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Patient walks in for a contact lens check-up. Patient reports no problems. Practitioner carries out aftercare procedures. Patient walks out. A familiar scenario? Hopefully not too familiar. With a wealth of new lenses and different modalities becoming available, there has never been a better time to offer contact lens wearers new products that provide even better performance.
Upgrading your patients may be as simple as offering them the latest version of their existing lenses or decreasing the replacement interval. But in many cases, refitting to a new lens or modality may well be the best option. Improved clinical performance, greater patient satisfaction, fewer unscheduled visits and reduced dropout rates are the obvious advantages but there may be other, less tangible benefits to you and your practice.
Recent market research has suggested that nine out of 10 monthly replacement contact lens wearers are interested in trying a new lens that would give them better comfort and almost all expressed an interest in a lens that would give them better ocular health.1 This survey, interviewing 271 hydrogel wearers and 163 silicone hydrogel (SiH) wearers, also found that more than two thirds reported a decrease in comfort over the course of a month, with no significant difference between hydrogels or SiHs.
A majority of wearers also said that they would consider seeing their practitioner more frequently if they were proactively recommended lenses that could be more comfortable. Having their eye care professional offer them a better solution for their ocular health was ranked among the top criteria that would increase their loyalty towards their practitioner.
So how do practitioners communicate the benefits of the latest contact lens innovations? To find out, we asked 17 European eye care professionals (see panel), working in a variety of practice environments, to answer questions about their approach when upgrading patients to new products and to share their tips on how to achieve growth in contact lens business.
What's the best way to introduce the idea of upgrading to patients?
A majority of our practitioner panel use the aftercare appointment to present new products to their patients, making them aware of the latest developments and discussing the features and benefits in the consulting room. But for some, fitting the best products starts before the patient even enters the practice.
French ophthalmologist Dr Stephane Rubolini-Fiat says her first responsibility is to update her own knowledge of a new product and to know its features well. She makes sure that she reads scientific articles about corneal physiology, lens materials and interactions with solutions, and applies what she learns to practice procedures. She also gets involved in pre-marketing trials of new lenses, which she finds makes her more critical when assessing product benefits. 'This also allows me to suggest a new solution to my patients before it becomes widely available.'
For other practitioners, point-of-sale material and well-briefed staff are a key part of the equation. Swiss practitioner Eduard Bosshard displays posters on new products in his Zurich practice to encourage patients to ask about them. Bosshard says he's often asked, 'Could that be an option for me?', which allows him to talk about the advantages the patient might expect. He's also adamant that patients pay for trials of new lenses. 'Otherwise they feel like guinea pigs and resent paying for our "research",' he says.
Once in the consulting room, the obvious approach is to determine whether the patient is experiencing any problems with their current lenses. In fact, UK practitioner Ian Loveday finds the most successful way to upgrade is to assume that the patient has problems with his or her present lens system unless proved otherwise. 'It's important to ask questions that encourage the patient to mention any problem they're experiencing, no matter how trivial it may seem. It's very common for patients to assume their symptoms are normal unless you inform them to the contrary.'
Loveday argues that changing the emphasis of questioning away from the assumption that they are 100 per cent happy also gives patients the impression you're interested in their problems and makes them much more receptive to the suggestion of a product upgrade. 'It's sometimes important to introduce the possibility of an upgrade at a relatively early stage in the conversation - it's surprising how many patients are frightened to criticise their present lenses if they think you might advise them to reduce or even stop lens wear.'
Spanish optometrist César Villa takes a similar approach, as he explains: 'I ask my patients what limitations they've found with their current lenses and about their expectations of contact lens wear. I recommend an upgrade when new materials meet these expectations.' French ophthalmologist Evelyne Leblond also looks for dissatisfaction with lens wear and uses specific questions to elicit symptoms such as dryness or decreased comfort at the end of the day, rather than simply asking patients if they're happy. 'Poor satisfaction is not always spontaneously described by the patient,' she warns.
Do you discuss new products with every patient or only selected patients?
In an ideal world, every aftercare appointment would provide information on the latest advances in contact lenses, but with limited chair time, and a growing battery of tests to perform, this may not be realistic. Ophthalmologist Florence Jourdan provides the most direct response to this question, saying: 'It depends if I'm on time or not!'
But in general, our panel is split between those who discuss lens developments with most or almost all of their patients, and practitioners who select only those they think might benefit. Bournemouth optometrist Craig Wilcox is firmly in the former camp: 'Every suitable patient is offered a new product. The only limiting factor is lens parameters,' he says. Several point out that, even if the end result is no change, the discussion itself can have intrinsic benefits. Italian ophthalmologist Fabrizio Zeri is typical in that he generally tries to talk about new product developments with every patient. 'I think it's the practitioner's responsibility to do this. But I give a specific and strong recommendation for a new product only if I believe it's important to prevent a potential drop-out or in order to improve a particular clinical condition.'
Loveday says that his questioning technique inevitably results in new product discussions for the vast majority of patients. 'Even if patients are 100 per cent happy with their present system, we would always introduce the possibility of newer products to keep them informed of developments in the market and reinforce the impression that we're interested in their eye care needs.' Bosshard agrees: 'Our patients are used to us always having the most recent products available. We initiate the discussion even when the product is most probably not suited to that patient - maybe he'll talk about the new product with friends.' Dr Leblond adds that her patients clearly value the information and often ask 'What's new?' during their aftercare visit.
For Middlesex optometrist Adnan Malik, careful questioning to determine whether the patient would be open to a trial of new lenses is key. He broaches the subject with most patients but tends to select those who have an issue with discomfort or slightly reduced vision. 'A patient who is very happy with his or her current contact lens without any anterior eye problems won't see the benefit of trying a new lens,' he argues.
German practitioner Heiko Pult also takes a more cautious approach, only introducing the idea of new lenses if he feels that the product fits with the evaluated subjective or objective results. But he often finds that a careful history and symptoms leads to add-on sales. 'We're always asking our patients if there's anything new we need to know from them: medication, or business, or sports or hobbies. Often we can sell them an additional set of lenses for holidays, skiing or sailing. Our aim is to give the best lens to suit individual needs - the prize is that the decision comes from the patient not from us,' he adds.
Another important advantage of discussing new products is that it offers a further chance to emphasise the value of regular check-ups, as Dr Rubolini-Fiat explains: 'I tell my patients it's very important to have an annual follow-up visit as it could be the opportunity to suggest to you new products more focused on your needs.'
How do you communicate the benefits of better performing lenses?
Many of the practitioners we spoke to recognise the role of support staff in communicating product benefits to customers and the importance of keeping all team members well informed. Yet several say that where clinical issues are involved, these need to be dealt with inside the consulting room. Loveday agrees with this view but suggests that support staff can be useful in other ways: 'For example, prior to the appointment, one of our staff will place a pair of trial lenses in the record card of patients using older lens products. The lenses may not be appropriate for the patient and they may not be dispensed, but it acts as a reminder and a timesaver for the practitioner.'
With the patient in the chair, practitioners use a variety of ways to communicate the need for an upgrade. Craig Wilcox directs his discussion towards one or more of four potential benefits: health, comfort, convenience and cosmetic advantages. Spanish practitioner Joan Gispets Parcerisas says his approach depends on the individual: 'It's pretty easy for those who aren't fully satisfied with comfort or any other symptom or sign - I just explain that the properties of the new material will improve what's not perfectly OK. For those who are happy with their lenses, I let them know it's my goal to provide them with the best lens option for now and for the future. The change isn't going to improve comfort but will avoid future complications.' Fernando Hidalgo agrees, saying: 'I educate the patient about mid-term benefits.'
The French ophthalmologists on the panel tend to focus on health rather than lifestyle benefits when recommending new products. Dr Rubolini-Fiat always gives her patients a medical reason for changing lenses, saying: 'Your problem can be resolved by this lens because of its better oxygen supply, better wettability etc, or you can minimise adverse events with this new lens.' Marseille-based Florence Jourdan adopts a similar tactic: 'I explain the benefits of oxygenation and frequent replacement, and also discuss wearing time and safety.' But Evelyne Leblond uses a more pragmatic approach, comparing contact lenses to cars. 'I tell the patient, "You're certainly happy with your Renault Clio but I suggest you try the same car with ABS and power steering and tell me if you don't feel safer - it's the same for your eyes!"'
Some practitioners stress the importance of using visual information to argue the case. Dr Zeri, for instance, shows images to illustrate the benefit of a particular lens on ocular physiology, such as a decrease in limbal hyperaemia or neovascularisation when upgrading from traditional hydrogel lenses to silicone hydrogels. He also likes to use research findings to explain the advantages of new products. For Pult, a video slit lamp is the perfect tool to show the patient what he is discussing. 'The key point is good education using simple phrases that can easily be understood,' he says. If the patient is unsure of the benefits, Pult offers a two-week trial with the new lens in one eye and the previous lens in the other. Villa is another practitioner who highlights features that patients can either see or readily appreciate - whiter eyes and longer comfortable wearing time.
Practitioners may have different ways of communicating product benefits but almost all agree that patients are receptive to the idea of upgrading and appreciate advice. 'In our experience, they all welcome the opportunity to discuss upgrading to new products as long as it's done in a positive, informative manner and doesn't come across as being dictatorial or a sales pitch,' says Loveday. 'One of the biggest mistakes we used to make in practice was assuming that asymptomatic patients didn't want better products - or, worse still, that they couldn't afford them.'
Others make the point that offering the best possible products reflects well on them and their practices. Dr Rubolini-Fiat, for instance, says that patients are aware of her skills in contact lenses and that she is a specialist in this area. Dr Leblond observes that it adds value to show her competency and that her information is up to date. 'They often tell me they're happy because nobody has suggested something new to them before.' And Italian optometrist Rossella Fonte has a similar view: 'They feel I'm a professional who is doing her best for their health and comfort.'
A minority of practitioners, however, find that not all contact lens wearers welcome the advice to upgrade. Dr Zeri says some would prefer not to change, although most are prepared to consider the possibility of using a better performing lens. According to Villa, the response depends on the performance the patient gets from his or her current lenses and how dependent they are on lens wear. Most patients, he says, are interested in upgrading when this can improve dry-eye related symptoms.
How do you schedule your appointments when upgrading?
Refitting an existing wearer with new lenses traditionally meant booking another appointment for a lens trial and then having the patient come back for a further check-up. Now that many practices hold large banks of lenses in stock it is often possible to refit during the aftercare appointment and, in some circumstances, the patient may be followed up by phone or email, or advised to self-report any problems with new lenses. Among our panel, policies tend to vary from country to country.
All three UK practitioners say they are likely to refit during the aftercare appointment rather than ask the patient to come back. Ian Loveday argues that increasing his professional fees dramatically in recent years has allowed longer appointments which enable him to discuss new products and refit at the same visit. For Malik, one further appointment would then be required if the refit was straightforward otherwise two are required, one for the fitting and the second for a check-up. Wilcox's policy is to refit during the aftercare and then schedule a check-up for a week later.
Malik and Wilcox both strongly favour seeing the patient once the lenses have been worn. 'Patient care is upmost in my mind,' comments Malik, 'I'd therefore like to see every patient to hear their views on a new lens and see for myself the effect on their eyes compared to their previous lens.' Loveday, on the other hand, says he only asks patients to come back for a check-up if they want to upgrade to the new product but will telephone or email the patient after a few days to see if they are having any initial problems with the new lens.
For other practitioners, scheduling an appointment to refit will depend on whether trial lenses need to be ordered. If Gross has the lenses in stock, he will refit immediately but otherwise he fixes a separate appointment. Gispets Parcerisas is the only member of the panel who routinely makes another appointment for refitting and asks the patient to come back.
Most practitioners we spoke to see patients for a check-up having worn the new lenses but there are exceptions. Dr Leblond, for instance, refits the patient and writes a prescription at the aftercare visit but doesn't insist on a follow-up appointment, other than for specialist lenses such as RGPs and multifocals. 'I say to my patients, call me back if there's any problem. I have one call every three months on average,' she reports. Dr Rubolini-Fiat only checks patients who had a clinical problem with previous lenses, such as keratitis, CLPC or allergy. 'For other patients, I wait for their phone call and their feedback on the new lenses. If they feel good I send them a new prescription,' she explains.
What effect does upgrading have on your business?
Using the best contact lenses has many benefits for wearers but is clearly profitable from a business point of view too, and not just due to higher value sales. Loveday is among those who cite increased patient loyalty to the practice as one of the rewards of proactively recommending new products. In fact he sees this as vital to the success of his business: 'We like to think our patients get the best professional advice and products from us and we wouldn't be able to sustain this if we didn't continually move our patients into the best available products. A large proportion of our new clients are word-of-mouth referrals from patients who have had their contact lens problems solved by upgrading into better lenses,' he adds.
Fonte's experience has been similar. 'Patients talk about my practice and tell others the kind of practitioner I am. Some of those people are previously unsuccessful contact lens wearers who feel they can come to me to try lenses again.'
Gross says that compliance with aftercare visits is very high among his patients, because he provides them with feedback and additional information about their lenses. 'They know that if we can improve their contact lens comfort, we'll do that.' His Zurich neighbour Bosshard cites another, increasingly important reason for encouraging loyalty: patients are less likely to shop around or buy on the internet. For other members of our panel, keeping patients in contact lenses is a key reason for upgrading them regularly. 'I don't have accurate figures,' says Joan Gispets Parcerisas, 'but I believe one of the long-term effects is a reduction in dropouts.'
What lenses are you currently most likely to upgrade from and to and why?
With so many new lenses and modalities becoming available, there is no shortage of opportunities for upgrading (Table 2). We asked each of our panel to tell us their current preferences. Regardless of where they practise, practitioners tend to favour refitting patients from conventional hydrogels to SiH lenses as their most likely upgrade. Most cite improved oxygen performance as the reason, although those upgrading from first to second-generation SiHs also mention features such as lower modulus and better wettability, and the benefit most important to patients, comfort. Ian Loveday sums up his current strategy: 'I'm most likely to upgrade patients from hydrogels to SiH lenses for increased health and comfort.'
Malik says he has refitted all his patients on monthly hydrogel lenses with SiHs. 'If a patient was to wear contact lens on a regular basis for long hours then I would give them the option to trial a silicone hydrogel lens, even if they were to wear daily disposable lenses. I essentially go through with a patient the advantages and disadvantages of different modalities and their materials.' Hidalgo is another practitioner who advises wearers using any disposable lenses to change to SiHs. And in his Weinheim practice, Pulk has been upgrading his RGP wearers to high Dk lenses.
But oxygen permeability is by no means the only issue. Fonte says she is likely to opt for either SiH or biomimetic lenses, and daily disposable lenses are also a popular recommendation for many of our panel, for clinical reasons as well as convenience. Villa and Blond both mention problems associated with lens care solutions as a reason to refit with one-day lenses. Villa also finds there is potential for switching from spheres to toric soft: 'It's remarkable the additional advantages gained - in this case visual advantage - from refitting a small astigmatism with a toric lens.' Loveday also finds he is refitting low astigmats with the new generation of toric lenses for better vision.
What's top of your wish list for the next significant development in contact lenses?
If these are our panel's current preferences, what single product would practitioners like to see emerging in the near future? Opinions were almost equally split between a SiH daily disposable, and better performing multifocal lenses, preferably with a choice of reading additions. Both of these lens types feature on the wish list of Dr Rubolini-Fiat, who argues that daily disposable wearers can have long wearing times, even if they are only occasional wearers, and would benefit from increased oxygenation compared to a hydrogel. There is also some support among our panel for new SiH designs, for high hyperopes and high astigmats as well as for presbyopes.
But there are hints that practitioners would still welcome further improvements in material technology. For Pult, the next significant development should be lenses that solve the problem of discomfort and dry eye, which he argues is not fully resolved with current materials. Fonte would also like to see less interference with tear film stability. And two of the three Spanish practitioners we spoke to, Villa and Hidalgo, were looking for comfortable and safe extended wear lenses, Hidalgo mentioning antimicrobial activity as a desirable property. Whatever their preferences for future innovations, today's contact lens practitioners already have many opportunities to offer better performing lenses to their patients. The coming months will bring even more options to choose from, with still greater improvements in product performance and new modalities emerging.
Last week saw the announcement of the world's first daily disposable SiH lens from Johnson & Johnson Vision Care, offering comfort, oxygen performance and convenience benefits in one lens.
Follow the top 10 tips of practitioners across Europe (Table 3) for even greater success in upgrading your contact lens wearers and you, your patients and your practice will see the benefits.
References
- Monthly contact lens wearers, France. Gallileo Consumer Survey, 2007.
Further reading
Rumney N and Donne S. Ten top tips to build your contact lens business. Optician, 2005230:6030 13-15.
Moss I. Upgrading, uptaking and avoiding drop-out. Optician, 2006231:6046 30-33.
Optometrist Anna Sulley is a professional affairs consultant, medical writer and clinical investigator at Visioncare Research, and a Fellow and Past President of the BCLA