Optometry Today Contact Lens Guide 2009

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Contact lens guide 27/03/09

Life through the lens The latest developments in the contact lens sector Produced in association with

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Life through the lens ISSN 0268-5485 Supplements Editor and OT Deputy Editor: Robina Moss T: 020 7202 8163 E: robinamoss@optometry.co.uk Supplement edited by: Ryan Bradshaw Editorial Office: Optometry Today, 61 Southwark Street, London SE1 0HL Commercial: Sunil Singh T: 020 7878 2327 E: sunil.singh@tenalpspublishing.com Production: Ten Alps Publishing plc T: 020 7878 2361 E: louise.greenall@tenalpspublishing.com Design: Ten Alps Publishing plc T: 020 7878 2349 E: juanita.allard@tenalpspublishing.com Advertising and Production Office: Ten Alps Publishing plc, 9 Savoy Street, London WC2E 7HR E: info@optometry.co.uk W: www.optometry.co.uk ©

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technology, training and expertise ahead of this summer’s BCLA conference.

Dr Philip Morgan gives his predictions for the future of contact lenses, focusing on the importance of comfort and ocular physiology.

Cheltenham-based optometrist, Keith Holland examines another growth area, taking the reader through his ten golden rules for fitting children with contact lenses.

OT has also spoken to four up and coming young practitioners to find out how they have differentiated their practices by making contact lenses a focal point of their businesses.

I hope readers will find this OT Contact Lens Guide both an interesting read, and helpful in boosting the business potential of a growing sector.

Ryan Bradshaw Assistant and Production Editor OT

inside your Contact lens supplement...

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Meeting the needs of wearers CooperVision’s latest developments

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Fitting astigmatic patients Bausch & Lomb reviews its new lenses

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New options for astigmats Johnson & Johnson Vision Care

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Contact lens supplement

n this current economic climate it has never been more important for practitioners to provide top quality service to their patients.

Research conducted by TNS Vision Track in 2007 revealed that there is room for growth in the British contact lens sector.

Contact lens penetration in Great Britain is 6.2%, which is far behind Sweden (18%) and the US (15%).

In another survey, CIBA Vision discovered that the drop-out rate for wearers is 12% per year, with 48% stopping use because of discomfort.

In this first-ever OT Contact Lens Guide a number of the sector’s most respected clinicians and commentators have revealed how practitioners can capitalise on these areas of weakness to secure and retain future contact lens wearers.

Some of the world’s leading contact lens companies have contributed to the guide by letting readers get a first glimpse of some of the latest developments in contact lens

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

Keeping up with contacts Michael Charlton, AOP Chairman

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ome years ago, I overheard a conversation along the lines of, ‘There’s nothing new to learn about contact lenses’. But the contact lens story over the last 30 years is one of continuous evolution.

The BCLA has run a series of Pioneers lectures and produced a DVD of some of the famous trail blazers in the field.

In those early days, it was like school boy chemistry with design of, and modifications to, PMMA lenses being done in the kitchen. The advent of GP lenses occurred in the late 1970s followed quickly by the explosion of 38% hydrogel lenses. Hands up those who remember fitting U3, U4 and O3, O4 Bausch & Lomb lenses, or Zero 6 from Hydron. Now, of course, manufacturing is closely regulated and there is little scope for pioneering development outside the major research facilities which have grown so much in the last 25 years.

These facilities owe a great deal to the investment in research and development of the major manufacturers.

The development of GP lenses continues and, despite forecasts of their demise, they still play a small but important role in everyday practice as well as being significant within a hospital setting. They are certainly first choice for irregular corneas – for

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example, the Rose K lens from David Thomas works really well for keratoconus cases. There are a plethora of GP materials available and practitioners will know that the characteristics and properties vary – not all materials suit all patients. A well motivated GP lens patient will wear lenses for years and often will be very loyal to the practitioner.

One of the difficulties these days is keeping up with contact lens developments and barely a week goes by without an increase in parameters or a new design/material in soft lenses. One manufacturer (CooperVision) now boasts over 500,000 parameter combinations.

Now astigmats of ±20 with 5D cyls can be fitted with a monthly replacement lens, along with presbyopes (see Mark Ennovy).

Silicone hydrogel lens materials and powers are increasing all the time with moderate astigmats and presbyopes now covered (Air Optix from CIBA Vision and Purevision from Bausch & Lomb).

Another new material (Clariti from Sauflon) has come onto the market since the autumn. New lenses generally come in a limited parameter range and it is worth just checking availability before recommending a particular lens or brand to a patient.

For many patients, the ultimate in convenience is the single use lens, or daily disposable. Here again the parameters continue to widen so that presbyopes and astigmats can be fitted with this modality. The first silicone one day lens came to market in autumn 2008 and I’m sure it is not the last.

There seems no reason that the rate of progress and development will slow.

Each new development, be it in design, material or solution systems, is intended to give a manufacturer an edge. All this progress is ultimately in the patient’s interest. As practitioners, we are beholden to stay up to date with all these developments. It is not in the patient’s interest to continue to supply ‘the same

as always’ and each contact lens aftercare should include a review of potential lens or solution upgrades. Practitioners can only do this effectively if they are fully aware of all the options. Part of contact lens practice is meticulous record keeping; in another two years, will you remember why you recommended a lens/solution change?

A challenge for manufacturers is to make their information available in a ‘user friendly’ format which stays current. (A personal plea would be for all information/data sheets to be dated then at least I could throw the old ones away).

The BCLA offers meetings which help to keep practitioners right up-to-date and some of the contact lens manufacturers arrange regional events.

Fitting a patient with some of the new complex designs such as a multifocal toric soft lens can involve prolonged chair time and repeat visits to the practitioner. Fee structures should reflect the expertise and time involved but the reward should also be a satisfied contact lens wearer. These patients make great practice builders over time.

I hope everyone will find something useful and informative in this special OT supplement.

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

2020: Vision for the Future 5

with the various silicone hydrogel materials available (eg limbal redness), practitioners are still hesitant about their use for extended wear. Indeed, we have not seen as much improvement in terms of infiltrates and keratitis as we might have thought.

For patients sleeping in lenses, the severity of contact lensassociated keratitis may be less with silicone hydrogels than with conventional hydrogels but infections still occur.

Perhaps lens modulus has some role to play in the infections seen with extended wear? The move to silicone hydrogel lenses does mean stiffer lenses for the benefit of increased oxygenation. We have reported a tendency for corneal infiltrates to occur in the superior cornea with silicone hydrogel extended wear, supporting the notion that mechanical pressure is implicated. In a way this is good news; this research was carried out with the first generation of silicone hydrogels, whereas newer lenses have a lower modulus. We can speculate that new studies of contact lens infections might find lower infection rates due to the general lowering of silicone hydrogel modulus since the first studies were conducted.

One development which may help improve ocular physiology is the move to antimicrobial lenses. These are lenses coated with biological agents conferring resistance to infection and which may also reduce inflammatory events such as contact lens peripheral ulcers and contact lens-associated red eye. The first human trials of these lenses are already underway.

That is the state of play in 2009. By 2020 or earlier we can expect to see exciting developments in some of these areas.

Certainly, manufacturers are already able to modify the surface of soft lenses to improve comfort, and continued efforts with antibacterial technology may lead to a silicone hydrogel lens that is safer for extended wear. These will be just some of the topics to be presented at future BCLA events.�

Dr Philip Morgan is director of Eurolens Research at the University of Manchester. His primary interests are the clinical performance of contact lenses and the nature of the UK and international contact lens markets.

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CONTACT LENS practice around the world was on the agenda as the British Contact Lens Association recently held its first European Day. Dr Philip Morgan hosted the event and presented his predictions for the future of contact lenses. “Although predicting the future for contact lenses requires a degree of guess work, I think we can be confident that new lenses need to excel in five key areas. First, three clinical aspects in which the lens must succeed: vision, comfort and ocular physiology. New products must also be user-friendly and they must be readily available in the marketplace which means that they are prescribed by a large number of eye care practitioners.

On this last point, contact lenses are now more accessible to consumers than ever, via internet and supermarket sales, as well as through established supply routes and free trials. While some of these routes have given rise to clinical concerns, this widespread availability of contact lenses is unlikely to change dramatically in the near future.

Vision is excellent with all modern contact lenses. Toric lenses are now much more predictable and reproducible, with better visual outcomes. New multifocal designs which will be coming to the market will get us talking more to presbyopes about contact lenses. Another area which has been in the spotlight in recent times is aberration-control with contact lenses. There are some reports of measurable improvements in vision in some situations with current lenses, which tend to offer correction for an average amount of spherical aberration.

Future products might see a more customised approach with more bespoke lenses becoming available.

I believe that comfort remains the major issue for all contact lenses. We know that rigid lenses tend to be uncomfortable initially and that soft lenses become less comfortable as the day progresses. A majority of drop-outs from lens wear are due to discomfort and major efforts are underway to tackle this problem in an appropriate manner.

An important initial step is to characterise lens-related discomfort and to understand what the eye actually feels. We need better ways for patients to report their comfort throughout the day in real-world situations and we hope that the automated text message system we operate in our clinical trials at Eurolens Research will go some way to achieve this. We also need better understanding and measurement of in-eye wettability; perhaps the nature of the tear film on the surface of a contact lens is the critical issue, or maybe surface friction is the main determinant of lens comfort. The influence of these and other material properties on comfort will be a focus for future research.

The usability of contact lenses is an important feature to consumers but is often neglected, and we may see major developments in this area in the coming years. The application of flat-pack technology has led to prototype contact lens packaging eight times thinner than conventional blisters making lenses as easy to carry as a credit card.

Although some aspects of ocular physiology are improved

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES COMMERCIAL FEATURE

DIRECTORY INFORMATION Who are we:

CIBA VISION

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When were we formed: CIBA Vision was established in 1980.

In 1996, CIBA Vision became the eye care unit of Novartis.

Top selling products: Air Optix Aqua, Air Optix Night & Day, Air Optix for Astigmatism, Air Optix Individual, Air Optix Aqua Multifocal.

Dailies AquaComfort Plus, Focus Dailies All Day Comfort, Focus Dailies All Day Comfort Toric, Focus Dailies All Day Comfort Progressives.

What are our resources for eye care professionals: The Academy For Eyecare Excellence

What are our major developments: The New Air Optix Aqua Multifocal is a major development to realise the unmet need in the presbyopic market. The sustained moisture release technology used in our lenses offers a great leap in lubricating and maintaining comfort.

CIBA Vision aims for academic excellence Innovation is at the core of CIBA Vision’s values and professional education is no exception. The Academy for Eyecare Excellence, since its launch at the BCLA in May 2008, has provided training and education to support every individual in the practice: eye care professionals, support staff, students and practice business managers.

he Academy for Eyecare Excellence has helped eye care professionals to remain up-to-date with their clinical knowledge of contact lenses, communicate effectively with their patients so that they can fulfil their patients’ lifestyle, vision and eye health needs, and also helps build strong, sustainable businesses.

Since its launch, the Academy has been constantly updated with innovative educational programmes and resources making the content richer and more diverse. Structured under four pillars, each pillar of the academy offers education specific to the needs of every practice individual. Details of the programme can be found at www.cibavisionacademy.co.uk.

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Consumer website: www.cibavision.co.uk

Professional website: www.cibavisionacademy.co.uk

Delegates at the ‘Maintaining the EDGE Roadshow’, found the conference to be an excellent way of building confidence in fitting multifocal contact lenses, making the most of every appointment practitioners have with their patients and effectively communicating and offering recommendations which go beyond meeting the expectations of their patients. Later in the year, CIBA Vision’s Academy for Eyecare Excellence will be running more ‘EDGE Roadshows’ which will focus on attracting new patients to the practice.

The Business Academy

What are our future projects: CIBA Vision endeavours to develop the Academy for Eyecare Excellence to continue to offer the best educational resources for eyecare practitioners. We see silicone hydrogel materials as the future of our industry and the rich R&D innovation pipeline at CIBA Vision will offer some exciting new product developments in the foreseeable future.

integrating insight into the contact lens market.

Through a recent series of six one-day conferences, the ‘Maintaining the EDGE Building Patient Loyalty Roadshows’ have educated eye care practitioners in delivering the quality of service that can help maximise patient loyalty.

Particularly relevant now that we are facing challenges in these current economic conditions, it is recognised that it can be highly effective for practices to retain their existing patients and optimise value from them.

The Professional Academy The educational programmes delivered under the professional academy pillar have successfully delivered the latest clinical education to eye care professionals to an excellent standard, comprehensively helping to combine high quality clinical skill with effective patient communication as well as

The Business Academy pillar continues to actively offer business education.

Through its acclaimed Management Business Academy (MBA) CIBA Vision has delivered quality business education, offering an opportunity for practices to take part in an in-depth benchmarking exercise to enable individual practices to compare key variables with other leading practices and identify areas of strength and weakness.

The second module of the MBA was successfully launched this month to help practitioners build on the business acumen developed through the first module. A significant part of the course focuses on practice marketing. This complex subject is broken down into sections, so the concepts can be adapted

In 2009, CIBA Vision has expanded the programme with a second module, MBA 2. For those delegates who attended the first module, a follow-up programme has been designed to build on the fundamentals of MBA module 1.

to individual practice requirements. Prior to attending, delegates have the opportunity to complete a confidential questionnaire to better understand their management style.

The Business Academy also provides a guide to help practitioners wishing to change to a professional fee-based pricing structure. The professional fee journey plan takes practitioners through a series of small, achievable steps to ease the changeover, providing resources such as the professional fees template which helps calculate the true cost of patient chair time, and downloadable patient letter templates and brochures that can be adapted to include individual practice logos.

Also part of the Business Academy, the ‘Making Contacts Easy Guide’ specifically looks at simple ways to maximise the contact lens part of the business. It shows how through offering home delivery, setting up direct debit programmes, improving in-store visibility, managing inventory, and educating all members of staff, contact lens sales can be boosted.

The Business Academy publishes a quarterly newsletter, Contacts in

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Practices, offering up-to-date market and consumer insight and information on new product innovation.

Support Staff Academy The Support Staff Academy has been well received by practitioners and the range of resources are widely used, not only by the support staff themselves, but also by those who are involved with training support staff in practices. The Optical Assistants Guide to Contact Lenses is a DVD presented by Sarah

Morgan and educates staff on the benefits of contact lenses, what is involved in getting contact lenses for the first time, and shows how to handle specific patient enquiries.

Another DVD entitled 5 Steps to Success, is also available free of charge from the Support Staff Academy. It has proven to be a very useful in-store training tool for practitioners, showing staff how, by following five simple steps, communicating with patients and making recommendations can be made easier for support staff.

Student Academy The final pillar of the Academy for Eyecare Excellence is the Student Academy. Students have actively used the ‘Ask the Expert’ facility to pose questions to the Faculty and receive advice on aspects of their course. To help give direction to their future careers, students can read about the career paths taken by members of the Faculty.

The Student Academy has also seen great demand for the highly-rated CIBA Vision student packs which include a differential diagnosis poster, a clinical guide to complications, an occluder and a memory stick containing a CIBA Vision product fact file.

Coming soon to the Support Staff Academy is a contact lens insertion and removal training video to help optical assistants show patients how to insert and remove their lenses. It also gives appropriate advice on hygiene and aftercare. The video can be given to patients to take home.

The Academy for Eyecare Excellence will continue to develop and deliver high quality, cutting-edge education through a variety of formats and cater for every aspect and need of the optometric practice. This will maximise CIBA Vision’s support of eyecare professionals to help them achieve every success in their clinical and business objectives.

Visit www.cibavisionacademy.co.uk

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

Differentiating into contact lenses Striking out alone By Amar Shah

The essentials for a healthy practice and business

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By Dr Ian Moss Having been in practice now for over 15 years I have been able to develop a successful contact lens strategy.

In the last 10 years we have grown our contact lens category compared to spectacle category from around 10% to nearly 25% of our total practice income. The key to a successful contact lens practice has to begin with the overall attitude of your team.

Through regular staff training our communication skills have developed. We have had in-house support, the skills of leading industry experts in support staff training and also the excellent CET and professional development offerings provided by the industry and the BCLA. All staff must have the ability to listen, be adaptable, and be positive and professional, especially in the consulting room. I know my clinical routine, when newly qualified, was pretty rigid. With time my routine and conversation has become more varied to allow more interaction with the customer. Discussion on lifestyle events allows a conversation to develop and allows an opportunity to offer a trial of contact lenses. In at least 95% of occasions a suitable trial leads to a successful purchase of contact lenses. This may be for a cyclist or the emerging presbyope who wants to continue with their ‘visual freedom’.

The use of diagnostic trial lenses to allow people to choose their glasses is an excellent way of providing a better service. Ensure you have a good supply of diagnostic lenses to seize the opportunity when it arises.

Regular check-ups are excellent

for promoting regular patient care and loyalty but have also given me the opportunity to promote new developments. Including tips on compliance issues such as rub/rinse, and contact lens case management.

There is the additional opportunity in using slit-lamp microscopy and even digital imaging skills to demonstrate and manage dry eye.

The development of new technology has been a huge factor in developing our contact lens strategy. We have been extremely proactive in offering existing contact lens wearers upgrades to silicone hydrogels. When a new lens comes out check your database and get a number of people (10 or more) to have a trial, this usually gives you a reasonable feel on how a new product is performing. The widespread use of care schemes, which many practices have embraced, including the separation of fees and products, has allowed a more transparent pricing structure.

A good explanation of the care offerings are usually enough to satisfy those who are anxious about buying from the Internet or supermarket. The offering of direct debit payment schemes are in place but the more flexible cash payment option is beneficial in these more uncertain economic times.

To conclude, the satisfaction of improving the comfort of a contact lens wearer is immense.

Such examples and successes will improve your profile ensuring your customers recommend their friends and stay loyal to your practice.

I qualified from Aston University back in 1985, and spent the first few years of my working life in the multiple and independent sector. In 1995 I joined a small group of practices in the Bristol area with a view to buying out the existing partners. However, after 10 years working together we were unable to do a deal.

In the winter of 2004, without a job, I went off hoping to have an epiphany on some deserted beach and decide what to do with the rest of life. On my return I tried my hand at some locum work and found it completely unrewarding. I then started looking into setting up my own practice, which I finally opened in October 2005.

From the outset I tried to create a practice which looked and felt different. I wanted to create a boutique style environment that reflected my personality. It still had to communicate professionalism but also make the consumer feel comfortable and relaxed. I had great help from my wife, a graphic designer, and she created the ‘Amar Shah Optometrist’ brand. From in-store graphics to our website, and all other promotional material, we have a strong corporate image. The practice has grown rapidly over the last three years, mostly from word-of-mouth.

We have actively tried to stock frames that are not widely available and are more individual. A large proportion of our patients are contact lens wearers and by using the most up-to-date equipment and products we are attracting a lot of disheartened wearers, and finding solutions for them.

We have used my expertise in sports vision to help promote the business. Customers are interested in what I have been doing since their last visit. The fact that I have worked with Olympic athletes reinforces in their own mind that they are seeing the right optometrist.

One of the most important decisions I made when starting my business was in recruiting the best staff.

Getting that right has played a massive part in our ongoing success. They are reliable and enthusiastic about the service we provide. They know how the practice is doing, and from day one I have been open with them, so that they feel part of the business.

I think good independent practices will go from strength to strength. Identify your niche and then go for it. There’s no need to try and be all things to all people, the market is too congested to make that sustainable in the long-term.

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A sporting chance of success By Colin Moulson and signed jerseys from former clients. In the waiting room a video shows athletes undergoing a sports vision assessment.

The sight testing programme, using the latest testing equipment, includes automated refraction, anterior and posterior eye photography. Clients are offered relevant contact lens fitting and sports-specific dispensing, using daily disposables wherever possible. The clinic’s sports vision assessment and training programme is designed to be the most comprehensive vision assessment available to any athlete.

The initial assessment includes sight testing. Additionally each athlete is given a full orthoptic assessment, including measurement of ocular motility, convergence, accommodative speed and range.

Also measured are contrast sensitivity and dynamic visual acuity.

Specialist Sports Vision testing equipment includes the Acuvision VTA, the Dynavision 2000, and the SVT (Sports Vision Trainer). This allows assessment of an athlete’s reaction and response times, their hand, foot and body coordination and their peripheral awareness. The recently acquired SVT is the gold standard for measurements of this kind, allowing accurate measurement of hand-eye coordination, down to 0.001 of a second.

Although sports vision is never going to generate huge amounts of revenue it does allow practitioners a good way of differentiating their practice from the competition.

Revitalising a practice By Simon Donne I qualified in the early 1980s and was fortunate to have gained a wide experience working in practices ranging from the small independent to busy multiples. In the early 1990s, I was working as a locum in an independent towncentre practice which had let service levels slide and had lost any clear direction with regard to eyecare products on offer.

The practice eventually closed down but I felt strongly that with improved levels of patient care it could have succeeded even though, at the time, the country was in the grip of a recession. The practice did, in fact, reopen but this time with my name over the door.

The first policy we implemented was to offer all patients a wider choice of products always explaining, at the outset, the added benefits of premium products. This had

not been done previously, possibly because the staff thought it to be ‘hard sell’ or that patients would not want, or could not afford, thinner spectacles lenses or frequent replacement contact lenses.

Nearly everyone, whether the supplier or the consumer, enjoys the benefits of superior quality goods but if the customer or patient is not made aware of their existence they are unable to make an informed choice.

We also regularly held contact lens open days, with the support of Johnson & Johnson, who provided

diagnostic lenses and extra staff for the day. Potential contact lens wearers would walk in with their spectacle prescriptions, discuss their visual requirements and be offered a lens trial there and then.

The immediate effect was an increase in revenue per patient.

Upgrading to superior quality frequent replacement contact lenses saw an increase in the number of patients signing up to direct debit schemes.

Secondary to this was an increase in the number of patients who were recommended to us by satisfied friends and relatives.

We began to be seen as a problem-solving practice. “My friend told me to come and see you because if you couldn’t help then no-one could,” was the sort of thing we would often hear.

Being interested in what

someone has to say and offering a solution, which may be as simple as offering toric contact lenses to an astigmat, will result in a loyal patient who will gladly refer people to you.

Staff are trained to discuss contact lenses resulting in 50% of our appointments being contact lens-related. The urge has been resisted to drop prices during quiet periods and we decline requests for discounts from patients and customers. In fact, having more time is seen as a benefit, allowing even more interaction with the patients, and my contact lens business has grown by 12.5% per year over the last two years.

I believe the way forward for our practice, and for other independent practices, lies in concentrating on the premium end of the market in terms of customer service and products.

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Black & Lizars’ specialisation in sports vision dates back to the 1990s when company chief executive, Peter Ivins, set up the original Sports Vision Clinic.

During these early years, Peter was involved as a lead clinician in the Olympic screening programme in Barcelona in 1992. In 1998, I joined the company and took over as lead clinician for the Sports Vision Clinic. During this period, highlights included working with Great Britain’s Olympic Gold Medal curling squad in Salt Lake City in 2002.

During these formative years, it became obvious that one of the major hurdles is the logistics of getting athlete, practitioner and equipment all in the same place at the same time.

With this in mind it was decided in 2007 to move the Sports Vision Clinic to larger premises in South Glasgow. The equipment is available all of the time and athletes can visit whenever they like.

Current clients include Scotland Rugby and Tennis Scotland.

The practice is set up to provide a unique experience from the moment the client arrives. A separate waiting area for sports clients helps to emphasise that they are attending for more than just a routine sight test. The walls are covered with sports images

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES COMMERCIAL FEATURE

DIRECTORY INFORMATION Who are we:

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When were we formed: Founded in 1979 and employing over 7,500 people worldwide, CooperVision is one of the largest manufacturers of contact lenses in the world.

Top selling products: Biofinity (silicone hydrogel) monthly disposable and the Proclear portfolio of contact lenses including Proclear 1-Day.

What are our resources for eye care professionals: CooperVision offers a wide range of resources and support for eye care professionals. This includes everything from branding solutions to clinical and commercial workshops; marketing support to business administration solutions.

What are our major developments: The development of Aquaform Comfort Science has set the benchmark for next-generation silicone hydrogel material technologies. It has enabled practitioners to offer contact lenses that overcome the compromise of previous silicone hydrogels.

What are our future projects: CooperVision’s significant commitment to research and development has allowed the company to plan an exciting pipeline of products and technologies which will continue to enhance the wearer experience in the future.

Website: www.coopervision.co.uk

Meeting the needs of all wearers ooperVision has a single-minded focus: developing contact lenses to meet the needs of all wearers by utilising its expertise in the development of new materials, advanced optical designs and manufacturing processes.

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Technological Innovation CooperVision has been responsible for some of the most significant technological breakthroughs in the industry such as PC Technology – the basis of the Proclear portfolio of lenses.

Aquaform is a major breakthrough in silicone hydrogel lens technology. It establishes hydrogen bonds with water molecules which creates a naturally hydrophilic contact lens that retains water within the lens, thereby minimising dehydration. Aquaform underpins Avaira, Biofinity and Biofinity Toric.

Tomorrow’s Products, Today’s Needs Biofinity – the next-generation silicone hydrogel contact lens Biofinity and Biofinity Toric lenses are perfect for those who would like the option of wearing lenses late into the day or even overnight.

Combining a perfect balance of water and exceptionally high levels of oxygen sets Biofinity apart from other silicone hydrogel contact lenses. Without additives, coatings, wetting agents or surface treatments, Biofinity offers real comfort and natural breathability, giving improved contact lens performance.

Biofinity Toric benefits from an advanced patented toric design which delivers high predictability. And, importantly, Biofinity Toric is available around-the-clock in all powers.

Avaira – a naturally wettable silicone hydrogel lens for daily wear Avaira, like Biofinity, utilises Aquaform material technology to provide a contact lens which offers a combination of high oxygen transmission and low modulus.

In delivering high oxygen to the eye,

Avaira maintains a high water content of 46%, thereby overcoming the compromises that have been associated with first and second-generation silicone hydrogel lenses.

Avaira is the ideal daily wear upgrade for monthly hydrogel wearers.

Proclear – allowing practitioners to fit over 99% of all patient prescriptions The Proclear family of lenses offers outstanding all-day comfort. Thanks to unique PC Technology, they stay moist and comfortable all day long.

Proclear is the perfect material for anyone looking for more lens comfort and outstanding vision quality.

The Proclear family of lenses boasts, not only a wide range of products, but also the parameters that allow practitioners to fit well over 99% of all patient prescriptions: Proclear – Premium monthly spherical disposable lens available in a +/-20.00DS. Proclear 1-Day – Daily disposable lens, provides outstanding all-day comfort.

Proclear Multifocal – Monthly disposable lens available in +/-20.00DS and +4.00 add.

Proclear Toric – Monthly disposable toric with cylinder powers up to -5.75DC. Proclear Multifocal Toric – The world’s first monthly multifocal toric with powers up to -5.75DC and +4.00D Add. Proclear EP – For the early presbyope.

CooperVision’s commitment is to provide the eye care professional with the product expertise that allows them to offer more patients the opportunity of wearing contact lenses. That benefits the patient, the practitioner, and, ultimately, the whole optical industry.

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

Contact Lens Landmarks Tim Bowden, author of Contact Lenses: The Story

T

HEMA initially intended as a surgical material. On Christmas afternoon 1961 he successfully made soft lenses by spincasting using a Meccano device powered by a bicycle dynamo.

The National Patent Development Corporation acquired a licence, and after much research required by the FDA, Bausch & Lomb launched the Soflens in 1971.

In 1970, US polymer chemist Norman Gaylord, working for optometrist Leonard Seidner, patented the first rigid gas permeable material, launched in 1974 as the Polycon lens.

The Griffin Naturalens, the first higher water lens, was invented by chemist Ken O’Driscoll and optometrist Allan Isen, owner of the Frontier Contact Lens Lab in Buffalo. The lens was made by Griffin Contact Lenses in Toronto to avoid the US FDA regulations.

Overwear was a recurrent problem so London optometrist John de Carle developed a higher water content soft lens. With Geoff Galley he formed Global Contact Lenses, producing the Permalens in 1971, the first lens specifically for extended-wear.

As spin-casting was restricted by patents and lath cutting was slow and inconsistent, many workers started looking at cast moulding. Professor Wichterle had already tried this but Tom Shepherd was first to patent a usable process. Problems with the formation of the edges were solved by Geoff Galley, allowing increased accuracy and yield.

Danish ophthalmologist Michael Bay found that dirty lenses caused problems so launched Danalens, the first disposable lens, in 1982. Johnson & Johnson bought his unique manufacturing process, changed the material to etafilcon A, added packaging and marketing from the pharmaceutical industry and Acuvue was born.

Working in his garden shed, Ron Hamilton found he could increase yield and reduce costs, making daily disposability viable. He launched daily disposable lenses in early 1995 through Boots Opticians whilst Johnson & Johnson launched 1-Day Acuvue to the world.

In 1999, Bausch & Lomb and CIBA Vision gained European licences for 30 night continuous wear for silicone hydrogel lenses. The first major change in soft lens materials in over 40 years was a complex fusion between the hydrogels of Professor Wichterle and the silicon elastomer lenses proposed by Walter Becker, a Pittsburgh Optometrist, in 1956.

Present modalities in hydrogel and silicone hydrogel include daily disposable, weekly extended wear, daily wear with two week discard, daily wear with monthly discard and monthly continuous wear with spherical, aspheric, toric, bifocal, multifocal, UV blocking, tinted and coloured variants. Contact lenses are also available for corneal remodelling.

www.contactlensesthestory.com

11 27/03/09 THE OT GUIDE TO CONTACT LENSES

homas Young was the first to use a lens filled with liquid in contact with the eye, demonstrating in 1800 that the cornea was not involved in accommodation. In 1827 Sir John Herschel suggested that corneal distortions could be neutralised by the application of a glass shell filled with animal jelly. There is no evidence that Young or Herschel ever tried to correct vision in this way.

In 1887, a glass shell was blown by artificial eye makers F Ad M ller Söhne in Wiesbaden, Germany, to protect the eye of a patient who was already blind in one eye and was about to lose the other due to exposure. Lenses were also made for Adolf Eugen Fick, a German ophthalmologist working in Zurich, and Eugene Kalt, a French ophthalmologist working in Paris, both were trying to fit keratoconic patients but with little success.

The first to correct myopia was August M ller, but, even with cocaine, wearing times were very short.

Carl Zeiss produced fitting sets of ground glass scleral lenses from 1911, giving wearing times of around four to five hours.

Adolf M ller-Welt in Stuttgart improved things from 1928 fitting blown glass lenses with a very thin layer of tears under the lens, greatly increasing wearing times. He fitted extensively in Germany before moving to Canada and then Chicago, forming the Breger M ller-Welt Company.

In the late 1920s, Hungarian ophthalmologist Josef Dallos established a technique for making lenses from moulds of living eyes. When the physiological needs of the cornea were addressed wearing times increased. He arrived in London in 1937 where, with Theodore Hamblin Ltd, he set up the first contact lens only practice in the UK. New York optometrist Theodore Obrig discovered the combined use of fluorescein and UV light in lens fitting, before founding the Obrig Contact Lens Laboratory in 1939 and writing the first contact lens text book in 1942.

The commercialisation of Perspex by ICI in 1932 heralded a new era in contact lenses with Theodore Obrig, Ernest Mullen and Istvan Györrfy all claiming priority.

In 1912, Zeiss was unsuccessful with glass corneal lenses but in 1948 Kevin Tuohy, working with Solon Braff in San Francisco, accidentally found the optic section of a scleral lens more comfortable so started making lenses 10-11mm in diameter. Although Tuohy gained the US patent in 1950, Heinrich Wöhlk had similar experiences in 1946 in Germany leading him also to make corneal lenses.

In 1952 the Microlens was launched by Frank Dickinson, Wilhelm Söhnges and Jack Neill with a diameter of only 9.50mm. Lots of variations of diameter and curvature followed.

Also in 1952, Czech chemist Otto Wichterle discovered

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES COMMERCIAL FEATURE

DIRECTORY INFORMATION

Cantor + Nissel invests in contact lens development

Who are we: CANTOR + NISSEL

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12

When were we formed: David Cantor formed the original company in 1964 in London and it relocated to Brackley in Northamptonshire in the 1970s.

Top selling products: A very comprehensive range of specialised contact lenses for all applications as well as ocular prostheses, scleral shells and artificial eyes.

What are our resources for eye care professionals: We have a dedicated professional services consultant, Karen Hughes FBDO CL, as well as a highly trained and specialised manufacturing team who have grown with the company and who bring many decades of experience.

What are our major developments: ChromaGen: a range of coloured filters available as contact lenses or spectacle lenses for the management of colour vision deficiency and dyslexia. Hand painted soft and hard contact lenses for prosthetic application.

What are our future projects: In the immediate future we aim to offer aberration control on all soft lenses at no additional cost and single-use injection moulding shells for artificial eye and scleral lens fitting.

Consumer website: www.cantor-nissel.co.uk. We prefer to answer individual queries as they are addressed. Telephone 01280 702002.

avid Cantor, managing director of Cantor + Nissel Limited, the leading UK manufacturer of specialist contact lenses, is convinced that in order to continue as a leading supplier of specialist soft lenses the company must continue to invest in the best available technology and use this significant investment to deliver added value products to the company’s client practitioners.

In the past year, Cantor + Nissel has invested substantially in new automated manufacturing technology with the purchase of several Optoform 40 lathes from Sterling Ultraprecision Inc. The Optoform 40, complete with its ground-breaking fast tool servo, is widely regarded as the most sophisticated contact lens manufacturing platform now available. Cantor + Nissel use this combination to deliver high accuracy toric lenses to its worldwide client base.

D

Wavefront technology now available in any Cantor + Nissel soft lens An immediate benefit to practitioners is that the new technology has enabled Cantor + Nissel to include high accuracy aspheric wavefront optics as an option across the company’s complete range of soft lenses, including toric soft lenses. When applied to soft contact lenses, the terms aspheric optics and wavefront technology mean that the power profile of the lens has been modified to reduce the spherical aberration when the lens is worn; usually this feature is only noticeable in cases when the wearer’s pupil diameter is relatively large. David Cantor believes that by providing practitioners with the choice of having any Cantor + Nissel soft lens delivered with wavefront technology optics, he is providing added value which will benefit many wearers.

While acknowledging that, although there has been some discussion as to the clinical benefits such lenses may offer1,2, it is also clear the lens design is a factor in the clinical outcome3. As a significant proportion of the soft lenses supplied by Cantor + Nissel have higher powers, the benefits of controlling spherical aberration will be noticed by many wearers. While

Left to right: David Cantor with senior optometrist Annette Parkinson, Dr Ed Mallen and Professor Bill Douthwaite of the Department of Optometry at Bradford. many wavefront technology products do not specify clearly what it is that the lens is designed to correct, the Cantor + Nissel lens is well defined and has been measured to be exactly as it says on the label.

The optics of the new lenses are based on a development of the company’s EV product range. The new design has developed the EV concept further, based on recent work in the analysis of wavefront controlled aspheric soft lenses.

The standard Cantor + Nissel aspheric optics lens is calculated to have negative spherical aberration of 0.12 dioptres at an optic zone diameter of 6.00mm; this is intended to neutralise the average spherical aberration of the human eye which is about +0.12 dioptres at a similar zone diameter4,5. This power management is achieved by using an aspheric front surface which controls the power profile across the optic zone.

Cantor + Nissel has used power mapping instruments to measure a very large range of lens powers to confirm that the power profiles are as intended. The quality control system at Cantor + Nissel will guarantee that every wavefront technology lens will be measured using a power mapping instrument to confirm that its power profile matches the specification.

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Custom wavefront technology lenses also available The Cantor + Nissel lens design system has the additional feature that, if specialist practitioners have either an aberrometer or a topographer which includes aberrometry, then the mapped values can be used to calculate a customised wavefront controlled lens for that patient – this feature is offered by Cantor + Nissel at no extra cost to the practitioner.

“Adding value has been the key driver for this investment,” said David Cantor, “our new system of lens design and manufacture enables us to deliver customised wavefront lenses at the same unit cost as standardised wavefront lenses – we simply take the aberrometry data and key this into our lens design software. It makes commercial sense to have this very advanced feature available to our practitioners.”

Aspheric surface accuracy confirmed by independent measurement The accuracy of the new system has been confirmed by research work carried out by the University of Bradford. The geometry of Cantor + Nissel’s proposed EV lenses is similar to surfaces which Professor Bill Douthwaite at the University of Bradford required for a project to measure aspheric convex surfaces.

Cantor + Nissel therefore took up the challenge of manufacturing a range of test surfaces which Professor Douthwaite could use as reference surfaces. Professor Douthwaite specified a range of conic section aspheric surfaces and these were cut using Cantor + Nissel’s new Optoform 40 lathes. The lathes were equipped with controlled radius diamond tools supplied by Apex Diamond Products. Optoform lathes are recommended to use ‘minifiles’ which were generated in this case using algorithms developed by CLS Software Limited based on new mathematical strategies to control the surface asphericity during the cutting process.

The surfaces were measured independently by Taylor Hobson Ltd using its form Talysurf instrument. The results demonstrate very high accuracy across the complete range, as shown in table 1.

“This level of accuracy and consistency across a wide range

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Surface No.

Apical radius ordered

p-value ordered

Talysurf apical radius

Talysurf p-value

1

7.60

0.40

7.600

0.401

2

7.60

0.80

7.597

0.796

3

7.80

0.20

7.791

0.194

4

7.80

0.60

7.796

0.605

5

8.00

0.00

7.995

0.006

6

8.00

0.40

7.998

0.397

7

8.20

0.20

8.207

0.203

8

8.20

0.60

8.195

0.585

9

8.30

0.80

8.303

0.796

10

8.40

0.00

8.401

0.014

Table 1. The results of Form Talysurf measurement on 10 aspheric surfaces confirm the accuracy of the Cantor + Nissel manufacturing technology will enable practitioners to be fully confident that the aspheric optics in Cantor + Nissel’s soft lenses are exactly as the company intends,” said Professor Douthwaite when he met David Cantor recently.

At the meeting, Mr Cantor and Professor Douthwaite also took the opportunity to review ways in which the university might cooperate with Cantor + Nissel in future projects.

References 1. Dave, T. Aspheric contact lenses – what’s the deal? Part 1. Optician 2008 Vol 236; No 6177. 07.11.08: 22 25.

2. Dave, T. Aspheric contact lenses – what’s the deal? Part 2. Optician 2008 Vol 236; No 6181. 05.12.08: 26 30.

3. Kollbaum P, Bradley A. Aspheric Contact Lenses: Fact and Fiction. An examination of whether soft aspheric contact lenses can correct astigmatism and spherical aberration.

Contact Lens Spectrum. http://www.clspectrum.com/article.aspx?article=12770 4. Thibos L, Hong X, Bradley A, Cheng X. Statistical variation of aberration structure and image quality in a normal population of healthy eyes. Journal of the Optical Society of America 2002;19(12):2329-48.

5. Wang Y, Zhao K, Jin Y, Niu Y, Zuo T. Changes of higher order aberration with various pupil sizes in the myopic eye. Journal of Refractive Surgery 2003;19(March-April (Suppl. 2):S270-4

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Contact Lenses and Children: Ten Golden Rules for a Successful Practice Keith C Holland BSc, FCOptom, FCOVD, FBABO, FAAO, DipCLP

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hildren make great contact lens patients. Yet for some reason, many practices demur at fitting children with contact lenses, and tell parents that children cannot wear lenses until they are teenagers – or sometimes older. In this, they are doing a huge disservice both to their patients and to our profession. There is no clinical reason why young children (in our practice we fit children from the age of five upwards) should not make very successful contact lens patients and be visually better off as a result. As with so many things in optometry, it is perhaps the reticence of the practitioner that holds the public back from embracing this

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1. Understand where contact lenses will be a positive benefit when compared with spectacles A high percentage of child patients under the age of 12 will be attending the practice because of significant levels of hypermetropia, astigmatism and anisometropia. In all of these cases, it is the practitioner's desire that as stable a prescription as possible is being worn as much of the time as possible. Yet we all know that spectacles get bent, work loose and in many cases spend much of their time being taken off and not used. Switching to contact lenses ensures a child has a stable and consistent prescription that is correctly fitting on a full-time basis. For any prescription over three dioptres, or where there is more than two dioptres of anisometropia, poorly fitting spectacles are likely to lead to a significant loss of visual performance which can in turn enhance and entrench amblyopia and lead to reduced stereopsis.

For spectacle-wearing children playing sport, moving to soft contact lenses should greatly enhance their ability to enjoy the game – and to perform better with improved stereopsis and spatial awareness, as well as the obvious safety benefits of not having spectacles on. Two exceptions to this are swimming, and playing squash. In the latter case it is much cheaper and safer for a child to wear plano safety squash glasses than to invest in prescription squash glasses. For swimming, this is one of the few situations where contact lenses are unacceptable, but modular swimming goggles are cheap and widely available for these special situations.

2. Consider a longer term strategy for child contact lens patients We generally try to fit children with daily disposable lenses initially in order that they can become used to lenses without the problems and expense associated with replacing monthly or durable lenses that have perhaps been damaged during the early stages of wear. Where appropriate, we prefer to keep children in

area of practice. But why is it that so many practices are nervous fitting children? Is it because of the feeling that they may do irreparable harm? If this is the case, then they would not be fitting adults either. Is it from a fear of hurting somebody? If this is the case, why would children feel pain when adults do not? Or is it simply because they do not like working with children? If so, then surely a colleague should be employed who does? In order to encourage more practitioners to work with children and contact lenses, consider the following points and then look at what you are doing in your practice.

daily disposables rather than move to monthly lenses where there may be more issues with cleaning. However, with higher powered lenses, accurate prescription may only be available in monthly or more durable lens forms. In these cases, we will sometimes start by fitting a daily disposable in the short-term before moving to a full prescription lens after a few weeks. In these cases, we would explain that there will be some reduction in acuity in this first stage before children move on to their ‘final’ lens form, which may be a custom-made toric or extended prescription lens. Parents appreciate this, and know that accidents to lenses in those first weeks of wear are not going to be a disaster.

3. When introducing contact lenses for children, include both children and parents fully in the discussions So often, the discussion is held with either the child or the parent, leading to uncertainty, confusion and sometimes refusal to proceed. Explaining to parents and children together that contact lenses will be the best clinical option for the correction, and then explaining how and why they work can remove these worries and leads to better compliance. Parents in particular will often be

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negative initially until the clinical benefits and lack of feared pitfalls are explained. It is useful to have a leaflet available that covers the salient points. It is important too to explain the potential pitfalls of lens wear and the need for hygiene and attention to detail.

4. Nervousness in the practitioner leads to nervous patients It is important that parents see contact lens fitting as a straightforward and routine part of practice with the practitioner clearly being in control and knowing what they are doing. This is especially important when inserting and removing lenses for the first few occasions, where children may naturally be more apprehensive than adult patients (although they can often be surprisingly relaxed about this). Giving children some old lenses to handle and play with can be a useful way of introducing handling, and showing how thin and light lenses can be.

An essential tool in our contact lens teaching room is a large stuffed bunny rabbit (pictured on page 14) with particularly large eyes which are appealing to children – and ideal for inserting a contact lens onto. Although the bunny does not have lids which keep trying to close, it is nonetheless great for seeing how the lens can go on the eye, and how to ‘pinch off’ a lens, and what force is required . Obviously, use old lenses in this situation and not the patient’s prescription ones.

6. Teach the parents as well As well as teaching the child patient, teach a parent or carer at the same time. With younger children, we always ensure that the child is able to remove their own lenses, even though they may not be able to insert the lenses themselves. A parent is always taught both insertion and removal, so there is confidence in the home about handling.

7. Teaching is the key As children may often be very nervous about contact lenses, we will sometimes reverse the fitting process and teach handling before an actual fitting is carried out. Really good tuition can make the difference between a successful fitting and a failure, and the staff you use for this are key. Our training staff will sometimes use coloured contact lenses on their own eyes to show children just what to do, and are quite prepared to spend long periods of time, often on several occasions to ensure that both the patient and parents are confident and comfortable about what is needed. This then makes the practitioner's job much easier, and ensures more successful fitting.

9. Becoming a contact lens patient does not remove the need to monitor binocular vision Many children fitted with contact lenses have manifest binocular vision issues, such as anisometropia, amblyopia and strabismus.

Others, often with significant myopia, may have issues associated with near vision and reading, and it is essential that full binocular vision assessment is carried out both before fitting, and after fitting as well as on an ongoing basis during follow-up. Often, visual acuity in anisometropia will improve by one to two lines following contact lens fitting, not only increasing stereopsis, but increasing the chances of stabilising binocular vision with appropriate vision training. The need for this should be monitored carefully. It is so easy to ‘pigeonhole’ patients as contact lens patients, and ignore other aspects of their visual needs.

10. Take longer and charge more Fitting children is rewarding and great fun, but also takes longer. If we are truly working in a professional fee-based situation, then it is entirely appropriate to charge more in such situations, and we find that this has the effect of increasing the perceived value of our services, with parents appreciating that we are taking extra time and care – on average, we expect to spend an additional one hour with our child contact lens patients over the first year.

Fitting children with contact lenses is an important, if underpractised area of optometry, but the rewards are great, both in quality of life terms for our patients, and in the additional family referrals and loyalty that are generated. With a few simple modifications to general practice routines, and a preparedness for flexibility, child contact lens fitting can easily be incorporated into busy practices in the knowledge that both patients and practitioners will benefit.

8. Ensure out-of-hours cover is available With many new contact lens patients, but especially with children , a mobile phone number is provided for patients to use if needed. Although this service is very rarely used, it provides a reassuring backup for concerned parents, who know they can receive help outside office hours when there is a panic!

Keith Holland runs a busy independent practice in Cheltenham, Gloucestershire, where well over half of the patients are children.

With a particular interest in children's vision, Mr Holland has lectured and written widely on vision and learning, and on contact lens practice.

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5. Demonstrate handling on a ‘thirdparty’

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES COMMERCIAL FEATURE

DIRECTORY INFORMATION

Fitting More Astigmatic Patients the Right Way – A Review

Who are we: BAUSCH & LOMB

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16

When were we formed: The company began in 1853 in Rochester, New York.

Top selling products: Our core businesses include soft and rigid gas permeable contact lenses and lens care products, ophthalmic surgical and pharmaceutical products.

Contact Lenses: Our offerings span the entire spectrum of wearing modalities and include such well-known brand names as SofLens daily disposable and PureVision.

Lens Care: Our lens care products include the ReNu brand, EasySept and the UK’s number one selling RGP solution brand Boston.

What are our resources for eye care professionals: We provide a wide range of support through our Professional Services department including the Bausch & Lomb Academy of Vision Care.

What are our major developments: A recent launch is SofLens daily disposable Toric for Astigmatism which builds on our rich heritage in toric lens design.

What are our future projects: We are continually working to develop new materials, engineer new technologies, and create pioneering ways to help perfect vision.

Consumer website: www.bausch.co.uk www.thinkeyegiene.com www.winning-look.com

Professional website: www.bausch.co.uk www.academyofvisioncare.co.uk

sing Lo-Torque technology and advanced aspheric optics, Bausch & Lomb has now designed SofLens daily disposable Toric for Astigmatism.

The new lens can provide wearers with increased confidence, thanks to the clear, stable vision achieved through its orientation, rotation and reduced spherical aberration. This is the first time that this unique design has been offered in a daily disposable lens for astigmatic patients, helping to ensure an easy fit and all-day comfort.

A group of eight leading eye care practitioners from around the United Kingdom were recently given the opportunity to experience the new lens on uncorrected astigmats and spectacle wearers. They met in Birmingham to review their experiences of fitting the new lens.

The meeting commenced with a discussion on spherical aberration led by Dr Shehzad Naroo – a lecturer from Aston University, Birmingham. Dr Naroo explained what causes spherical aberration with emphasis on the benefits of correcting this on the quality of vision.

“Spherical aberration can be one of the most disturbing higher order aberrations in terms of quality of vision. Typical features of spherical aberration include a reduction in contrast sensitivity and haloeffects around light sources, which can be particularly troublesome when the pupil is large such as in night driving,” said Dr Naroo.

Lenses such as the SofLens daily disposable family and PureVision family are designed to control both the inherent and induced aberrations – therefore, helping to promote crisp, sharp vision especially in low light conditions.

The session was then followed by Nick Dash (pictured above), Director of Visual Edge Optometric Practice in the UK – who challenged five myths which may be the reason why some eye care practitioners currently choose to mask astigmatism in low cylinder patients rather than use a soft toric contact lens.

U

Is vision with torics significantly different to single-vision spherical (SVS) lenses for low astigmats?

Mr Dash commented on a controlled clinical study in which a group of randomly selected low cylinder astigmatic patients wore a monthly toric lens with an - 0.75 cylinder correction for one week.

The following week, patients switched to single vision spherical correction. At the end of each week, visual acuity was evaluated. The results showed a significant reduction in all acuity and visual function measured with monthly toric lenses, both statistically and clinically1.

“We should no longer be reluctant to fit low cylinder patients. I think a toric lens is a first choice for ≥0.75DC,” said Mr Dash.

Is the higher cost of toric lenses a barrier to patient acceptance?

Mr Dash discussed that the higher cost of toric lenses is not a barrier to the patient’s acceptance.

“Second best is not good enough. Sight is the most valuable sense we have, and to compromise its quality for a couple of pennies per day is nonsensical,” said Mr Dash.

Is vision with aspheric SVS lenses good enough to correct low levels of astigmatism?

Mr Dash discussed a study reported in

2005 by Morgan et al2. which evaluated high and low contrast vision with a popular aspheric lens and toric lens on patients with 0.75D or 1.00D astigmatism.

Because spherical aberration increases as pupil diameter increases, the study evaluated vision achieved through 2mm, 4mm and 6mm diameter pupils.

The toric lenses provided 6/6 high contrast acuity and 6/9 low contrast acuity to significantly more patients with 4mm and 6mm pupil diameters compared to Aspheric lenses.

“We should be looking to correct low cyl patients fully and not try to mask them with aspheric or SVS lenses.

SofLens daily disposable Toric for Astigmatism can correct not only myopia and astigmatism, but also spherical aberration. This is unique within the daily disposable format,” exclaimed Mr Dash.

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rotational stability and predictability will actually reduce chair time in the long-run.

“It takes no more time to fit toric lenses than spherical lenses,” Mr Dash told the meeting. “Over 90% of patients I fit empirically from their spectacle correction orientate correctly, and this predictability reduces initial chair time and reduces unscheduled visits.”

Practitioners’ experiences with the new lens The attendees then discussed their individual experiences with the new SofLens daily disposable Toric for Astigmatism.

Are toric lenses as comfortable as SVS lenses?

Mr Dash highlighted a clinical evaluation which was performed on over 800 astigmatic patients who were previously wearing a hydrogel SVS lens and were switched to the Lo-Torque SofLens Toric lens for a period of 2 weeks1. They were then asked (forced choice questionnaire) which lens was more comfortable.

Significantly more patients preferred the toric lenses to their previous SVS lens when asked about comfort upon insertion and end-of-day comfort.

Mr Dash reported “excellent” comfort with SofLens daily disposable Toric for Astigmatism both on insertion and at the end of the day.

“I now have no hesitation in using a SofLens daily disposable Toric for Astigmatism lens in one eye and a SofLens daily disposable SVS lens in the other, as I know patients will not notice any differences in comfort,” said Mr Dash.

Do toric lenses require more chair time?

Mr Dash highlighted that some practitioners feel that a toric lens consultation may require more chair time.

Mr Dash believes that the availability of new toric lenses with innovative design features which improve their

When commenting on enhanced visual acuity and performance of the SofLens daily disposable Toric for Astigmatism, the group confirmed the importance of vision quality for all astigmats but in particular those patients who have a lower level of astigmatism. They discussed whether a lens that combined both toroidal correction along with spherical aberration control would be a helpful addition to the group’s contact lens portfolio.

“In visually demanding, low light, situations, SofLens daily disposable Toric for Astigmatism will correct most patients optimally,” said Mr Dash.

“I had one patient who was very happy wearing another daily disposable for astigmatism. We swapped him to SofLens daily disposable Toric for Astigmatism. He then achieved a whole line better in vision and was just bowled over by his night vision. He would not go back to his previous lens,” said Christopher Kerr (pictured above).

The ease and predictability of fit of

SofLens daily disposable Toric for Astigmatism was also discussed.

David Goad said “The lens is incredibly stable on the eye and doesn’t rotate. And stabilisation is very quick, almost instantaneous.”

The group also commented on the comfort and easy handling of SofLens daily disposable Toric for Astigmatism.

“We may have a preconceived idea that another brand will probably be the most comfortable. However, when I examined SofLens daily disposable Toric for Astigmatism against the market leader for comfort, SofLens daily disposable Toric for Astigmatism was liked just as much,” said Ian Chalmers.

“One of my patients was wearing a spherical daily disposable. I switched them to SofLens daily disposable Toric for Astigmatism and they said how much better it was to handle,” added Amy Clarke.

The group concluded that low astigmats masked with spherical daily disposable lenses may not receive the astigmatic correction they need.

“The lens works extremely well, if the patient’s prescription is suitable, SofLens daily disposable Toric for Astigmatism will be my first choice lens for the low astigmats,” concluded David Goad.

“The vision was excellent especially in low level lighting and my patients noticed how comfortable the lens was,” said John Stevenson.

Meeting participants agreed that daily disposable toric lenses have had a really positive impact on their businesses, and are in great demand.

After having the opportunity to try SofLens daily disposable Toric for Astigmatism on uncorrected astigmats and spectacle wearers, the attendees reported SofLens daily disposable Toric for Astigmatism was easy to handle, had excellent comfort and vision, and was predictable in performance and stability.

To request a copy of the full round table meeting report, “Fitting More Astigmatic Patients the Right Way”, please call Bausch & Lomb Customer Service on 0845 602 2350 (UK) or 1800 409 077 (IRL)

References and Attendees See www.optometry.co.uk/references

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Evaluating and Recording Soft Contact Lens Fit Professor James Wolffsohn, Ophthalmic Research Group, Life and Health Sciences, Aston University 27/03/09 THE OT GUIDE TO CONTACT LENSES

18 itting soft contact lenses is a daily part of the workload of most optometrists. However, the evaluation of soft contact lenses varies greatly between individual practitioners and the record of lenses trialled is often limited to descriptions such as “good”. It is acknowledged that practitioners have limited time for evaluating and recording contact lens fit. However, accurate recording fit characteristics is important legally in case of future contact lens complications and to assist in overcoming contact lens discontinuations which are common (Young et al., 2002) and rely on knowledge of previous unsuccessful lens details.

If you look through the common contact lens textbooks there is no consensus on soft contact lens fit evaluation and recording. Most, such as Contact Lenses (Editors: AJ Phillips and L Speedwell) and Essential Contact Lens Practice by Jane Veys, John Meyler and Ian Davies imply describing movements in terms of millimetres and tightness of push-up (although it is not clear whether this is tightness or recovery speed) as a percentage. This article was developed from a recent paper in the journal Contact Lens and Anterior Eye by the author (Wolffsohn et al., 2009) which provides evidence of which are the most important measures of contact lens movement.

dramatically (also the case with wearing lenses when showering or swimming; Little and Bruce, 1995).

Figure 1: Pre-lens tear film break up showing distortion in the first Purkinje image with increasing time after blink

Centration and Coverage

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Lens Details The stated lens parameters and name should be carefully recorded, particularly with the development of newer generations of the same lens material, eg Fictitious Daily Disposable with Enhanced Comfort 8.5BC: 14.2mm; -3.75D.

Test order and Illumination

Figure 2: Fitting cross indicating the centre of the cornea with a circle marking the slightly inferior lens position which crosses the limbus with the superior edge

As lens fit can be affected by invasive techniques and stimulated tearing, the examination should be conducted under sufficient, but minimal illumination. Tear film should be evaluated first and the pushup test should be performed last.

Pre-Lens Tear film Dry eyes, as determined by non-invasive break-up time, tear menisus height and the number of symptoms are an important determinate of comfort wearing contact lenses (Glasson et al., 2003). The tear film on the front surface of the contact lens appears to relate to contact lens comfort, but not to predict those who would remain comfortable in their contact lenses with continued wear (Fonn et al., 1999). Non-invasive break-up time assesses contact lens surface wettability, responsible for limiting the friction with the upper lid and should be recorded as part of the evaluation of lens fit (Figure 1).

Despite the limited published evidence for the proposed damage caused by contact lenses repeatedly crossing the limbal area, as assessed by lens centration and coverage, the change in surface curvature, end of the corneal avascular area and stem cells in this location suggest this is an important aspect of soft contact lens fit (Barramdon, 2007). Some practitioners indicate the centre of lens with a cross with the centre of the lens marked by

Settling Time Most studies have shown a decrease in lens movement over the initial 10 to 15 minutes post-insertion (Schwallie and Bauman, 1998; Brennan et al., 1994; Golding et al., 1995; MaldonadoCodina and Efron, 2004). However, movement increases again during the day’s wear, with the movement after eight hours wear equating to the movement measured five minutes after insertion (Schwallie and Bauman, 1998; Brennan et al., 1994). Therefore it would seem appropriate (and perhaps beneficial to the practitioner’s limited appointment time) to assess soft lens fit about five minutes after insertion. If there has been a lot of tearing with lens insertion, then the lens can tighten-up

Figure 3: LEFT: A 0.3mm slit beam height placed on the lower contact lens margin with patient looking up. RIGHT: Immediately after the blink the lens appears located above the beam by another third of the beam height (therefore equivalent to 0.4mm)

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Figure 4: LEFT: Adjusting the slit-lamp beam width to match the lens sclera overlap in primary gaze. RIGHT: Comparison of this beam width to the overlap in temporal gaze a small cross as this is easier to draw accurately rather than a circle. I suggest a cross to indicate the centre of the cornea, with a circle to mark the relative position of the lens, which has better face validity and allows the position of any crossing of the limbus by the lens edge to be marked (Figure 2).

Comfort Although contact lens comfort and fit are not strongly related (Young, 1996), the prescribed lens must be comfortable for the wearer as discomfort is the major cause of discontinuations (Young et al., 2002). Some record discomfort on a Likert scale such as 0 (need to remove) to five (can’t feel), while a yes/no response may be sufficient as one is unlikely to fit an uncomfortable soft lens.

Lens Movement On Blink Our research showed that contact lens movement on blink with the patient looking up was more diagnostic of overall lens movement as well as being easier to observe than movement on blink in primary gaze (Wolffsohn et al., 2009). Moderate magnification of 16-25x should be used. The movement of the lens can be estimated compared to the proportion of lens overlap onto the sclera relative to the diameter of the contact lens and patients HVID (eg overlap of well centred 14.2mm total diameter contact lens = 1.1mm if the HVID is 12mm, therefore a movement on blink of 1/3rd of this distance would be 0.3-0.4mm). Alternatively, the height of the slit-lamp beam can be reduced to the smallest setting (eg 0.3mm) and this distance used as a comparator to estimate the size of movement (Figure 3).

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movement (Wolffsohn et al., 2009). Although some refer to lens sag rather than lag, this describes the distortion or geometry of the shape of the lens, not its movement, although the two are related.

Due to the movement of the eye on changing gaze, the actual movement of the lens is not easy to estimate. Instead, with the patient looking straight ahead, the slit-lamp beam can be adjusted to match the width overlap of the contact lens onto the sclera (Figure 4: left). When the patient looks to the nasal and temporal side, the slit-beam can be relocated to the new overlap, for comparison (Figure 4: right). Presuming the overlap is ~1mm (see above), then an average 50% increase equates to a 0.5mm lag.

Push-up Test The importance of the push-up test in evaluating soft contact lens movement and adequate fit has been previously highlighted (Young, 1996) and was supported by our research (Wolffsohn et al., 2009). However, our findings suggested the speed of recovery was more important than the difficulty in dislodging the lens as has been previously evaluated (Figure 5).

Recording of Contact Lens Movement Parameters Movement on blink in up-gaze and lag on horizontal excursion can be recorded in millimetres, but the push-up recovery speed is more difficult to assess as it involves both movement and time. Professor Wolffsohn and colleagues showed that a three-point scale was just as descriptive of lens overall movement and recommended (Figure 6):

Figure 6: Lens schematic indicating a slightly low lens centration, with no limbal incursion, movement on blink in up-gaze of 0.25-0.50mm, horizontal lag of 0.5-1.0mm, but a sluggish push-up recovery • if blink movement =0.25-0.50mm (as in this case) then record B0, if less then B- and more B+.

• if the sclera centration overlap increases by on average 0.51.0mm between nasal and temporal lag, it should be recorded as L0, if less then L- and more L+.

• an instantaneous drop to the original position on push-up displacement of the contact lens should be recorded as P+, a slow relocation as P- and a steady relocation (2-4mm/s) as P0.

Lag

Outcome of Lens Evaluation

Lag refers to the resistance of the lens to move with the eye on excursions away from primary gaze. If the lens is mobile, then the lens will tend to shift centration away from the direction of gaze due to the architecture of the lid anatomy. Our research shows that only horizontal lag is diagnostic of overall lens

The decision on whether contact lenses should be trialled on the eye is based on clinical judgement, and may depend on the lens material and thickness. However, it would not be normal to accept more than two ‘minus’ grading in movement on blink, lag and push-up, or limbal incursion. Comfort must also be acceptable to the patient and acuity good and stable, with the prescription checked by over-refraction.

Acknowledgements The British Universities Committee on Contact Lens Educators helped to formulate this article.

References Figure 5: Digital displacement in the push-up test

www.optometry.co.uk/references

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DIRECTORY INFORMATION

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Who are we: JOHNSON & JOHNSON VISION CARE

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When were we formed: Johnson & Johnson Vision Care was formed in 1988 in the USA.

Top selling product: 1•Day Acuvue Moist with Lacreon Technology is designed to give patients the freedom of daily disposable lens wear that is fresh and comfortable, letting patients’ eyes stay moist and fresh even at the end of the day.

What are our resources for eye care professionals: The Vision Care Institute, an independent training facility for practitioners to enable them to learn more about the latest developments in the optical field under the leadership of top eye care professionals. The first Vision Care Institute in the UK opens this month (March 2009).

What are our major developments: Johnson & Johnson Vision Care continually strives to create new and innovative products, such as 1•Day Acuvue TruEye.

What are our future projects: The new toric lens, Acuvue Oasys for Astigmatism, is launching in May 2009.

Consumer website: www.acuvue.co.uk Professional website: www.acuvue.co.uk (See section for professionals)

Now astigmatic patients need never miss a moment1 houldn’t astigmats be able to experience clear, stable vision outside the consulting room? A study involving 335 people with astigmatism found that 98% of people wanted clear vision and comfort from their soft contact lenses, but one-in-four said their current lenses failed to provide that.

Nearly half said they had blurred vision and three-quarters said that the quality of their vision changed throughout the day2.

Also as 65% of all contact lens drop-outs have astigmatism3, many astigmatic patients are demanding more. This is why Johnson & Johnson Vision Care recognised a need to continue to innovate in the toric category and in listening to the needs of eye care professionals, they developed Acuvue Oasys for Astigmatism, to create an opportunity for practitioners to further improve astigmatic patients’ vision and comfort satisfaction.

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“.. it is the best toric product on the market.

My patients comment that it is the most comfortable lens for astigmatism too.”

Martin Lea, contact lens specialist

Increasing the Acuvue range = Increasing patient satisfaction With the addition of Acuvue Oasys for Astigmatism to the Acuvue range for Astigmatism, Johnson & Johnson Vision Care now offers astigmatic patients further choice.

New Acuvue Oasys for Astigmatism, launching in the UK in May 2009, combines Johnson & Johnson Vision Care’s unique Accelerated Stabilisation Design with its patented Hydraclear Plus technology to give patients crisp, clear vision and comfort which lasts throughout the day.

Exceptional stability and comfort The technology behind Accelerated Stabilisation Design harnesses the natural pressure of the blinking eye to balance the lens in place; quickly realigning the lens if it rotates out of position. In a recent peerreviewed study Accelerated Stabilisation Design was found to be significantly more stable than a leading prism ballasted lens during certain important eye movements4.

This exciting new lens is the smoothest toric lens on the market and is significantly more flexible than several current silicone hydrogel toric lenses5.

The lens also offers high oxygen availability resulting in an oxygen delivery which is significantly greater than current hydrogel toric lenses, helping to keep eyes white.

“It’s a superb lens, all astigmatic patients should use it!”

Jonathan Rodgers, contact lens specialist

In addition to these benefits, Acuvue Oasys for Astigmatism has received the World Council of Optometry seal of acceptance for UV absorbing contact lenses6, offering Class 1 UV block, the highest UVA and UVB blocking of any soft toric contact lens in today’s market7.

New Acuvue Oasys for Astigmatism offers a winning combination, allowing more patients to choose a lens that enables them to live their lives with fewer moments of blurry vision and in excellent comfort. No other toric lens offers your patients all these benefits. Offer Acuvue Oasys for Astigmatism to your patients today and let them see the results!

References See www.optometry.co.uk/references

“Acuvue Oasys for Astigmatism offers outstanding visual acuity and fit for astigmatic patients, providing clear, consistent vision and comfort throughout the day. We are confident that no other toric lens has all the benefits of this product,” said Ian Pyzer, professional affairs manager, Johnson & Johnson Vision Care.

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

Exceeding expectations ACLM’s secretary general Simon Rodwell discusses the future of the sector

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improving fitting skills, increasing product knowledge and revitalising communication techniques with patients. The everpresent risk of counterfeit products can be removed if patients are given the incentives to purchase from their practitioner and not drawn to the Internet. Substitution can be virtually eliminated if practitioners follow professional guidelines and specify the exact (manufacturer and brand) contact lens on the specification.

There have been plenty of well-written and concise business articles in the optical press over the past few years, and practitioners are encouraged to absorb and implement the excellent practical advice they give. Some of these articles have discussed the need to be ‘sales-aware’. Everyone who walks into the practice is a potential contact lens customer, but the whole team has to be well-trained and committed to the consistent objective of promoting contact lenses. And selling is not a dirty word – we all have to sell ourselves to get a new job, to create relationships and to retain patients. Most of us are definitely not good at it, and it does require both effort and practice, but it is certainly rewarding and arguably the most essential life skill. We are not talking about ‘box-shifting’ here, but an altogether much more sophisticated sell of our capabilities, our energy and our integrity. It is said that 90% of our thoughts and decision-making processes are subconscious. It therefore follows that by creating a bond of trust with our patients we will be encouraging them to reward us with their business.

Manufacturers in the UK are only successful when practitioners are successful. A casual trawl through their marketing material and websites clearly demonstrates their commitment to practitioners with a large range of offers, specialist clubs, road shows, training opportunities and other initiatives. Many of them exhibit at the BCLA exhibition and at Optrafair. Their contact lenses, solutions and eye-drops are listed in the ACLM Contact Lens Year Book, voted recently by practitioners as the top benefit of BCLA membership. There are many opportunities to be gained from this range of support, and even to come up with new and more innovative joint ideas.

ACLM member companies are committed to supporting practitioners and the growth of the contact lens category. Through continual investment in new products and initiatives they are working to create a prosperous future. In a welcome move, the optical bodies recently announced their intention to work more closely together in a Confederation of Optics for the greater benefit of practitioners. For those who like acronyms then this welcome initiative supports three important ‘Cs’ highlighted in this article: Cooperation, Communication and Customer Service.

As we move from unbridled consumerism to a more realistic trading environment, readers might like to reflect on the ‘two CLs’ – Contact Lenses create Customer Loyalty.

21 27/03/09 THE OT GUIDE TO CONTACT LENSES

he contact lens industry today has an increasingly global feel about it, and there is more product choice for the wearer than ever before. Manufacturing methods continue to become increasingly sophisticated, and more technical innovation in materials and lens care solutions accelerates this trend. Techniques such as Ortho K and new materials like silicone hydrogels are cases in point. Almost every refractive error is covered today, providing a fully reversible alternative to laser surgery, and the correction of presbyopia – which is the biggest potential market for existing wearers as they age – will increasingly be serviced by an ever-wider range of contact lenses.

Sometimes the marketplace does look like a free-for-all, but this is the inevitable outcome of increasing consumer choice and developing sales channels.

There is no need to reinforce all the gloomy predictions we daily hear about on the news, but it is worth reiterating some of the messages which are borne of real research.

Firstly, the Internet is here to stay so practitioners need to adapt by charging for their professional time and resisting the temptation to load costs onto the products they sell. Secondly, although buyers are cautious, there is still plenty of wealth about and contact lenses are still regarded as an essential rather than a luxury item. The market is polarising to some extent, so it is important to stress the benefits of premium products and not just cut prices. In the same way, it is also worth offering enhanced services such as are now available through local PCT initiatives. Thirdly, what to many practitioners is a patient is actually a consumer, and needs to be managed properly and encouraged as one. We all have experience as consumers, so imagine yourself in their position and critically appraise what you are offering them.

It is easy to fall prey to what commentators call ‘the rumour’: “in the time it takes to sell contact lenses I could sell two pairs of spectacles”. The London Business School (LBS) clearly demonstrated how very misleading this was in 2001 when it produced a contact lens business model for the ACLM. The LBS spelt out the absolute need to encourage patient loyalty with the concept of lifetime value, and discouraged practitioners from thinking in the short-term. Exceeding patient expectations will be vital in this recession, but it takes time, training and hard work.

The most successful practices already spend a good deal more practitioner time on contact lenses, especially in the pre-sale time and in aftercare. They are looking to the medium and long-term benefits of patient loyalty. But the longer term rewards are there for those who persevere, as contact lenses generate more income and offer greater interest to the practitioner’s day.

The difficult areas with contact lenses can nearly all be overcome by greater practitioner diligence. Drop-outs are too numerous, although still fewer than the growth in new wearers.

But drop-outs can be reduced to a quarter of the current level by

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES COMMERCIAL FEATURE

DIRECTORY INFORMATION Who are we: ALCON LABORATORIES INC

When were we formed: Alcon was founded in 1945 and is the world's largest eye care company employing over 15,000 employees. Alcon’s portfolio of specialist eye care products includes leading surgical, pharmaceutical and consumer eye care products.

Top selling products:

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What are our resources for eye care professionals: Dedicated territory managers and customer service for opticians, marketing support, educational literature and CET, point of sale material and free starter packs.

A proven solution for contact lens wearers lthough contact lens wearers generally have healthy normal eyes and ocular tear films, they still frequently complain of ocular discomfort, usually irritation or dryness.

While some tolerate this discomfort, believing it to be normal and blaming external factors like computer use, others stop using their lenses altogether. Wearers often continue to experience dissatisfaction or discomfort even after changing lens brands. Opti-Free RepleniSH from Alcon offers contact lens wearers a whole new level of patient satisfaction. It is the only solution with TearGlyde, the world’s first Tear Actuating Complex, which reconditions lenses to retain surface moisture for at least 14 hours. This prolongs comfort of all silicone hydrogel and soft lenses, in addition to providing unsurpassed cleaning and disinfection efficacy.

Opti-Free RepleniSH meets the highest FDA “stand-alone” standards for multipurpose disinfecting solutions. Opti-Free Replenish also contains the tried and trusted preservative system of Polyquad and Aldox, delivering 20 years of efficacy history.

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works with the patient's own tear components to retain moisture on the lens surface, allowing for a continuous shield of moisture between the lens and the eye which provides comfort all day.

TearGlyde is a combination of Tetronic 1304 and C9-ED3A which interacts with natural components of the human tear film to further enhance the wetting properties of this unique solution.

Fact Opti-Free RepleniSH makes contact lenses more comfortable for wearers of the most common soft lens material2 Fact: Opti-Free RepleniSH is the only lens care solution with TearGlyde to recondition lenses for outstanding surface wetting ability2 Fact: Opti-Free RepleniSH means less use of rewetting drops for patients using silicone hydrogel lenses2 Fact: Opti-Free RepleniSH rids lenses of bacteria, fungi and kills Acanthamoeba and keeps disinfecting as long as lenses are stored, for up to 30 days Fact: Opti-Free RepleniSH moisture shield helps keep eyes free from redness and helps promote clear vision.3

What are our major developments: We have large investment in R&D with a strong product pipeline for contact lens care, dry-eye, nutrition and therapeutics.

What are our future projects: The majority of our customers have already upgraded to Opti-Free Replenish and look out for more exciting new additions later this year.

Consumer website: www.Opti-Free.co.uk Professional website: www.alconlabs.com

The majority of optometrists have now upgraded their patients from Opti-Free Express to Opti-Free Replenish designed for today’s lens modalities

It’s a winner with contact lens wearers1 • 82% of contact lens wearers felt that Opti-Free RepleniSH gave their lenses long lasting comfort • 92% agreed that their lenses felt clean • 94% agreed that the solution was gentle on their eyes • 77% stated that the whites of their eyes appeared free from redness during the day when using the solution.

How does TearGlyde work?

While lenses soak, TearGlyde absorbs a proprietary wetting agent to their surface.

When lenses are inserted in the eye, this

For further information, visit www.Opti-Free.co.uk. To request Opti-Free RepleniSH starter kits, please contact your local territory manager or Alcon direct on 0800 092 4567.

References 1. Data on file 2. Potter B, Stiegmeier MG et al. A clinical evaluation of solutions. Review of Cornea & Contact Lenses.

2005;32-36 3. Opti-Free RepleniSH Package insert

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LIFE THROUGH THE LENS: THE OT GUIDE TO CONTACT LENSES

Specialist contact lenses – Meeting the needs of your non-standard prescriptions Andrew J Elder Smith MSc FCOptom DCLP FAAO FBCLA

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Thinking of some of my most grateful wearers, I can come up with examples of people with astigmatism who found that the mass produced soft lenses just did not perform to give really crisp and stable vision, early keratoconics, some with steeper or flatter corneal profiles than average, scarred and disfigured eyes needing prosthetic contact lenses and post surgical cases with small residual refractive errors and corneal irregularities. Throw into the mix several older people with anisometropia who coped until they hit presbyopia and then found that spectacles just did not work for them – who not only discovered the freedom of multifocal contact lenses but also the joys of being able to walk around seeing clearly and not feeling sick.

How do you make yourself into a contact lens specialist?

First of all, open your eyes to the wonder of vision with contact lenses rather than glasses. Remember the face that lights up the first time you apply a contact lens and the person sees the world as it should be – clear and undistorted – for the first time in many years. That should be motivation enough to help all those who have previously not been offered contact lenses or have been told their eyes are too bad for contacts. You can then start viewing everyone who requires vision correction as a contact lens wearer. Then it helps if, like me, you find it difficult to say “No,” to people. Now, this can take you to some interesting places but you will learn a lot getting there. And remember that people with complex prescriptions generally know they have “bad eyes” so do not expect instant solutions – this gives you valuable thinking time.

If you really want to challenge yourself then contact your local hospital eye department and see if they have any sessional work available. There really is no substitute for hands-on experience, but sound background knowledge is essential and there are many courses run to help enhance specialist fitting skills of gas permeable lenses. There is contact lens tuition available from Contact Solutions Consultants, which will offer one-to-one training in your work place where your own patients can be fitted under the watchful eyes of an experienced practitioner.

So what is a specialist lens? It could be a simple rigid gas permeable or a complex bi-toric multifocal rigid gas permeable, a specially design keratoconic lens or an orthokeratology lens. I suppose it is what ever the practice up the road is refusing to fit because they view it as too complicated or too time consuming for them to bother with.

All the suppliers of these more exotic lenses have professional and technical help on hand at the end of the telephone to advise in lens and material selection and to troubleshoot when things don’t go quite how you expect – don’t be too proud to use them.

In the last few years there have been some exciting advances in specialist lenses that have really helped make our job easier.

Many of us think of specialist lenses being rigid, however there are some pretty special soft lenses out there too. Several companies are now manufacturing tailor-made silicone hydrogel lenses which can be made in a wide range of diameters and radii with powers up to +/- 30DS with cyls to 11DC and adds to 3.00DS if you want a multifocal which should cover most eventualities. And in case it doesn’t, there is even a version for keratoconics.

Rigid lenses are keeping up and can now be manufactured with asymmetric peripheries – this means that if a lens fit looks really good except in one area (where it might stand off too much) you can get the lens made with a steeper periphery in that area to improve the fit. Comfort with RGPs need not be so much of an issue – with the advent of extremely oxygen permeable materials, several companies are manufacturing very large 13mm to 15.5mm rigid lenses which give excellent comfort, not to mention a new hybrid lens with a soft skirt and a high Dk rigid centre which is available in many more parameters than its predecessors.

I haven’t even mentioned topographers and lenses made directly from the data downloaded so that the corneal shape is reflected in the back surface of the lens. Which leads me on to orthokeratology or CRT (Corneal Reshaping Therapy) lenses worn while you are asleep, then taken out in the morning by which time they will have corrected your vision and allow you to see clearly all day – now that is something special.

For more information, email Contact Solutions Consultants: ajes@contactsolutionsconsultants.co.uk

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hat I would like to address in this article is how you make the jump from fitting standard mass produced contact lenses to fitting the more challenging cases that present in your chair. I am not going to discuss really complex cases, like advanced keratoconus that may require a scleral lens, in any detail. I am going to concentrate on the five to 10% of cases that do not fit into the ranges of the mass produced lenses but where, with some effort, a huge improvement can be made to that individual’s quality of life.

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