OptometryStudents.com had the pleasure of talking with Dr. Pal of Toronto, ON following a presentation on toric soft contact lenses at PCO. Dr. Pal is a graduate of SCCO. Upon graduation Dr. Pal completed a residency at the Northeastern State University Oklahoma College of Optometry in Tahlequah, Oklahoma. Dr. Pal has taught at both NSUOCO and University of Waterloo. In her spare time she writes for the AOA Cornea and Contact Lens section newsletter as well as for The Young OD Perspective and the American Optometric Student Association’s paper Foresight. Dr. Pal currently owns her own private practice where she specializes in contact lens fittings.
OS: What do you think are the most common mistakes that students make (and should avoid making) when prescribing contact lenses?
Dr. Pal: I don’t like to call things mistakes but things to look out for … (1) Always make sure you check your refraction before you start a CL fit. If the refraction is not right then every thing you do after that point will be wrong. (2) Make sure you do proper follow ups. Don’t get lazy on this part. Lenses change after they settle on the eye for several hours and you have to make sure you are dispensing the right lenses for long term use. (3) Educate your patients – the more you tell them about their lenses, the right cleaning products to use, how to avoid damaging their eyes, proper handling, proper schedules for replacement, etc. – the better. You will avoid a lot of problems if you discuss things beforehand. (4) Make it a rule that any contact lens wearer has a backup pair of glasses. Glasses come first! If you don’t stress this then over abuse of contacts WILL happen.
OS: Are there any opportunities while in school that students can take advantage of to improve their contact lens knowledge and comfort with dealing with contact lenses?
Dr. Pal: Practice! Practice on each other. When in primary care – talk about contact lenses. When in disease talk about CLs, and when in VT talk about CLs. When you are out of school, your practice isn’t divided into different areas. Your patient is there for all aspects of optometry and you have to be thinking of all approaches. So do the same in school. The second would be to create opportunities for yourself. If you know of a particular staff that specializes in GP fitting, ask them if you can work with them or sit in on exams that other students may have. When I was at SCCO, I was interested in prosthetic lenses and ocular prosthetics. One faculty specialized in this and I asked if I could work with her a few times on my off days to learn more. She was more than happy to teach me what she knew. The last is to go to meetings – the AOA, the Academy, GCLS etc to learn more in an environment that is different from your classrooms at school.
OS: Do you have any advice for presenting harder to prescribe and more costly lenses in a positive manner to patients (such as daily disposable multifocal lenses or torics multifocals, toric dailies, etc.)?
Dr. Pal: Always be positive. Cost should never be a factor when you are prescribing. Make your best recommendation and then let the patient decide if that is the right choice for them. If you believe a product is best for your patient then that should be your best recommendation. I don’t worry about cost initially. I pick the best product and tell the patient that this is the best option for them, I explain why. I let the patient bring up the question of cost and then I will tell them. I will never say “they are more expensive” or “I know they cost more but…” – I always come from a positive, encouraging place. If I think something is overpriced then so will they. At the end of the day, the patient will either want to pay for the better product or convenience or they won’t. Let them decide.
OS: I know that many practitioners are really concerned about 1-800 Contacts and having patients purchase their contacts from outside vendors. Do you have any advice as to how to be competitive in this market and maintain your patients?
Dr. Pal: In my practice, my prices are slightly higher than online vendors. We do not price match. We do monitor the differences on a regular basis to make sure we are within reason. I do charge for my services, my exams fees and contact lens assessments. I don’t do this for free. My staff are not afraid to ask patients where they buy their lenses and they explain all the benefits to buying lenses from us instead. For example, our easy to exchange powers if prescription changes, the free delivery to patients home or business, the replacement of ripped or torn lenses, giving them spare pairs to tide them over until their next visit, the safely in knowing their eye doctor is taking care of them, etc. I give them no reason to leave our office. You have to make them want to buy from you, and the extra attention and care that we give them along with the reassurance that they are covered in case something goes wrong is more than enough to keep our patients in house.
OS: Do you have any essential questions to include in your contact lens history that you feel that many students overlook asking?
Dr. Pal: The big areas that need to be addressed when asking patients about their history are (1) Lifestyle – what do they do on a daily basis? You want to know what type of lens will work best for the activities they do. (2) Their wants and needs when it comes to wearing contact lenses. You want to make sure you address these points so that the patient feels satisfied that you haven’t omitted anything. (3) Past history of lens use, care system, and habits – you want to make sure you don’t repeat things that went wrong in the past and you want to correct any bad habits that they may have formed. (4) Health – you want to know about allergies and medications and diet. All of these will impact dryness of the eyes and it will influence the type of lenses you choose for them. (5) Most importantly if they wear lenses ask specific questions about how they like their lenses, in the morning, afternoon, evening, end of the month, or wearing schedule. Look for areas in which you can improve their wearing experience. The more you delve the more you will find.
OS: Many patients misuse their contact lenses and either do not clean their lenses adequately or follow the proper schedule. Do you have any advice as to how to have an honest and non-confrontational conversation with your patients to prevent this from occurring?
Dr. Pal: You always have to create a comfortable environment so that your patients can be honest with you. When you ask them about how they care for their lenses, let them tell you and then tell them the correct way that things should be done, and most importantly tell them why. If you explain the short and long term consequences of poor habits then it will influence their motivation to change. Remember our corneas are very robust and can take a lot. They can handle abuse but eventually the corneas will break down and reject contact lenses. I have many elderly patients who cannot wear contact lenses because they abused their lenses for years. Their corneal sensitivity is so high that anything touching the cornea is uncomfortable. Those who experience a severe keratitis related to lens wear are prime examples of how CL wear changes after this experience.
OS: Do you have any advice as to when to fit patients into specialty lenses or an RGP lens?
Dr. Pal: This is a tough question – the short answer is if you are not achieving good vision or comfort or fit with a soft lens, or the parameters are not available, then a specially lens or RGP would be better. There are situations where starting with a GP may be better – for example using ortho k or myopia control.
OS: In your presentation at PCO you said that 65% of toric contact lens wearers drop out of wearing toric lenses in a year. Do you have any advice to prevent this from occurring?
Dr. Pal: Make sure you do a good fit. Pick the right products for your patients that provide good fit, good vision, and good comfort. Do regular follow ups and make sure you ask the right questions to look for areas to improve their comfort. Vision instability and poor comfort are the biggest reasons why people drop out of lenses. With the great products we have available, this shouldn’t be a problem today. You just have to be on top of your game and don’t get lazy and be satisfied when you know you can improve any of these areas. We owe it to our patients to give them the best.
OS: Do you have any advice for fitting older people/presbyopes who have never worn contact lenses before and think that they are too old to wear contacts into contacts?
Dr. Pal: You’re never too young or too old to wear contact lenses. You can teach anyone to insert and remove lenses. I ask everyone if they have any interest in not wearing their glasses and if they say yes than I tell them that I will take care of the rest. With the availability of one day disposable and one day multifocals, we can provide so much to our patients. Age has nothing to do with it, if they are motivated we can make it happen. You just have to be encouraging and supportive and provide the tools to make them successful.