THE LABORATORY CONSULTANTS
These individuals are invaluable and essential resources for successful management of specialty contact lens patients.
Whenever you make a major purchase (for example, to construct a home), do you simply think: “I know exactly what I want, how to design it, where to build it, and what furniture and appliances would be optimum”? Similarly, what if you or a loved one have a systemic health condition that will require frequent monitoring from an appropriate medical specialist. Would you simply throw a bunch of names against the wall and see which one sticks? We didn’t think so.
Let’s say that over the course of a week you treat a severe dry eye patient, a keratoconus patient who is seriously considering some form of corneal transplant, and a post-refractive surgery patient—all of whom have failed with conventional contact lenses. In addition, two other patients are young, progressing myopes who are interested in contact lens wear. In your heart, you know that there are multiple specialty lens options that could be the answer for the first three patients, and orthokeratology could allow the latter two patients to have freedom from correction during the day while potentially slowing myopia progression. However, the perceived complexity of the fits and their associated learning curve makes you very hesitant. You wonder where you could go for assistance. The answer, provided in this article, is pretty simple: the laboratory consultants.
The Benefits provided by Laboratory Consultants
1) Guidance
Consultants can help guide eyecare practitioners (ECPs) through every step of the process, from material and design selection through fitting and troubleshooting. Once ECPs establish initial contact with a laboratory consultant, it becomes evident that there is no such thing as a “dumb” question. A consultant’s primary motivation is to partner with ECPs to help make their patients successful while increasing the practitioners’ confidence in lens fitting.
2) Design Education
Every contact lens laboratory has a large and varied portfolio of lens designs to match the needs of many different types of contact lens candidates. They can discuss which design may best fit a patient’s needs and can make recommendations based on their extensive experience. No one understands the nuances of their designs better than they do because they consult on hundreds if not thousands of cases pertaining to each particular design. This includes making minor design modifications that may or may not be documented in their fitting guides.
“Consultants can help ECPs feel more confident in making lens design and troubleshooting decisions. ”
Additionally, they can help ECPs feel more confident in making lens design and troubleshooting decisions for future patients. The consultants are true experts in their designs, and they deal with their unique lens designs on a daily basis. This expertise and experience should not be taken lightly; the consultants want ECPs to ask them questions, and they want to help educate those practitioners.
3) Material Recommendation
In a world with a large and expanding number of GP and latheable soft lens materials, “Which lens material should I use?” is a common question. Laboratory consultants can recommend specific materials, and this is particularly important when the design being ordered is available only in certain materials. When troubleshooting a particular case, consultants can also recommend whether a lens treatment or coating would benefit a particular patient or whether a change in material may be helpful in certain circumstances (e.g., to help improve the wetting angle or oxygen permeability of a lens).
4) Specialty Assistance
This is where the laboratory consultants are worth their weight in gold. For beginning practitioners, consultants can make recommendations in a variety of areas, ranging from educating patients, making specific design suggestions, fitting and evaluation procedures, and where to go for help. For experienced practitioners, laboratory consultants can make recommendations about how to improve the fit or give other troubleshooting input to help optimize patient success.
5) Reassurance
For novice as well as experienced contact lens practitioners, it may take several lenses to achieve success with a challenging specialty contact lens-wearing patient. The consultants are right there assuring the ECPs that this is not their fault and that it represents a normal process with some patients. Consultants will also work with the practitioners to make these patients successful.
6) Online Resources
Laboratories have many extremely beneficial online resources, especially for the fitting and troubleshooting of their specific designs. This often includes calculators to determine the lens parameters to be ordered, fitting guides, and problem-solving guides that often include photos, videos, and webinars. They will also often recommend the resources available from industry organizations. For instance, the GP Lens Institute (GPLI; www.gpli.info) offers more than 70 archived webinars, an interactive empirical GP fitting program called “Click n’ Fit,” a spherical and toric GP lens empirical fitting lens calculator, and a “Lab Consultant FAQs” module. In addition, the Scleral Lens Education Society (SLS; www.sclerallens.org) has information about everything scleral, such as care and handling instructional videos for patients, videos and a living library for practitioners, and calendars detailing upcoming SLS hands-on workshops. These two examples are just the tip of the iceberg, as many other industry groups and schools of optometry also have free and downloadable useful resources.
The GPLI Advisory Board members were surveyed as to what they perceived were the benefits of laboratory consultants for them and their practices. The sidebar on p. 31 provides some representative responses.
Common Questions
We asked many laboratory consultants what common questions they receive from practitioners. The following six areas were given as most likely to be asked.
1) Warranties/Return Policies
This is a commonly asked question, and it should be. When ECPs consider the cost of some of the special lens designs (notably scleral lens designs), the warranty policy provided by the laboratory can factor into whether or not practitioners will fit a specific contact lens. A liberal return policy is especially important for practitioners who are trying to get started with scleral lenses or with other specialty lens designs. It is also important to inquire about return fees and cancellation fees, because these can play a role when developing a system for a contact lens fee structure.
2) Scleral Lenses
Consultants are often asked questions pertaining to scleral lenses, including: “Should I use a scleral in this case?” “What type of scleral lens should I prescribe?” “What constitutes a good fit?” “How do I manage problems such as lens decentration or tear debris?” or “What online sources are available?” Consultants can guide ECPs through the fitting and troubleshooting process, recommend workshop programs (sometimes occurring within the laboratory facility itself), and customize the type of scleral lens to be used based upon the ECPs’ experience with scleral lenses.
“[A good history] helps a consultant determine which design a practitioner should fit first.”
3) Multifocal Lenses
Consultants are often asked about how to approach presbyopic patients with GP and/or custom soft multifocal lenses. Consultants will not only assist with what contact lens to use and how to approach the fitting, but also with how to have that conversation with patients. For an established multifocal practitioner, no one can assist with problem-solving a specific lens design better than a consultant from the laboratory that manufactures that design. Over time, this results in fewer refits, more successful contact-lenswearing patients, many patient referrals, and greater practice revenue.
4) Irregular Corneas
For patients who have all types of irregular corneas (e.g., due to keratoconus, corneal transplant, or refractive surgery), laboratory consultants are invaluable in recommending a specific design, which could include small-diameter corneal GPs, intralimbal GPs, sclerals, or hybrid lenses. Once again, the design selection is only the beginning of a process in which they can assist throughout the fitting and follow up of a patient who has an irregular cornea.
5) Assistance with the Lens-to-Cornea Fitting Relationship
For all GP lenses, laboratory consultants can assist with both describing and also providing resources pertaining to how a specific design should fit, beginning with basic spherical lens fluorescein patterns. Sending a patient’s topography and photos or videos of the contact lens fit can be immensely helpful to consultants. Instead of saying “I see touch on the cone and some midperipheral pooling,” it is much more helpful for consultants to actually see the contact lens fit with their own eyes.
6) Insurance/Third-Party Billing and Reimbursement
This area is especially important for the success of any practice that fits specialty contact lenses, and laboratory consultants are well qualified to provide assistance to commonly asked questions on this topic. Some consultants will also recommend the GPLI’s coding and billing module under the direction of Clarke Newman, OD, and available at www.gpli.info/coding-billing.
Necessary Information to Provide
We asked both laboratory consultants and specialty contact lens practitioners about what information needs to be provided to get the most out of their interaction. The responses can be placed into the following five categories.
1) A Good History
It is important to have an initial conversation with a consultant that details a patient’s contact lens history (if applicable). What design(s) has a patient already attempted, and why did he or she desire to change? Describe what lenses are currently being worn, and provide information such as hours of comfortable wearing time, symptoms (if present), and a thorough description of the fit. This helps a consultant determine which design a practitioner should fit first. For example, if patients have irregular corneas, consultants can provide the appropriate diagnostic fitting set to initiate the fitting process.
2) The Basic or Minimum Information
Most GP lenses today are fit empirically, including spherical, toric, multifocal, and orthokeratology designs. The laboratory consultants advise that the more information they can obtain, the better. At minimum, however, provide a patient’s refraction, keratometry values, and horizontal visible iris diameter; for presbyopic patients, also obtain the photopic pupil diameter and possibly the lower lidto-limbus relationship. Consultants will often suggest that practitioners reference the lab’s online calculator and ordering system as well.
3) Corneal Topography Maps
If corneal topography maps are available, they can be of great assistance in both lens design selection and problem solving. Certainly, these maps are essential when fitting patients into orthokeratology, but they can be invaluable for most other contact lens patients, notably those exhibiting irregular corneas. At a minimum, providing the sim Ks and axial maps are beneficial; however, it is ideal to export the files to laboratory consultants so that they can have more extensive information, including tangential and elevation maps.
4) Photos and Videos of the Fit
If a picture is worth a thousand words, then imagine how valuable a video would be. Both are easy to obtain and share with consultants, even in the absence of an anterior segment camera. With numerous slit lamp adapters available today that can be attached to a cell phone, ECPs can obtain good images and videos of the contact lens/eye fitting relationship. This makes it much easier for consultants to see what practitioners see and to know what specific modifications to the lens design are indicated. For scleral lenses, this can assist with the central fit, the limbal transition zone, and the peripheral fit.
5. Optical Coherence Tomography (OCT)
The application of OCT with scleral lens designs has been very beneficial to their success, and consultants both welcome and embrace this technology. In particular, consultants desire accurate information for the amount of central clearance (i.e., something more specific than “good” or “plenty”), as this can result in the success of failure of a given design. OCT is ideal for that purpose. Likewise, OCT can assist as to whether there is clearance at the limbal transition area as well as ensuring that the lens periphery is resting on—not embedded into—the conjunctiva or underlying sclera.
Phone or Online Consultations
It is evident that, although phone consultations are still predominant, the use of online consultations is increasing. One large GP laboratory has no less than 10 full-time consultants, with one completely dedicated to online consultations.
Phone consultations offer many benefits because consultants can quickly and accurately determine how they can assist ECPs while being able to ask the right questions to help with a given patient. The use of the phone would minimize any possible miscommunications that could occur via email. There is also the option of using a video chat system to have a visual consult with a laboratory consultant.
There are benefits, however, to using online consultations. Certainly, any topography maps, OCT images, photos, and videos can be sent online, and some ECPs initiate a phone consultation after sending this information to a consultant. It is also evident that younger practitioners tend to prefer email over phone consultations.
For very busy specialty lens practitioners, online consultations provide numerous benefits. Dr. Woo noted that in her practice, which can see 50+ patients per day, waiting on the phone to talk to a consultant was very inefficient. She says that email has become an excellent way to communicate with consultants. Specifically, it works well because she is able to give the consultants all of the information about the fit (via photos, videos, descriptions, etc.), the consultants are able to view the information and get opinions from their team, and then they can get back to her when it is convenient for them. It works the same on her end, because she can view their emails at her convenience; patients don’t have to wait for her to finish a phone call.
How often should Practitioners use their Laboratory Consultants?
The members of the GPLI Advisory Board communicate with their consultants quite frequently (Table 1). In fact, 68% of the respondents interact with their laboratory consultants more than once per week, and almost 30% contact them daily.
The Future Role of Laboratory Consultants
The future role of laboratory consultants is even more beneficial to ECPs. This is due not only to advances in ease of photography, corneal topography, and OCT, but also with the increasing availability of online virtual fitting and troubleshooting resources. One laboratory has already introduced an online program that allows practitioners to select and modify their scleral lens parameters (e.g., sagittal depth, limbal height, midperipheral clearance) with a visualization of the post-lens fluid layer with those modifications. Practitioners can also observe the calculated Dk value with lens thickness and lens clearance.
“On the horizon, consultants will be able to [virtually] see through the slit lamp in real time.”
On the horizon for ECPs is the ability to perform live virtual consults with consultants who would be able to see what the ECPs see through the slit lamp in real time. There already exists an app-based software that allows for HIPAA-compliant, secure, and encrypted peerto-peer communication. The system is currently being adopted by multiple contact lens laboratories to facilitate improved consultation and outcomes while reducing consultation time, remakes, costs, and chair time. By simply attaching a smartphone or tablet to the slit lamp oculars via an adapter, the platform allows practitioners to connect with laboratory consultants to aid in the lens design process. These communications can be synchronous (i.e., real-time consultation via a live video call that shows a laboratory consultant a first-person view through the slit lamp of the contact lens on a patient’s eye); asynchronous (i.e., an anytime consultation in which images, video, tests/scans, and other pertinent information are submitted and reviewed by a consultant); or via secure and HIPAA-compliant chat messaging.
The Bottom Line
The recent advances in contact lens designs, not to mention material and coating technology, are extremely exciting and allow more options and often better alternatives for patients. However, the successful application of these new designs and technological advancements is only as good as the ability of practitioners to design, fit, and troubleshoot them. For this to occur, an integral part of the formula (and often the difference between success and failure of a contact lens patient) is the active and ongoing engagement of laboratory consultants to serve as partners in the management of these patients.