So, today I’m returning to one of my favourite topics: contact lenses.  There’s only one type of contact lens I don’t like: the illegal, cosmetic ones that pop up in the news around this time of year (the ones you buy from those weird shops that sell body jewellery, goth/emo/skater clothes and smell like musty incense*).

Recently, I’ve fitted a good number of complex cases and there’s a certain joy that comes from finally getting the fit right on someone with -5.25DC cyls (thank you, Clariti XR… and Mr S, for all your patience), especially if that someone has always wanted lenses but been told they can’t have them because of their astigmatism.

I feel that contact lenses are an underused part of our clinical arsenal and a lot of practitioners dislike them (maybe because they are unfamiliar with the changing contact lens landscape or they’ve seen too many corneal ulcers caused by poor compliance).

You wouldn’t fail to recommend reading specs to a previously emmetropic 45 year old so why not recommend monovision or multifocal lenses? Likewise, if someone has significant anisometropia, perhaps caused by phako, then lenses might be a better option than specs (think image size).  They are an option for most patients and they solve problems.

It’s not just the big problems, though.  It’s little things that a patient may say in passing that makes you think that lenses would help.

During my pre-reg, I tested a man who had a small minus Rx.  He was a scuba diver and someone had sat on his prescription dive mask while he was on a boat (this happens a lot, btw) and he was loathe to buy a new one.  I asked him if he’d ever tried contact lenses (he hadn’t).  I fitted him with dailies for his dives.  He could wear them in the water, with his dive mask on, then throw them away when finished.  He had only been booked in for an eye test but I had dailies in my test room in his Rx so did the fit on the day and arranged for another member of staff to sit with him for the I&R.

In that year, most of my fits happened on the same day – there was a wonderful selection of lenses at my disposal.  We had several different brands of dailies, monthlies and the Acuvue inbetweenies**, including multifocal lenses and torics (but, alas, no toric multifocals – we had to order those in).  It makes sense to keep a good stock of lenses – you want to strike while the iron is hot.  You have the patient there and you’ve (hopefully) got them reasonably enthused about trying lenses so why would you send them away and trust them to come back later? There’s a chance they’ll go home and lose that enthusiasm, maybe they’ll think they won’t be able to do the I&R (this is the number one reason patients tell me they don’t think they can wear lenses – they don’t believe they can touch their eye) or hear a story from a friend or family member who couldn’t get on with contacts***.

If you are a pre-reg, you’ll need to find the sweet spot in your routine, that place where you can talk about contact lenses organically.  It might be in history and symptoms when you are asking about their current specs (“What do you wear your glasses for? Do you wear contact lenses? Have you tried them?”) or when you ask about their occupation and hobbies.  It might be during your recommendation (although, I wouldn’t leave contact lenses until the end of the test because that doesn’t give the patient long to think about them).  I tend to ask if they’ve tried lenses before and if not, after asking about hobbies and occupation, I can then mention them in a way that would benefit their lifestyle.  Play sport? Contact lenses.  Baking? Isn’t it annoying when your specs steam up when you open the oven? Contact lenses. Swimming? Daily contact lenses. Paratrooper who has to be up at 4am to parachute behind enemy lines? Extended wear contact lenses. Socialising or a special occasion coming up? Contact lenses!

There is a trick that I use in my routine that seems to really make a difference.  As you know, I am a lens wearer myself (currently wearing CooperVision MyDay although I’ve tried most of the lenses on the market, excluding the torics and enhanced monovision multifocals) so I will tell a patient that I wear lenses and have done for 17 (!) years.  I will ask them if they’ve seen someone putting their lenses in and taking them out.  This is usually a “no”.  I then ask if they’d like to see how easy it is.  Most of the time, they say “yes” so I wash my hands, dry them carefully, ask them to put their specs on (there’s no point in demonstrating it if they can’t see) and then I ask them to look at my right eye.  I sit a couple of feet from the patient and show them the lens moving on my eye (I pull it over to the side with my finger then let it slide back over my cornea).  “Can you see the lens?” “Yes.” “Now, I’m going to take it out.” And I just pull it to the corner of my eye, pinch it gently with my thumb and forefinger and then show them it (usually on the tip of my finger).  “Getting it back in the eye is the same, but in reverse” and I pop the lens back in.  Sometimes I’ll use one of the spare lenses kicking around, remove it from the packet and hand it to the patient so they can feel the lens and press it between their fingers.  A lot of patients think lenses will be hard or, at the very least, more rigid. I say that it’s more like an eye drop going into their eye than a foreign object, like an eye lash.

Needless to say, I’m very comfortable getting my lenses in and out.  This quick demonstration is followed by me telling them that, with practise, they’ll be as good as me but don’t worry if they may struggle at first. I always mention that we teach patients how to get their lenses in and out – we will spend time making sure they are confident handling the lenses. “We don’t just pop them in your eyes then throw you out,” I joke.

Our store does free trials, which I love.  It means patients can experience lens wear with no financial outlay.  The only time the free trial annoys me is when someone comes in for a lens fit just because “it’s free”.  “So, why do you want to try lenses?” is the first question I ask.  Usually it’s because they have a special occasion coming up, for sport or just for a change.  “Because it’s free” is the worst answer because those patients have no motivation to try lenses apart from feeling they’ve gotten something for nothing.  You can usually gauge when a patient is genuinely interested in lenses because they will ask questions about them or put the lenses in context (“I could wear those when I’m on holiday” or “They’d be handy for cycling”).

When thinking about lenses, you’ll need to consider your patient’s prescription. Daily torics are annoyingly limited, especially for hyperopes, so check the range available before telling the px you’ll order them (a lesson I’ve learned the hard way).  If someone is more than +4.00DS with a cyl, dailies are out unless you can do best vision sphere and omit the cyl (this will work for sports or limited social wear but not for everyday wear if the cyl is >0.75DC).

If someone has high cyls (>2.25DC), you are limited to monthlies such as Proclear XR, Clariti XR or a custom monthly lens from a manufacturer such as mark ennovy.  There are also 3-monthly lenses but I tend not to fit these as much.  If someone is very high minus or plus, there’s Biofinity XR.  Remember to take into consideration the back vertex distance when ordering lenses in a power over +/-4.00DS.  You’ll need to decrease minus and increase plus (again, this is more of an issue for hyperopes as, when fitting someone who is +8.00DS in their spec Rx, you’ll need to add some more plus therefore tipping them over the top of the range for dailies).

You can also get contact lenses with prism.  I’ve just learned about these recently and haven’t had an opportunity to fit them – if anyone has experience with them, let me know.

Remember the statistic that >95% of people are suitable for contact lenses so that means you could be fitting 19 out of every 20 patients.  Ask them: the worst thing they’ll say is “no”.

* I have nothing against these shops, I spent most of my teenage years in one.

** Fortnightly lenses like the Oasys and the soon to be discontinued Advance.

*** These are the same friends/family members who tell everyone who’ll listen about how varis ruined their life, their relationship and burned their houses to the ground.

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