there, ready to go, they think, ‘yeah, why not? I’ll try them.’ And away they go.”

Patel agreed: “Once they leave the store, life takes over. They forget about it; it’s not a priority.”

She added: “I also find that not complicating things and not giving them too many options, because sometimes that overwhelms them, is helpful.”

Making a proactive recommendation and not setting unrealistic expectations is also helpful, Patel noted.

“Keep it really simple and tell them, ‘Just try it out and see how it goes, and there are other options that we can upgrade to if this one doesn’t work,’” she advised.

She also emphasised the importance of the lifestyle conversation – explaining how the lens is going to benefit their lifestyle and make things easier for them.

For Callaghan, simplicity in the conversation is key.

“There are patients for whom the presbyopia conversation is a lot to take in,” he said: “It might be their first time in spectacles.”

He added: “For some people, presbyopia is quite a negative thing: they’re getting older and they don’t want to accept it. Having a whole contact lens conversation might be too much.”

Ahmed also noted the importance of managing expectations, and making it clear that finding the best contact lens is a process.

“It might not be the perfect option that they put in straight away, but if they understand that it might take a little bit of time to get to the end result, they are more positive about it,” she shared.

Mistry emphasised the importance of introducing the presbyopia conversation early.

“If you know your patient is an existing contact lens wearer, if they’re getting close to presbyopia, having that conversation about updating it or changing it to a presbyopia contact lens next year when they come in could be an option too,” she said.

Patel also believes that the early conversation is valuable.

With this advanced warning, “they notice that they’re maybe struggling a bit more,” Patel said.

She added: “I find they come back sooner. They realise they are ready for it, and don’t wait for their appointment.”

Managing patient expectations around adaptation and visual performance

Callaghan acknowledged that some patients, especially those who are used to very detailed vision, might expect their contact lens to provide perfect vision on the first attempt.

Over promising can “start you off on the back-foot,” Callaghan believes.

Instead, practitioners must communicate clearly and let patients know what to expect going forward, he advised.

Ahmed noted that patients often compare their vision in contact lenses to their vision in spectacles, so explaining the differences is key.

“I explain how the lens works, and that it is actually your brain that’s picking out the information, and sometimes your brain has to learn how to use them,” she said, adding: “I often find that, after a week, the visual results are much better.”

Patel agreed: “That adaptation piece is really important, and so they know what the expectation should be, and they shouldn’t set unrealistic expectations.

“The neuro adaptation definitely is a big factor in that, and just making sure they’re aware that it takes time.”

She also emphasised the importance of reminding patients to take drops, especially if they are often in an air-conditioned environment that might be liable to increase dryness.

In terms of practitioner confidence, Callaghan explained that “from the practitioner point of view, it’s nice that there are more products available, because then if one doesn’t work, you’re not stuck – you have got other options available.”

Patients might think that one multifocal contact lens not suiting them means none of them will, but having a range of products helps in explaining that this is not the case, he believes.

Patel emphasised: “Confidence is a big thing. I think patients can smell it on you if you're not confident.”

The more lenses fitted and the more opportunity to reflect on what was successful and what was not means “you know what will work better the next time around,” Patel said.

Utilising remote feedback from patients can be useful here, Ahmed advised.

Improvements in handling, particularly for patients with arthritis, and increased wettability to promote comfort, are vital considerations with the ageing population and increases in long-term contact lens wear in mind, the practitioners noted.

It’s nice that there are more products available, because then if one doesn’t work, you’re not stuck – you have got other options available

Myopia management and contact lenses: overcoming barriers and driving growth

OT is interested in hearing about how the role of contact lenses in myopia management has evolved in our practitioners’ practices in recent years.

Ahmed shares that her practice lets myopic patients test a lens in practice early in their journey, and that this approach “sows the seed that this is an option.”

Again, for Callaghan it comes down to preparing ahead of time.

“A bit like with the presbyopic patients, I might try and pinpoint those myopic young people or children who are due in, and have some MiSight® 1 day contact lenses ready,” he said.

Having the conversation openly and having the tools ready to go is important, Callaghan emphasised. He noted that having these conversations when needed is also what the College of Optometrists’ guidance suggests.

Patel noted that: “The education piece is really important for parents and for children.”

As with presbyopic patients, pre-educating young patients that there might be a time when looking into some form of myopia management is required will be helpful in the long-term.

Ahmed believes that the momentum behind new designs in myopia management lenses are driven by a demographic of young patients who are increasingly active, with sports and activities scheduled outside the home.

Mistry agreed: “You might have a patient who is 12 or 13 who is a first-time myope, and typically teenagers do lots of sports and would be inclined to want to wear contact lenses. It’s just picking and choosing your patient.”

At the same time, Patel noted an increase in the use of screens amongst children and young people – and that there is more evidence, including studies focusing on MiSight® 1 day contact lenses, to support the efficacy of myopia management working.

She added: “An improvement area would be around cost. If the NHS could support it, that would really help parents who sometimes can’t afford to pay that extra [cost].”

On the cost aspect, Patel believes that focusing on the long-term health benefits is important, including talking to patients about risk reduction, and that myopia management is prevention rather than correction.

“It’s an investment in long-term healthcare, to make sure that they don’t get increased risk factors as they get older,” Patel said.

“Being transparent with the parents and the children is important, and letting them know that results can vary.”

Typically teenagers do lots of sports and would be inclined to want to wear contact lenses. It’s just picking and choosing your patient

Ahmed acknowledged that the unpredictability of cost can be a challenge for parents, especially because myopia management lenses often cost significantly more than spectacles.

To mitigate this, the majority of her patients are signed up to a direct debit plan, she explained, “so that they know this is how much they’ll be paying per month, they can spread the cost.”

Callaghan’s patients are often also on direct debits, and his practice shares written information on what is included – lenses, aftercares – so that they can make an informed decision, he explained.

Mistry added: “It is just being really transparent when you first see that child. With the parents, if you set those expectations to begin with, and you have those payment plans in place, at least the parents aren’t then disheartened later down the line.”

When engaging patients in myopia management, Mistry finds it helpful to demonstrate an axial length measurement, explaining that “this is the length of a child’s eye at the moment, and we can measure that over a period of time,” and show the patient photographs of the back of the eye at the same time.

For Patel, it is important to keep the messaging as simple as possible.

“Visual aids are always helpful, showing the axial length charts, progression graphs, and mentioning that we’re focusing on control, and it’s not a cure. We’re aiming for slower progression, and it’s not necessarily going to stop it completely,” she said.

Ahmed finds it useful to explain to parents that there may be periods of axial length growth – for example at certain ages, or when the child has a growth spurt – and that this is normal.

“Myopia management isn’t just linear. Manage those expectations, where there may be periods of more rapid change,” Ahmed advised.

Practical experience has been the most useful tool in building her confidence as a myopia management practitioner, Ahmed shared.

She also suggested considering myopia management lenses for low myopes, who might be less compliant than their high myope peers in wearing their spectacles.

“Quite often contact lenses benefit them, because they can be more compliant,” she said.

Patel has found taking continuing professional development (CPD) around myopia management lenses useful in building her confidence.

“Continued learning really makes a difference,” she said.

Callaghan noted the CooperVision Learning Academy as a great source of CPD, especially for training in MiSight® 1 day contact lenses.

Mistry emphasised that parents are often extremely well informed, and that as practitioners, it is vital to keep on top of new developments in the area, such as atropine drops.

“It’s about being a bit more informed as a clinician,” she believes.

The content of this article reflects the discussion and viewpoints presented during the live debate. Any opinions expressed are those of the individual contributors.