Some eye care practitioners spend considerable marketing resources driving potential new wearers to our practices. We dedicate chair time to guiding patients through their first experience of contact lenses. And our practice team spends many hours helping patients attain the freedom that contact lens wear provides.
Yet, despite all our efforts, research suggests that while more than three-quarters of a million (0.77m) people in the UK may start wearing contact lenses over the course of a year, as many as half a million (0.54m) drop out.1,2 Are we as enthusiastic with the more established wearers as we are with the new ones, or does the ‘new wearer’ novelty wear off? Do we simply let them drift away, hoping there is someone to take their place?
Whether you are newly qualified or have been around for a while, working as a consulting practitioner or trying to build and maintain your own practice, you will encounter long-term contact lens patients whose visual and lifestyle needs are either changing or are about to change.
We must identify those needs, such as developing presbyopia, uncorrected astigmatism or dryness symptoms, which may be starting to become a problem, and offer alternative options to those at risk of dropping out of lens wear before we lose them altogether.
Gallery: look out for clues to identify changing needs in long-term wearers
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Dropout in the longer term wearer
Recent research found that practitioners believed nearly a quarter of their contact lens patients (24 per cent) would have dropped out of their lenses in a year’s time3 and in many practices this seems to be clearly evident. Have you ever had a patient wearing their lenses less frequently than they used to?
Most of us would agree that dryness and discomfort are problems for many lens wearers and studies suggest this could account for between 43-73 per cent of dropouts.4,5 A large number of longer term wearers stop wearing their lenses because their vision is not as clear as they would like it to be.6 When the disadvantages of lens wear outweigh the advantages, wearing time may be reduced or the lenses may be discarded completely.
The population as a whole is getting older. Once presbyopia becomes impossible to ignore and it starts to become difficult to see things ‘up close’ there is a danger the contact lens wearer will revert to wearing only spectacles. As our patients become older or spend more time in front of their computers, they may develop dryness symptoms, which can start to make eyes and contact lenses less comfortable.
A change in personal circumstances, such as a new job, may mean new visual tasks or that lenses need to be worn for more hours in the day. Learning to drive and long hours of study are other situations that can precipitate the need for a change. Retirement may be a prompt for taking up new hobbies or activities with different visual demands.
Any compromised vision – for example, uncorrected or gradually developing astigmatism, that was previously deemed acceptable – will now need correcting. It may be surprising to know that uncorrected astigmatism is as much, if not more, of a reason for stopping lens wear than uncorrected presbyopia.4 While presbyopia is a significant factor in contact lens discontinuation, almost half of dropouts (46 per cent) are under the age of 30.8
Opportunities and patient benefits
It is flattering and rewarding when someone insists on seeing us over anyone else. There is something satisfying about having a ‘following’ of patients, or working at a practice where they happily drive 30 miles for their appointment.
This high level of loyalty results from not only good clinical skills but showing we are in tune with our customers’ and patients’ needs, and is the cornerstone of a successful practice. We should not underestimate the impact improving the quality of vision or comfort can have on our patients’ well-being, whatever their age. Contrary to previous beliefs, presbyopes are interested in looking and feeling younger.
Whether it is the signs of ageing creeping in, or the young astigmat heading off to university, having the option of being spectacle-free whenever patients choose can have a significant impact on their confidence and improve functional vision when they need it most.9
We should advise patients on their ‘visual buffet’ for when, at various times, either spectacles, contact lenses or a combination of both may be the more suitable option.10 They may also want to supplement the ‘buffet’ with prescription or non-prescription sunglasses. As well as ensuring our patients’ individual needs are met, our practices will see the benefits from multiple sales of different forms of vision correction.
Importantly, we need to be able to restore the freedom to choose. Where laser eye surgery may have been reluctantly considered as a last resort, patients will now feel empowered as they become aware of the full range of options available to them; for example, the plumber or electrician who may find contact lenses better than multifocal spectacles when working at difficult or unusual angles.11
Happy customers and patients tell others about their experience, resulting in more relatives, friends and family members consulting us. A happy practice creates an enjoyable environment for everyone who works there or visits. The power of personal recommendation is second to none; it attracts new people to our practice, improves retention rates and costs us nothing.
Involving the whole team in identifying customer needs and providing expert education about the latest products enables all team members to be a part of the consultation. This can be a positive influence on the practice, motivating staff while building trusting relationships with patients. It allows opportunities for communication around customer needs from reception to consulting room. Due to the perception of our collective expertise we will be seen as a specialist practice, even though we may not realise it.
What to look and listen for
Patients rarely tell us everything. They may already assume that there are no other lens options and, now that their ‘arms are too short’, that this is the best there is. They may decide it is easier just to wear spectacles. When we ask how their lenses are, they may assume that contact lenses are supposed to be a bit uncomfortable ‘because your eyes do get drier as you get older, don’t they?’ or that the vision isn’t as good as glasses ‘when you’ve got a stigma’. They may automatically say their lenses are ‘fine’ (if only for a four-hour night out!).
We may assume that the person in the chair is happy with us, our service and our products when, in fact, the temptation of a free second pair of glasses at the practice down the road may be just what they need to make them abandon their contact lenses. Our consultations can end up being a mass of assumptions on both sides, leading to an unsatisfactory outcome for everyone. So what should we be doing to make sure we are providing the best advice for those changing needs?
The warning signals may present to us in the lens wearer who has decided to return for an eye examination earlier than they are due or has started using their spectacles more than their lenses. They may arrive for aftercare not wearing their lenses. Or they may show a greater than expected interest in your frame display while waiting for their contact lens appointment.
It could be someone who has decided to purchase ready-readers and asks for your assistance. Perhaps you have a patient who frequently returns to purchase re-wetting drops which you haven’t prescribed, or cancelled their direct debit scheme last week because they have a backlog of unworn lenses.
It might even be something so subtle that it is easily missed – they may be sitting in your waiting room looking ‘not quite right’ because they feel guilty that they haven’t been wearing those lenses which you lovingly fitted all those months ago and they don’t know how to break the news to you.
What to say and do
Create opportunities
Discussions about symptoms and the latest products can happen anywhere in the customer’s journey and do not need to be limited to the consulting room. When our patients receive a reminder for their eye examination or contact lens check-up, whether by email, text or letter, we can provide them with information about the latest products and technologies we have to offer.
When they telephone the practice to make an appointment, rather than just asking, ‘When would you like to come in?’, there’s an opportunity for our reception staff to gain insight into the customer’s needs. Try asking: ‘Is your appointment purely for an eye examination or do you want to talk about contact lenses as well?’ or, to elicit more information about the reason for their visit: ‘Is it your routine check-up or are you having any problems you’d like me to let the optician know about before you come to see us?’
Visual information about the latest products and how they work, through window displays, patient leaflets and posters can prompt customers to enquire and also opens the opportunity for dialogue about our customers’ needs. Your website and social media presence is another opportunity to explain that age and prescription are not a barrier to getting the best out of contact lens wear.
Prepare your patients
We need to be fortune tellers, and prepare our patients to expect their needs to change. If a patient’s accommodation is reducing year on year, we need to talk about impending presbyopia. It is tempting to announce that there has been ‘no change’ at the end of an examination but, in fact, if their accommodation or ‘focusing ability’ was 10D two years ago and is now only 8D, there has been a change.
They won’t be experiencing presbyopia yet but discussing the reduction in their focusing power over the coming years means that, rather than being taken by surprise, when the time comes they know that multifocal options mean contact lenses can provide them with ‘vision for life’. In addition, this starts to set expectations that might help achieve successful outcomes in future.
They may be unwilling to freely admit that close work is becoming a problem. Once we ask the open question: ‘How is your vision when you’re reading and doing close work?’ they will be delighted that someone cares enough to be interested and a whole new conversation will develop.
Be an expert
It is vital that the entire practice team is as up to date as possible with the latest technology developments so we can confidently discuss all available options to maintain adequate vision correction and improve comfort.
Explain additional benefits such as: ‘I wear lenses which hold on to the moisture so they feel better for longer’, ‘We’ve just started fitting a new lens which helps you see far, near and all the bits in between!’ or ‘We can now fit you with a contact lens that’s tailored to your prescription to correct your astigmatism’ or ‘…which matches your glasses prescription more closely than your current lenses’. Follow up with: ‘Would you like to make an appointment so you can try them out?’
We must be seen to be at the cutting edge of contact lens care. If a patient has to ask us for a contact lens ‘like my friend has, that helps them to see things up close without their glasses’ before we’ve told them about it, we’ve already put ourselves at risk of losing a customer to our competitors and lost an opportunity to delight our customers with expert knowledge just when they needed it.
Look for clues
Play detective to anticipate those changing needs. Ask open questions and actively listen for patients who may be in a new stage of their life, whether they are experiencing the first signs of presbyopia or a new mum who wears her lenses longer than she cares to admit. Look out for the patient proudly announcing they finally got the job they always wanted, which may involve long hours at the office and a more up-to-date correction of their vision.
Investigate! Ask probing questions to determine exactly when and where any issues are experienced, how often and how severe. Have there been any lifestyle changes in their work, hobbies, leisure pursuits or environment that may alter their vision and comfort needs? Are they spending many hours on-screen either at work or at home?
It is not just eye examinations that benefit from pre-screening. Pre-screening before a contact lens aftercare appointment, either through an informal chat or a pre-consultation questionnaire, provides an opportunity to establish any lifestyle and occupational changes. While a patient may say ‘fine’ when we ask how their vision is, they may only give it a 5/10 which gives a starting point for further questioning.
Enquire whether the vision with their contact lenses is as clear as the vision with their spectacles. Then follow up with high-quality open questions – those which give high-quality answers containing useful information. Try: ‘Tell me about the quality of vision with your contact lenses and spectacles,’ or ‘At what times during the day is your vision blurry?’, ‘How does your vision compare in poor lighting and in bright lighting?’ or ‘How often do you notice your eyes feeling tired?’
Other useful questions might be: ‘Do you ever use glasses with your contact lenses?’ or ‘Do you have to remove the lenses during the day for vision reasons?’ To elicit dryness symptoms specifically, you might ask: ‘Are there occasions when your eyes feel dry?’ or ‘Do you ever feel you need to use dry eye drops and, if so, when?’
Think about how you ask the question to get the best response. Look at the possible difference in conversational outcome between, for example, asking ‘Can I help you?’ and ‘How can I help you?’ Or how a patient may respond to ‘How is the comfort?’ as opposed to ‘Are your lenses always as comfortable as you would like them to be?’
When a patient mentions the intention to reduce the frequency of lens use, it is just as important to use open questions to elicit reasons. It could well be that they simply were unaware of the new lens that was not available 10 years ago when they were first fitted. While they reluctantly consider laser surgery treatments, you may tell them the news they always wanted: that there is a lens more suited to their needs.
Be sensitive and avoid jargon
Whether they have astigmatism or presbyopia, our customers don’t want a label; they want an explanation they can identify with. Jargon can overload customers and stop them from retaining the important information.
Don’t stigmatise customers with ‘You have astigmatism!’ Remember it is every patient’s worst nightmare to walk away from any appointment being told they have a ‘condition’. Tell them about the common need for a more tailor-made or precise correction which they already have in their glasses.
When we are having to deal psychologically and emotionally with the effects of ageing, of not being able to read what you want when you want, it is made far worse by being informed by someone who looks ‘about 12’ to them that ‘it’s because of your age’. The person in the consulting room chair may well be old enough to be your parent but won’t thank you for being reminded of that fact.
For those of us who are already presbyopic, knowing ‘exactly what you mean’ will enable us to empathise and put the patient at ease. If you don’t have the benefit of advancing years, using personal experiences of similar situations will help you to build rapport. Having seen and fitted contact lenses to ‘lots of patients with similar issues’ will inspire confidence in the younger practitioner.
Be tactful. If you are about to tell them you have fitted your mother with these lenses, think again; they may well hear ‘you are old enough to be my mother/father’ and you may not necessarily convey the empathy or rapport you hoped to achieve.
[CaptionComponent="654"]Try telling patients that ‘the lens inside your eye naturally loses elasticity over time’. ‘This is a change that happens to everyone and it’s why you can’t see your watch clearly with your contact lenses or glasses’ is likely to bring a very different emotional response to ‘You need multifocals because your eyes are ageing’. While the first is likely to prompt the patient to ask what can be done about this, the latter is likely to make them walk away thinking ‘My eyes are old and complicated – I might as well stick to my glasses’.
Remember, patients may not be forthcoming in telling us about the discomfort they experience with their lenses for a variety of reasons. ‘Do your eyes ever feel dry?’ may make the customer say no, especially if they know they sometimes wear them too long – they may blame themselves not the lens. Instead, give the customer the impression you expect this by asking: ‘As time goes on, we commonly find that customers find lenses uncomfortable – how often do you experience this?’
Show the difference
In the consulting room, holding cylindrical trial lenses over the contact lenses while the patient reads the test chart can demonstrate how being refitted with toric lenses will improve vision. Asking them to look at their watch or mobile phone rather than the near acuity card after being fitted with their new multifocals reminds them of how they will benefit in their everyday lives, outside of the consulting room, from the lens change.
Showing our customers how our recommendations help is integral to the impact we have on both their short-term wearing success, but importantly their long-term loyalty to our practice. Whether we are in the consulting room or not, by highlighting benefits to that new mum by saying ‘this lens will allow you to wear your lenses comfortably for longer’ shows our customers in simple terms how our expertise gives them the highest standards of care, while also growing our practice. Most importantly, it gives us the satisfaction of knowing how we make a difference to our customers’ lives every day.
[CaptionComponent="655"]Manage expectations
Though we should be trying to meet and even exceed our patients’ expectations, we may need to prepare them for a more realistic outcome, for example when fitting multifocal contact lenses. It is important for us to harness their growing excitement about the newfound freedom from spectacles to get them through the fitting and aftercare process. Losing a patient’s enthusiasm usually translates to losing the customer.
It might therefore be useful to balance ‘Wouldn’t it be great if I could fit you with a contact lens that means you won’t need your glasses?’ with ‘While this lens will give you better all-round vision, you may notice that your distance or near vision may not be quite the same as your glasses’. Or you might want to phrase your question: ‘Wouldn’t it be great if I could fit you with a contact lens that means you won’t need your glasses for 80 per cent of the time?’ to which the answer is likely to be yes.
Both practitioner and patient should expect an increase in chair time, perhaps for the tweaks necessary for a successful multifocal or monovision lens fit, or for any re-fitting of rotated toric lenses. It is important that customers are counselled about this in advance, and trial ordering or appointments are organised to minimise the need for repeat visits to the practice.
You may feel that this gives the impression that the fitting of lenses is a rather ‘hit and miss’ affair. Don’t worry – the patient is only likely to see that we are taking the time and trouble to obtain the best outcome. Investment in chair time is an investment in the patient and you will be rewarded with loyalty, retention and reduction in dropouts.
Finally, make it clear to your patient that there are other options if the change of lens doesn’t give the desired improvement or becomes less effective over time. Only 19 per cent of contact lens dropouts have tried an alternative lens and 48 per cent drop out without seeking any advice from their practitioner.11
Conclusion
Being aware of and successfully managing the changing needs of our long-term contact lens wearers should be a part of everyday practice for all of us. Our patients’ eyes, their lives and visual requirements may be in a state of flux – whether they are developing dryness due to age or working in a more challenging environment, suffering with uncorrected astigmatism that can no longer be ignored or developing presbyopia that is now beginning to cause problems, we should be able to quickly identify those needs and offer more suitable options for correction.
We should not be relying solely on a constant stream of new wearers to grow our contact lens businesses. We must also work with our existing wearers who don’t want their lives to change just because their vision is changing. Keeping up to date with developments in contact lenses and management of conditions such as contact lens-related dryness will give us the chance to improve retention and loyalty as well as enhancing the lives of our patients. Talk to them, really listen to what they have to say and be aware of what they might not be saying. We have nothing to lose and everything to gain.
The next part of our series will look at ways of eliciting the need for an upgrade in lens technology in the long-term wearer who needs no change in prescription and how upgrading can help maintain comfort and satisfaction.
Acknowledgement
Images courtesy of The Vision Care Institute
References
1 Internal Estimates based on Primary Research and Category Volume Sales Data, Johnson & Johnson Vision Care 2012.
2 Data on File. Contact Lens Incidence Survey. Johnson & Johnson Vision Care 2011.
3 Contact Lens Retention Research, Reed Business Insight, September 2013.
4 Young G. Why one million contact lens wearers dropped out. Cont Lens Anterior Eye, 2004;27:83-85.
5 Nichols J et al. The TFOS International Workshop on Contact Lens Discomfort. Invest Ophthalmol Vis Sci, 2013;54:TFOS1-TFOS203.
6 Naroo SA. Contact lens dropouts – ‘must try harder.’ Cont Lens Anterior Eye, 2013;35:5 195.
7 Chalmers R. Overview of factors that affect comfort with modern soft contact lenses. Cont Lens Anterior Eye, 2014;37:2 65-76.
8 Data on File. Contact Lens Incidence Survey. Johnson & Johnson Vision Care 2013.
9 Donne S and Rumney N. Top ten tips to build your contact lens practice. Optician, 2005;230:6030 13-15.
10 Aslam A. CLs and spectacles: a winning combination. Optician, 2013; 246:6425 26-28.
11 Tranoudis I and Sulley A. Simple steps to grow your contact lens practice. Optician, 2010;6272:240 38-43.
12 Data on File. Usage & Attitudes Survey. Johnson & Johnson Vision Care 2014.
Shireen Bharuchi is an optometrist with experience in contact lens training and practice growth. Simon Donne owns an independent optometric practice in Bedfordshire. He is also a clinical investigator, a member of faculty at The Vision Care Institute and a professional affairs consultant for Johnson and Johnson Vision Care