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Contact lens recommendation has never been easier than it is today, in view of the availability of disposable lenses in a wide range of powers and parameters, designs and materials, and their enhanced performance and success rates. The introduction of daily disposable lenses has meant that initiating contact lens wear is easier for both patient and practitioner.
Despite these advances, the uptake of contact lenses in Europe continues to lag behind other regions. In the UK, the number of wearers equates to 7.2 per cent of adults, a value which is half the wearer base of Japan (14.6 per cent) and the US (14.7 per cent), although higher than in other European countries.1 Low uptake of contact lenses may be attributable in part to reactive rather than proactive prescribing to potential contact lens wearers.
So how can you increase your contact lens business by opening up new opportunities to prescribe contact lenses? This article will provide some tips on increasing your contact lens business based on recent research, and reveal some directions practitioners could take to expand the total contact lens business and drive this in a more productive way.
Trialling contact lenses with EASE
One way of promoting contact lenses in your practice is the use of contact lenses during the spectacle dispensing process. The EASE (Enhancing the Approach to Selecting Eyewear) study was a multi-centre, practice-based study into the effect of applying contact lenses prior to spectacle dispensing.2
The study involved 91 subjects with no previous contact lens experience and six practitioners around the UK. Subjects were randomly assigned into either a test group (52 subjects) or control group (39 subjects). The test group was offered contact lenses before spectacle dispensing, presented as an aid to spectacle dispensing rather than as a longer term method of vision correction. The control group proceeded to spectacle dispensing in the normal way without being offered contact lenses.
Response to the offer of wearing contact lenses during dispensing, fitting success, the impact on the spectacle dispensing process and the longer term purchase of contact lenses were measured and compared for the test and control groups. The study results are summarised in Figure 1.
Of the test group, 88 per cent agreed to try contact lenses and 98 per cent of these subjects were successfully fitted with soft disposable lenses. They reported a superior subjective spectacle dispensing experience, as measured by a questionnaire on attitudes to various aspects of the experience. There were significant differences between the two groups for choosing the shape of a frame, seeing the detail of the spectacle frame and confirming that the frame suited them. As many as 91 per cent of the contact lens wearers said their vision was comfortable and 85 per cent said contact lenses were helpful in choosing their spectacles.
The contact lens-wearing group also spent 32 per cent more on spectacles than the control group. At three months post dispensing, 33 per cent of the test group had purchased contact lenses compared with 13 per cent of control subjects.
The use of contact lenses clearly enhanced the spectacle dispensing process, allowing wearers to make a choice of spectacles in which they had greater confidence, and allowing them to choose better products in the process.
The authors noted the tendency of the test group to spend more on their spectacles. This is presumably related to increased confidence in their frame selection and perhaps the improved ability to see and appreciate the more subtle characteristics of better quality spectacle frames such as hinge quality or decorative features.
Practitioners should consider offering contact lenses to all suitable patients who are proceeding to spectacle dispensing to optimise the dispensing process and to provide an opportunity to try contact lenses.
The findings of the EASE study support other reports that practices that are strong in both contact lenses and spectacle dispensing are more successful, both clinically and commercially. Research among independent practices in the UK shows that the top quarter of successful practices spend an average of 26 per cent of their time on contact lens work.3 The average UK optometrist spends only 15 per cent of total patient time on contact lens work.4
Contact lens practice may be seen as being less commercially viable than the dispensing of spectacles only. However, a study by the London Business School has shown that in both the medium and long term, contact lens wearers are more profitable and more loyal than the average spectacle wearer.5
Increasingly, patients are looking for a combination of products to suit their visual and lifestyle requirements rather than considering a choice of contact lenses or spectacles alone. In fact the two categories can be seen as having different attributes that satisfy complementary needs (Table 1).
Consumer research has confirmed that most people who purchase contact lenses (82 per cent) also buy spectacles.6 A recent survey among soft contact lens wearers in the UK found that, even during the recent economic recession, fewer than one in four (22 per cent) used only contact lenses. About one in three (34 per cent) were 'triple users' with three types of correction, combining contact lenses with prescription spectacles and either prescription sunglasses or non-prescription sunglasses, or with a combination of other vision correction products.7
Proactive recommendation of contact lenses
Adopting a proactive approach in your practice can also increase contact lens fitting and offering products and services that deliver the greatest benefits can strengthen patient loyalty. Research has shown that being proactive and discussing contact lenses with all suitable patients and offering a short 'comfort trial' can increase purchase by 86 per cent.8
In this study, 150 patients presenting for routine eye examination were prescribed contact lenses only if they specifically asked to try them and 150 patients had the option of contact lens correction presented to them. Every patient trying contact lenses was offered a free trial (five pairs of etafilcon A daily disposable lenses or one pair of etafilcon A reusable lenses, or other products if clinically necessary).
Patient-initiated trials resulted in 17 per cent of patients being fitted with lenses, whereas practitioner-initiated trials resulted in significantly more patients (31 per cent) being fitted. This study demonstrates that a proactive approach to contact lens fitting is likely to have a positive impact on increasing the number of contact lens wearers.
The importance of regularly talking about contact lenses was also illustrated in the STAR research, a survey conducted to show how often contact lens conversations took place in practice.9 Without any intervention, practitioners initiated a conversation about contact lenses with 21 patients out of every 100 patients and mentioned them to a further 27 patients. This meant that over half of the customers had no discussion about contact lenses at all. The result was that only 14 out of the 100 patients became contact lens wearers.
Practitioners were then asked to ensure that every patient was spoken to about contact lenses. Of the next 100 patients, those who did not bring up the subject themselves were introduced to the possibility of contact lens wear. This time, the proportion who became contact lens wearers nearly doubled, to 26 per cent.
Despite the evidence for a proactive approach, contact lens recommendation habits in the UK have not improved in nearly a decade and practitioners may even have become less proactive in recent years. A 2009 survey found that one in five UK practitioners (20 per cent) only initiated discussion of contact lenses if the patient asked about them (Table 2) and this proportion was similar to 2001 (19 per cent) and slightly lower than in 2003 (22 per cent).10
Proactive means moving forward or ahead. It's a positive action. Proactive contact lens prescribing creates new opportunities for practice growth. A more proactive approach to your contact lens business is essential to increased success and involves educating your patients, your staff, and yourself. Keeping abreast of the latest in technology, techniques, products and equipment is certainly important, but you must also be able to communicate and implement those ideas.
You first need to be proactive in all areas of your practice. Motivate your staff by sending them to contact lens and practice management seminars. Ask sales reps to hold staff meetings to discuss new contact lenses and answer staff questions. Use audio tapes or CDs and encourage staff members to use the internet to obtain more information. Hold staff meetings to educate all staff on new contact lenses so everyone is aware of the latest technology in contact lenses. And take every opportunity to upgrade to new products.
Educate your patients through newsletters, mailings, brochures, videos and through your well-informed staff. Send brochures and flyers from contact lens companies with your monthly billing and recall letters, or send them out in separate mailings. Start a practice newsletter and send it out on a regular basis.
Giving contact lenses higher visibility in your practice also stimulates interest. Simple measures such as a visible reminder at reception and in the dispensing area to 'Ask us about contact lenses', as well as leaflets, posters, freestanding units or a contact lens section in the waiting area, can all help to engage with prospective wearers. Pre-screening interviews or questionnaires may also be used to elicit interest in trying contact lenses and identify lifestyle needs.
Contact lenses as an option for children and teenagers
As well as being more proactive in recommending contact lenses, you can increase your business by widening the age range of patients to whom you routinely offer and fit contact lenses. Although many eye care practitioners do not consider contact lenses as an option to children under 12 years of age, the results of the Contact Lens In Pediatrics (CLIP) study have shown that children as young as eight years old can be given an option of wearing contact lenses.11,12
Among possible reasons why some practitioners prefer to postpone contact lens fitting until children are older is concern about the amount of time required to fit young children. The CLIP study revealed that children (8-12 years) and adolescents (13-17 years) require approximately the same amount of chair time with the practitioner for their initial lens fitting and follow-up visits.11 Although children need, on average, 10 minutes longer for insertion and removal training, this can be performed by a staff member, allowing the practitioner to concentrate on the clinical part of his/her job.
Children have also been shown to benefit as much from contact lenses as do adolescents. In the ACHIEVE study, contact lenses showed an improvement in quality of life among both young children and teens just one week after switching from spectacles to contact lenses, and this improvement remained unchanged through a three-month follow up period.13 Both age groups reported that wearing contact lenses improved their appearance and made participation in sports easier. They reported much greater satisfaction with their visual correction with contact lenses than with spectacles. Children and teenagers wearing contact lenses also experience similar rates of slit-lamp findings and adverse events.11
In studies involving children, the use of daily disposable, two-weekly disposable lenses, gas-permeable and corneal reshaping lenses have been evaluated over the years. With all the types of lenses, children have been proved capable of inserting and removing contact lenses successfully, as well as looking after their lenses. Given the wearing habits of teenagers, a preferable lens material is arguably a silicone hydrogel, but a desirable modality remains that of daily disposability.
With the recent introduction of daily disposable lenses in silicone hydrogel materials, the health and convenience advantages of this new group of lenses can be offered to many patients including teenagers, for whom this modality may be an excellent choice.14
It may be time for you to rethink kids and contact lenses. According to the CLIP and ACHIEVE studies, younger patients are not only capable of caring for their lenses but also enjoy significant improvements in their self-perception and quality of life. This means that you, as an eye care professional, have an opportunity to make a significant impact on the lives of your young patients simply by offering to fit them with contact lenses.
Contact lens studies on kids and teens show that contact lenses can provide a viable alternative to glasses for children as young as eight years old who may require vision correction, thus adding potential contact lens customers to your practice.
Introduce discussion of contact lenses with children and parents at an early age and mention them as an option at all visits as well as in your patient literature and communications on children's vision. Educate both groups on the benefits and ease of use of contact lenses and offer a lens trial.
Trying a new group of patients: presbyopes
Since the early 1980s, we have seen a surge in the development of contact lens options for presbyopes. Although these advances have improved the comfort, safety and vision that presbyopic contact lenses provide, potential vision compromise remains. This may, in part, account for the fact that a majority of practitioners in the UK discuss contact lenses with their presbyopic patients only occasionally (55 per cent) rather than frequently (37 per cent).10
Presbyopic patients not only have work demands requiring clear and predictable vision at all distances, they also have expectations that require new levels of performance from their lenses. In our field, the key to any good technological advancement is ease of use in the clinical setting and, ultimately, patient satisfaction.
Presbyopic contact lens wearers are highly motivated to stay in contact lenses and are willing to tolerate some visual trade-offs for the lifestyle benefits of wearing contact lenses. First-time lens wearers can be excellent candidates and often are the most appreciative patients. Monovision and enhanced monovision contact lens wearers can also be successful with multifocal contact lenses, especially when fitted with lenses that address dryness and comfort issues.
Patient education is key to successfully fitting presbyopes with contact lenses. As with any contact lens fit, you must start by considering patients' expectations. You need to find out what each patient's visual needs are and then tailor a contact lens recommendation to those needs, taking into account the patient's most frequent visual tasks, personality, and other health issues. You and your staff need to understand how each of the presbyopic contact lenses works and be enthusiastic about recommending them.
Be willing to adopt a flexible approach to solving problems. Some patients will be most satisfied with a single-vision lens for distance in the dominant eye and a multifocal lens in the non-dominant eye, or some other variation. It does take more fitting skill and expertise to fit presbyopes, and practitioners should make sure they are compensated fairly for their time.
There is no doubt that we need more contact lens options for presbyopes. Practitioners should welcome each new entry into the market as an opportunity to broaden the range of presbyopic patients who can wear contact lenses more comfortably and with crisper vision as they age.
Fitting more astigmatic patients
Advances in lens design mean toric soft lenses are becoming a popular choice for practitioners and patients. Toric soft lenses have been a growing segment in the European contact lens market in recent years15 with toric lenses in the UK accounting for nearly one in three soft lens refits in 2009 (30 per cent) and a similar proportion of new fits (28 per cent).16
However, practitioners are no more proactive in recommending lenses to astigmats than in 2003, despite the introduction of new toric lenses and designs.10 Toric soft lenses are yet to realise their full potential with a shortfall in their prescribing, in particular for those with less than 1.00DC.17
One reason for this low level of toric prescribing may be that only half of astigmats have heard about toric contact lenses as a corrective option.18 This highlights that practitioners need to communicate the availability of these lenses to all astigmats to increase their use.
New manufacturing techniques have brought improvements in toric soft lens reproducibility and made them simpler and quicker to fit. Daily disposable and silicone hydrogel (SiH) options are now available for enhanced physiological and comfort performance. Modern soft toric contact lenses now combine the proven successes of spherical reusable or daily disposable contact lenses with the latest toric designs for clear, stable vision, in a wide range of parameters, making them a valuable addition to our options for astigmatic patients.
Practitioners should not consider the level of astigmatism to be too low to require a toric soft lens or assume that astigmatism is sufficiently corrected with spherical lenses. Studies have shown vision improvements when fitting toric soft lenses to those with 0.75 and 1.00D astigmatism compared with spherical soft lenses.19,20 New opportunities can come from simply fitting under-corrected low astigmats who are currently wearing spherical soft lenses with toric soft lenses.
Analysis of a database of spectacles prescriptions has shown that a surprisingly high proportion of patients with astigmatism, approximately half, have 0.75DC or more in one eye only.21 This level of astigmatism is considered the threshold at which we consider using toric soft lenses and is the lowest power from which stock toric soft lenses are available. Although some of these patients may be considered borderline for needing a toric lens, which depends on factors such as cylinder axis, sphere power, eye dominance and visual needs, this is large group of potential toric soft wearers that should not be overlooked.
Reviewing an existing patient database to identify potential astigmatic patients to offer the vision benefits of toric soft contact lenses is an ideal way of increasing contact lens business. This could be for current spherical soft contact lens wearers with low levels of astigmatism, lapsed contact lens wearers who have not recently tried the latest advances in toric soft lenses, and new wearers who may not be aware that contact lenses can be an option with their refractive error.
Conclusion
Adopting a proactive approach will increase contact lens fittings and offering products and services that deliver the greatest benefits can strengthen patient loyalty. By emphasising our professional skills and offering new, innovative products to our patients as a way of improving their comfort and better meeting the health needs of their eyes, we are taking important steps in building and maintaining their confidence in our professional capabilities, while underlining their dependence on our expertise. The aim, as always, is to help our patients to continue enjoying comfortable, healthy contact lens wear in the long term.
References
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2 Atkins NP, Morgan SL and Morgan PB. Enhancing the approach to selecting eyewear (EASE): A multi-centre, practice-based study into the effect of applying contact lenses prior to spectacle dispensing Contact Lens & Anterior Eye, 200932 103-107.
3 Myers La Roche. Market Intelligence Summary, August 2008.
4 Ewbank A. Who fits contact lenses? Part one. Optician, 2009237:6200 12-17.
5 Ritson M. Which patients are more profitable? CL Spectrum, March 2006.
6 EMA Purchase Channel Attitudes and Behaviour Quantitative Study. Neilson, July 2008.
7 Ewbank A. Has the recession impacted the contact lens market? Optician, 2010239:6246 19-22.
8 Morgan SL and Efron N.The benefits of a proactive approach to contact lens fitting. Journal of the British Contact Lens Association, 1996:19:3 97-101.
9 NOP Healthcare. STAR performers. Optician, 1996212:5580, 18-9.
10 Ewbank A. Who fits contact lenses? Part two. Optician, 2009237:6204 16-21.
11 Walline JJ, Jones LA, Rah MJ et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optom Vis Sci, 200784:9 896-902.
12 Walline J, Gaume A, Jones L et al. Benefits of contact lens wear for children and teens. Eye and Contact Lens, 200733:6 317-321.
13 Walline JJ, Jones LA Sinnott L et al, the ACHIEVE Study Group. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci, 200986:3 222-232.
14 Ruston D and Moody K. Daily disposable designed for healthy contact lens Wear. Optician, 2009238:6222 34-37.
15 GfK data Jan-Nov09 vs Jan-Nov08, V5 (UK, Germany, France, Italy, Spain).
16 Morgan P. Trend in UK contact lens prescribing 2009. Optician, 2009237: 6205 20-21.
17 Morgan PB and Efron N. Prescribing soft lenses for astigmatism. Contact Lens Ant Eye, 200932:2 97-98.
18 Astigmatism consumer awareness and usage study. Bruno and Ridegway Research Associates, March 2007.
19 Dabkowski JA, Roach MP, Begley CG. Soft toric versus spherical contact lenses in myopes with low astigmatism. Int Cont Lens Clinic, 199219:252-256.
20 Richdale K, Berntsen DA, Mack CJ, Merchea MM, Barr JT. Visual acuity with spherical and toric soft contact lenses in low- to moderate-astigmatic eyes. Optom Vis Sci, 200784:969-75.
21 Young G, Sulley A and Hunt C. Prevalence of astigmatism in relation to soft contact lens usage. In Press October 2010.
? Dr Ioannis Tranoudis is professional affairs director in Central Eastern Europe, Middle East and Africa for Johnson & Johnson Vision Care and is fellow of the International Association of Contact Lens Educators and the British Contact Lens Association. Anna Sulley is clinical affairs manager, Europe, Middle East and Africa for Johnson & Johnson Vision Care and is past president and fellow of the British Contact Lens Association
