How to implement a custom contact lens fitting model into your practice

Luis Rojas, OD

Luis Rojas, OD, sat down with Optometry Times®' assistant managing editor, Emily Kaiser Maharjan, to discuss custom fitting contact lenses as a business model.

Editor's note: This transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:

Hello and welcome to Optometry Times On Air. My name is Emily Kaiser and I'm the assistant managing editor of Optometry Times. I'm here with Dr Luis Rojas, custom contact lens fitting extraordinaire. Welcome to the show, Dr Rojas.

Louis Rojas, OD:

Hi, how are you? Thank you for having me.

Kaiser Maharjan:

I'm good. Happy to have you here, really excited to really dive into it. So first, can you please describe what custom contact lens fitting means to you? What sets it apart from a standard lens fitting?

Rojas:

Yeah, that's a great question. When I think about custom contact lens fitting, I truly mean it in a tailored type of way. You're tailoring it to the needs of the patient [and] the visual demand of the patient. When I think about custom contact lens fitting, I really refer to it in terms of soft lens customization and tailoring to the patient's needs. The visual demand of the patient, any particular hobbies, their day in and day out from morning till night, and I'm tailoring it to their life.

Whether or not I have full control over the material, the aspects of the size, the prescription, I'll do my best to do that. But, I really want to listen and take the time to listen to the patient, and really address all their concerns, their visual demands, [and] come up with the solution. More importantly, just have the realistic expectations of how to tackle all those issues.

Kaiser Maharjan:

Fantastic. How can optometrists give their patients the custom fitting experience? Do they need any equipment to level up, is that pretty approachable?

Rojas:

You don't have to have the fancy equipment. I will say, if you have a typographer that has a pupillometry, that will kind of explain some types of designs out there. So if you can explain to the patient, "hey, I'm measuring your your corneal shape, and on top of that, I'm measuring your pupil size in different light settings, whether it's nice optics go topic." You can explain to the patient, I'm selecting a type of lens that has a certain type of power profile that's tailored to the patient's pupil size. So, you can use that instrumentation to help.

I'm very visual in my office. We have a lot of technology, we have screens to show them all the tech and scans that were that we're doing. So do you have to have these fancy toys? You don't, you just need to listen. You need to have a really good case history. Most of the equipment that optometrists will have in their office should be sufficient to tailor to their needs. But, I think that one of the biggest things is finding the time clock and trying to take that time to really listened to the patient.

And I think that, going back to your original question, it's more of that custom contact lens fitting approach, where you're just taking the time to really tailor that suit to them. In regards to vision, this ends up being that tailor contact lens.

Kaiser Maharjan:

So, it sounds like you know patient communication is a huge part of the custom contact lens fitting experience. It's not just about getting the lens to fit the eye. It's also getting the patient to understand why it fits the eye or why you're doing the steps that you're taking to make sure that this is what fits.

Rojas:

Yeah, that's correct. I mean, we're in 2023. Moving forward, almost every contact lens has an amazing perk or some type of technology that's just fresh. There's a lot of leaders in the space as well. So in regards to what you're saying, that's absolutely right. The fitting process in itself, the actual physical fitting, ends up not being the hard part. It's trying to select which awesome lens is out there that can better fit the patient's visual needs.

Kaiser Maharjan:

So nearly every type of contact lens on the market has a fitting guide or calculator. How can optometrists leverage these tools to get the best possible outcome?

Rojas:

These are offered by companies as guardrails. They want you to have first time fitting success and they want it to be easy, especially when we're talking about multifocal. [It's] one thing fitting a spherical product, but a multifocal is like fitting a progressive lens with so many corridors. If we're talking about glasses, we're talking segue height and power profiles [and] how fast you get into the different zones in the progressive. Well, if we change that conversation to contacts, we also have different power profiles.

Every manufacturer has some proprietary thing, so they have a different transition into that multifocal or bifocal segment. You have to understand what the limitations are and the guardrails of these calculators. Ultimately though, you're the doctor.

So yes, it's telling you stick to this, stick to that, but if your experience and understanding the patient's working distance, the expectation and again, going back to visual demand, you can go off those guardrails. That's something that we do all the time, we call it off label. I would say more than half of what we do is considered off label.

Kaiser Maharjan:

Right and once again, that's kind of feeding into the customer experience is fitting what fits the eye in front of you rather than this "fantasy eye" that we're working off of with the fitting guide.

Rojas:

It's not a schematic guy. This is a living breathing person and whether they had previous surgery or other medications that they're taking, maybe some trauma, you have to take in all of that. When you're looking at a calculator, it's giving you that perfect example, perfect patient. Let's be honest, there's not like a perfect patient.

Kaiser Maharjan:

For sure. So when sitting down to fit contact lenses, you aren't just looking at correcting visual acuity. You're looking at the patient's entire visual system, and you're considering their preferences. How do you usually factor in considerations for dry eye, for contact lens materials, for filtering for blue light, and stuff like that?

Rojas:

It all plays a big role, and it's just a big puzzle piece. You're collecting these pieces of the puzzle throughout the case history, throughout the examination process, whether you take photos of the cornea, whether you notice that there's a reduced tear breakup time. Perhaps they have very sensitive eyes or photophobic. So, you're considering whether we're trying to reduce glare and halos or light scatter. There's so many factors to consider.

As I'm doing the exam, I'm taking mental notes of where am I going with my contact lens selection [and] how can I leverage that? By the time I get to my contact lens room, I have all these products in front of me and you quickly, in a matter of seconds, whether you call that muscle memory or not, you have to go and select the right product, usually just trust your gut. You know the perks, you know the high points of every lens. Like I said, it's a puzzle piece, but you need to address the patient. For example, [the] patient has dry eye, but they also have light scattering at night. Well then, what lens is out there that can give you that? How can I reduce the evaporation rate of the eye? If I place this contact lens with a certain type of material will I exacerbate the underlying dry eye? Will I enhance the vision by preventing the evaporation of the tear film?

You have to consider all of these pieces and then explain it to the patient. Going back to communicating with the patient, if you have the mindset of, okay, this patient is going to leave my office and they're going to know exactly why I fit them in a particular product. I think a lot of us can do better about that. Sometimes we just, again, go muscle memory, grab a contact lens, here you go, here's your minus two lenses. The patient has no idea of why you chose it. Vocalizing everything that you're doing is so, so important. I tell the patient as they're washing their hands, "hey, you have this product it has a pupil optimized design. It's tailored to your pupil size, by the way it cuts evaporation rate." Some of them may or may not get that, but I do have a lot of engineers, and they ask those particular questions.

So it's a very, it's very helpful to explain that. But, I want them to know [they were] not just fit in a contact lens, it was tailored to [their] visual needs, [I] listened to [their] needs, and [I] selected a product and [they] know exactly why.

Kaiser Maharjan:

I'm sure that that helps a lot with patient satisfaction. And even the patients who maybe go home and try out their lenses, and they don't like them for whatever reason. They can come back and have a more informed discussion with you about, "I know that you fit me in this for this reason, but my dry eye is still really bothering me. Can we do something about that?"

Rojas:

I let them know you're not married to the product. At any point in time, we can make changes. That's part of that tailoring process. We have up to, at least in my clinic, 60 days to do that. I'm not going to take the full 60 days, but it's nice and comfortable for the patient to know [they] can come back and re-tweak this and just give it a shot. Again, that perfect patient, you think they're gonna do great in this power profile, this material is gonna be great for them. Or, maybe they have a high prescription [and] they need a breathable lens so they don't have any corneal pathology that develops later. Then they come back, they say it's too stiff, or it's too difficult to use. So, you just have to keep an open mind. In our office, we are about 90 to 92% Johnson and Johnson.

I am a consultant for Johnson and Johnson, but I feel like their products are very tailored to the patient. We have a wide variety of lenses in our office that we can help [fit]. We fit every type of brand, there is no brand that we don't fit. But, I do feel like the moving forward and the technology aspect of Johnson and Johnson's lenses have have really pushed the boundaries, especially with the new blue light filter that they're incorporating in the max lens and that pupil optimized design. So I do feel like that is the next level of tailoring a prescription and a contact lens that almost matches the tailoring approach that you're doing in a progressive glass. So I think that's pretty unique.

Kaiser Maharjan:

Yeah, absolutely. Going back to our conversation earlier about how you never really have the perfect patient in front of you. Part of that also comes down to patient behaviors. Maybe they aren't always following the correct timeline of how long you should be wearing their contacts or the correct cleaning protocols and stuff like that.

So, how do you address those issues as they come into the clinic? If they come in and they say, "oh, man, my contacts feel like they don't fit well." And you [say], "Well, how long are you wearing them?" And they [say], "like 14, 16 hours." Do you bake that into your workflow, or do you adjust for that when you're prescribing these contacts?

Rojas:

I listen to the patient. I'm understanding, I sympathize with the patient. I've been practicing for almost eight years. When when I first graduated, I'm wanted to be the people pleaser. So I said, "oh, don't don't worry you can continue doing that." That's a very bad approach just to win a patient over and just go along with their habits. I also, over time, have learned if you are really, really strict, you may rub somebody the wrong way. So there is something right in the middle where you understand their their habits, and you start making some micro changes over time. You don't have to instill a lot of fear, or show them acanthamoeba or an ulcer in a cornea and say this is what's going to happen to your eyes.

Some of them do need that. But, I'm very frank with them and said, "hey, you only have one pair of eyes, so daily disposable contact lenses are going to be the healthiest [and] the most hygienic." We always start off with daily disposables in our clinic. We don't even, how should I say this, ask what do you prefer? That's not the type of prescribing psychology and philosophy that we follow.

What we do is we just assume that they're going to be a daily disposable contact lens where unless proven otherwise, you have to give me a reason why you need to downgrade to a different type of lens. We're in a market now where daily disposables today, there's just so much benefit towards them. Let's face it, we don't want to be cleaning, buying solutions and cases, etc. If I can just give you a lens, that's one less thing for you to worry about. At the end of the day, you just toss it. But I do listen, and I try to sympathize with them as well.

Kaiser Maharjan:

Yeah, absolutely. So part of the challenge of providing a customized contact fitting experience is finding a lens with enough power profiles. Do you have any favorite lenses for this particular workflow?

Rojas:

Yeah, absolutely. When it comes down to power profiles, like we said, there's a lot in the market that offer a low and a high example, and we're just referring to multifocal here. You can have a low and a high, you can have a low, mid, high. That's about 2 or 3 power profiles. There's another brand. I know biofinity offers more power profiles as well, with a distance lens and the near lens, etc. You get to up to several.

But, another reason why I've kind of stuck with a maximum multifocal, [is] we have 183 power profiles, 183. Not just the low to mid and a high. Now the cool thing here is you don't have 183 drawers in your fitting kit, that would be crazy, that's a lot of real estate.

Let's say I go to a low drawer and a multifocal. I grabbed the low drawer and in between all those power profiles, I know that if I grab a minus one and I compare it to a minus five, I'm getting a different power proof [and] I'm getting a different optical zone. That pupil size of a given patient is going to match that optical zone a lot better. If I can customize that in such a way where I'm now matching the patient's pupil size to the obstacles under the contact lens, you get this perfect marriage of distance, intermediate and near. Now getting everything perfect, we know perfection is hard to find, and some of them might fall out of this range. But, I've had really good success with that lens. Just understanding how this lens was made, understanding the mechanics and how they reengineer the curing process, and how to make this lens more breathable.

To answer your question, that goes back to knowing how to fit the lens, listening to the patient, and then selecting a lens that's going to match the power profile of that lens to the patient's pupil. So, a patient's pupil size from from a 14 year old versus a 6 year old is going to be completely different. We know that the pupil size gets smaller as we age. We know that myopic patients or nearsighted patients are going to have larger pupils versus farsighted patients. So again, going back to my kit, instead of having 183 drawers, I don't have to think twice. I grab a mid or a low, whatever I'm going to grab, and I know that has a unique tailor to power profile to the patient's pupil.

Kaiser Maharjan:

Yeah, that's such a fantastic option. So we've talked a lot about the clinical side of fitting things. Obviously, that is what you're here to talk about. But, I also want to touch on the practice management, the business side of things. Do you use customized contact fittings as a marketing tool? Do you use that as part of your business model?

Rojas:

That is 100% of what we do. In fact, most of our patients are referral based because of that model. So, our entire business model and philosophy of fitting contact lenses has been in the specialty niche, in the customized and tailored niche. This has led to a lot of referrals from ophthalmology as well, where they said, "hey, I did such surgery and now they're stable from an anatomical perspective, but can you fix their vision because we're not there yet."

Sometimes the patient and I feel bad for these retina specialists because they'll do scleral buckles and they'll do these amazing retinal surgeries to get them the foundation of vision, and then they're left with a lot of cylinder or a lot of other things that they just can't see. At the end of the day, they might not see the benefit of that retinal detachment surgery, but ultimately just want to drive or they want to see. So they come to me with, "hey, they fixed me, but I still can't see, so what solutions do you have?" That has led our practice to grow and thrive, just focusing on that. Other colleagues around the areas, fellow ODS that said, "hey, I don't have the expertise to fit a gas pump lens or a scleral lens." Or even if it's [a] simple soft lens, "hey, I don't have the availability or the lenses in stock, so can you take care of this patient's needs? Okay, great." So, we do that. It's basically what we do. So, it's embedded in my DNA. This is what we do, it's all about that tailored approach.

Kaiser Maharjan:

That's so great. I know a lot of people these days love a tailored approach, especially in the days of online shopping and influencing and all that kind of stuff. It's so easy to take the stock option, but getting something custom fit, especially for your one set of eyes is so huge.

Rojas:

We all want a one size fits all approach, and that would make our life a lot easier. But you really have to dig deep, especially now there's so many great ones. So again, explaining to the patient why you're selecting such product is so, so crucial.

Kaiser Maharjan:

Absolutely. Do you have any lingering advice for people who maybe want to get into the custom contact lens game?

Rojas:

One would be [to] have the time to listen to the patient's visual demands. Listen to their hobbies, what do they do? Maybe just not ask those simple questions, but "hey, Ken, do you have time to explain to me day in and day out? I mean, are you at your house working remotely? Are you outdoors a lot? Are you going in and outdoors? Do you drive a lot at night? Do you have dry problems? Do you have allergies?" Asking all of these questions, not just to put it in your medical record for thoroughness, [and] really listening to the patient, going out there, and just telling the patient, "I understand where you're coming from, I actually have a product or solution for you." Whatever brand that's going to be, and voicing that out. So that's number one.

Number two would be the psychology of how confident you are. They're going to listen to you, they're going to read your body language. I would say one of the biggest pitfalls for most practitioners [is] when they're troubleshooting a contact lens, or maybe it's not coming out as they expected, they sort of give up [and say], "oh, it's I'm another multifocal, these are going to be quite difficult." Your body language will show a lot. If you're doing over-refraction and the patient doesn't say wow, then you kind of start losing the confidence. I would say this, be super confident about the changes you're making about the lens selection that you're prescribing. They read it, they feel it, you just have to be super confident and always know there's another option if you can't fix it. We haven't given up on any patient. We always find a solution. Whether it's A, B, or C, you can end up finding a solution for a particular patient.

Kaiser Maharjan:

All right. Well, thank you so much for taking the time to join us On Air today, Dr Rojas, this has been a fantastic discussion. I've really enjoyed it. So thank you.

Rojas:

Thank you for the opportunity. Thank you so much.