Finding your niche WITH A SPECIALTY CONTACT LENS CLINIC

There’s no denying more chair time is a prerequisite of fitting specialty contact lenses in Australia, but when the practitioner's skills are highly sought-after and they've built a supportive network with product suppliers and peers, there is no limit to the lives that can be changed.

Most of Custom Eyecare Newcastle’s specialty contact lens patients are directly referred by optometrists and ophthalmologists in the surrounding area. The fact other eyecare professionals are happy to send their patients to a potential nearby competitor is a reflection of the reputation the practice has built over several years.

Some come from further afield, explains optometrist and managing director Ms Heidi Hunter.

“Some of my patients come from Armidale and Tamworth; they drive four or five hours to come down for their specialty contact lens fitting,” she says.

In an optometry landscape where independents are increasingly required to differentiate, Hunter is among a selection of Australian optometrists who have found their niche in specialty contact lens fitting.

She believes there’s several advantages to offering such a service but in Newcastle and the surrounding area specifically, fulfilling an unmet need is the greatest benefit.

“For some reason, Newcastle and Lake Macquarie has a much higher incidence of keratoconus than the national average, so for me, the main reason to upskill and specialise in this area, is that there was a need, and it was about looking after people properly,” she says.

“I used to work in the rooms of a corneal specialist, so I got exposure to lots of interesting corneal disease patients, and realised they needed looking after by a local optometrist. It didn’t start out as an area of interest, but it has grown into an area of specific interest.”

Hunter believes there’s demand for more specialty contact lens practitioners that give better access to patients.

“When I used to work in the rooms of a corneal specialist, I realised that a lot of Newcastle keratoconus patients were being sent to Sydney for specialty contact lens fitting. That’s a two-hour drive, a lot of expense, dealing with Sydney parking and Sydney traffic, where there isn’t any reason that an optometrist couldn’t do it locally,” she says.

“At Custom Eyecare Newcastle, we have gone above and beyond in terms of learning to fit all types of specialty lenses – scleral, hybrids and rigid – absolutely everything. We offer the full suite of lenses whereas a lot of the other optometrists in our area that do fit keratoconus patients, most of them will just be fit into a conventional RGP.”

But learning to fit all types of speciality lenses is not achieved overnight.

Especially at the beginning, Hunter found the learning curve is steep, so she sought as much support as she could get.

“Most of the learning comes from either educating yourself, or simply experience, so if you don’t put in the hard yards to educate yourself, and you don’t see enough patients, I think it would be quite difficult to develop your skills,” she explains.

Peer support can come from groups including the Cornea and Contact Lens Society of Australia (CCLSA) and the Orthokeratology Society of Oceania (OSO).

Hunter is a national board member of CCLSA whose CEO is the well-respected specialty contact lens fitter Mr Alan Saks. OSO is an Australian-based group led by president Mr Gavin Boneham (principal optometrist at Boneham Optometrist in Sydney’s CBD) and secretary

Ms Celia Bloxsom (principal optometrist at Eyeconic Optometry Southport on the Gold Coast).

“CCLSA and OSO run bootcamps in Australia and New Zealand, as both organisations teach beginners about orthokeratology, including how to kickstart your learning, how to find patients, what equipment you need, and what to look for when you’ve just started using a corneal topographer but don’t yet have enough experience. If you haven’t had enough throughput of patients to really develop your skills, these bootcamps are incredible for learning,” Hunter, who was formerly on the OSO board, says.

A corneal topographer is a must-have, not a nice-to-have, in Hunter’s opinion.

“I honestly think you can’t do anything without a corneal topographer. As I explain to patients, it’s akin to a surveyor mapping out the hills and valleys in a landscape; a corneal topographer maps out the hills and valleys in the surface of your eye and that’s what we’re trying to fit a lens around. In the case of ortho-k, if you don’t have a corneal topographer, it’s difficult to work out where the lens is sitting overnight,” she says.

“We also have an anterior OCT in our practice. You don’t need an anterior OCT for ortho-k fitting or for simple straightforward keratoconus fitting, but when you start to get into hybrids and sclerals, certainly it’s an advantage.”

Hunter estimates hybrid lenses make up about 10% of her specialty contact lens fittings. She says they’re ideal for patients who have mild keratoconus, or those who can’t deal with the discomfort of rigid lenses.

“Hybrid lenses are much more comfortable because the edge of the lens is hidden in the soft skirt. They’re good for patients who have keratoconus in only one eye because adapting to a hard lens in one eye is quite difficult. A hard lens can feel like a little piece of eggshell on the surface of your eye, while you’re getting used to it,” she says.

According to Hunter, the best way to stay informed about hybrid lenses and product developments from suppliers such as Gelflex and Capricornia in Australia, and Corneal Lens Corporation (CLC) – New Zealand’s largest contact lens manufacturer – is to attend conferences.

“The CCLSA runs a conference and trade show every second year, which industry attends. On the off year, the OSO runs their conference and again, it’s attached to an industry trade show. Whether it’s equipment suppliers or specialty contact lens suppliers – anybody that has anything to do with specialty contact lenses will attend one of these two events because that’s where their customers are,” Hunter says.

“I love being able to say to patients that these lenses are manufactured by an Australian lab, so they understand this isn’t something that’s bought in a box from China.”

When considering the business case for branching into specialty contact lens fitting, Hunter suggests weighing up whether there is going to be enough demand for speciality contact lens fitting in the immediate area, or whether another nearby practice is already providing the service, or whether patients are driving four hours to attend the ‘nearest’ optometrist who can fit custom lenses.

“There is scope. In cities like Melbourne, Sydney, or Brisbane, there’s plenty of optometrists that fit custom contact lenses. From a patient’s perspective, I wouldn’t think there’s a lack of choice. But if you’re in a regional area, where are keratoconus patients going for specialty contact lens fitting?” she asks.

Hunter recommends optometrists consider how contact lens prescribing – beyond daily disposables and the like – can set their practice apart.

“Corporate practices don’t tend to do specialty contact lens fitting because it doesn’t fit with their practice model. I spend an hour with a new keratoconic patient. If I worked in a corporate practice that had a half-hour appointment schedule, I just can’t do it in 30 minutes,” she says.

“I spend a lot of time outside of hours ordering lenses and answering emails back and forth with the lab to try and customise and refine the fit. I don’t know if there is the scope in a busy corporate practice to be able to take this on, and with more and more practices being owned by corporates, I think it’s a niche and a point-of-difference that a corporate practice is never going to be able to encroach on.”

While it may require more chair time, the difference that time makes can be immeasurable, in Hunter’s experience.

“My typical patient would be somebody who, because of their eye condition or corneal disease, has gotten to the stage that they’re about to lose their driver licence because they no longer meet the visual requirements for the RMS standards – and for lots of people that runs the risk of losing their job,” she says.

“When you get to the stage that they’ve already contemplated early retirement because they’ve lost their vision, and with a specialty contact lens, you can get them better vision than they’ve had for the last 20 years, that’s the stuff I love. It makes such a big difference in a patient’s life by literally just restoring their sight back to something that’s reasonable or incredible in some cases.”

Test Your Limits

For optometrist and practice owner Mr David Foresto, the biggest advantage of going above and beyond soft contact lenses to fit specialty lenses is the clinical challenge itself.

“I feel if you really want to get the most out of your career you need to be willing to take on difficult cases and put your energy into helping the people who need it the most. Yes, you can enhance people’s lives with regular glasses and soft contact lenses, but custom and complex contact lenses aren’t just life enhancing, they are life changing,” he says.

Beyond the clinical challenge, is another off-set advantage.

“A practice built around addressing people’s needs is more economically secure than one built on wants or trends. Businesses based on refraction and low-cost optical products will be the first to be replaced by technology in the future.”

Foresto, who established Advanced Optometry (formerly Foresto EyeQ) in 2015, says incorporating specialty contact lenses into an existing practice requires analytical thinking and planning.

“You have to educate yourself first before taking on new clinical services. That means attending contact lens conferences, reading articles and staying up-to-date with new technology,” Foresto, who has been a guest lecturer at Queensland University of Technology for a

“Once you have formed a good basis of knowledge, then taking on some of the more basic custom lens fits is appropriate, but you need to always be willing to stop what you’re doing if a case becomes more complicated than you thought it would be and refer the patient onwards.

“You can easily find your own orthokeratology and high astigmatism patients for custom lenses first before you put yourself out there for more complex referrals.”

While most custom lens patients at Advanced Optometry have keratoconus or corneal grafts, Foresto says there are outliers.

For example, fitting orthokeratology for myopia control has “taken off to levels I never would have imagined when I first graduated”. He also fits lenses for babies from four weeks of age, which, sadly, there remains some need for despite how good the surgical options for various congenital eye diseases have become.

Foresto’s practice in Brisbane has invested in the latest diagnostic equipment, some of it essential, in his opinion.

“A corneal topographer is absolutely necessary for fitting custom lenses. There really is no debate about that. An anterior segment OCT is also necessary if you are fitting sclerals,” he says.

“As far as the investment side of these devices is concerned, we have three topographers, and we would have paid those off many times each by now easily. We also have a wavefront aberrometer. I don’t think this is strictly necessary however we use it every day and I really do believe it leads to better visual outcomes than ever before.”

For custom lens fitting troubleshooting and support, Foresto says there are several options.

“I think optometry Facebook groups are very helpful for practitioners needing some clinical support. Australian Optoms, SiCo and Scleral Lens Practitioners are all great resources filled with generally helpful practitioners. I also think CCLSA does a great job of bringing the contact lens community together, so getting along to their CPD events really helps build your network of people to call on if you need help.”

A Mentor To Many

A keratoconus patient who works in a hospital in Perth is adamant he would be on a different career trajectory if not for the help of optometrist Mr Damon Ezekiel.

“He said I’m not allowed to retire because without me, he can’t hold down a job, or drive. He keeps telling me he would be weaving baskets if it wasn’t for what I do. What a difference you can make to someone’s life,” Ezekiel says.

“These patients cannot see without what we do with specialty rigid lenses.”

Ezekiel has been fitting custom contact lenses his entire professional life. From a purely business revenue perspective, he says some practitioners see one particular downside to fitting specialty contact lenses – but there is an upside.

“There is a lot of chair time involved in treating keratoconic, post-graft, post-surgical patients. The great thing is, patients come in who’ve been elsewhere, and no one can help them – and you can. The look on their face when they say, ‘I can see’, and ‘Is this what normal vision is like?’, because they can now drive a car, they can hold down a job,” he says.

“Yes, there is a lot of chair time but the upside of that is, you chat to patients, you find out more about them and their family. They know they’re not just a number that’s coming in and out, getting a pair of reading glasses or whatever. You’re doing something that not many people do and they’re exceptionally loyal because they can’t go down the road to get this, they can’t go on the internet and get anything that we’re supplying. It’s the quality of life that you can give them which is just

Ezekiel is owner and manager of Ezekiel Eyes, a third-generation optometry practice in Perth, Western Australia. His father, Don Ezekiel, was a pioneer in developing specialty contact lenses in Australia.

“Getting lenses from London in those days took forever so my father went over to London, learnt how to make lenses, bought a lathe, came back and set up Gelflex, which he’s now sold,” Ezekiel says.

“I learned from him because you don’t do many rigid lenses going through university. Now, I have lots of optometrists and students sitting-in because they’re wanting to know what we do and how we do it. Masters optometry students from Sydney and Melbourne come in, and students from the University of Western Australia program now, as well."

When he was speaking at conferences in Sydney and Auckland earlier this year, Ezekiel tells those interested in the field to find a mentor; there’s no need to reinvent the wheel.

“We’ve spent thousands of dollars making mistakes. I’m more than happy for anyone interested to come and sit in with me,” Ezekiel says, explaining an optometrist from Orange recently flew over to sit in and observe for a few days.

“Ninety-nine percent of patients are more than happy to have someone sit in, because they know their eyes are not normal, and they’re helping other optometrists learn, so they can then continue the tradition of helping more patients like them, to see.”

Along with a corneal topographer, Ezekiel is one of only a handful of practitioners in Australia with a scleral topographer, to measure the profile of the sclera.

“It’s only $30,000. By comparison, a Medmont is about $26,000; an OCT can be $70,000 to $100,000, so a scleral topographer is ‘affordable’. But if you’re going to do the job right, you need a corneal topographer, bottom line. I also have 10, 12, 15 different trial sets, depending on who walks into my room. You need to have all that sort of armoury.”

Ezekiel, who is also president of The International Society of Contact Lens Specialists, a non-profit organisation comprised of distinguished contact lens practitioners and educators, says networking at industry events is a prime opportunity to discuss cases with colleagues and learn from their experience, but this can also be done with suppliers.

“I order the occasional lens from the UK, France or the US, depending on what the patient needs, if I know I can’t get it locally. But local labs like Gelflex, Capricornia and CLC have really good technical advice. They know their designs well and if you need extra edge lift, for example, you ring up and they can talk you through the nuances depending on what that design is,” he says.

If a problem still needs a solution, Ezekiel has the answer: “There’s plenty of fellows within the CCLSA that I’m sure would be more than happy, like myself, to take emails and phone calls and have a chat.”

Lately, he has noticed more comfortably-fitting scleral lenses are performing particularly well, especially among WA’s ‘fly-in, fly-out’ mining and agricultural workforce, who are operating in harsh environmental conditions which affects their lenses, with dust, dirt and grit.

“They’re a little tricky to fit but one patient, who sent me a video showing the environment he works in, used to wear smaller lenses now wears big scleral lenses, and he can do whatever he wants without his vision affected. Another patient, a farmer, used to put eye drops in 17 times a day. Now he wears bigger scleral lenses and he can do anything – dust, wind, doesn’t matter. Scleral lenses have undergone huge change,” Ezekiel says.

The future of custom contact lenses is also brimming with opportunity, as technology advances.

“Now you can take the corneal topography in a scleral profile and send that directly to a lathe and you can specify how much clearance you want, as in a tear layer between the back of the lens and the front of the eyes, so there’s lots of really amazing stuff taking place.”

Is the warm weather and luxurious beaches of Far North Queensland calling you?

George & Matilda Eyecare is currently recruiting Optometrist to join our team in Airlie Beach, Innisfail & Atherton. Reach out to our HR Team at opportunities@georgeandmatilda.com.au to find out more.