With the year rolling along, have you taken the chance to evaluate the progress of your contact lenses business? Is your growth where you would like it to be, or are you experiencing the all-too-familiar feeling of just treading water? We all are aware of the often-cited statistic that about 16% of contact lens patients drop out of lens wear each year, essentially eliminating the gains we might have experienced from new patients entering the modality. Many practices end the year with the same number of contact lens patients they started with. What will it take to break the cycle? A broader view of who’s a candidate for contact lens wear. 

Many practices rely on everyday wearers as their primary source of contact lens revenue—they’re easy to fit and easy to please—but forgo considering specialty and custom contact lens wearers. Patients with unique visual demands and/or more challenging ocular anatomy to contend with have often been told they cannot wear contact lenses, due to an irregular cornea or high amount of astigmatism. Others who wore contact lenses previously may have given up due to discomfort or fit issues. While these patient types will take a bit more effort and expertise than a garden-variety -3.00D myope with healthy eyes, when handled correctly they can be your biggest catalysts for growth.

In this newly retooled column, now called Practice Progress, we’ll focus on strategies for growth as well as retention. Success in a contact lens practice requires more than just “derailing dropouts,” the topic we addressed for the last eight years. It also takes a willingness to embrace new ideas, lens technologies and challenges. Custom-fitting contact lenses for challenging cases is the perfect place to start.

Spread the Word
The first step to getting these patients on your side is making them the offer of custom lenses. It sounds simple, but many patients have preconceived notions that they cannot wear lenses. Once the patient expresses interest in trying a custom lens, record their history, including their occupation, hobbies and daily visual requirements, and discuss suitable lens options with them. Technology can aid with determining the correct lens option for each patient. Topography is a must for corneal mapping, while anterior segment OCT can aid in fitting vaulted lenses. Newer OCT applications can image the tear film to get a better sense of tear dynamics, so even borderline dry eye patients can wear contact lenses.

Custom contact lens offerings comprise a large number of lens types, including those for high and irregular astigmatism, keratoconus, post-traumatic and post-refractive corneas, myopia control, poor visual acuity and ocular surface disease. Because of the uncommon nature of some of these lenses, fitting these patients often takes more time and energy; thus, many practitioners don’t even make the offer. Below, we review a few patient populations who have custom lens options to consider.

High Astigmatic Patients
These patients offer a good opportunity to add a significant number of underserved contact lens wearers to your office. While there are many toric options available in the soft contact lens market, on-eye lens stability can sometimes be a challenge for those with moderate to high levels of astigmatism, especially of the irregular variety. Uncorrected astigmatism and the subsequent distorted vision results in frustration, headaches and eye fatigue. 

For these patients, gas permeable (GP) lenses provide more stable vision than traditional soft lenses and mask corneal irregularities. Though GPs typically require longer adaptation times, spherical GPs are often a great starting lens. However, patients with significantly higher astigmatism (i.e., more than 3.00D cyl), may need a back toric or bitoric GP lens to further ensure lens stabilization.

	Fig. 1. The center optic zone is apparent in this photo. The NovaKone (Alden) has variable lens center thickness (IT Factor) to neutralize irregular astigmatism; however, a higher IT Factor is necessary for more advanced levels of keratoconus.

Astigmatic Presbyopes
Another great opportunity to improve the patient’s contact lens experience is the high astigmat with presbyopia. GPs can often be fit empirically for these patients and typically provide the greatest range of clear vision at all focal lengths near to distance. GP multifocals are often the best way to ensure good visual function. These lenses are typically customized to the patients’ specific cornea shape and visual needs. Note that some lens movement is necessary, but significant movement will impede visual function.

Soft toric multifocals are another good option for these patients. To properly fit theses lenses, fit the toric aspect first and adjust for rotation and instability before fitting the multifocal aspect. As with any lens, be sure to discuss appropriate visual expectations and the importance of follow-up care. For this technology, on-eye stabilization is key.  

Hybrid lenses are a third possibility for patients who desire the clear vision of GP lenses with the comfort of soft lenses, as the soft skirt surrounding the rigid center helps reduce lens awareness. The second-generation Duette multifocal lenses (SynergEyes) are currently the only hybrid lens with a silicone hydrogel skirt (Dk=84).

Corneal Irregularities
There are a number of scleral lens designs available for corneal irregularities like keratoconus, post-trauma and post-surgery, including corneal-scleral, semi-scleral, mini-scleral and conventional scleral fits. These rigid lenses are becoming increasingly popular due to their ability to mask irregularities while being better tolerated than traditional corneal GPs. As scleral lenses are fit to vault the cornea, much of the lens rests on the sclera, as opposed to the cornea. Typically, their diameter is greater than 10mm; fitting sets are a must for this technology.

Additionally, there are a few soft designs for the irregular cornea. These lenses typically use thicker center optic zones to mask irregularities. Some limits exist with these designs, but they may be a good option for mild to moderately distorted corneas.

Case in Point
A new 44-year-old male patient presented with complaints of decreased vision with his glasses at distance and near. He reported his vision was worse in his right eye and that he had been told at his previous eye exam that he may have keratoconus; however, he had never been fit with contact lenses. His BCVA was 20/30 OD with an Rx of +2.50-4.00x049 and 20/20 OS with an Rx of +0.75-2.00x132. He was trial fit into the NovaKone (Alden) soft keratoconic contact lens, and later fit with the NovaKone Toric for his right eye and the NovaKone Sphere for his left eye (Figure 1). His vision with contact lenses was equal to his best corrected spectacle prescription, and he expressed satisfaction with his vision and comfort.

Developing Your Market
Though you have an existing patient base to draw from, it is important to develop marketing tactics to expand this group. Some possibilities include talking to other doctors in the area—including ophthalmologists, primary care practitioners and even school nurses—to spread the word of your ability to fit custom lenses. These professionals would welcome the opportunity to help their patients and would have no problem admitting their shortcomings in this particular area of care; knowing a specialist to refer their patients to gives them the ability to help without the obligation of developing the expertise in-house.

In addition, consider external and internal advertising efforts such as newsletters, emails, websites and social media outlets. Don’t forget to capture the reaction of your patients as they experience a successful fit and use it to promote your practice. For instance, a happy patient who’s just been fit with a custom lens might want to post a selfie right from your exam chair, providing everyone in their social network with an endorsement for your practice. Boom—instant, real-time marketing. And it’s free.

The above options offer a unique platform and design, which allows the contact lens practitioner to provide unique products to your patients. Some patients will be intolerant of any lens design, but in those instances where a patient would benefit from the optics that a GP delivers, but cannot wear the lenses because of discomfort issues, consider a soft or hybrid lens.