As Seen In...
By Barbara Marrs	June 1996

Yes EyeCare Offers Progressive Eye Care And Traditional Values

"Progressive Eyecare and Traditional Values" is the philosophy at a unique eye care center in Coral Springs. Following five years of private practice in Broward County, Dr. Kenneth Maller established Yes EyeCare. Relying on patient input, Dr. Maller became aware of a need to provide a center for eye care, glasses, and contact lenses to treat patients in the manner that they deserve - Progressive Eyecare with Traditional Values in a warm, friendly environment.

The advancements that have taken place in his field have been encouraging to Dr. Maller. With the help of computers and technology the examining equipment has become more "patient friendly." An example of this is the "Refraction Station." Using automation and infrared beams the station allows Dr. Maller to determine the patient's best prescription in a method that is actually easier for the patient. Yes EyeCare is the only office in South Florida to offer this sophisticated technology.

Dr. Maller is involved with a revolutionary surgery using the Excimer Laser - revolutionary in that no knives are used. "The Excimer Laser uses a beam of light to reshape part of the eye allowing patients to see clearly without glasses or contacts." Many other advancements are incorporated into Yes EyeCare, all with the same goal in mind - to provide the very best visual and medical eye care available.

The developments in contact lenses over the last few years have been overwhelming. Disposables, daily disposables, frequent replacements, torics, gas permeables, bifocals, daily wear, extended wear, handling tints, enhancement tints, opaque tints and prosthetics, to name a few. "We offer FREE contact lens consultation and have had numerous success stories with patients who have been told that they could not wear contact lenses," says Dr. Maller. Dr. Maller fits all types of lenses. He will use standard design or personally design a custom lens to achieve the proper lens for the patient's needs.

Yes EyeCare has a beautiful selection of quality ophthalmic frames and sunglasses that are very competitively priced. All types of options are offered such as the newer thin and light weight lenses, progressive bifocals, and photochromatics (lenses that change between light and dark when going outdoors). It is not uncommon for children to have subtle visual problems (for example, eyes that don't function together as a team). Unless specifically tested for, this will typically go unnoticed, delaying or stagnating proper development. Children will rarely complain that their eyes don't work properly because they don't know what "normal vision" should be. It is recommended (but not generally known), that a child should have their first comprehensive eye examination in their thire year of life. Yes EyeCare also has a nice choice of children's frames for these little and very important people.

Dr. Maller's progressive yet traditional approach to eye examination and treatment is refreshing. Where old is new again, the return of caring professionalism and personalized service, is much appreciated and a benefit to all patients.

As Seen In...
By Christa Dean	September 1996

An eye for detail distinguishes office.

From all indications, one of the region's best eye care practices sits right here in the city's own back yard. The 1,600 square foot office sits quietly, an unimposing figure in the northeast corner of a shopping center at the intersection of Wiles Road and University Drive. But this office is no small deal. Step inside and the eyes are greeted with carefully planned eyeglass displays and sleek, spotless display cases. But you won't smell any glass cleaner here. The openness and the professional decor of the entry and awaiting space is further enhanced by the faint sound of contemporary jazz music throughout the room. However -- there is an obvious lack of paper in this office. In fact, you don't even see any filing cabinets. That's because there is very little paper at Yes EyeCare. And lots of computer screens.

Dr. Kenneth E. Maller, optometrist, owner and creator of the practice he opened last March, has installed an integrated database and examination system to replace much of the manual, handwritten work of his profession. The result is an unobtrusive, non-threatening eyecare experience that requires virtually no effort for the patient. For Maller, it means a more efficient, accurate consultation and an immediate record of patient data. "(And) it makes my day go better," Maller added. At the patient's first meeting with Maller, eyecare history is entered into a database and instantly assigned a number. No charts, no clipboards. Patients already wearing eyeglasses have their current prescriptions read by placing them underneath the lens meter, a specialized unit that prints a receipt-sized ticket of the data. The information is automatically added to the patient's computer record.

On to the Refraction Station, a unit that allows Maller to test a patient's vision and the basis of any eyecare professional's practice. While the patient is seated in a comfortable office chair, Maller pulls up the appropriate patient record and begins testing, using a touch-sensitive console on a small island table. Any need for vision correction can be determined at the touch of a button -- no clicking and flipping of lenses. Patients can quickly decide which lenses enable them to see most clearly. Noticeably absent is the standard letter chart on the wall -- it is now inside the Refraction Station. Maller conducts glaucoma testing in an adjoining room using a small machine that literally photographs the patient's eye and transfers the image to a television monitor for patient review. Using corneal topography in yet another area of the office, Maller can graphically analyze the shape of the cornea to determine any corrective action that should be taken or simply the proper contact lens fitting for a patient's eyes.

Maller hand-picked the equipment used in the office based on feedback from patients he had examined prior to opening the practice. Offering the patient hassle-free yet accurate exam was their foremost concern and the thrust of the office design. Custom display cases and the file cabinets (they are integrated with a reception-area wall) were drawn by Maller and presented to builders for construction. He realizes most doctors do not involve themselves with such minor details, but, he explained, sometimes the details are everything. "The key thing is doing your homework. I'm not the smartest guy out there -- but I looked!" he said. Several area doctors have toured the facility to examine not only the equipment but also the office design. Maller said at least three local eyecare professionals will implement some of the concepts he uses in their practices. Much of the technology Maller uses is the first of its kind in South Florida.

Maller specializes in contact lenses and said his success rate hovers near 100%. The uncommon is an everyday occurance with this doctor -- bifocal contact lenses and prosthetic lenses are two of more than 100 different types of contact lenses Maller regularly prescribes. Larry Wine, a sales and marketing professional from Broward County received follow-up care from Maller after undergoing photo radialkeratotomy (PRK) to correct a near-sighted condition. The procedure involves using a laser to reshape the cornea and is non-invasive. After wearing eyeglasses and contact lenses since childhood, Wine now in his 30's, said he has found freedom. "For anybody that is a candidate for this, it's a no-brainer," he said, adding a few suggestions for selecting an eye professional. "Be very, very thorough and selective about where you have the procedure done and the follow-up care doctor you choose." Throughout the follow-up, Wine said, Maller has proven himself a professional, convenient and thorough eyecare provider.

As Seen In...
By Greg Carr	May 1997

Parkland Music Guild Needs Your Help.

The Parkland Music Guild held their Spring Scholarship Luncheon on April 24th at the Coral Springs Country Club, to raise funds for the guild. Everyone attending the luncheon enjoyed an intimate concert with three members of the Florida Philharmonic Orchestra, Edward Martinez (piano), Janet Clippard (bassist), and Huifang Chen (violin). The musicians donated their time playing for about an hour and a half. Over 60 guests attended raising a total of $1200 for the scholarship fund of the Guild.

As Seen In...
By Carol A. Schwartz, O.D., M.B.A., F.A.A.O.	May 1997
Case #1: By Ken Maller, O.D.

How RGPs Can Change Your Patients' Lives.

The stories of how five fitting specialists helped shape the careers of three adults and the lifetimes of two children.

Managed care, mail-order lenses and backed-up reception suites can sometimes make us forget why we went to optometry school in the first place. So much so that we don't always appreciate the the magnitude of the impact we have on our patients. With that in mind, I asked five leading contact lens practitioners to share with you case histories that demonstrate how rigid gas permeable (RGP) lenses can forever change the dimensions of someone's life.

CASE 1: SURGICAL MISADVENTURE TO HYPEROPIA

Paula, a 42-year-old landscape architect, had undergone refractive surgery on her left eye in 1988. Because the outcome was less than perfect, she elected not to have the right eye done and became a soft lens wearer. In May 1996, she presented to me complaining of poor vision. Her right-eye vision seemed blurry through her contact lens and her left-eye fluctuated during the day.

Startling discovery.
With a struggle, her acuity with these contacts was 20/30- OD and 20/40 OS. In doing the refraction, I made a startling discovery: Other than belonging to the same patient, her eyes had nothing in common. Her right, unoperated eye was extremely myopic, with astigmatism (-5.75D - 1.75 x 180, 20/20). Her left eye had an equal amount of error - but in the opposite direction and with oblique astigmatism (+5.50D -1.75 x 120, 20/25). At near, she required unequal adds of +0.25 OD and +0.75 OS. Her keratometry readings were dissimilar as well.

Surgical Overcorrection.
As you can see by the topographical map on the previous page, the refractive surgery had created a sizable hyperopic overcorrection. Paula wanted no part of spectacles. Frustrated because she couldn't function, she began to worry if she'd ever be able to see properly again. When I recommended RGPs, she hesitated. She'd had a poor experience with them long ago. Still dubious about new materials and technology, she reluctantly agreed to re-try RGPs. Then - suprise. She was astounded by the comfort and the vision the first time she wore them.

As Seen In...
By Carol A. Schwartz,O.D., M.B.A.	June 1997

Eight Great Ways To Reel In RGP Patients
How to build your contact lens practice among the most loyal of patients.

Simply being excellent at fitting contact lenses is not enough to set yourself apart and succeed as an RGP specialist. You also need a way to get patients interested in them. Experienced RGP fitters agree: The most powerful tool for attracting new wearers and keeping existing ones is word of mouth. Hear are some ideas that will help get patients and prospects talking about your RGP fitting prowess.

1. Target Refractive Surgery Rejects.
The two fastest growing subspecialties in contact lenses are bifocals and myopia reversal. The demand for bifocals will keep rising dramaticall as baby boomers keep moving into presbyopia. Greater marketing of laser correction as sparked interest in cornal molding and myopia control among patients who are surgery-averse, too young or otherwise contraindicated for PRK and LASIK. Adding bifocals and myopia control to your practice can enhance the number of patients you fit with RGPs, say members of the Rigid Gas Permeable Institute's Advisory Committee. But, you'll need to let these patients know you offer these services.

As Seen In...
By Greg Carr	November 1997

Accelerated OrthoKeratology

AOK or Accelerated OrthoKeratology has been available for many decades but even today is still not generally well known. It is the use of contact lenses to gently reshape the cornea to reduce the prescription, in a similar way to the surgical procedures. This story is about Patti Velle, a Coral Springs resident, who recently has had great success with this procedure.

"I have been wearing contacts for maybe 30 years, I never had glasses. Actually, I was devastated when I was told I would have to wear glasses. I really only had a problem with seeing long distances in the beginning. Going to a drive-in movie was hard to watch. But I insisted that I was not going to wear glasses so I got contact lenses. I Always wore hard lenses, because back then that's all there was. They were a lot more durable than the soft lenses of today, I wore one pair of hard lenses for about 10 years." As Patti got older her eyes began to change, her doctor eventually switched her to mono lens. "They were bothering me at one point, which is about the same time that I began to hear about RK surgery, Patti said. I thought it would be great to be lens free all day long but the cutting when I went in and spoke to my doctor about it I didn't like the burning and the cutting because if a mistake is made at that point, that's it." Patti had also heard stories that a blur could result from the laser surgery and that is permanent. "When I went to see Dr. Maller I learned that there are actually four choices....RK, Laser, Bi-Focal, or you can wear these special lenses at night and not during the day, and I said whoa, backup...what was that last choice?" Patti had never heard of that last choice, so Dr. Maller proceeded to tell her about the corneal molding. Corneal molding is a contact lens that fits on to your eye like a suction cup and actually reshapes your eye to its proper shape for correct vision. Corneal molding has actually been around for a long time, but for whatever reason (mainly because some doctors consider it alternative medicine, and not many doctors are skilled in fitting this type of lens) it is not a viable option many doctors suggest.

Now, Velle has been wearing the corneal molding lenses since April. "I work for a title agency and I do four or five closings a day, talk to people all day long and you get into every kind of subject, nobody has ever heard of corneal molding, it's amazing. But then again its just like anything else." What interested Velle about this option was that the worse thing that could happen was that if the contacts didn't work your vision would just revert back to the way it was. You could then go back to what you were doing before the corneal lens fitting. In Velle's case she would just continue to wear her old contacts.

"It was interesting, when they came in I went into the office and Dr. Maller put them in, I wore them for about an hour, basically I am thinking oh....he wants to make sure they fit correctly....we chit-chatted a bit, and I read my book...then I went back in and he popped them out and he said well?...I said well what? he said you don't have lenses in...and then I said, oh my god I can see! I can read the chart! after only one hour! He then put them back in, I wore them all that day and night until the next morning and then I toke them out. I figured each day I could leave them out for another hour or so. The next day I had to go to Florida Prudential Realty. I was there talking to people telling them about it and they didn't believe me. To prove it to them I started reading license plates from quite a distance, needless to say everyone was quite surprised."

After about four hours Patti's vision started getting a little blurry, she had the lenses with her and just put them back in and went about her day and wore them through the night. Velle explained, "The next morning I took them out and started my day. That day I had a busy day, about four or five closing, I had forgotten all about them, at 6:00pm I was driving home and then I said whoa!....I could see. I called Dr. Maller on my mobile phone and said you aren't going to believe this....I haven't been wearing the contacts since about 7:30am. I didn't put them in until I went to bed that night. From that day on that was it, it took two days! and now I put them in at night when I go to bed and take them out first thing in the morning."

Velle used to wear the extended wear lenses where you take them out once a week, so she was used to wearing and caring for lenses. "I don't notice they are in when I sleep, they're great! Every now and them when I wake up in the morning and they might be a little dry I put a drop or two in them, but I did that with the extended wear also, so that was no big deal to me. I never wore the soft lenses, but I think they are easier to wear than those", said Velle. They are fitted, almost like suction cups, they pop right on, very easy to put on and off. If there made correctly then they will fit the right way and you shouldn't have to worry about losing them. "I am on Dr. Maller's web site (http://www.YesEyecare.com) under patients you can look for my initials P.B. and see my eyes. Dr. Maller is very progressive which is what I like about him. It's the main reason I left my old eye doctor. I met Dr. Maller at the right time I needed a change my old doctor wasn't responding to my needs, I wasn't happy with the contacts I was wearing and he made it sound like it was something psychological", said Velle.

The other thing many people like about the corneal molding is that it is about half the cost of RK surgery. You normally see the doctor about every two weeks or so, for adjustments and to check on the progression.

As Seen In...
By Dominick Maino, O.D., M.Ed.	December 1997

The WWW Page of Ken Maller, O.D. (http://192.41.15.170/yeseyeca/index.html)

In my last column I asked you to send me the URL of your practice's web page. Ken Maller, O.D., submitted his web page to be the first one I look at. IMMHO (that's cyberspace talk for "in my most humble opinion") Dr. Maller has done just about everything right.

His home page initially comes up on the screen and shows the office name, location, hours and how to contact him. It even asks if you want to make an online appointment. It then goes on to state all the services he provides, what "specials" the practice is offering, and the emergency eye-care services that are available. Those visiting Dr. Maller's WWW site can review information concerning bifocal contact lenses, orthokeratology and laser vision correction.

As you discover what he has to offer, you'll see pages specifically designed for other doctors, those that discuss medical issues, and reviews of interesting patient cases. He also has a page just for fun that has links to pages for the "Wonderful World of Disney" and "Star Trek." One of his best pages features "specialty contact lenses." This particular page should be interesting to just about anyone -- patient or doctor -- who likes the unusual.

Dr. Maller's WWW site answers the vital questions: who, what, when, where and how. It also adds in just the right amount of bells and whistles (animated graphics, on-line appointments) with plenty of reasons for potential patients to come back for more than one visit (like that strange contact lens page featuring "cat eyes," Halloween contact lenses and "monster eyes" contact lenses).

As Seen In...
By Ken Maller, O.D.	December 1997

Attracting Challenging Cases - Use these tips to establish yourself as an expert at treating unlikely contact lens candidates.

Plenty of potential contact lens patients could benefit from good contact lens services. The trouble is, many of them have extensive eye histories, such as vision loss from glaucoma or retinal problems caused by detachments that discourage them and their doctors from considering contact lenses.

Instead of shying away from these tough cases, I've carved a rewarding niche for myself by letting other doctors know that I'm willing and able to treat them. Here are some pointers to get you started.

What to keep in mind.
Take a creative approach. You'll need to move away from conventional thinking to treat these patients because most will have unconventional criteria. Some problems you'll typically address include irregular astigmatism, obliquely oriented astigmatism, dry eyes, loose lids, and lid disease. Your patients are likely to be presbyopes as well. So, you'll also need to address their near activities. I've found that rigid gas permeable (RGP) lenses are a major part of the arsenal in treating these kinds of cases. I also use corneal topography on each patient so I know what I'm up against from the start.

Be realistic.
Your first rule of thumb in treating difficult cases is to set realistic expectations - for yourself and the patient. If a patient has a visual field with large deficits, no contact lens in the world is going to restore the lost field. You should also expect to invest some time in managing these cases. For a post-radial keratotomy (RK) patient who was recently referred to me, I fit an RGP bifocal on one eye and a distance-only, back surface aspheric RGP in the patient's other eye. Unfortunately, the over-refraction on the distance-only aspheric had a great deal of cylinder. So, I had to spend a fair amount of time finding a lab that would manufacture a back-surface aspheric, front-surface toric RGP. There's nothing wrong with investing a lot of time fitting a patient as long as you get reimbursed for it. I charge a flat global fee for my professional services, based on the time I expect to spend on the case, and a separate lens fee.

Spread the word.
The key to generating referrals is communicating with the physicians who manage the tough cases. To get started, look no further than your own backyard. You probably already work with ophthalmologists for surgical referrals. Let them know about the contact lens services you can offer their patients.

I took this route with an ophthalmologist in my area who specializes in advanced glaucoma cases. By her own admission, she has no idea of how contact lenses can help these patients. She now relies on me as her key refractive referral source because I've sent patients back to her with visual performance beyond what she thought was possible.

This is the kind of result that generates additional referrals. Referring doctors will come to think of you as an expert, and they'll continue to send other tough cases your way. They'll also spread the word about you among their colleagues, who may become another source of referrals.

Follow protocol.
Being on the receiving end of referrals brings with it certain responsibilities. First and foremost, you must send patients back to their referring physician after fitting them - regardless of whether you can manage their glaucoma or offer them other services. Verbal and written correspondence is also very important. When a cataract surgeon refers a patient to me, he appreciates knowing how his patient is progressing. This courtesy results in better patient care, keeps the referring physician in the loop, and keeps me in the forefront of the referring physician's mind.

Rewarding niche.
Most of the patients that I treat are very gratified to have their vision restored to its best possible function. It's equally gratifying to me to help them and earn the respect of my colleagues by doing so. Once you can get a handle on managing these cases, I think you'll agree.

As Seen In...
By Joseph Shovlin, O.D.	January 1998

Cornea And Contact Lens Q & A
the Downside to mixing solutions.

Q - I've heard reports of lens swelling when mixing SupraClens daily protein remover with other solutions. Is this permanent, and are there any other effects of mixing solution?
A - Lens swelling can result from improper use of the product. Alcon Laboratories says it designed SupraClens to be used by placing one drop in each side of the lens case in Opti-Free Express multipurpose solution or Opti-One multipurpose solution for soft lenses, or Opti-Soak conditioning solution for RGP lenses. If a patient uses SupraClens only or rubs it directly on a soft lens, the lens will temporarily change parameters, says Ralph Stone, Ph.D., a senior director at Alcon. Storage of the lens in Opti-Free Express or Opti-One will re-equilibrate it. Frank Fontana, O.D., of St. Louis, says that he's occasionally had patients use SupraClens with other solutions with no reported problems, but he generally doesn't advocate mixing and matching solutions. Solutions contain varied ingredients, so you can't predict how they will work with each other. Dr. Stone cautions against mixing SupraClens with other solutions than those Alcon recommends. The new combination may change its safety and efficacy. Art Epstein, O.D., of North Shore University Hospital in Manhasset, N.Y., agrees. "I think that from a clinical perspective, products are designed to work as systems," he says. "The only way of being completely assured that a product is compatible with its components of the system is to use products within the system." By mixing and matching solutions, you also risk incompatibility between the solutions and certain contact lens polymers. Says Dr. Epstein: "The concept of labeling basically says we've used this combination of products with every possible combination of lenses that you'll come into contact with, and we find that it's safe." If you use solutions outside the labeling, make sure you know beforehand that there won't be any interactions or other harmful effects. In any case, regular follow-up with patients is important.

As Seen In...
By Ken Maller, O.D.	April 1998

Giving Back What Presbyopia Steals
Use these practical strategies with RGP multifocals to keep your presbyopic patients in contact lenses.

Contact lens wearers entering presbyopia have three options if they want to stay in contact lenses. They can wear spectacles over their contact lenses for near tasks. They can wear monovision. Or they can choose what I consider the superior option - multifocal RGP contact lenses. Multifocals do require a commitment in time and cost from both you and your patients. But beyond this, I believe they offer the most natural restoration of the pre-presbyopic state. This article will show you how I've succeeded with multifocal contact lenses in my practice, and how you can, too.

Selecting the best lens - one lens at a time.
Location, location, location - it's as important to bifocal contact lenses as it is to real estate. If a lens doesn't position and move as it was designed to, your patient won't achieve the appropriate vision. For example, translating designs should ride low and center laterally in primary gaze, while freely translating up without moving laterally on downgaze. Back surface aspheric multifocals should position towards the vertical center or higher on the cornea. Of course, these are generalities, but if a particular design doesn't move and position well, it won't work. In fitting bifocal or multifocal contact lenses, you'll address the usual criteria - prescription, tear film and corneal curvature - as well as such other very important issues as pupil size, lid position, lid tension, pupillary aperture, occupational requirements, computer use and lifestyle. Just as you know a flat-top bifocal spectacle generally doesn't function well for the computer user, you also need to know that a translating bifocal contact lens doesn't work well in these instances either. And forget the concept of "lens of choice." My lens of choice is the one that works, and there's no single bifocal or multifocal lens that addresses all the needs of all patients. But because RGP bifocals almost always provide superior vision, I've concentrated my efforts on becoming proficient with them. Here's how.

The first fitting session.
Selecting the appropriate lens can eat up a lot of chair time, but a little planning can minimize this (see sidebar 2). After performing a comprehensive eye exam, I schedule the patient for what I call the first fitting session. At this visit, I try 2 or 3 different designs. While each may be close to an appropriate fit, what I'm actually looking for is the design that performs best on a particular eye. I use the biomicroscope to see how the lens positions and moves, and to view the fluorescein pattern. A small amount of nasal rotation is often normal with a segmented translating design, but too much rotation will negatively affect near vision. If the lens looks good otherwise, I'll decide if a truncation will help keep it from rotating. If I believe that it will, I'll design a truncated lens and order it regardless of whether that particular design is usually truncated. Truncation may also help the translating lens that doesn't translate up adequately on downgaze. Poor translation is usually due to a thicker upper edge on the lens, or lid architecture that keeps the lens positioned low. It may be difficult to get a lens to translate up properly on downgaze if 1mm or more of the inferior sclera shows. This often prevents that lens from giving the patient a usable reading area because the lens won't move high enough to allow a normal reading postion. An aspheric lens must center laterally. Vertically, the lens must center or ride slightly high on the cornea. If topography reveals that the corneal apex is decentered laterally or inferiorly, it may be difficult to position an aspheric lens properly. Against-the-rule corneal cylinder is another tough factor to overcome due to lateral decentration. This applies to translating as well as aspheric designs.

Checking lens dynamics.
To check the lens dynamics, I use the direct ophthalmoscope with the patient's head in free space so that I can identify the seg position in relation to the pupil. Small pupils can be helpful, but it's sometimes nearly impossible to get good distance and near vision when a patient has large pupils. Check the patient in a room with normal illumination. If the pupils demonstrate excessive dilation in dim illumination, night-time flare may be a problem. Discuss this with the patient to determine which activities are most important and fit the lenses accordingly. For example, you may decide to position the seg of a translating design lower than you normally would because your patient is a truck driver who spends a great deal of driving at night. On the other hand, placing a seg too low won't work for an accountant who spends most of the day doing paperwork. Let the visual requirements of the patient guide your fit. If the lens is not positioned and moving as it should, I go on to the next design. Only after I find a lens that performs well do I check the vision. Since the prescription of the diagnostic lens is usually off by a considerable amount, I do a monocular trial lens overrefraction in free space ot obtain the appropriate power for the lens. I also check the usable near range both in distance from the eye (12 to 20 inches) as well as reading height (an arc of 20 to 45 degrees below primary gaze). Very often I'll end up with different design on each eye. Don't be intimidated by mixing designs (see sidebar 1). Capitalize on it by taking advantage of the strengths of each design. If all goes well at the first fitting session, and I have two lenses that I believe will perform well, I calculate the actual design parameters for these lenses. If I haven't come up with an appropriate design, I schedule the patient for a second fitting session to try additional lenses. I rarely need more than two fitting sessions before having a pair of lenses that I believe will work.

The dispensing visit.
When the lenses arrive, I schedule a dispensing visit to evaluate fit and vision. The fit of the new lenses may be quite different from the diagnostic lenses due to the prescription (a high plus translating bifocal will sit lower than a minus diagnostic lens, for example). I check the vision in a binocular field and perform a monocular trial lens overrefraction from +0.50 to -0.50. If the vision is not reaching the goal and takes more than the +0.50 to -0.50 at distance or near, the patient will not leave with the lenses that day and I'll perform a full overrefraction. It's important at this point to reorder lenses rather than let the patient leave with them. If the patient takes these lenses he'll have problems, and this will make it much more difficult to fit him successfully. if all is as it should be, however, I instruct the patient on lens application, removal and care, and explain any limitations of these lenses. Set reasonable goals and make sure the patients understand what they'll be able to achieve. If you prescribe a translating lens, be sure to include instructions on head and eye position.

One-week follow-up.
At this visit, I check vision binocularly in free space at distance and near, and we review any problems that the patient has encountered. Unless the vision is not even close to the goal, I only overrefract with trial lenses over each eye from +0.50 to -0.50 while the patient is viewing binocularly. Sometimes, I do my "hall" overrefraction where I take the patient into the hallway where he as an unobstructed view of true distance in free space. The hall measures about 60 feet to the glass front door where patients can see outside. Remember, this free space is how they're going to use these lenses, so don't use the phoropter for any evaluations. A biomicroscopic exam will confirm that the lenses fit well and the cornea is healthy. At this visit, we review lens application, removal and cleaning techniques to reassure the patient who is still new to contact lenses.

A creative and systematic approach.
There's no cookbook approach to prescribing multifocal contact lenses, and creativity is important to fit these lenses successfully. The general protocols I've outlined here help me give patients the best of what's available. Until we can restore full accommodative functions through innovations like implantable liquid collagen, movable IOLs or whatever else might be coming to help us give back what presbyopia steals, bifocal and multifocal contact lenses are the best options for the presbyope.

Sidebar 1: Mixing and Matching Multifocals
An approach that works exceptionally well for me is to use a translating design for the dominant eye and an aspheric multifocal on the non-dominant eye. Among the strengths of a translating design are crisp distance and near vision, and the ability to address the high add. Unfortunately, comfort can sometimes be a problem. Also, the translating designs are highly head and eye-position sensitive, and they're not the optimum choice to correct vision in the midrange. Aspheric multifocals perform exceptionally well in the midrange, but tend to give slightly softer vision at both distance and near. They're also limited to the lower add powers. By combining these designs, however, you can provide sharp distance and near vision while also giving a very useful intermediate range. Mixing designs also comes with a cautionary word. You can't mix a translating design that's prism ballasted, such as a typical crescent seg type bifocal, with a concentric design. This combination creates a vertical imbalance that's likely to cause vertical diplopia.
- Ken Maller, O.D.

Sidebar 2: Fees that Make Sense
You may wonder how I account for the increased chair time that bifocal contact lenses take, particularly with a potential for mor than one fitting session. In my practice, I charge a flat, global contact lens fitting fee based on the type of lenses I'll be prescribing. this fee also includes any follow-up visits. My fee schedule covers more than 200 different scenarios in contact lens fitting - everthing from a simple spherical soft lens fit to a complex specialty RGP case. It took some time to calculate these fees (they're all in my computer now), but I believe this is the only way that's fair to both me and my patients.
- Ken Maller, O.D.

Sidebar 3: Preparing Patients
Preparing your patients to wear bifocal contact lenses is at least as important as your ability to fit them. By establishing reasonable goals, you'll avoid undue cost, chair time, aggravation and disappointment. I always begin a new bifocal contact lens fit with a review of the available options, comparing the pros and cons of each. I make it a point to explain the two important negative factors - time and cost. Patients are very understanding if they know what to expect. You can head off impatience and unreasonable expectations by informing patients at the first session that it will be at least a month before they'll receive their contact lenses. New lens wearers only know what their friends have told them, and current wearers may have been conditioned in the past to expect to leave your office with lenses that day. Explain that these lenses are custom-made, which increases the turnaround time from the lab. Remember, you can wait 10 to 14 days for a lens to come in, and if you need to reorder, a month can go by very quickly. When a patient asks why it's so difficult to fit these lenses, I explain that we're dealing with a moving lens on a moving eye that still must always be in the correct place so that they can see clearly whenever they're looking. That means that measurements of tenths and hundredths of a millimeter can make the difference between success and failure.
- Ken Maller, O.D.

As Seen In...
By Kenneth E. Maller, O.D.	June 1998

Helping Patients Make The Hard Choice
How to position RGPs in a favorable light.

Many patients, and even some doctors, are leery of rigid gas permeable (RGP) lenses because they have a reputation of being uncomfortable. But I've fitted between 65% and 75% of my contact lens patients in these lenses by presenting them in a positive light. Here, I'll give you some suggestions on how you can increase patient acceptance of these lenses along with your percentage of RGP fits.

What's in a name?
The first step toward making RGPs more popular with your patients is to stop referring to them as "hard lenses." This conjures up an image of pain - and image your patients aren't likely to embrace. If you described a soft lens as a floppy, slimy, hard-to-handle piece of plastic, you wouldn't see many patients excited to take that path, either. When discussing RGPs, I refer to them as "inflexible oxygen permeable" (IOP) contact lenses and stress that they aren't to be confused with the old hard polymethylmethacrylate (PMMA) lenses from 40 years ago.

Talk 'em up.
The next thing to do is change your own bias that patients won't tolerate the sensation of the inflexible lenses. Remember, the patient sitting in your chair only wants to accomplish three things - to see, be comfortable and have healthy eyes. If you explain that an inflexible lens accomplishes these criteria better than a soft lens, then the patient is likely to accept this modality. When discussing the benefits of IOPs over soft lenses, I say that IOPs provide sharp, non-fluctuating vision, transmit more oxygen, are deposit-resistant, don't dry out, are easier to maintain, are more durable, provide better long-term comfort and are less costly in the long run. To overcome the comfort issue during the adaptation period, I tell my patients that they'll have success and satisfaction with the lenses, but they'll need to give themselves from 1 to 3 weeks to adapt to the sensation (not the pain) of the lenses.

Get the right fit.
Because IOPs take a little more effort and chair time to fit, I explain the extra cost and chair time to my patients. I use the analogy of a tailor-made suit and explain that the lenses are custom fit to their unique set of eyes. Rather than trial fit the lenses, I design them and have them manufactured based on exam data. This ensures an accurate fit and lets the patient leave with the lenses the same day he first experiences them. I use a topical anesthetic to help the patient adjust to the initial sensation of the lenses. Because the lenses settle quickly this way, I can usually evaluate the patient for fit and vision without delay. When the anesthetic begins to wear off, I explain that the sensation the patient is experiencing is normal and the lenses will gradually become more comfortable. If the patient reports any lingering discomfort at the follow-up visits, I modify the lenses on the premises while the patient is in the office. I've found that very minute changes can take a pair of lenses from just being tolerated to being entirely comfortable.

Not so hard.
Offer this modality freely to all your appropriate patients, not just the difficult refractive cases, and you'll find that many will make the "hard" choice very easily.

As Seen In...
By Ken Maller, O.D.	July 1998

Solutions From Our Readers
Give Group Contact Lens Lessons

Try to schedule several patients at a time for lessons in contact lens care. Patients enjoy learning from and encouraging each other, and they'll ask about how their classmates are doing when they're in for subsequent follow-up visits.

As Seen In...
By Edward S. Bennett O.D., MsEd	July 1998

RGPs And The Young Practitioner

During a recent discussion on Walt Mayo's Optcom e-mail network, it became apparent that many young practitioners ar not fitting any RGP contact lenses! In addition, some participants of the discussion suggested that the "20/80 rule" exists, indicating that only 20 percent of all eyecare practitioners fit 80 percent of all RGPs. Many Optcom participants placed much of the responsibility for this trend on the the contact lens educators. However, I can justify that my colleagues in the Association of Optometric Contact Lens Educators (AOCLE) and I are only a small part of the problem. Certainly one factor for why our students insufficient RGP experience is the impact of, and fascination with, treating ocular disease. Likewise, the curriculum at some schools has been changed to limit students' exposure to contact lenses, often to the dismay of the affected contact lens educators.

Addressing The Problem.
Enhancing students' RGP fitting experience is extremely important and accounts for a significant part of the Rigid Gas Permeable Lens Institute (RGPLI) budget. Many RGPLI dollars fund a one-day, hands-on workshop and seminar program conducted at most schools of optometry with the gracious support of the AOCLE members at each participating institution. There are spherical, aspheric, toric, bifocal, keratoconic and postsurgical RGP-wearing patients at each workshop. The RGPLI and other cntact lens industry members try to help students understand how much practice income is derived from contact lenses, as well as the profitability of RGPs. It's a message that the students can't hear enough (Table 1).

An Optimistic Resolution.
The good news is that several young practitioners on the Optcom list who fit 40 percent or more of their new patients into RGPs spoke up about taking the initiative to try RGPs and about the subsequent benefits of practice growth and profitibility, vision, ocular health and ease of care. RGPLI advisory committee member Ken Maller summed it up best when he said, "If RGPs are so wonderful for so many reasons, why are they being reserved for only the exotic cases? Instead of waiting for the next keratoconus patient, maybe this [discussion] will inspire some doctors to try them on the next easy one who sits down in the chair."

Patients may be "soft" in their thinking, but if you recommend RGPs, most will be satisfied and successful with them. Remember that they still look to you for advice on which type of contact lens is best for them.

As Seen In...
By Ken Maller, O.D.	August 1998

PERRL Of The Month
Refitting Soft Lens Wearers Into RGPs

As your presbyopic patient base grows - and it will - you may find that you're refitting some long-time soft lens wearers into rigid gas permeable lenses. To give these patients greater confidence in their chances of success, take a little extra time to counsel them. Stress the issues that are most important to patients - ocular health, sharp vision, ease of care and handling, and long-term comfort. With your reinforcement, they'll place more importance on long-term benefits than initial comfort.

As Seen In...
By Kenneth E. Maller, O.D.	September 1998

Disposable Lenses Aren't A One-Size-Fits-All Option
Fitting patients with RGPs can be a healthier, more profitable choice.

Disposable lens wearers often consider themselves the experts when it comes to contact lenses. They'll tell you things like "I can wear these 2-week lenses for a month because they don't really bother me," or "I sleep in my lenses until my vision gets a little foggy, which is usually after about 3 week." And, "Solutions? Why would I need to use solution? I wear disposable lenses!" Did you ever notice how their "know-it-all" attitude disappears when they show up with a painful corneal ulcer? A painful red eye is an excellent educator, but waiting for a sight-threatening infectious keratitis to educate your patients about the benefits of rigid gas permeable (RGP) lenses isn't really necessary. You can start this education the next time they're in for their examination. Here's what I recommend.

Deliver the facts.
Disposable contact lenses can provide many advantages over rigid lenses. However, contrary to public opinion, they're not "one-size-fits-all lenses," nor are they the best choice for everyone. Many times, patients will sacrifice their visual acuity or ocular health, consciously or subconsciously, because they have the erroneous belief that a disposable lens is always best. There's an entire disposable contact lens wearing population that can be better served by other lens modalities. Instead of watching your profit margin shrink to $0.25 per box, having your patients leave your practice, and making compromises on the ocular health and vision of your patients, you should take the time to educate your disposable contact lens patients to these two important facts:
1 - You're the doctor, and you know significantly more about contact lenses and their eyes than they do. Therefore, you can recommend a better option.
2 - Wearing disposable lenses may compromise their vision and their ocular health.

Identify the benefits.
I've heard many of my colleagues say that it's impossible to refit a soft lens wearer into rigid contact lenses, especially a disposable soft lens wearer. But RGP lenses can compete exceptionally well with disposable lenses if you present them the right way. To be successful with RGPs, you need to identify the specific weakness that a disposable contact lens presents to a patient and then refit the patient into a rigid contact lens that improves on that weakness. (See "Success the Second Time" below.) Here are some of the key advantages RGP lenses can offer your patients.
- Higher Dk.
The oxygen transmissibility of the newest generation of rigid lenses far exceeds the soft lenses of today. The smaller size of the rigid lenses also allows much of the cornea to remain exposed to the air while the movement of the lens causes tear pumping and flushing of metabolic waste. Research suggests that increased oxygen reduces the risk of microbial keratitis and other serious ocular complications. Corneas that require more oxygen, as well as ocular surfaces that are habitually drier, will maintain better integrity with an RGP lens.
- Better health.
Because they're composed of such a high percentage of water, soft lenses act as a reservoir for allergens, protein, bacteria and other contaminants. These factors can all lead to higher risk for infection, inflammation, allergy and corneal vascular changes. If you have patients who are suffering from any of these problems with their disposable lenses, they'll probably have more success and feel much better in rigid lenses.
- Improved visual acuity.
The main reason that patients wear contact lenses is because they want to see better. How often do patients have some uncorrected astigmatism that you just "let go" to allow them to continue in disposable lenses? If a patient's vision is better served with a rigid lens and you present the options of better vision or disposability to the patient, the patient will most likely choose the better vision option.

A Superior Option.
I'm not advocating that all patients stop wearing disposable lenses because there are clearly some patients who are best served with this modality. But I do think that there are too many patients wearing disposable lenses for all the wrong reasons. Refitting these patients will better serve their needs. Refitting disposable lens wearers into more appropriate lenses will also be much more profitable for your practice. Sure, rigid lenses and bifocals require more chair time, but I don't see anything wrong with giving the chair time they need as long as I get reimbursed for it. Another benefit of fitting RGPs is that patients stay loyal to your practice. You're providing them with a premium service that they can't get elsewhere. You'll rarely have RGP wearers ask for a prescription to fill by mail. Those who do quickly learn that they can waste time and money trying to get the proper replacement. Don't make assumptions about whether the RGP option is too costly for a patient up front. When I make recommendations for the contact lens wearer, I only bear the patient's vision, comfort and health in mind. It's not my decision whether it's too costly. When you educate your patient's properly, you'll find that very few will choose an inferior option bases on cost.

Give Your Patients The Filet.
The next time a disposable lens patient is sitting in your chair giving you and "order" think about the possiblity of refitting him or her into a superior lens option. Instead of taking the order for the "eight boxes, fries and shake," offer the filet that your patient didn't even know was on the menu.

Sidebar 1: Success The Second Time
Here's an example of how a refit benefited both the patient and my practice. A 52-year-old woman came to my office complaining that her near vision was poor. She was wearing a -6.50 disposable lens on each eye, which I guessed to be a monovision prescription, using the left eye for near vision. Her distance acuity with these lenses was OD 20/25, OS 20/30. Both lenses were coated and deposited, and both corneas were showing 1.5-mm, 360-degree limbal superficial vascularization. She commented that she liked the convenience and comfort of her current lens modality. She'd been wearing them daily for 10 years, with 1-month replacements. She was in good health and the only medication she was taking was a hormone supplement. Her refraction was OD -6.75-1.50x030 20/20, OS -6.75-1.00x140 20/20 with a +2.00 add in each eye. Her keratometry was OD 44.37/45.12@112, OS 44.25/45.25@058. After the exam, I explained to the patient that her distance vision, as well as her near vision, was not very sharp and could be improved. I recommended that we abandon her disposable lenses for the superior option of inflexible oxygen permeable bifocals. (I refer to RGPs this way when talking with patients to present them in a more favorable light. See "Helping Patients Make The Hard Choice," page 28, June 1998.) The patient told me that she had tried and failed in RGPs several years ago. I explained that she would be better served with the option I recommended and she agreed to try it. I refit her into a translating design RGP bifocal on each eye. Her corrected distance vision is now 20/20 in each eye, and she has 20/20 near (Snellen equivalent) with a clear reading range of 13 to 22 inches. She says that she is able to see the television clearly and didn't realize how blurred her vision was with her disposable lenses. She's also delighted that she has such clear near vision and has started to read for leisure, an activity she'd discontinued. She is wearing the lenses 16 to 18 hours per day, and they're remaining clear, comfortable and uncoated. Her corneal limbal vessels have receded to about 0.5 mm. It's easy to see how the patient benefited from being refit with RGPs, but I would like to point out the benefits to my practice. An average life expectancy of a pair of these bifocals is about 2 to 3 years. Even if the patient came to me for disposable lens replacements every year for 3 years, the profit of those replacements would yield less than 25% of what I collected in profit up front at the refit. Maybe it's time for you to consider fitting this modality more for your patients, as well.

As Seen In...
By Carol A. Schwartz, O.D., M.B.A.	November 1998

Photodocumentation: Optimizing Today's Contact Lens Practice

There was a time when records consisted of only paper and ink. What the doctor saw and then wrote or dictated to file was pretty much all that could be expected. Technology has changed all that. The definition of what constitutes a patient record or what serves as the standard of care in keeping patient records is somewhat more obscure today, but may include slides, hard copy images and digital images. Chief among these elements for contact lens practitioners are digital or film images, but the type of services you provide dictate to some extent the type of record that will prove useful. For example, an eyecare professional performing an orthokeratology procedure needs to document baseline findings to illustrate the patient's status prior to contact lens fitting. In addition to refraction, some description of the corneal shape is a must. Keratometry readings might suffice, but the standard of care is quickly moving to corneal topography.

Photography often comes to mind for documenting pathology, but it also has great potential for use in contact lens practice. Contact lens fitting following penetrating keratoplasty, radial keratotomy, photorefractive keratectomy, giant papillary conjunctivitis and neovascularization are all examples of cases where photodocumentation of baseline findings and progress examinations are useful.

Dr. Maller uses a digital camera mounted on a slit lamp and a software package called "Reveal TV for PC" to capture, freeze and save images. He admits his set-up is cumbersome, but when he purchased it two and a half years ago, it was the only thing available. Dr. Maller cautions those shopping for photodocumentation systems to brace themselves. "It's exactly the same as computers - whatever you buy, you don't even make it to the checkout counter before it's obsolete!" he says. "You have to figure out if it will do what you want it to do, bite the bullet, and then just use it until it's absolutely antiquated." For example, his current unit cannot easilly make a hardcopy image to file, but he promises that his next system will include this capability.

As Seen In...
Ken Maller, O.D.	November 1998

Venturing On To The World Wide Web
Why you should consider developing a site and how to get started.

Continuing to attract new patients and keeping existing ones is at the heart of every practice's development. One of the newest means to achieving this goal is creating a personal Web site on the Internet. I decided to create my own office Web site (http://www.YesEyecare.com) 2 years ago, and I've had tremendous success with it. Here, I'll explain why I think you should consider reserving your own place on the Internet and how you can benefit from it.

What is a Web site?
A Web site can be anything from an advertisement to a more in-depth communication vehicle from your office to the general public. It can be as simple as a "billboard" to tell the public who you are and what you do, to a totally dynamic interactive site that allows patients to make appointments, ask you questions or get directions to your office.

Starting construction.
Getting started on a Web site is easy. Approach it the same way that you would any venture. Start by outlining what you want to accomplish. Then, allot an appropriate amount of resources, time and money toward accomplishing your goal. The actual nuts-and-bolts construction of a Web site requires a variety of disciplines - from information and design, to writing the code, registering your domain (address) and updating the site. If you have a fair amount of computer knowledge, it's possible to develop your site yourself using one of the Web authoring tools currently on the market. However, if you're looking for something unique and dynamic, and you don't have much computer experience, you may want to hire a Web site development service to create your site. Depending on your budget, a Web site developer can create an inexpensive "generic" Web page, or provide you with a fully customized site. The cost increases proportionately.

What to put on your site.
Take full advantage of this unique medium by posting information about all of the services you offer. This will inform and educate patients and potential patients in much the same way that the brochures in your reception area do. In addition, you can use your Web site to record patients' medical histories and allow patients to make appointments online. This will give your patients 24-hour access to your office. I also use my Web site to provide my patients with a free e-mail newsletter. To sign up for this service, patients and Web surfers simply enter their names and e-mail addresses. My e-mail newsletter accomplishes several goals. First, it conveniently delivers eye information that might be of interest to my patients directly to their e-mail addresses. Secondly, it saves me money on the design, layout, printing and postage costs associated with a traditional patient newsletter. It's a very cost-effective way to deliver information to my patients and the public. When you're deciding what to put on your site, keep in mind that the Web is still very much a wide open playing field. The possibilities are unlimited. Use your creativity to come up with ways to market your practice so that it'll stand out from what's already been done.

The advantages are clear.
One of the main reasons you should give serious thought to putting your office on the Web is because your patients spend a fair amount of time there, searching for everything from pet supplies to tax information and medical knowledge. Having a Web site will also give your patients the impression that your office is up-to-date. Patients want their doctor to be current. Don't make the mistake of assuming that the Internet is just for younger, computer savvy people. While I was writing this article, I received an online appointment request at my Web site from a new 61-year-old patient. He filled out my online eye and medical history forms, and even asked that my office confirm the appointment with him not by telephone, but by e-mail. The Internet is only going to increase in popularity as more people find out what a convenient and valuable resource it can be. Those companies and practices that don't invest in developing a Web site may be at a disadvantage when it comes to advertising their services.

The potential is unlimited.
The ideas I've shared with you really just scratch the surface of the Internet's power and potential. Taking advantage of this medium by developing your own place on the World Wide Web will enable you to effectively communicate with your patients now and in the future. The key is to start simple and build on your site gradually. Remember, the Internet is an evolving medium, so everything doesn't have to be perfect right away. You can modify your site as often as you like. One of the things that's so great about the Internet is that it's always changing. So take the plunge. Hopefully, I'll see you in cyberspace!

As Seen In...
By Ken Maller, O.D.	November 1998

PERRL Of The Month
Low Astigmats May Need Toric Lenses

If you've fitted a spherical RGP lens on a toric cornea of low cylinder (1.50D, for example) and the patient complains of discomfort, Ken Maller, O.D., suggests you try an aspheric or even a bitoric lens instead. Often the specialty lens will enhance comfort even though it isn't required for vision correction.

As Seen In...
By Ken Maller, O.D.	January 1999

PERRL Of The Month
Managing RGP Patient Expectations

Warn first-time RGP wearers that side-to-side eye movements will be the last of the comfort adaptations to come and can take as long as a month. Knowing that this sensation is a normal part of the adaptation keeps patients motivated.

As Seen In...
By Judith Lee	January 1999

10 Lessons for All Time from the Start-ups of the ’90s.
Despite heavy debt and managed care, the way is still open for doctors who want to start their own practices. O.D.s who have “opened cold” share what’s worked for them, and how it can benefit even established practices.

For optometrist Pam Ellis, the drudgery of working in a commercial setting was getting to her. For Arlene Hughes Gorny, the desire to call her own shots motivated her. For Steven Maxwell, O.D., the clock was ticking. For all three, the dream of private practice lives on, and they’re making a go at it despite a health-care marketplace that ranges from indifferent to hostile. These optometrists are among the few who have opened new practices in the past several years. A select group, they freely acknowledge the challenges and rigors of starting a practice in the 1990s, but at the same time their practices are growing. Some have recently transitioned from part-time to full-time hours. Dr. Maxwell has even opened a second location. “I was never comfortable in a commercial setting, and did not enjoy it,” Dr. Ellis says from her Bel Air, Md., practice. “I worked in other settings, too, but I never felt I could practice as conscientiously as my patients deserved. I never felt my professional service was valued.” Despite the pressures of opening a practice in the 1990s, these doctors are finding success. “My practice is right on target with the busi- ness plan I wrote before I opened. We’ve had a lot of repeat business and referrals from patients,” says Dr. Gorny, who opened a practice in Cape May, N.J. in mid-1996. Dr. Maxwell agonized over his decision to open cold in Dubuque, Iowa. “I thought about this for 10 years,” he says. “My wife reminded me I wasn’t getting any younger.” The lessons they’ve learned apply to any independent practice. These doctors say there’s no secret to their success. Along with constant dedication, they put everything they have into making their practices grow. And, nobody told them it was going to be easy. Says O.D. Tim Van Kirk, of San Diego, “In optometry school, they told us it takes three years to establish a practice. They didn’t say the first year was pure hell.”

Lesson 1: Invest in Yourself
All of these O.D.s who started their practices cold say you must invest in the practice. That means new instruments, appealing decor and a total look that tells patients you intend to succeed. “We put in the best of the best; we’re dressed to the nines,” says Kenneth Maller, O.D., of Coral Springs, Fla., near Fort Lauderdale. “Our office reeks professionalism. We do not carry schlock frames. It all helps to attract quality patients, and that’s how we make money.” When Dr. Maxwell first planned to open his practice, he budgeted $50,000. After seeking the advice of Denver consultant John Gay and office designer Will Rogers, he upped that four times, and it has paid off. “Right from the first month we opened, we earned three to four times our projections,” he says. “Patients keep mentioning that this is the nicest office they’ve seen in Dubuque”—a city of about 60,000 on the Mississippi River—“and I think that has a lot to do with our success.” Dr. Gorny put together an experienced staff that projects a competent, professional image. Her opti- cian came out of retirement to work four days a week at Dr. Gorny’s new practice. Her office manager (who is training to become an optician) and part-time assistant both were prior workplace acquaintances of Dr. Gorny’s. “I knew these people and knew their work. I know I can trust them,” she says. When Michael Bacigalupi, O.D., opened his practice in rural Ballinger, Texas, he also chose not to skimp. “The office is high-tech and professional. It tells people that we are here to stay; we won’t be gone next week. By investing in a nice office, we were investing in this community,” he explains.

Lesson 2: Operate Lean
Some experts will tell you to hire more staff, but these doctors believe in operating as lean as possible. Several of these doctors even answer their own phones at times. “It’s important not to hire staff that you can’t afford,” Dr. Maxwell says. “This places a burden on the practice, and will keep you in the red. Besides, I never want to get so high and mighty that I can’t pick up the phone in my own practice.” After a year in practice, he has one full-time employee, a part-timer and another employee for his second location. He says it’s particularly important to select staff mem- bers who work well as a team. “We had several that didn’t work out,” he says. “Now we have a good team, and I think patients can sense it. People enjoy it when the staff works well together.” Dr. Maller has just one employee who is a trained optician and operates the front desk. He says she does an excellent job of projecting a professional image. Dr. Bacigalupi has two employees, both trained vocational nurses. Right away, he says, this told the community that his office was oriented toward primary care. “This sets the tone for the practice,” he says. “When patients walk in and recognize a nurse they’ve seen in a family practice or at the hospital, they know we are offering professional health care.” These staff members have lived and worked in Ballinger for many years and helped introduce the new doctor to his community. “These are local people who know so many other people. It’s hard to measure the value of that for a new practice,” he says.

Lesson 3: Reach out to Everyone
These practice owners say you can’t be shy about promotion. They’ll do almost anything to gain visibility. “I wrote a column for a local paper that gives me editorial space along with my ad,” Dr. Maller says. “I’ve done school screenings and given talks at schools. I also have an interactive web site.” Dr. Ellis also writes a column, and shares the expense and the space with an ophthalmology group. Dr. Bacigalupi sponsors a radio show that runs before the broadcast of local high school football games. “Every week, people listen to the City Eyecare Pre-game Show. It keeps our name out there,” he says. Dr. Maxwell stresses that optometrists must do more to mine their current patient load. Along with advertising for new patients, he works hard to encourage referrals from current patients. “I’ve learned to get comfortable with this,” he says. “I’ve found that if people are happy with your service and products, they are willing to refer others to you. I give referral cards to every patient and ask them to send friends, coworkers and family to me. When I get a referral, I send a thank-you card, and I think this goes a long way.” Dr. Gorny’s practice also is growing from patient referrals. Although she does not ask for them directly, she feels patients truly appreciate her practice’s focus on service. “Before becoming an optometrist, I was a nurse,” she says. “I saw the other side of things, when some doctors are arrogant with patients. I just hate that, and patients do too. When you treat patients like human beings and valued customers, they really respond to you.”

Lesson 4: Go West, Young Doctor
New practice owners say it’s critical to locate your practice where you’re needed. If you have too much competition nearby, consider moving to a community that has few, if any, eye-care providers. “My wife and I were welcomed here with open arms. That would not have happened in a suburb of Dallas or Houston,” Dr. Bacigalupi says. “If you really want your own practice, you need to go where patients need you.” Ballinger is in central Texas, about 300 miles from either Houston or Dallas. If you’re unwilling to pull up stakes and move, you might find an opportunity nearby. Dr. Maxwell found out that an optical shop in an adjacent town had closed, leaving that town without any type of vision care. Because some of his patients lived on the side of Dubuque near that town, he worried that they might be attracted to a new practice that would open there. “I opened so no one else would. Now my patients on the south side aren’t so vulnerable to being drawn away from me,” he says.

Lesson 5: Subsidize Your Dream
A new practice, or even an established one that’s struggling, can greatly benefit from supplemental income. For three years Dr. Ellis worked three days a week at her own practice about 20 miles northeast of Baltimore, and three days at Aberdeen Proving Ground, a military installation nearby on the Chesapeake Bay. “It was exhausting, but it gave me an income while my practice was growing,” says Dr. Ellis. While Dr. Maller was dealing with contractors and setting up his practice, he worked for other optometrists who needed temporary help. One practice was 180 miles away, requiring him to stay over one night a week. “I did a lot of driving and it was tough on my family,” he says. “But we had an income during the time that I was spending money on the practice but wasn’t yet ready to see patients and make money there.” Arthur Clarke, O.D., of Landing, N.J., continues to work in jobs outside of optometry as his fledgling practice becomes established. A former teacher and coach, he now supervises lifeguards at all New Jersey state parks. “It’s a seasonal job that gets busy when the optometry practice isn’t. It helps me be patient as I wait to become established,” he says. Dr. Maller warns against spending too much time away from a private practice: “It’s like a baby—it needs you a lot in the beginning, and you don’t get that much in return.”

Lesson 6: Don’t Compromise Care
New practice owners say they took the big step to offer truly professional care, and all private doctors should be careful not to compromise on this. “Building a practice is like building anything of value,” Dr. Ellis says. “It takes time, and you can’t be in a rush to generate income. It only takes five years to pay off your equipment. We can outshine the retail establishments by providing great care and by really taking charge of our profession.” Dr. Maller observes that managed care squeezes doctors to reduce the time spent with patients and the service they provide. This only reduces the value of care and makes all practices look the same. “The only way we can be different is to be better,” he says. “We don’t chase after managed-care patients because managed care pressures us to be just like other providers. We’re chasing after the private patient who wants better care, values it, and will pay for it.” In the resort area where Dr. Gorny practices, many patients are small business owners without vision plans. She’s found that quality care is important to them, and appreciated. “This is a small town; everybody knows everyone else. If you give people quality care and treat them right, they’ll be back. If you don’t, they will take their hard-earned money elsewhere.” Dr. Ellis, who put in an optical dispensary in deference to vision plans, refuses to be paid mainly through optical sales. “It’s OK to offer the service of an optical, but that is not what our profession is about,” she says. “We must act like doctors and insist on being treated like doctors, or we will no longer be doctors.”

Lesson 7: Abolish Receivables
While some new practitioners complain about not being included in managed-care panels, others purposely shun them. That’s because managed care creates such a backlog of receivables. “Managed care costs doctors too much in three ways,” Dr. Maller says. “First, the fees are discounted. Second, we have to wait to be paid. Third, we have the cost of processing and re-processing claims.” Instead, he developed a complex fee structure that allows the office to cover all professional services. This has been input into the computer, and his optician/assistant uses it when presenting the final bill to patients. “It’s good to be able to show that there’s a system to your fees,” Dr. Maller says. “You aren’t just picking a number out of the air. We like to be able to explain exactly what the charges are for.” His assistant simply presents the bill to the patient without apology or embarrassment. She asks the patient if they would like to pay by cash, check or credit card, and almost everyone pays the whole bill up front. “We absolutely insist that the professional fee be paid that day,” Dr. Maller says. “If the patient is concerned about the cost, we tell him that he can pay for half the materials at that time, and we will order them. But he must pay the entire balance before taking contact lenses or eyewear with him.”

Lesson 8: Opportunity Knocks
Even though these new practice owners don’t have much of a security net, they say it’s important to continue to take risks. This is the only way practices can grow. Says Dr. Maxwell: “When I heard about the opportunity to open an office in Cascade, I wasn’t sure it was the right time to expand. But if I hadn’t opened the office, someone else would have. Then I wouldn’t have had the chance to gain a foothold in that community.” Cascade is a small town about 20 miles southwest of Dubuque. He could already see that his investment in Dubuque was paying for itself with revenue above his projections. “This [the Cascade office] is a much smaller investment, and it’s good for the future of the practice,” Dr. Maxwell says. In Maryland, Dr. Ellis finally was able to work at her practice full-time this year, but she is not about to become complacent. “Things are better,” she says. “They are going well. But I will have to partner with other doctors to achieve my goals. I’m not sure how I will do this, but I am seeking a window of opportunity. If you don’t capitalize on that, you lose the opportunity.”

Lesson 9: Be Proactive
New practice owners say they are trying to stay one step ahead of the marketplace. This means creating solutions to problems that aren’t big problems yet. Dr. Bacigalupi created his own vision plan and marketed it successfully to four large employers in Ballinger. He has gained 850 employees and their spouses as patients. “This is a simple discount plan,” he explains. “The patient presents a card and I give a discount on eyewear. It doesn’t cost the employer anything, and I have grown my patient base.” He says that vision plans are not common in west Texas, but he decided not to wait around. “Why wait for a big plan to call up your local employers? Why not call them yourself? I just presented a one-page proposal and got a very positive reception,” he says. There are two new companies in Ballinger, and Dr. Bacigalupi intends to offer them the plan next.

As Seen In...
Carol A. Schwartz, O.D., M.B.A., F.A.A.O.; Edward S. Bennett, O.D., MsEd, F.A.A.O.	February 1999

Specialty Lenses: Don’t Let Your Best Patients Disappear.
RGP wearers can be your practice’s biggest asset. Don’t allow your lack of knowledge to drive them to a competitor.

How much do you know about fitting specialty contact lenses, like rigid gas permeables (RGPs)? Maybe you’re not anticipating making these lenses a big part of your practice. You may even think of RGPs in particular as something most patients aren’t interested in. If that’s what you’re thinking, you’re not only selling these lenses short, you may be selling the future of your practice short as well. These lenses provide crisp optics that soft lenses can barely equal. And patients who wear them often become diehard supporters of the doctor and practice that prescribed them. In these economically tough times, that’s a factor you can’t afford to overlook.

A cautionary tale.
Unfortunately, ignorance and negativity about these lenses is widespread. The following true story illustrates the frustration many RGP wearers experience dealing with optometrists today. Our story is about a young man we’ll call Joe. Joe’s dad owns a contact lens lab, so when Joe was a teen and decided he wanted to wear contacts, his Dad hand-picked an O.D. who fit Joe with RGPs. Joe loved his -9.00D lenses and wore them all the time when he was awake. Everything was fine — until one day he lost his lenses. He had a spare pair, but it turned out that they needed polishing. He called his regular optometrist about getting them polished, but he was told that he’d have to leave his lenses in their office. Since he needed immediate help, he tried every O.D. in town, but he got the same response. Finally he called the optometry school clinic, and they said they could polish them, so he made an appointment. But as soon as he got there he discovered that they couldn’t find a record of his appointment! When they did find it, he waited 20 minutes and then a student in a white coat came to him and said, "Are you here for an eye exam?" Joe repeated that he was there to have his contacts polished. This was followed by another 20-minute wait. Finally a senior student came and asked Joe to follow him. When they arrived at their destination where another senior student was waiting, Joe started to take out his lenses. One of the students said "Oh, PMMA I see," then added, "That’s polymethylmethacrylate," obviously trying to gain some points with his erudition. "No," Joe answered, "As a matter of fact they’re high Dk fluorosilicone acrylate gas perms." "I thought all rigid lenses were PMMA!" said the surprised student.

Setting the record straight.
What’s wrong with this picture? Aside from the fact that Joe had so much trouble getting a simple need met, the students "helping" him weren’t second-year students on their first case. They were seniors just weeks from graduation. And yet their patient knew more about RGPs than they did! Unfortunately for us all, this sort of thing isn’t rare. Many RGP-fitting optometrists have heard stories similar to Joe’s from their patients. For example:
• Dr. Bob Copeland tells of a nurse-practitioner who could find only one practice in the Philadelphia area that was able to replace a lost RGP lens. Was this because RGPs aren’t popular in Philadelphia? Apparently not — the practice had a 6-month waiting list of new patients!
• Dr. Kenneth Maller of Coral Springs, Fla., fits about three quarters of his patients in RGP lenses. Although he opened cold a few years ago, referrals from enthusiastic RGP wearers have fueled the growth of his practice. Dr. Maller tells the story of a 16-year-old patient who lost a lens while out of town on vacation. Her father took her to a local O.D. who told her how awful rigid lenses were and insisted on refitting her into soft lenses. When vacation was over the teen insisted on being taken back to Dr. Maller, and proceeded to tell him how much she wanted to get back into the RGPs.
• Dr. Donna Higgins of Prairie du Chien, Wis., tells the story of a teen-age Type I diabetic patient whom she fitted in high Dk RGP lenses because of health concerns. The patient proudly showed off her lenses at a family reunion, also attended by her uncle — who happened to be an O.D. Her uncle got very upset that she was wearing rigid lenses, believing she’d be better off in a soft lens. The upshot? The young lady ignored her uncle and remained in rigid lenses. And she still sees Dr. Higgins for her eyecare, proving that blood is not thicker than saline.

The four R’s of rigid lens patients.
While we find true stories like this frustrating, they illustrate the four characteristics of the typical RGP wearer:
• Respect. The first of these attributes, and the most important for optometrists to note, is that RGP wearers respect their fitters. Conversely, they don’t respect those who speak ill of the lenses or who don’t seem to know much about them. In fact, if an RGP patient discovers that his present doctor falls into the latter category, the patient will go out of his way to get a new doctor and delight in telling the new doctor what an idiot the previous doctor was.
• Reliability. As demonstrated in several studies, RGP patients are loyal to a fault. Once they find an optometrist who understands rigid lenses and can fulfill their needs, they’ll stay with that fitter, no matter how inconvenient it becomes. They recognize a specialist’s knowledge and value his or her expertise.
• Referrals. These are the heartblood of any practice, and to a new practice they’re vital. Even if your "practice" is a position in a hospital or HMO, you’ll be expected to cultivate your own patient base and help grow the aggregate practice by bringing in new patients. Studies have shown that RGP wearers are more likely to refer their friends and co-workers than soft lens or spectacle patients. Young practitioner Dr. Maller, whose story we told earlier, proves that specialty contacts are something you can build your future on. If you’re one of those young O.D.s who believes your prowess in treating ocular disease will be your ticket to the future, think again. Pathology patients rarely refer. You seldom hear someone say "Gee, Harry, the next time you get a nasty red eye, run right in to see Dr. Smith." But patients often recommend their contact lens fitter. And this is a service patients can initiate at any time; they don’t have to wait for an annual check-up or a disease occurrence.
• Retention. Marketing experts will tell you that it costs five times as much to find a new patient as it does to keep one existing patient. That’s why it’s so important to hang on to patients once they choose you as their doctor. And as you can see from Drs. Higgins’ and Maller’s stories, retention is a key attribute of RGP patients. Rigid and specialty lens patients return year after year for contact lenses and professional services.

Treating the whole patient.
Awareness of the advantages of specialty lenses like RGPs seems to come hard to new O.D.s. Some never get the message, spending their careers wondering why some of their classmates are so much happier and more successful in their work. After long, hard years of thinking about the minutia and complexities of the eye, it’s hard to change gears and think about the whole patient — relating what you’re doing for your patients’ eyes to their systemic health, their lifestyle, their occupational needs and their overall happiness. (Note how many practices didn’t think that it might be inconvenient for a 9D myope to walk around uncorrected while they mailed his lenses to the lab for polishing!) But meeting the needs of the whole patient is what really counts, and specialty lenses like RGPs are an important way to do exactly that.

How your patients see you.
Earlier, we talked about the issue of respect, and how your attitude toward (and knowledge of) lenses like RGPs affects your patients’ attitude toward you. To many O.D.s who are just starting out, it may seem too glossy and superficial to worry about how patients view you instead of concerning yourself with their visual field results. Somehow, it seems less than "doctor-ish." In reality, what your patients think of you will be a deciding factor in your success (or lack of it). "Marketing yourself" doesn’t just mean taking out an ad in the Yellow Pages. It means deciding which services to offer, giving your patients the level of service they want and creating the image you want your patients to have of you and your practice. You can decide right now to separate yourself from the pack by serving your patients in ways your peers are overlooking. Don’t do what everybody else is doing! Remember: Patients value and respect doctors who’ve demonstrated exceptional skill in fitting specialty contact lenses. By making yourself an RGP expert you’ll earn — and keep — your most valuable resource: your patients.

As Seen In...
By Ken Maller, O.D.	February 1999

Witnessing Change
This O.D. refit a young girl with contacts and watched a transformation occur.

The timid 12-year-old girl sitting in the exam chair had her arms folded tightly across her chest and her eyes fixed firmly on the floor. One look at her lengthy history form told me that this young girl had seen a lot of eye doctors in her 12 years. Judging from her body language, I was just one more.

Eye Adventures.
Patti's eye adventures started with a pair of cataract extractions when she was about 3 years old. Because implants weren't done at that time, she was fitted with soft aphakic contact lenses. A couple of years later, she received spectacles to wear over the contacts to correct for her astigmatism and provide a reading add. Additionally, she'd had a large retinal detachment in her left eye. After a scleral buckle repair to correct the detachment, she developed some macular scarring in the eye. As a result, even with the contact lens and spectacle combination she was wearing, she only had 20/200 vision in her left eye.

Setting a Goal.
I tried to put Patti at ease during the exam by asking her about school, but she barely answered my questions. I had the feeling that, given her vision problems, school wasn't all that enjoyable for Patti. Her mother later confided that kids at school often teased Patti about the lenticular bifocal spectacles she wore when she wasn't wearing her combination contacts and spectacles. My plan was to refit Patti's right eye into a rigid gas permeable (RGP) multifocal and the left eye into an RGP sphere for distance only, because the apparent potential for acuity in this eye was still fairly poor. I told Patti that our goal was to have her see well enough with contacts so that she wouldn't have to wear glasses over them, and she managed a shy smile.

Mission Accomplished.
After overcoming a few design obstacles, I was able to fit Patti with lenses that gave her 20/20 vision in her right eye at distance and near, and 20/60 distance acuity in her left eye. This acuity wsa enough to give Patti a peripheral awareness that she'd never really experienced. We also made her full field polycarbonate bifocals with anti-reflective coating for when she wasn't wearing her contacts. She actually wore them out of the office smiling! At Patti's 6-month visit, I was pleased that the multifocal contact was still performing well and she now had an acuity of 20/40 in her left eye.

A Changed Girl.
A year went by before I saw, Patti again. When she sat down in the exam chair, I honestly didn't recognize her. She was confident and full of life. Her eyes were "proud" and she looked at me, instead of the floor. The shy girl of a year and a half ago was gone. Patti's mother told me that after we refit her with contacts, Patti became more sociable and started doing much better academically. In addition to her newfound self-confidence, Patti now had distance acuity in the left eye of 20/25. I recommended that she start a vision therapy program to further sharpen the acuity in the left eye and to work on binocularity. Time will tell if this is possible. When a jewel of a case like this surfaces, it really makes some of the daily aggravations we through seem worthwhile.

As Seen In...
By Diane Donofrio Angelucci	February 1999

6 Steps To Success In Prescribing Contact Lenses For Today's Presbyopic Patients.

Eighty-nine million Americans have presbyopia - a number that's growing by 4 million each year as Baby Boomers age. It's a hefty market to consider when assessing options for these patients. Unlike their parents, Boomers are looking beyond traditional measures to correct their vision - and technological advances are making contact lenses an increasingly attractive option.

Who they are.
"If you picture a presbyope as the little old man sitting at hes accounting desk with his lined bifocal ophthalmic lenses, that's not the person we're treating with these contact lenses," said Thomas Quinn, O.D., M.S., of Athens, Ohio. "We're treating the woman who's an executive, providing child care and playing tennis in her free time. Those are the kinds of people who are attracted to the contact lens option because of the freedom it gives them in performing all of these tasks." Many patients in this group have used single-vision contact lenses for decades. "We've got more contact lens patients entering presbyopia than ever before," said Jon Kendall, O.D., of Santa Ana, Calif. "It's a different population of people." And many Boomers aren't deterred by the extra expense for multifocal contacts. "If they perceive this will improve their quality of life, they're willing to pay for it," Dr. Quinn said. Although some Boomers are sensitive about the issue of presbyopia, most realize that it's part of the aging process. "I think most of us accept it," said Peter Bergenske, O.D., Middleton, Wis. "I don't see people dealing with it like it's particularly traumatic. On the other hand, it is cetainly commonplace for patients to say, 'Well that's fine,' but they don't want their glasses to have lines in them. They don't want to wear reading glasses." Because the topic may be touchy for some patients, Dr. Kendall suggested treading carefully, "Be cautious in your wording, especially if you're a younger doctor," he said. "You don't want to alienate them."

Steps to success.
To meet the needs of this new generation of presbyopic patients and boost your success rate with these complex lenses, these doctors recommend that you follow these steps:

1 - Present the option.
"A lot of people don't even know that multifocal contact lenses exist," said Dr. Quinn. "If we don't bring it up, it may never be something they investigate because they don't know it's a choice for them." Dr. Quinn and his associates use a patient questionnaire to find out who may be interested in this option. This is particularly important because many patients mistakenly believe they aren't suitable candidates for multifocal contact lenses. "About 30% of the patients I've fit with the soft multifocals have never worn contact lenses before," Dr. Quinn said. "They were okay with glasses for single vision, but when you make the leap to multifocals, all of a sudden they don't want glasses." To prepare your patient, bring up treatment options before presbyopia surfaces. "If they're already wearing contact lenses, chances are that, even before they begin having reading or nearpoint problems we've planted the seed or raised the topic of how we're going to handle that problem when it arises," Dr. Kendall said.

2 - Be prepared to offer a variety of options.
In pursuing this market, invest in several types of lenses. "A lot of times you can send the information to the lab and have them send you a lens, but that may be a crap shoot," Dr. Kendall said. "That's going to lengthen the fitting process. Having fitting sets and several manufacturers' lenses is important." Although you may prefer prescribing a certain lens, one lens won't meet every patient's needs. "Sales reps come in and ask, 'What's your lens of choice?' said Ken Maller, O.D., of Coral Springs, Fla. "You know what my lens of choice is? The one that works. They hate when I answer them like that, but it's true." "The way I approach every multifocal case is I have a diagnostic fitting session when I will put on several different designs and the one that looks to show the most promise is the one we pursue," Dr. Maller said. "That's how my lens of choice gets decided." Dr. Bergenske agreed with the process. "There's no magic bullet," he said. "There are some things that work well for a given patient and some things that work well for others." "There may be more than one way to solve a certain patient's problems. You have to have some facility with a variety of lenses if you're going to have a high level of success. You can't put all your eggs in one basket."

3 - Give your patients what they need.
At times, you may need to look beyond what your patient says to determine what she really needs. A new patient came into Dr. Maller's office for a refill on her disposable lenses. "She was wearing -6.25D on both eyes," he said. "She's about a 2D presbyope. She also had about 1.25D of uncorrected astigmatism, her distance vision with her lenses was about 20/25 or 20/30, and she couln't read." Although the patient insisted she was fine, Dr. Maller explained that her lenses didn't let her read or see distance well. Reluctantly, she agreed to try rigid multifocals at his suggestion. "She's doing great," Dr. Maller said. "She said to me, 'I can actually see the television now, and for the first time in I don't know how many years I actually picked up a book just because I could read it.'" "That was the first time I'd seen her. She'd been in that other lens for 10 years," Dr. Maller continued. "No one ever took the time to take the contrary approach and say to hr, 'But you're not seeing that well.'" "If a patient mentions that he no longer has time to devote to his model railroad hobby, I'll consider his age and wonder if it's eye strain," Dr. Kendall said. "Maybe he needs special glasses for that hobby. It may be unconscious on his part." You also need to address other aspect of a patient's lifestyle when prescribing lenses. For example, Dr. Kendall explained, someone who does a lot of overhead work, like a carpenter or librarian, may fare better with a simultaneous lens rather than a segmented lens. Computer users also have unique needs.

4 - Let the patient know what to expect.
Be sure to tell your patients that the fitting will be longer because adjustments will be necessary. This is especially true for previous single-vision lens wearers. "In discussing multifocal contact lenses, the first and most important thing to get across is that the patient is not going to come in for the next visit, put on a pair of contact lenses and leave," said Dr. Maller. Also explain what their lenses will - and will not - do. "No matter what we do, we're not going to make their vision like it was when they were 25 years old," Dr. Bergenske said. "There's going to be some kind of compromise." "You have to set a level of expectation that suggests we're going to give them very functional vision. Ther're going to be able to see far and see close and see in between, but there are going to be situations when a better alternative is going to be needed for certain tasks." For example, patients may feel more comfortable with glasses if they're driving a long distance at night. "The contact lens isn't going to be all things to them at all times," he said.

5 - Educate your patient.
If you're like most practioners, many of your patients request disposable lenses bases on a recommendation by a friend or relative. "They need to be educated," Dr. Maller said. "They may come with a preconceived idea and say 'I want disposable lenses,' and I'll say, 'That's fine. You have 1.50D of astigmatism and you're not going to see all that well, but I can give you great vision in a gas perm multifocal. Would you like to talk about that as a better option?" "When you're presenting alternatives, you can't be intimidated by the impression that patients prefer soft lenses," Dr. Maller explained. "That's one place where some doctors can drom the ball. "When was the last time you went in and said to your doctor, 'I need some Cardizem because of my PVCs?' Patients don't know. They're paying you for professional advice, so give it to them."

6 - Fit lenses carefully.
There are a number of ways to be sure you get the best results:
- Find the correct eye.
"For monovision, the key thing that I like to emphasize is to not get hung up on the concept of dominant eye," Dr. Bergenske said. "I think it's kind of an inaccurate dogma that you always have the dominant eye as the distance correction. I think that's wrong at least half the time. One needs to keep an open mind when testing patients for monovision."
- Have the patient keep both eyes open when testing for monovision.
"If you cover one eye, then cover the other eye, it underestimates how well the patient sees when both eyes are open," Dr. Quinn said. With both eyes open, you will get a more realistic assessment of how the patient will perform in the real world, he explained.
- Have an accurate baseline spectacle refraction.
"If you have an outdated refraction or a refraction you haven't taken the time to really tweak, that makes your job a lot harder," Dr. Quinn said. "If you spend a few extra minutes to really tune that spectacle correction, then you have a firm foundation upon which to build your bifocal contact lens design."
- Try loose lenses.
Dr. Quinn also suggest using loose trial lenses that you can hold up in front of hte patient's eye during real-life experiences, rather than relying only on the phoropter. "Base your determination of success on patient performance in the real world, not on how well they can read the acuity chart," he suggested. "If a patient feels like he can see what he needs to see - far away and up close - then consider that a success, even if the patient is reading 20/25 far away and 20/30 up close. If we adjust the power to try to improve the far vision, we may foul up the close vision. The goal is to find the right balance so the patient can perform tasks at all the different distances with comfort."
- Be flexible.
With simultaneous vision design lenses, which include all soft multifocals and some rigid multifocals, you may need to try a variation on monovision if necessary, biasing one eye for close and one eye for distance, especially in patients needing a high-multifocal strength. "If the patient has just turned 40 and he needs a weak multifocal, it's likely you'll do fine with an equal multifocal in each eye," Dr. Quinn said. "But if he's 60 and needs a strong multifocal, we may need to cut the multifocal strength back in the dominant eye."
- Turn up the lights.
In addition, because pupil size is important in fitting simultaneous vision lenses, Dr. Quinn recommends turning up the lights a little in the exam room for patients with soft multifocal lenses. The patient's pupil will be a more normal size and more accurately reflect visual performance.

Plan for succcess.
By understanding and responding to the needs of today's presbyopic patients, you can successfully build the contact lens portion of your practice. "It's clearly a big opportunity in contact lens practice," said Dr. Bergenske. "They're a population that is very interested in this - and they can afford it."

Sidebar 1: Weighing the Options.
To successfully fit contact lenses in presbyopic patients, know the strengths of your contact lenses.
Monovision Contact Lenses
Advantages:
- Reduced cost.
- Good for beginners. Dr. Kendall said good candidates are patients who've recently reached 40 and are needing light or needing to hold reading material further away. "It's really easy for them to accept," he said. "I think that's why monovision is still so successful and you get at least an 85% success rate. I always tend to introduce these things as the path of least resistance. I can simply put one contact lens in for reading, instead of having them wear two contact lenses. Then I can go to multifocal contact lenses. I go up the scale that way."
The downside:
Patients may have difficulty with depth perception and night vision and see halos around lights. In adddition, monovision contact lenses may offer only a short-term solution.
Bifocal Contact Lenses
Advantages:
Both eyes are used for distance and near focus, resulting in better depth perception and night vision, compared to monovision.
The downside:
Multifocal lenses are more expensive than monovision lenses.

Sidebar 2: Choosing Soft vs. RGP Lenses.
Practitioners often have preferences when deciding between soft ad rigid gas permeable RGP lenses. Although frequent replacement (soft) aren't appropriate for all patients, they let patients have a spare lens in case they lose or tear one, are convenient for travel, and may be more comfortable for some patients. Others contend, however, that RGPs provide crisper vision and are cheaper to maintain in the long term. "The more frequently you replace a lens, the more costly a system becomes." Dr. Kendall said. In addition, he explained, you also may be able to achieve more add power with rigid lenses. He added that RGP designs are generally the better choice for patients with more than 0.75D of astigmatism.

As Seen In...
By Ken Maller, O.D.	April 1999

Getting The Word Out About Contact Lenses For Presbyopia
If many of your 40-plus patients think they're "stuck" in glasses, it may be time to introduce them to bifocal contact lenses.

So you have yet another presbyope sitting in your examination chair and this time you would really like to promote the idea of bifocal contact lenses to this person. Before you do, you'll need to lay some groundwork.

Raise bifocal awareness at your reception desk.
Start on a positive note when patients arrive in your office. Display manufacturers' brochures and information sheets about presbyopia and bifocal contact lenses in your reception area, your dispensary and your exam rooms. This gives patients every opportunity to browse through the material and digest it before their exam. Then have your staff follow up with a brief discussion. For instance, if a patient says he's just coming in for eyeglasses, your receptionist can ask, "Have you ever thought about contact lenses?" Typically, a presbyope will answer this question in one of three ways:
"But I wear bifocals." This common response is a natural lead-in to a dialogue about bifocal contact lenses. Many presbyopes are confused about their options for vision correction and don't even know that they're candidates for contact lenses.
"Oh, I tried monovision lenses and they drove me crazy." Although monovision does work very well for some patients, there are people who just don't like it and don't do well with it. Failed monovision patients are excellent candidates for bifocal contact lenses. They may be a bit skeptical about trying contacts again, so be sure to explain how bifocal lenses differ from monovision.
"But I've been told I can't wear contacts." Your staff should note this response on the patient's chart so you can discuss this with the patient during the exam. Rest assured, these discussions at the reception desk will often prompt patients to broach the subject of bifocal contact lenses to you, making presentation easier in the exam room.

Now it's your turn.
Once patients bring up the topic of bifocal contact lenses, you must be able to answer their questions and address their needs, which can vary greatly. Understanding the different types of bifocals and multifocals lets you present realistic expectations to your patients. I always focus these discussions on the positive aspects of what bifocal contact lenses can accomplish, but I'm also careful to be honest about what they can't do. As you know, anyone who expects bifocal contacts to make their eyes work like they did when they were 20 years old is bound to be disappointed. And having spent a lot of time for an unsuccessful fit - so will you. All optical devices (especially for presbyopes) have limitations that you should point out to your patients before they make a decision. For example, progressive spectacle wearers need to know their limitations - that they must point their nose in the direction they want to look for clear vision. This doesn't detract from the advantages of progressives, but it does properly prepare your patients. When recommending bifocal contact lenses to patients, you should provide the same type of information so you'll be able to meet their expectations. I find that when you address the specific needs of a presbyopic patient, bifocal contact lenses will surpass any spectacle modality in performance. When you eat, sleep and breathe this philosophy, you'll not only be ready to present bifocal contacts to your patients - you'll have more bifocal contact lens wearers than you ever thought possible.

A word to the skeptics.
You may have tried fitting bifocal contact lenses in the past without much success, and now you're skeptical about trying them again. Believe me, some of the best designs are the newest ones - in both soft and rigid lenses. They use the latest technologies to produce advanced optics in a comfortable lens. These really can succeed when properly. You should start with some of your less-demanding cases and build on your successes until you're comfortable with the more challenging bifocal cases. When you can get into the mindset of thinking of bifocal contact lenses as a first-line treatment modality, you'll be more successful, with more cases, than you ever thought possible. And in doing so, you'll be adding a valuable facet to your practice while changing your patients' lives for the better.

A knowledgeable patient spells success.
When you start the educational campaign I've outlined here - and it's important to start now - you'll quickly be surprised to learn that most people don't even know that bifocal contact lenses exist. Raising patient awareness is the only way to ensure that your presbyopic patients will be ready for bifocal contact lenses.

Sidebar 1: Kids Often Bring A Presbyope Along.
Parents of pediatric patients are often presbyopic. These early presbyopes are usually looking for any possible way to avoid wearing bifocal spectacles. When you examine children, you should always ask their parents if they've given any thought to wearing bifocal contact lenses. Give them literature to read while you're examining their child. Later, ask if they have any questions or are interested in scheduling an exam to see if this modality will work for them.

Sidebar 2: Broken Spectacles? Don't Sit On This Opportunity!
How often do presbyopes have to bring their mangled eyeglasses to your office for repair because they sat on them. "I'm constantly putting my glasses on and taking them off all day," they complain. These patients are "screaming" for bifocal contact lenses but they just don't know it. After the glasses are repaired, you or your optician might suggest to the patient that wearing bifocal contact lenses would alleviate this problem.

Sidebar 3: Go Outside Your Patient Database.
Try these simple external marketing techniques to bring more presbyopes into your practice.
Direct Mail.
A direct mail piece with information about bifocal contact lenses is a good place to start.
Practice Newsletter.
Think about devoting an entire section of your next practice newsletter to bifocal contact lenses.
Newspaper Articles.
A highly effective and frugal way to get information to the public is via your local newspaper. Most editors would welcome an article written by an expert, on presbyopia and new vision correction options. You can display reprints of the article in your waiting area, republish it in your newsletter and post it on your website.
Cable TV.
Advertising on local cable TV costs less than you might think, and it gives you a chance to get a specific message out to a specific audience.

As Seen In...
By Philip M. Buscemi, O.D.	April 1999

Solving Mysteries with Corneal Topography.
Four experts tell how this technology can help.

Corneal topography has come a long way since I got my first instrument 7 years ago. It’s become a useful clinical tool, largely through the pioneering work of Dr. Steve Klyce. Besides creating the color map and simulated keratometry readings that have become familiar parts of clinical practice, he helped design the algorithms that determine corneal shape and height, and developed a system of true statistical analysis of corneal data. Dr. Klyce developed the first clinical contact lens application that showed a simulated fluorescein pattern. He also created corneal topography software, which accurately identified keratoconus. These innovations have since been copied and improved upon by other companies. Corneal topography is now part of all levels of eye care. Cost reductions have made it widely used in primary care for fitting and evaluating the effects of contact lenses, and for diagnosing corneal disease. Surgeons employ corneal topography pre- and post-op to improve their outcomes with cataract and refractive surgery. The future will be even more fascinating. Corneal topographers are now being connected to lasers. Soon, we’ll be able not only to correct refractive errors, but also to improve the optics of many patients’ corneas and smooth out the irregularities that occur with certain diseases. Here, four doctors discuss their experiences with this tool and explain how it’s helped their practices – and can help yours.

CASE #1
Topography after LASIK
BY PAUL KARPECKI, O.D.
Overland Park, Kan.
(Orbscan by Orbek)
D.G.J., a 34-year-old man, was sent to our office by his primary care physician for evaluation of shadows and ghosting following laser-assisted in situ keratomileusis (LASIK) a year earlier. His surgeon no longer practiced medicine. Before LASIK, the patient’s records indicated that D.G.J. had uncorrected visual acuity of 20/400 OU. His cycloplegic refraction was - 4.25 - 1.25 x 030 OD and - 4.25 - 0.25 x 135 OS. Keratometry readings were 43.25 x 024 () 45.00 x 114 OD, 43.00 x 144 () 44.00 x 054 OS. Slit lamp exam showed a clear cornea with a deep and quiet anterior chamber and a clear lens. Fundus exam revealed no apparent pathology. No topographies had been obtained. D.G.J. underwent LASIK OU.
1-month post-operative visit.
At the 1-month post-operative visit, D.J.G. told his surgeon that his vision was good, but that he noticed ghost images and glare at night, although both had improved over the past 3 weeks. His uncorrected visual acuity (VA) was 20/15 OU, and his manifest refraction (Mrx) was plano – 0.50 x 070, OD -0.25 DS OS. His cornea was clear, the flap was adherent and smooth, and the interface was clear.
12-month post-operative visit.
D.J.G.’s uncorrected VA at 1 year was 20/40 OD and 20/30 OS, with Mrx: plano -0.75 x 070 OD and -0.25 -0.75 x 140 OS. Slit lamp exam showed a clear cornea and a well-healed cap with a clear interface. External and fundus findings revealed no apparent pathology. I performed topography when I saw D.J.G. These data and the topography map alone gave no definitive reason for D.J.G.’s problem. In the maps, the bottom left shows topography. A possible fruste form or early keratoconus may be developing in the right eye. The left eye didn’t suggest keratoconus.
The solution.
Elevation maps of the posterior corneal surface solved the mystery. Note that the anterior corneal surface maps appear relatively normal. The top right hand map shows elevation of the anterior corneal surface. The map looks relatively normal, especially in the left eye. The blue central zone indicates an excimer laser procedure showing a flattened central cornea. The right eye also looks normal for post-operative LASIK, with a relative central flattening on the front corneal elevation and topography. However, elevation maps of the posterior corneal surface show a truly decentered posterior curve of both eyes, greater in the right eye. This inferior decentration explains the shadows D.G.J. experienced, because he was essentially looking through the slope of an elevation on his posterior corneal surface. This decentered posterior corneal apex could be an early sign of keratoconus, particularly because it’s decentered inferiorly. Unfortunately, we couldn’t solve the patient’s problem, but he felt much better once we explained what was happening and what keratoconus is. Perhaps one day a LASIK procedure to ablate and neutralize the decentered apex of the posterior cornea will be possible. Elevation maps appear beneficial in optimizing post-operative outcomes. Posterior corneal curves may be more valuable than anyone anticipated as early indicators of conditions such as keratoconus. They may also help us alter placement of the ablation to improve results and perhaps eliminate symptoms such as shadows or ghosting in patients whose posterior corneal apex is decentered.

CASE #2
Tail Lights
BY JOHN WARREN
Racine, Wis. (Keratron)
My patient of 5 years, a 42-year-old woman, presented for a contact lens fitting. After discussing her visual needs and ocular health concerns, we decided to proceed with rigid gas permeable (RGP) lenses. My usual fitting approach is about 0.50D steeper than K, with an intrapalpebral fit being the optimum vertical lens position. Menicon Z was the material used in the Alpha 1 design. My patient’s initial lenses were designed utilizing her manifest refraction, and corneal topography and contact lens design software. I dispensed the initial lenses and scheduled my patient for follow up in 1 week.
Signs of trouble.
At 1 week the lenses fit as desired. I made a small power change in the right eye to optimize near vision, but the fit was otherwise unchanged. At a chance meeting later, my patient mentioned seeing a "tail" on point sources of light. This occurred only after she removed her contact lenses and wore her glasses. Although annoying, the "tail" disappeared about 6 hours after discontinuing lens wear. She didn’t report other symptoms except that the left lens was more difficult to remove at the end of the day. I told her to return to my office at her earliest convenience. At that visit, her vision with her contact lenses was 20/20 OU. The right lens showed good movement with an interpalprebral position and a slightly steeper than K fitting relationship. The left eye was adherent at the lower limbus. After I removed the left lens, there was a compression ridge from the 8 o’clock to the 4 o’clock positions. I suspected the left lens was causing irregular astigmatism in the pupillary zone and causing the "tail."
The solution.
Corneal topography confirmed this in the left eye. The topography of the right eye was very similar to the prefitting topography. The base curve of the left lens was flattened by 0.75D, and the design was changed to the Z Thin design to decrease lens mass. The new lens continues to move well without any signs of adherence. The topography in the left eye has also reverted back to very close to the prefitting topography.

CASE #3
Corneal Irregularity at Visual Axis
BY KEN MALLER, O.D.
Coral Springs, Fla.
( Tomey)
Patient W.D., a 51-year-old woman and a new patient, had a refraction of OD+0.50 DS +2.00 add, OS+0.75 DS +2.00 add. Keratometry showed OD 43.25/43.87 at 072, OS 43.75/44.00 at 073 with clear mires. The remainder of the exam data were normal. She had never worn contact lenses. She used progressive spectacles for reading. The prescription was OD +0.50 sphere +1.50 add, OS +0.25-0.25X173 +1.50 add. Her vision with the spectacles was satisfactory for near activities.
Fitting solutions.
We tried to fit soft bifocals. After several attempts with different designs and prescriptions, the patient was having trouble getting clear vision in the right eye. We pursued soft lens monovision, but that didn’t work. I performed topography. The right eye showed irregularity to the cornea at the visual axis. We then fit RGPs in a monovision fashion. This brought the visual acuity to crisp 20/20 in the right eye. The RGPs provided a good optical surface, and my patient was now able to see clearly.
A detailed picture.
In general, topography gives us a much more detailed clinical picture of the cornea. For unexplained decreased vision, the topographer can give additional information that’s not readily available through other means. Topography is also easy to administer, and easy on the patient. Otherwise unavailable data are gathered quickly and can be used to more effectively fit contact lenses.

As Seen In...
Douglas Benoit, O.D.; Kenneth Maller, O.D.	August 1999

Contact Lenses - Small Steps to Big Rewards On Your Multifocal Fits.
These pearls can help you avoid problems when fitting presbyopes and quickly solve them when they occur.

You want to provide the right correction for your presbyopic patients and build your multifocal RGP practice at the same time. So, you perfect your presentation in which you stress the lenses' ideal optics, compatibility with the aging eye, and ease of use and handling. By the time you're done, the patient is eager to try the lenses, even if she had another option in mind when she first made the appointment. A few weeks later, however, that patient returns to your office. She can't see the computer screen, and printed material is blurry, she complains. You try to decide whether to modify the fit or try a different design. Meanwhile, your patient may be deciding to give up on contact lens wear altogether. You can avoid these problems by finding the right bifocal or multifocal RGP for each patient. Here are some pearls to help you do just that.

Solving Problems Up Front.
We prefer to avoid problems up front rather than solve them later. So, we concentrate on finding the right lens for the patient. But with so many different bifocal and multifocal designs available, how do you know which is the best for a given situation? To make the decision more manageable, think in terms of alternating vision designs and simultaneous vision designs such as aspheric lenses. We've found that aspheric lenses usually are easier to fit and allow for intermediate vision. Alternating bifocals typically offer crisper vision, but that correction is limited to distance and near. Alternating trifocals are available, but we believe aspherics are better for providing intermediate vision. The patient's needs eventually determine which design we choose. Ask about lifestyle and occupational needs. Does she use a computer, and if so, for how many hours each day? At what distance would she like to read, and how critical is this demand? Think about what add power this will require. Ask about distance requirements, too. Some aspheric designs are best suited for patients who require less than +1.75D add. Consider an alternating vision design or modified monovision for those patients who need higher adds. Patients with critical demand for distance or near vision will usually do best with an alternating vision lens. Computer users who need more than +1.50D add require an intermediate correction to see the screen. For these patients, you might fit a translating bifocal on the dominant eye and an aspheric lens on the other. You may adjust the power of the aspheric lens to optimize intermediate vision; in some cases you will need to over-plus the distance slightly.

Need Extra Help?
If you're just starting to fit bifocal or multifocal contact lenses, you have several resources available. Lens manufacturers often have consultants who can walk you through your first fits and help you with troubleshooting. These services usually are free, and they may save you hours of frustration and chair time. Also, organizations such as the Rigid Gas Permeable Lens Institute offer videos, books and articles about fitting bifocal contact lenses. Much information in this article is from a recent on-line chat session sponsored by the Rigid Gas Permeable Lens Institute and Review of Optometry. Optometrists David Hansen and Richard Baker will also discuss bifocal contact lenses in the next monthly chat session September 14. For more information, click here. We should point out that some doctors are not comfortable using different lens designs on the same patient. Their concern: The prism differential and tremendous difference in thickness will make it hard for the patient to tolerate both designs at once. Physiological factors also play a role in initial lens selection. Patients with large pupils generally are best suited to an alternating vision design. Patients with flaccid lids or whose lower lids are positioned below the lower limbus will probably not be candidates for alternating vision designs because there is simply no support for the truncation on downgaze. Many presbyopes also have borderline tear volume, so they'll benefit from wearing a rigid lens. However, you should also pay attention to the Dk of the lens material for hyperopic presbyopes; these lenses may be thicker than single-vision contact lenses.

Trial and Error.
Trial fitting sets can help eliminate much of the guesswork. They also may reduce overall chair time. By investing some additional time up front, you can eliminate many refitting or troubleshooting visits. You can use trial lenses to verify the effects of changes in diameter, base curve and segment height. An adequate trial lens inventory also allows you to verify that the lenses will be successful before you place the initial order. We suggest as a minimum trial set two aspheric designs and one translating design. As you fit more presbyopes, you might expand this inventory to five designs: two aspherics, two translating and one more set of either type for tougher cases. The reason you want a few is that the lenses are all different. For example, you might have an aspheric front, aspheric back or different amounts of asphericity, so the lenses each fit differently. The more types of lenses you have, the better the chance you'll find one that works for the patient. The design you choose as the fifth set usually depends on your patient population. If you routinely fit many computer users, you'll probably want another aspheric design. If you fit many absolute presbyopes, those patients who need adds of +2.50D or higher, another alternating design may be more useful.

Troubleshooting Pearls.
Even with careful trial fitting, however, the lens you choose may not behave as expected. Here are 10 of our favorite troubleshooting tips for when this happens.
1. Know when to change designs. This isn't always easy. If you change too soon, you may sabotage a successful fit. If you wait too long, you may lose patient motivation. As you become experienced with different lens designs, you'll learn when the fit will resolve as the patient adapts. You'll also learn when to modify the same design to solve minor problems and when to try another one. Generally, if the patient has worn the lens for two weeks and still isn't satisfied, consider refitting into another design. An exception: if over-refraction with loose lenses indicates that a power change of ±0.50D would fix the problem. It typically takes three fittings for you to become comfortable with a particular design, and over time you will gain additional expertise.
2. Never leave a patient partially satisfied. Learn to listen for key words that indicate the patient will not adapt to this particular design. If he or she reports "ghosting," you probably need to switch from an aspheric to a translating design. If the patient reads 20/20 with difficulty and tells you, "I see the letters, but they're blurry," you should generally abandon this design if you're beyond the adaptation period.
3. Use the ophthalmoscope to troubleshoot lens positioning problems. The slit lamp, although a wonderful device, limits range of motion. Use the ophthalmoscope to view the lens from arm's length. This lets you see what the lens is really doing in normal posture. To view translation, look up from the level of the patient's reading material to see how the lens behaves on downgaze.
4. Be cautious about interpreting reading distance requirements. For example, a 55-year-old may complain of blur when reading. However, you then learn that this patient's reading problem is at 28 inches when reviewing paperwork. So, he really needs an intermediate correction. Without asking very specific questions about when and where problems occur, you might misunderstand the problem and concentrate on optimizing the near zone of 16-18 inches.
5. Always use loose lenses to over-refract when trial fitting or troubleshooting multifocal contact lenses. The phoropter cannot adjust for downgaze and may affect pupil size. Some fitters have found ±0.25D or ±0.50D flippers useful for quickly refining power at near and far. If the patient's acuity does not improve to a meaningful or significant level, be mindful of residual astigmatism, especially against the rule. When available, consider cylinder correction for these patients.
6. Have the patient read something while still in the chair. This will help speed adaptation. Ask her to continue to read as the lenses settle. This task takes the patient's mind off the new sensation of contact lens wear.
7. When a lens rides too high and the segment interferes with distance vision, pull the upper lid away to see if the lens falls or remains in the superior position. If the lens remains high without the upper lid holding it, peripheral curve modifications (flattening, increasing peripheral width and reducing optical zone diameter) may offer a simple solution. Thinning the upper edge of the lens will reduce the effect of the upper lid and allow the lens to position normally. Other remedies include increasing truncation size and adding prism. Keep in mind, increasing truncation will increase prismatic effect on a plus lens but will decrease prismatic effect on a minus lens.
8. Use a very fine emery board or diamond file to polish out the roughness of the truncation or to slightly increase the amount of truncation. After you use the emery board, a fine polish using normal modification tools and procedures is necessary. By learning in-office modification techniques, you can speed the fitting process, retain wearing time adaptation and maintain patient motivation.
9. Always keep a close eye on the calendar. Warranty periods vary among labs. Schedule a final follow-up visit for about two weeks before the warranty expires, regardless of your customary follow-up schedule. At this visit, you and the patient must decide whether to keep the lenses, switch designs or abandon the fit completely. If the patient chooses to keep the lenses, this is an ideal time to order a spare pair.
10. Don't be afraid to mix and match designs. The best fit for the patient often is an aspheric lens on one eye and an alternating vision (or single vision) lens on the other. By learning the limitations and possibilities of each design, you will begin to truly customize the fit for each patient.

With time and experimentation, you will find bifocal or multifocal contact lens fits to be very rewarding, both for your patients and your practice. You can learn how to choose the best design for each patient to avoid problem fits and how to troubleshoot when problems do occur. That, in turn, can help avoid an even bigger problem: the dissatisfied patient who abandons contact lens wear, and maybe even your practice.

As Seen In...
By Carol Schwartz, O.D., F.A.A.O.	March 2001

Want to Get Ahead? Get a Gimmick.
Putting 'RGP specialist' on your resume will boost your value to employers and patients alike.

In the musical "Gypsy," two experienced dancers tell young Gypsy Rose Lee "you gotta have a gimmick if you want to get ahead." Similarly, optometrists just starting out in practice or looking for a good position also need a gimmick -- or specialty -- to set them apart from the competition. One of the hottest is fitting specialty contact lenses, especially rigid gas permeable (RGP) lenses. Why RGPs?
Profit now and later.
RGP lenses are more profitable than commodity lenses. But, higher fitting fees are only part of the profit picture. You should also consider that:
RGP wearers are loyal. They return year after year, ordering replacement lenses and spectacles and generating exam revenues.
RGP wearers will shop in your practice. A patient returning for his semi-annual clean and polish often finds something else to buy: solutions, sunglasses or spare spectacles. This add-on business is almost all profit and can make the difference between a thriving practice and one barely making it.
RGP wearers refer their friends and family members. These patients quickly begin generating referrals and scheduling routine care for their families. Because true RGP specialists are somewhat rare and patients value their skill, you'll soon be getting word-of-mouth referrals.

Welcome the Presbyopes.
How do you break into the RGP specialty where patients clamor for your care? Subspecialize. Perhaps the best opportunity for new practitioners is in the area of presbyopic care. Although there are several good soft lens bifocals on the market, the doctors on the panel believe rigid lenses are, by far, the most versatile multifocal correction. "As a young practitioner starting out, you'll find that the bifocal labs will bend over backwards to help you succeed," says Sonja Biddle, O.D., who specializes in RGP bifocal and postsurgical fittings in Dover, Dela. "They'll lend you fitting sets and guarantee the fit so you're not looking at much out-of-pocket expense." Get to know your laboratories and suppliers, says Dr. Biddle, and compare what each will do to help you with special fittings. Partnering with your suppliers is important, but don't just call when you need special favors, she says, make sure they get some of your easy fits as well. It helps foster good relations.

Getting started.
How do you become an RGP specialist? Start while you're still in school, says Robert Grohe, O.D., of Chicago. Fit as many RGP lenses as you can. Ask every patient, regardless of his chief complaint, if he's ever considered contact lenses. Key in on presbyopic patients who may not be aware of the contact lens options available to them. And take advantage of the RGPLI's educational seminars and materials (go to www.rgpli.org). After graduation, get in touch with your laboratory's consultants because they're a wealth of information. "Having a mentor is a very strong asset whether it's a lab consultant, a fellow practitioner or a member of the American Academy of Optometry, especially a Cornea and Contact Lens Diplomate," says Dr. Grohe.

RGPs and managed care.
As a new O.D., you may find yourself practicing in an area where managed care is an issue. You may hear from older colleagues that 'you can't fit RGPs in a managed care setting -- it takes too much time!' Our panel members disagree. How do they handle it? First, they've honed their patient management skills as keenly as their fitting skills. "I take a more positive approach than my colleagues," says Milton Hom, O.D., Azusa, Calif. "I look at what managed care will pay and what my RGP fees are and tell patients that the difference is their co-pay. Even though this fee is higher than the $10 they may be used to, I've already let them know that RGPs are the best option for them, so they accept that they'll have to help with the cost." For Sonja Biddle, O.D., who works in a large practice in Dover, Dela., the key to making RGPs work with managed care patients is staff. She's trained her technicians so that she can see patients in two to four rooms simultaneously. While a patient in Room 1 is adapting to trial lenses, she's checking a dilation in Room 2 and the technician is taking acuities and case histories for the progress exam in Room 3.

Saving RGP Chair Time.
To really streamline your practice, use a topical anesthetic for the diagnostic fitting, says Edward S. Bennett, O.D., M.S.Ed., St. Louis, Mo. Not only does it speed up the patient's adaptation time, but it reduces reflex tearing so that you can read the fluorescein pattern almost immediately after you apply the trial lens. Then, as the anesthetic wears off, the patient will adapt gradually to the sensation of wearing an RGP, which most practitioners find leads to greater success rates.

Breaking the fitting process out of the general examination appointment is how Doug Benoit, O.D., Concord, N.H., deals with managed care. If a patient wants to try rigid lenses, he's re-appointed for the fitting. Thus, the managed care portion of his care (general exam, dilation and so on) is completed at one visit and the add-on services (fitting, lenses, follow-up care) are taken care of separately. This helps the patient distinguish his financial responsibilities from those of his insurer. Another option is to remove yourself from managed care altogether. Jon Kendall, O.D., Santa Ana, Calif. and Dr. Maller take little or no third-party payment. In California, which has many staff model HMOs, Dr. Kendall's patients have no problem opting out of their plans for contact lens coverage. "They have the lenses now and don't want to give them up, but the HMO doesn't offer this care," he explains. "So they come to me for their contact lenses, and once a year, they see their HMO eyecare provider for an annual exam."

Be the boss.
One skill these successful doctors had to learn for themselves was how to take control of the patient, and do it in such a way that they gain the patient's respect without alienating or offending him. Dr. Grohe reminds young practitioners that they may not realize how much influence they have over their patients and unconsciously abdicate their role as the doctor. "You don't just ask a patient what treatment he'd like for glaucoma, so don't ask a patient what type of contact lenses he'd prefer -- he doesn't know!" he says. "Go through the options and then explain which one is best for the patient in your professional judgement."

As a recent graduate, Ken Maller, O.D., started his specialty RGP practice cold in Coral Springs, Fla. "I came into an area with many doctors on every block, yet I was quickly seen as a specialist. The ophthalmologists started referring their tough fits to me. RGPs really established my practice."

Master the craft.
Contact lenses are an important profit center in optometric practice. RGP lenses, in particular, separate the novice from the true contact lens specialist who fits what's best for each patient, taking into consideration his visual demands, eye health and interests. As these contact lens specialists have emphasized, you are the primary decision-maker, the expert. As such, if you make RGPs an integral part of your contact lens practice you'll have the loyalty of your patients as well as the respect of your peers. Having mastered the craft of RGP fitting, you'll be ready to offer a special skill for the benefit of the practice -- the gimmick that will help you get ahead.

As Seen In...
By Phyllis J. Neuberger	May 2001

A.O.K. Can Let You "Sleep On It" To Improve Vision And Drop Glasses.
Local optometric physician helps patients avoid surgery in quest for better vision, no glasses.

The truth is, boys do make passes at girls who wear glasses. Still, there are a lot of spectacled guys and gals who dream of being free of glasses which explains the recent popularity of Laser vision correction surgeries. "However, there's as alternate way to correct vision without surgery," says Dr. Kenneth E. Maller, Board Certified Optometric physician, who claims to have treated over 1,000 patients successfully over the past ten years. "If a patient meets the criteria for A.O.K. (Accelerated OrthoKeratology), daytime glasses can be eliminated almost immediately," he said in a recent interview at Eyewear 4U2C, 910 Powerline Road, Pompano Beach where he is available for a consultation.

Maller explains what A.O.K. is and does. "This procedure uses contact lenses to gently reshape the cornea into an improved shape which reduces or corrects myopia (near sightedness) and astigmatism (non symmetrical surface of the cornea). The goal of A.O.K. is to free the patient from both contact lenses and glasses for most or all waking hours. A retainer lens must be worn each night or part of each waking day to maintain the maximum correction achieved." Continuing, Maller says, "A.O.K. has several advantages over Excimer Laser surgery. There is no surgical risk or down time. A person has clear vision from the start until the goal of waking hour freedom is reached. There is no post operative pain, hazy vision, or loss of Bowman's membrane. Both eyes are done together and the procedure is reversible while excimer laser is not." Because eyes continue to change, Maller claims at some point in the future, those corrected by laser surgery might eventually need prescription eyewear. "With A.O.K., on the other hand," he claims, "eye changes can be dealt with by updating the retainer lenses all through that person's life." According to Maller, the technique of OrthoKeratology has been around for forty years, but is now dramatically more effective because of new lens designs, better materials and manufacturing methods.

Ophthalmologists have a different take on this subject. "Laser surgery is over in a few moments and the patient is done with glasses," says Dr. John F. Sciarrino, eye physician and surgeon. "Sure, there's a down side. There might be a problem in one in 10,000 surgeries. And yes, the patient may have to wear glasses upon occasion years down the line. Although OrthoKeratology is an acceptable method, the patient has to wear the corrective lens every night during sleep to maintain the correction. This can be a nuisance to the average person. And there's a small risk of scratching and infection in this process. The people who use OrthoKeratology are usually working in aviation, law enforcement, fire departments and the like where near perfect vision - without glasses - is a job requirement. I've known some who corrected their vision and once secure on the job go back to glasses."

Dr. Maller's patient for the past one and one half years, Tom Reid of Miami, is very pleased with Dr. Maller's methods. "I am enjoying the benefits of OrthoKeratology and my ophthalmologist never even offered me the option," he says. "I have been free of glasses during the day and it's wonderful after being in glasses for 20 of my 43 years. I work for a steamship line, often sitting at a computer terminal for hours. OrthoKeratology has enabled me to play sports actively and do my intricate work without glasses. I don't mind wearing the corrective lenses at night. It becomes a habit. I've forgotten them upon occasion and my vision held. I see Dr. Maller every six months and I'm happy with the results.

As Seen In...
By Phyllis J. Neuberger	August 2001

Accelerated OrthoKeraology Heralds The Demise Of Glasses.

Dr. Kenneth E. Maller, an orthokeratologist has been helping people to see without glasses or contacts for more than 10 years withour expensive surgery - or surgery at all. The medical term is A.O.K. (Accelerated OrthoKeratology). "This procedure uses contact lenses to gently reshape the cornea into an improved shape which reduces or corrects myopia (near sightedness) and astigmatism (non symmetrical surface of the cornea). The goal is to free the patient from both contact lenses and glasses for most or all waking hours. A retainer lens must be worn each night or part of each waking day to maintain the maximum corrction achieved," says Maller.

"It's unlike lasik surgery that may have some adverse side effects," says Vincent Temaat. "We have patients who begin seeing without their glasses with 20/20 vision, and in some cases 20/10." Temaat says 20/10 is seeing like a "hawk.

As Seen In...
By Bette Kozarek	October 2001

Procedure Can Give Patients Insight.

How would you like to improve your vision while you sleep? It sounds too good to be true but that is exactly what is being accomplished at Eyewear 4U2C in Pompano Beach. Dr. Kenneth Maller explained the process to me. "OrthoKeratology has been around for over 40 years but is now becoming well known in this country. It is more popular in Australia and the Orient," Maller said. It was discovered during the 1950s when patients began to tell their doctors that they saw better immediately after removing their contacts. This was because the contacts had reshaped the cornea. From this came the idea to use this reshaping of the cornea to advantage.

The name OrthoKeratology come from the word "Ortho" which refers to reshaping or realigning while "Kerato" refers to the cornea and "ology" is a word for "the study of." In other words, it is a study of the realigning of the cornea. The procedure begins with a comprehensive eye examination where a series of AOK contact lenses are made from highly oxygen permeable (allows the eyes to breathe) rigid material. They are fitted in progressive stages to gently reshape the cornea towards less curvature and into a more spherical shape. Most of the visual changes occur rapidly in the first few days and weeks, requiring frequent examination and progressive lens changes. AOK reduces myopia (nearsightedness) and astigmatism while dramatically improving unaided eyesight. The main purpose of AOK is to be free of both contact lenses and/or glasses for the majority of - and possibly all - the waking hours. The AOK lenses are usually worn only while sleeping and you need no eyewear during the day. However, since the cornea is highly elastic, it returns to its original shape. Therefore, retainer lenses are prescribed after the ideal corneal shape or maximum change has been achieved. As easily as updating a pair of glasses, you can update the retainer lenses, allowing you to maintain your freedom. The program length varies between three and six months depending upon the amount of prescriptions and rates of change.

The procedure has several advantages over Excimer Laser surgery: it is about half the cost, it does not involve post-operative pain and it does not have the potential to leave the hazy vision that can be experienced by patients following laser surgery. Dr. Maller and his assistant, Vincent Temaat, told me about several of their patients who had been greatly helped by AOK. One was Stephanie, an 11 year old, who was able to see only the big E at the top of the eye chart when she came in wearing glasses she had only had for one year. Her vision was 20/400. She had progressive myopia, which is very common in young children. After wearing her specially designed AOK contacts for only one night, her vision had improved to 20/40 and is soon expected to be 20/20. I spoke with one of the employees at Eyewear 4U2C who said that he could even see underwater now and enjoyed much more freedom when playing various sports. As Dr. Maller says, "The magic is that you can see as well with the contacts off as on. Wearing the night contact retainer is like wearing a night retainer for realigning teeth."

As Seen In...
By Judith Crocker	August 2002

Vea mas claro con El Metodo Orthokeratology

Esta cansado de depender de los lentes tradicionales y de contacto para realizar tareas sencillas? Sabia usted que la libertad a esa clase de dependencia se puede alcanzar SIN CIRUGIA!!!

As Seen In...
By Judith V. Wilson	April 2003

Non-surgical Process Offers Long Term Benefits For Nearsightedness.

Myopia, more commonly known as nearsightedness, affects nearly 30 million Americans, but few know of a process that helps control and reduce it's progression. Orthokeratology (Ortho-K) is a process that reshapes the cornea of the eye, reduces the prescription and therefore the dependence upon eyewear. It is a safe, non-surgical technique using specially designed and fitted gas permeable (GP) contact lenses that gently reshape the cornea. As one of South Florida's only hubs to the Ortho-K preocess, EyeWear4U2C's on-staff physician, Dr. Kenneth Maller, finds this non-surgical, non-invasive process more appealing than the refractive surgical procedures that have been developed to attempt to accomplish the same purpose.

If Ortho-K is a successful non-surgical approach, why have so many people opted for Lasik?
"Marketing," says Dr. Maller. "Corporations in the Lasik industry have deep pockets. The more people know about it, the more doctors practice it and recommend it to their patients," Dr. Maller said. "Ortho-K doesn't have the big marketing behind it, so unfortunately not that many doctors are trained in it. Ortho-K is usually not suggested as an option during an eye exam." This is beginning to change, however, as more people become familiar with the process.

There are many benefits to the Ortho-K process over Lasik that should be considered.
"Ortho-K is reversible," says Dr. Maller. "This flexibility is important as a long-term benefit because as a person's prescription changes, the lenses are adjusted. A Lasik patient is limited to the correction made in surgery. It does not account for the changes in a person's eyes over the years. All you have to do is ask an eye wearer if they can imagine themselves in one pair of glasses for the rest of their life? The answer is obvious, and they begin to understand," he continued. Other benefits to "Ortho-K," are that it is non-invasive and safe. Any surgery has risks and can cause permanent eye damage.

As Seen On...
By Marilyn Mitzel	January 2004

There's a new way doctors are helping people who can't see well after Lasik. They're prescribing personalized contacts molded specifically for a person's eyes.

As Seen In...
By Ken Maller, OD	April 2004

Using CAD/CAM Lenses for Orthokeratology.
Using this system allows a greater degree of control over lens design and allows you to expand options for your patients.

ORTHOKERATOLOGY HAS UNDERGONE many transformations since its beginnings four decades ago. From the types of cases that we can treat to the very approach used in treating these cases, procedures, protocols and lens designs used today by orthokeratologists have very little in common with those of just a decade ago.

I have primarily used EyeQuip Wave lenses for my current orthokeratology cases because of the degree of control that this system affords in lens design. Wave is a CAD/CAM (computer-aided design and manufacture) system. In using this system, I have brought all of my previous gas permeable and orthokeratology knowledge to the table and I’ve been able to modify and expand my approach within the parameters of this system. Following are several ortho-k cases and how I managed them.

Case 1
Patient R.S. is a 38-year-old African-American man who had photorefractive keratectomy (PRK) performed on his right eye in 1997. He had immediate problems after surgery: a central scar formed along the visual axis. He was placed on steroids and an analgesic for one month after surgery, but he was still left with an opacified scar in the visual axis. He did not proceed with surgery on the left eye. He presented wearing spectacles with a prescription of –1.50 DS OD and –3.00–0.25x175 OS. He was seeking options for his right eye because he was not happy with the quality of the vision in this eye with spectacles. His refraction that day was –1.50 DS 20/20– OD and –3.25 DS 20/20 OS. The patient struggled to read the letters on the 20/20 line, and he complained that they looked distorted. The remainder of the exam was unremarkable.

Orthokeratology came up when I discussed options with him. I explained that the left eye would do very well very quickly but that the results on the right eye were unpredictable. In fact, I told him, I was skeptical that we would reach a satisfactory goal in that eye. Although I have successfully treated post-PRK eyes with ortho-k, the position, opacification and height of this particular scar greatly concerned me. After a lengthy discussion about my concerns with his right eye, the patient decided that he still wanted to move forward with ortho-k.

As you can see from the topography of the right eye, the scar is almost perfectly centered along the visual axis. This was the best topographical image I was able to obtain for this patient, and you can also see that the tears continued to break up adjacent to the scar. The height of the scar at its peak is about 65.00 diopters, whereas the surrounding valley created by the PRK at its flattest point is about 14.00 diopters. I felt that this great variability of the corneal shape along the visual axis and its effect on tears were greater contributing factors to the degraded image quality than was the scar opacification.

Because the central portion of the right eye was already very flat from the PRK, my goal with ortho-k was twofold: flatten the apex of the scar so that its curvature would be more aligned with the surrounding tissue and “homogenize” the already surgically flattened central optic zone while widening the treated area out to the reverse curve area. The left eye would be a very straightforward myopia reduction case.

The left eye responded as expected. A very sharp endpoint resulted in acuity of 20/10–2 in this eye throughout the entire day. This topography was completed after the lens had been removed for about eight hours. The map is very “clean” with a great deal of homogeneity in the central, reverse curve and peripheral areas of his cornea. The patient had not achieved this level of acuity in this eye with his best spectacle correction prior to treatment. This improvement in acuity is due to the cleaner nature of his central cornea subsequent to o r t h o k e r a t o l o g y treatment.

The right eye has also shown some significant changes. The scar has been reduced to a peak of about 40.00 diopters. The surrounding area shows more regularity out to the area of the reverse curve with its flattest point at about 25.00 diopters. The quality of uncorrected vision still suffers, however, even though uncorrected acuity has now reached 20/30. With the lens on the eye, acuity is 20/20, with a great deal of improvement in subjective quality of the image. This patient has been treated with orthokeratology for almost a year. I reviewed additional options, including additional surgery. This patient has already made it clear however, that he is very satisfied with the results thus far, and currently feels that the 20/10- uncorrected crisp vision of his left eye combined with the 20/30 slightly distorted vision of the right eye is more than acceptable for his normal daily function and an adequate compromise to enjoy the freedom that his night-wear only Orthokeratology regimen affords him.

The lenses that this patient is currently wearing are designed as follows: the right lens is a geometrically symmetrical lens, which means that if you divide the back surface of the lens in half, it is symmetrical around that plane. Using this type of design allowed me to better align the back surface of the lens on the surgically altered irregular cornea. I needed a large diameter to keep the lens positioned properly, which can be seen as 12.10mm. The graph in the upper half of the Wave window on the sodium fluorescein selection represents the interaction at the tear layer of the back surface of the lens with the front surface of the cornea in the given semi-meridian. The green line at the base of the graph represents the curve of the cornea as a reference curve; the black line above represents the back surface of the lens with respect to the green corneal reference line. The space between the two represents the tear layer formed be-tween the interaction of the back surface of the lens and the front surface of the cornea in that semi-meridian.

At the apex of the lens are 15.1µm of tear clearance. The peak of the reverse curve forms a circle with a diameter of 5.85mm and at its most shallow point has 86µm of tear clearance; at its deepest point it has 103µm of tear clearance. I was able to create this variability of tear clearance manually in this annulus by using the control points for design and taking advantage of the geometrical symmetry in this lens. In the 3.5mm-wide annulus between diameter 8.00mm to diameter 11.5mm, the lens is well aligned with the cornea and averages about 3.5µm of tear clearance. This helps keep the lens well centered.

The left lens is a rotationally symmetrical lens, meaning that it is symmetrical throughout the 360 degrees around the lens. Tear clearance at the apex of the lens is 12.1µm with about 57µm of clearance at the peak of the reverse curve. The zones of the lens have the 3.0mm annulus from diameter 7.5mm to diameter 10.5mm, well aligned with the cornea, with an average of about 3.0µm of tear clearance. This degree of alignment keeps the lens correctly centered. Centration is one of the keys to successful ortho-k.

Case 2
Over the years, ortho-k cases have been primarily aimed at reducing myopia. But what about inducing myopia? This technique has yielded fair results at best.

Case 2 is a 48-year-old Caucasian woman who currently has a refraction of OD Plano DS and OS +0.25–0.50x180 with an add of +2.25D. Six years ago, her refraction was OD +0.25D and OS +0.25D with an add of +1.50D. She had been wearing only progressive addition spectacles for near activities such as reading and computer work. At that time, she felt that she “needed” her glasses only for about half of her day. For that half, though, she was very unhappy about her vision. She asked me for alternatives to the glasses.

I reviewed the types of contact lens wear that might be appropriate for her needs, including multifocals and monovision, surgical intervention and ortho-k in a monovision fashion. After careful consideration, she decided to proceed with ortho-k.

I explained to the patient that she was going to wear one lens on the left eye during sleep hours only, and when this lens was off, she would still be able to do her close work comfortably. For a few years, she did quite well with this regimen, with a few updates in design. Earlier this year, however, her topography suggested that her centrally treated area was not “clean” enough, nor was there enough induced myopia and this was a limitation of her current lens. I explained that technology has progressed since she first started ortho-k, and that if I could start over with Wave, I could attain much better results for her. Although the patient was reluctant to give up her near vision for a month while her cornea returned to its untreated state, she agreed to do so at a more convenient time, five months later.

When that time came, the patient came in so that I could refract her and get baseline topography. Her refraction at this time was OD +0.25 DS, OS +0.50-0.50x180 with +2.00 Add. I designed a new lens for her, which she began to wear on her nights-only regimen. Within two days of beginning this wearing schedule, she was back to normal function at her near activities for the entire day. This lens design is seen in Figure 6; the corresponding topography is seen in Figure 7. The patient remains in a sleep-only regimen, and she is happy to be independent of spectacle wear.

Case 3
Colleagues often ask me about the limits of ortho-k. What degree of myopia can be reduced safely and effectively? The answer depends to some extent on patient variables, but there are certainly guidelines: I believe that modern orthokeratologists are comfortable in addressing up to –4.00D. I am comfortable reducing –6.00D, but I have often worked with significantly higher-myopia cases as well.

This is one such case. The patient is a 22-year old African-American woman. She and her mother had done a great deal of research on ortho-k, and they had spoken by phone with several orthokeratologists before she came into my office. Her refraction that day was OD –7.75 DS and OS –7.50 DS. Other than her high myopia, her exam was unremarkable.

The patient also had the additional problem of having come from out-of-state, and she was leaving the area eight days after the visit. Although her high myopia concerned me, the main source of my stress was related to her schedule. I discussed my concerns about the restricted time period within which we had to work, especially in light of her high myopia. Ultimately, we decided to proceed with ortho-k.

The patient’s baseline topography is seen in Figure 8. I designed a pair of Wave lenses and had them shipped to me to arrive the following day. After the patient’s first night of wear, her uncorrected acuity was 20/25– in each eye. Two days later, her acuity was already 20/20, and she felt that she had been able to see clearly for the entire previous day. She was very satisfied with her uncorrected vision. At this visit, her lenses had been off for about six hours. Since the patient had only had three nights of treatment at this point, I was not really expecting perfect maps just yet. I was concerned at this point with the positioning of the lenses, and whether I had addressed the whole amount of her myopia. I decided, based on the quality of her vision and the results of the maps, that she could continue with these lenses for the next three nights.

After that time had passed, the patient returned for a visit. She was ecstatic with her vision and said that she never had seen this well with her spectacles. At the time of this visit, her lenses had been off for eight hours. Her uncorrected acuity was 20/15 with a plano overrefraction in each eye. You can see in this topography that the reverse curve is becoming better defined. Since the patient’s myopia had been so high, the treatment zone was relatively small, and fortunately, her pupil size is also relatively small. I asked her specifically whether she is bothered by haloes, especially at night when the pupil would be dilated. She said she noticed no haloes at any time and had clear vision from waking until sleeping.

Each of these cases entailed handling rather complex issues that I might not have attempted just a few years ago. With the control over design parameters afforded by the Wave system, I can now treat a wider variety of cases and achieve a better final result. Since the Wave system continues to evolve— as does our understanding of ortho-k—I am certain that the same cases that we now do not attempt will soon not only be addressable, but will also yield successful results.