There’s no better time than now to take advantage of the rising demand for this lens modality.
By Jane Cole, OD

44th Annual Contact Lens Report
Check out the other feature articles in this month’s report:
– Don’t Let the Scleral Surge Pass You By
– Are You Making the Most of the New Soft Lenses?
– Add Multifocals to Your Myopia Toolbox
While any optometrist can dispense mass-market soft contact lenses, fitting the full complement of contact lenses—including specialty lenses such as rigid gas permeables (GPs), sclerals, orthokeratology (ortho-K) and hybrids—takes time and commitment. Still, experts say, no matter where you are in your career, becoming a contact lens specialist offers significant benefits for the practitioner, the patient and the practice.

“Becoming an expert in anything starts with a passion for the subject. A specialty in contact lenses can be exceptionally rewarding; however, it will take a level of dedication that requires true clinical interest, not simply a financial goal,” says Cory Collier, OD, co-owner of a specialty lens practice in Florida.

Here, contact lens experts offer some pearls on the steps you can take to grow your contact lens practice beyond the basics.

Dr. Fischer fits a patient with 7.50D of corneal astigmatism in a scleral lens. After the fitting, she experienced much clearer and more stable vision during her daily activities, including sports.
Dr. Fischer fits a patient with 7.50D of corneal astigmatism in a scleral lens. After the fitting, she experienced much clearer and more stable vision during her daily activities, including sports. Image by Andrew Fischer, OD. Click image to enlarge.

Learn From the Best
To become a contact lens specialist, proper training is crucial, says Jeffrey Sonsino, OD, a contact lens specialist in Nashville. Students and recent graduates who already know they want to focus on a contact lens specialty can consider completing a cornea and contact lens residency. Those already in practice can specialize, too, although the path is more challenging, Dr. Sonsino says.

The knowledge required to appropriately treat patients using advanced contact lenses can’t be accomplished with a one-day course with a lab manufacturer, Dr. Sonsino says. Instead, he first suggests a serious study of textbooks, including optometrist Edward Bennett’s classic Clinical Manual of Contact Lenses and Contemporary Scleral Lenses: Theory and Application by Melissa Barnett, OD, and Lynette John, OD, along with a careful review of recent literature such as the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) studies and papers on scleral lenses authored by Langis Michaud, OD, and Greg DeNaeyer, OD.

“It’s not sexy or easy to tell people to go read, but my first question to docs who send me questions is, did you put in the time and effort?” Dr. Sonsino says.

As for in-person learning, contact lens seminars abound and practitioners should be selective on which ones they choose, experts advise.

Continuing education lectures at the major meetings typically gather the best and brightest. At these meetings, you can find practical workshops that will allow you to test drive the lenses and learn about best practices, evaluation techniques and fitting tips and tricks. However, with limited time, don’t expect to learn an entire area of optometry; instead, set your expectations to picking up one or two clinical pearls per hour of attendance, Dr. Sonsino says.

Other non-branded educational events run the gamut in contact lens education. The non-profit Gas Permeable Lens Institute (GPLI) hosts free monthly webinars by leaders in the field, according to Dr. Sonsino.

This post-LASIK patient was successfully fit with a scleral lens.
This post-LASIK patient was successfully fit with a scleral lens. Image by Stephanie Woo, OD. Click image to enlarge.

Start Slowly
Once you hit the books and build your educational background, it’s time for hands-on learning. The next step is simply to start fitting lenses and keep doing it, according to Andrew Fischer, OD, who practices in Indiana. “It’s a learning process, so, with time, a contact lens specialist will slowly learn the nuances and become comfortable with more advanced fits.”

When starting out, Dr. Fischer suggests fitting normal corneas or mild keratoconic eyes for an easy introduction.

An up-and-coming specialist should focus on two to three specific lens designs in each category, learn everything about those designs and gain relevant clinical experience with each, Dr. Collier says. “Having an expert level of knowledge on select options is far more valuable than a superficial level of knowledge on many designs,” he says. After you’ve mastered a selection of fitting sets, you can add more as you go.

“Once you have a relationship with a lab, some will loan out sets for specific patients or allow you the opportunity to try the product before purchasing,” Dr. Collier adds.

Your first fitting sets should provide options for a wide variety of corneas, explains Heidi Miller, OD, of the UC Davis Eye Center. “Select a few options, and become well versed in them. Otherwise, each lens fit will feel like ‘the first lens fit.’”

According to Stephanie Woo, OD, who practices in Nevada, it’s best to start with one fitting set of scleral lenses until you know it well. Then, once you are comfortable, you can add other types.

Still, scleral lenses aren’t the “be-all and end-all” for a true contact lens expert, says Dr. Fischer.

“It’s important to weigh multiple factors during the fitting process, including a patient’s personality and vision expectations, expected lens adaptation, cost to the patient and corneal health, when considering which modality to choose,” he says.

If the clinician lays the proper groundwork and completes a significant review of the available literature, most will be champing at the bit to get started with advanced cases, Dr. Sonsino says. “The lens designs will be dictated by the patient’s case. But it is always a good idea to identify a few options within each category. The key is to make sure that you are open-minded to each category.”

No Lens Left Behind
Next, interested optometrists have to consider all the lens options and become comfortable with each, including commercial soft lenses, custom soft lenses, corneal GPs, hybrids and scleral lenses.

You can’t call yourself a contact lens specialist unless you are well versed in every type of specialty lens, according to Dr. Sonsino. “Check the rule book, it’s in there,” he jokes.

This means developing proficiency with each lens type, and that includes the multifocal versions of each modality.

“Again, you treat the patient in front of you. If that includes presbyopes, you must have the most advanced treatment options in your tool belt,” Dr. Sonsino says.

Even if you are still working on your expertise with a given lens, “you have to be able to understand the benefits and limitations of each, feel confident identifying appropriate patients for each and be willing to refer to colleagues in the event the best option for the patient isn’t an option you are comfortable working with,” Dr. Collier says.

Scleral lenses with blanching at the edge, at left, or edge impingement, center, require modification to find a good edge alignment, such as the lens at right.
Scleral lenses with blanching at the edge, at left, or edge impingement, center, require modification to find a good edge alignment, such as the lens at right. Image by Stephanie Woo, OD. Click image to enlarge.

Specializing the Specialized
Two billion people had myopia in 2010, and that number is expected to grow to nearly five billion by 2050.1 Thus, myopia management options, such as ortho-K and soft, center-distance multifocal lenses, are crucial tools for a specialty contact lens practice, according to Dr. Miller. “As the general public learns more about myopia and its increasing prevalence, they will be looking for practices that can provide treatment options to manage myopia progression.”

While discussing myopia management options with all pediatric families, it is also critical to bring up the need for outdoor exposure, she adds.

Ortho-K uses custom GP contact lenses to reshape the cornea to temporarily reduce refractive error.2 Ortho-K is primarily used as a correction for low-to-moderate myopia (up to -6.00D) with or without astigmatism (up to -1.75D).2

With soft multifocals, the center of the lens provides the distance vision correction while the periphery is designed to reduce hyperopic defocus.2 This mechanism minimizes the stimulus for myopia progression by focusing the light in front of the peripheral retina.2

“Offering myopia management is very important,” Dr. Fischer says. “As we continue to learn more about myopia and its associated risks at higher levels, we recognize how important it is to intervene early and do all we can to limit myopic progression and try to mitigate future ocular health risks.”

Add Technology to the Mix
A corneal topographer is an absolute must for a contact lens specialty practice, Dr. Collier says. “It’s an essential piece of equipment in the evaluation of the corneal surface, contact lens design and follow-up care.”

Topographers provide a more comprehensive evaluation of the cornea than traditional manual keratometers, which measure only about 3mm to 4mm of the central cornea; topographers measure the entire corneal surface.3 Corneal curvature can be assessed on any portion of the cornea, a virtue that’s particularly useful when designing larger diameter GP lenses.3

In addition to a topographer, Dr. Sonsino suggests adding a pachymeter and anterior segment optical coherence tomography. “The good news is that with this equipment, the rest of your patients benefit as well. You will be picking up more keratoconus, glaucoma and retinal problems as a result.”

Topography is an essential tool for a specialty contact lens fitter. These refractive difference maps help illustrate ortho-K’s treatment effect. In map A, the patient is wearing a multifocal lens. Map B is the naked cornea, and map C is the same patient after a night of ortho-K.
Topography is an essential tool for a specialty contact lens fitter. These refractive difference maps help illustrate ortho-K’s treatment effect. In map A, the patient is wearing a multifocal lens. Map B is the naked cornea, and map C is the same patient after a night of ortho-K. Image by Daniel Press, OD, and Barry Eiden, OD. Click image to enlarge.

Get Close With Your Labs
A good relationship with your GP labs is paramount, Dr. Sonsino says. “Labs is plural because it is never a good idea to depend on one design or one supplier. Choosing your labs is among the most critical decisions.”

Dr. Miller recommends you consider geographic location of the lab, the shape of the eyes you’re trying to fit and add-on options such as multifocal choices, front surface toric power, Hydra-PEG (Tangible Science) coating, a variety of lens materials with varying Dk for increased oxygen permeability and quadrant-specific changes to landing zone. She also adds that warranty periods and availability of consultation are important when choosing a lab.

Dr. Sonsino suggests you consider several business-specific attributes when deciding on potential lab partners, including whether the lab supports the Contact Lens Manufacturer’s Association and GPLI and whether it is an independent lab or if it is owned by a larger corporation damaging your business in other ways (soft lenses).

Labs can also provide valuable trouble-shooting advice—a perk that shouldn’t be overlooked when choosing labs. “The lab consultants know their lenses the best, so when you run into problems, reaching out to them for help is definitely the first step,” Dr. Woo says. “They can help you make necessary adjustments to the lenses.”

During your first year as a contact lens specialist, Dr. Miller suggests you talk through the fitting process with a consultant. “I receive a wealth of knowledge each time I speak to a consultant. I may fit a patient in a certain type of lens a few days a week, but these consultants have experience troubleshooting hundreds of patient cases.” They are also known to pass along recommendations and tricks gleaned from other doctors, she adds. “Their expertise helps you excel during the learning curve.”

Billing Tips From the Experts
Many resources are available to help contact lens specialists get over any billing hurdles, including the GPLI, which offers numerous lectures and webinars on the topic, Dr. Fischer says. “I leaned heavily on these resources early on. I also sought advice from my mentors who have been fitting and billing specialty lenses much longer. Their experience is invaluable.”

As for the cost of these specialty lenses, doctors should be transparent with patients, Dr. Woo explains. Let patients know what is covered as far as services and materials and then present any additional costs.

Prior to initiating a fit, Dr. Fischer shows patients printed handouts that include pricing for different modalities, and he reviews the information with them. The pricing sheets outline everything from standard soft lenses and myopia management options to corneal GP lenses and sclerals, he says.

Needless to say, when tangling with insurance, coverage varies widely from one plan to another, as well as vision care plans vs. medical plans. But Dr. Fischer says most of the vision care plans his office accepts have great coverage for medically necessary contact lenses for conditions such as keratoconus, pellucid marginal degeneration, corneal scarring, high ametropia and high anisometropia, he says.

The best way to verify what is covered is to speak with the insurance provider and get prior authorizations before submitting, which can help prevent problems after the fitting process and also avoid unexpected expenses to the patient, Dr. Fischer says.

Finding the Motivation to Be a Specialist
Even the pros were once new to the game. Here, a few contact lens specialists share anecdotes about their humble beginnings:

Early interest. Throughout high school and during his undergrad studies, Dr. Fischer worked as a technician at his local optometrist’s office. Prior to starting optometry school, he sat down with the practice owners and shared his goal of working with them after graduation.

“Thankfully, they were open to exploring that opportunity, too.”

Together, they identified a few services not offered within a few hours of their location: dry eye and specialty contact lenses.

“Since then, I’ve done all I could to learn and grow in these areas.”

During Dr. Fischer’s fourth-year rotations, he worked in locations that had dry eye clinics and/or a thriving specialty lens practice, which solidified his drive to focus on these specialties. After graduation, he elected to do a residency, where he was matched with a dry eye and specialty contact lens focused private practice in Seattle. The residency laid the groundwork for Dr. Fischer to take his knowledge and set up his Dry Eye and Contact Lens Center back home at his practice in southern Indiana.

Swayed by happy patients. Dr. Woo, a scleral lens expert, first became interested in contact lenses during her third year as an optometry student.

“Witnessing keratoconus patients see clearly for the first time was incredibly rewarding,” she said.

From there, Dr. Woo decided to pursue a cornea and contact lens residency, which gave her the opportunity to work with a variety of lens types, in addition to an extra year spent with specialty contact lens patients.

“This was, by far, the best career choice I could have made.”

After her residency, Dr. Woo returned to Arizona and joined a private practice that did zero specialty contact lens fits.

“I implemented specialty lenses slowly but surely,” she says.

Inspired by the Academy. Early in Dr. Sonsino’s schooling, he was exposed to the Cornea and Contact Lens Diplomates of the Academy, which gave him the impression almost everyone at the helm of optometry—the leaders, researchers and inventors—was a member of this elite group.

“It was intoxicating, and I knew I wanted to be among them.”

Dr. Sonsino says it took the first 10 years of his career to build the expertise and confidence, but in 2012, he was accepted as a Diplomate of the Academy’s Cornea, Contact Lenses and Refractive Technologies Section. “Since then, the giants in the field have not only mentored me but have become my friends.”

One case changed everything. Dr. Miller’s interest in contact lenses began during in her third year of optometry school when she started shadowing contact lens residents.

An encounter on dispense day with a keratoconus patient who was new to GP contact lenses sealed her fate as a contact lens specialist.

“Seeing how emotional that day was for this patient and how excited they were to finally see the leaves on trees and ‘in HD,’ I knew I wanted to fit specialty contact lenses and impact my patients’ lives forever. It is a very rewarding experience despite the difficulty and time it may take to fit a patient in a specialty contact lens.”

Dr. Miller later completed a cornea and contact lens residency and was hired at an office that wanted to incorporate specialty contact lenses into their practice. She eventually developed an ortho-K clinic and then added scleral and prosthetic lenses to the practice.

On the other hand, Dr. Fischer has found other medical conditions such as dry eye do not have as good coverage and reimbursement when it comes to contact lens fitting fees and materials. Typically, the exam codes and appropriate special testing such as topography, pachymetry and endothelial cell count can apply to medical insurance deductibles, but contact lens fitting and material fees are rarely covered, he adds.

Schedule Adjustments
Since specialty lens fittings generally take more time than garden-variety soft contact lenses, it may be necessary to make some scheduling adjustments.

To help with the increased demands on your time, Dr. Fischer suggests training one or two staff members to serve as the “specialty lens liaison.”

“The liaisons can help with the pretesting measurements, initial insertion of trial lenses, insurance questions, insertion and removal training and even ordering,” Dr. Fischer says. “This frees up a lot of time for the doctor or contact lens fitter and allows them to provide care to more patients.”

For new contact lens specialists, allow for extra time in the beginning, such as a one-to-two hour timeframe for a new fitting, Dr. Woo suggests. “Then as you get more comfortable and proficient, you may adjust the schedule.”

Enjoy the Benefits
Offering specialty contact lens services in your practice is an incredibly rewarding experience, Dr. Collier says. “Patients consistently tell me they don’t know what they would do without the lenses we provide them. The life-changing capability of specialty contact lenses is extraordinary.”

Creating a niche within the practice builds a loyal patient base and is an asset to any practice that wants to provide services beyond the standard dilated exam and glasses, Dr. Fischer says. Many patients who need specialty lenses have had poor experiences in the past and have dropped out or are discouraged, he says.

“By being fully invested in your patients and specialty contact lens care, you are providing a service that many offices will not be able to provide. This alone will keep your patients happy, seeing well and in your practice.”

Specialty lens practices are also more insulated from online contact lens sellers because these lenses are highly specific and cannot be purchased online, Dr. Fischer says.

Additionally, increased fees allow doctors to focus their attention on fewer patients while reaping higher net gains, Dr. Collier adds.

For Dr. Sonsino, the reduced patient caseload has been a boon.

“When you schedule half the number of patients, it makes your life much more enjoyable,” he says. “When I went from an academic medical practice where I saw 25 patients in a half-day to private practice where I see 14 in a full day, I saw my quality of life improve drastically. My kids know my name!”

If you’re at the stage where you are going to consider yourself a contact lens specialist and incorporate custom soft and GP lenses into your practice, you need to be all in, the experts agree. “If you’re not fully committed, please do what’s best for the patient, which would be to send them to a practitioner who is proficient in GP lens fitting,” Dr. Woo says. “Think about how you would want to be treated as a patient.”

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