Contact Lens Options for the Non-Traditional Patient

Shane R. Kannarr, O.D.

Non-Traditional Patients forContacts

Dry Eye Sufferer

Astigmatic

Presbyope

Young Myope

Non-Compliant Patients

Benefitsof Fitting the Patients

Patient Satisfaction

Loyalty

Practice Builders34 Million current wearers12 million new fits11 million drop outs

PROFITABILITY

Contact Lens Fits by TypeSegmentTrendTotal Lenses+7%SVS+4%Toric+11%Multifocal+25%Colors+6%

Specialty lenses are driving the category growth Higher margin --> higher profits

Source: HPR 1H 2003

Comfort and Vision are Top Benefits for both Current Contact Lens Wearers and Considerers(% Absolutely Critical Top Box)Source: Vistakon Attitude and Usage Study of Vision Corrected Consumers 2002

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WearersConsiderers

Top Tier

Give me excellent vision8388

Comfortable to wear all day long8187

Designed to meet my specific vision correction needs8185

Middle Tier

Easy to insert and remove6075

Healthiest for the eyes6575

Durable5867

Convenient to care for5064

Keep eyes moist4960

Allow the most oxygen to reach my eyes4959

Specially designed for those with sensitive eyes or allergies2248

Provide protection against ultraviolet (UV) rays3045

Reasonably priced4443

A brand I can trust3543

Recommended by my eye doctor3841

Bottom Tier

Available for purchase at many types of locations2533

Can sleep in them without problems2532

A well known brand1320

Available in the best colors to enhance or change my eye color915

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Dry Eye

Todays ChoicesACUVUE ADVANCE with HYDRACLEAR Revolutionary Technology Exceptional Long Lasting Comfort

ACUVUE ADVANCE with HYDRACLEARACUVUE ADVANCE with HYDRACLEAR

A new generation in DAILY WEAR

The outstanding initial comfort of a hydrogel lens Exceptional end of day comfort that outlasts the competition

Uncompromized visual acuity of theACUVUE Brand

Oxygen delivery and lens properties that help keep eyes as white as with no lenses

Acuvue AdvanceSilicon LensHydrogel ComfortHigh Dk/t=83Daily Wear2 Week ReplacementSame Design as Acuvue 2

30 Day Lenses Not Just for Extended WearConsider Low Water Contact LensesLook at Systemic Medications (BCP and Antihistamine)Limit Wear TimeUse Artificial TearsConsider Plugs

Astigmatics

Not JustforRGPsAnymore

Expectations

Residual Astigmatism (RA)RA=Refractive Cylinder-Corneal CylinderExample on Next Slide

>1D consider RGP

Example:Refraction -3.00 - 2.00 x 180

K Readings 43.00 x 180 / 44.25 x 090

For Our Purposes:2 1.25 = .75(RGP probably not needed.)

LARS RULELeft Rotation Add

Right Rotation Subtract

From your vantage point

Each clock hour = 30 degrees

ExampleTrial Lens:-3.00-1.25x090----OD rotates 20 degrees left-3.00-1.25x090----OS rotates 20 degrees right

NEW TRIALSOD -3.00-1.25x110OS -3.00-1.25x070

Fuzzy Math..

Soft ContactLensOptions

A. Less than -3.00 D of Cylinder

Acuvue Advance and Purevision are nice compliments.

Both are -0.75 to -2.25 Cyl in -0.50 Increments.Both are Axis 0 to 180 in 10 Degrees Increments.Good Stability.2 Week to 1 Month Replacement. Avg. Sale Price/Box $42-45

Profit / Patient / Year =$93.00/$186Let Patients See the Improved Vision for Themselves.Up to -3.25 D of Cyl use Spherical Equivalent for Remainder. (example on next slide)Other Options: Frequency 55 Toric/Vertex Toric

ExampleRefraction: -2.00 -3.25 x 090Closest Lens: -2.00 -2.25 x 090Uncorrected Astigmatism (UA)-3.25 2.25 = 1.00DSpherical Equivalent of UA-1.00 / 2 = -0.50Add to Sphere of Refraction-2.00 0.50 = -2.50New Contact Script = -2.50-2.25x090

Greater than -3.50D of Cylinder

UCL, Sunsoft Toric, and Preference Work Well TogetherParameters Sphere:+20.00/20.00Cylinder:7DAxis is in 5 Degrees StepsEducate Patient about Possible Fluctuations in VisionOrder with warranty

**********IMPORTANT**********

Charge for your TIME

Can not use standard multiplier

Patient Satisfaction=Practice Builder

C. Rigid Lens Options

Front Surface Toric: Correction on the front of the lensLow Residual AstigmatismBack Surface Toric:Back of lens shaped to match corneaHigh Residual AstigmatismExcellent VisionComfort is the Issue

Presbyope

No One likes Growing OLD

A. Monovision

Start the Patient Early in PresbyopiaEducate the Adaptation TimeStart with the Non-Dominate Eye as Near (may switch)Return the Patient in 7-14 DaysManage Expectations

NO Contact Lens SaluteCost Effective for the Patient(any single vision lens will work)No Intermediate as Presbyopia ProgressesTrouble in Low Light ConditionsTrouble over 2.00 D of add

KEY POINTSWill require chair timeInexpensive to patientEasier to start early in presbyopiaPatients are happy that lens cost doesnt increaseWorks for the majority of the patientDecrease Depth perception (consider 3rd lens)

B. Soft Contact Bifocals

Usually Provides All Ranges of VisionComfort Over Rigid LensMaintain Stereo VisionWorks at All Add PowersCan be CostlySome Report Constant Blur

Halos at NightLet Lens Settle Before Rechecking10-15 minutes is goodManage ExpectationsReturn to Check After WearingUse Trial Lenses

** Great Options **

Multifocal Market by BrandIn only 9 months, SofLens Multi-Focal is the fastest growing product in the category. Multifocal SharesBrand ShareSharevs YAgoAcuvue Bifocal40.7(21.1)SofLens Multi-Focal34.3+34.3Focus Progressives12.1(13.8)Frequency 55 Multifocal5.9+4.2Dailies Progressives1.9(0.2)Source: HPR Q2:2003

Soflens 66 MultifocalBase Curve 8.8 / 8/5Powers:Add: Low (< +1.75) High (> +1.75)Design:Watch Pupil Size in High Adds

Consider Modified MonovisionCost / Box:$31.25Avg. Price / Box: $60.00Profit / Patient / Year:$119.00

Exceptional Visual AcuityNatra-SightTM OpticsBroad near to distance power transition to provide crisp, clear, natural visionAspheric center-near with broad add profile across optic zoneEqualized Mass Distribution Facilitates lens centration essential for effective functioning of the aspheric optics

SLMF Low ADDSLMF High ADDNatra-SightTM OpticsNot all aspherics are the sameCiba ProgressivesSingle Steep AddPower Profiles

Basic Fitting Tips

Know the Distance/Near DemandsControl ExpectationsAdd power +1.75/Start with high addAlways use 8.5 BC with high addAspheric Design offsets low amounts of Astigmatism

Rule of Thumbs for Add Powers< 47 Low Add in Both eye> 47 Low Add in Dominate eye

High Add in non Dominate eye

Be a little Creative Tailor your fit to your patients needs

Fits for Normal Demands/Distance DemandsFind PrescriptionFit on Rx OU/Low Add OULet Settle 10-15 Minutes Before CheckingAim for 20/25 at Distance/20/40+ at NearRTC 1 week (Patient to bring list of were lenses do and do not meet expectations)

DifficultiesDifficulties with Near

Dominate Eye Remains the SameNon Dominate Eye Distance is Rx + of AddLow Add

Difficulties with Distance

Check Over Refraction with Trial LensesLook at Base Curve

ExampleRefraction -3.00DOU +2.00 AddOUOD is Dominate

Initial Fit------- -3.00/Low Add OU1st F/U--------- -3.00/Low OD-2.00/Low OS

Excessive Near DemandsRefraction

Week 1 Fit on Refraction OU/Advise Readers

Week 2 Dominate On Rx / Low Add Non-Dominate On Rx / High Add

Week 3 Add + to Non-Dominate with Trial Lenses until Near is Adequate

ExampleRefraction -3.00 OU +2.00 Add OD DominateWeek 1 -3.00/Low OU/ReadersWeek 2 OD -3.00/Low OS -3.00/HighWeek 3 OR OS +0.50OD -3.00/LowOS -2.50/HighThink before you use High Adds OU

FREQUENCY 55 MULTIFOCAL LENS DESIGN

BC/Diam.: 8.7/14.4 mmSphere power: +4.00 to -6.00DAdd:+1.00 (NEW) +1.50, +2.00, +2.50 DOptical DesignD lens for dominant eyeN lens for non dominant eyeHandling tint: light blue edge-to-edgePackaging: blisters in 6-packs, single blister trialsModality: recommended for monthly replacementFREQUENCY 55 MULTIFOCALPARAMETERS

FITTING PHILOSOPHYDetermine Spectacle Rx and Best Vision Sphere.Determine Contact lens power adjusting for vertex distance, if required.Determine the dominant eye. Consider fogging with a +2.00 lens test to determine dominancy.Place the D lens on the dominant eye and the N lens on the non-dominant eye. Wait 10 minutes for the lenses to equilibrate.Under normal illumination conditions, evaluate visual acuities for distance and near, first monocularly then binocularly

Acuity expectations:

D lens Distance20/20 Near20/40 or betterN lens Near20/20 Distance20/40 or better Binocularly Distance 20/20 Near 20/20FITTING PHILOSOPHY

* Other Options *Acuvue Bifocal

Ciba Progressive

C. Rigid Bifocals

Simultaneous VisionConcentric DesignTranslating DesignsIs Great Vision Trade-Off for Initial Discomfort?Educate the Patient about Adaptation (It will get better!)Lots of Hand-Holding in the Initial Phases

In All Options, Charge Adequately for Your Time.

Non-CompliantPatients

Significant Neo or Corneal EdemaAgain Look at 30 Day LensesDK / L ComparisonPoor Mans LASIKLASIK

RapidlyProgressing Myope

Young Child -4.00 or AboveChanging More Than -0.50 D / YearFit a Half of a Diopter FlatReturn to Check at 6 Months /Watch Cornea and ComfortInform Patient of Proper ExpectationsPatience, Patience, Patience!

*Key Communication Points: > Comfort is THE unmet need . . . > CL comfort has increased significantly in last 2 decades but still enormous opportunity for manufacturers and eye care practitioners to increase patient satisfaction

*Key Communication Points: > Todays current CL choices force a compromise:- comfort, handling & vision excellence of traditional hydrogel but with limitations in maximum O2 supplied- or increased oxygen of high silicone lenses with stiffer, less comfortable materials & designs

> VISTAKON combined the best of both AND- incorporated HYDRACLEAR for silky smooth comfort that LASTS

Creating a new generation of contact lenses, revolutionary technology that provides exceptional long lasting comfort

***Power Profiles: Low vs. HighThe difference between SofLens Multi-Focals low and high ADD lenses is quite apparent in these 3-D power profiles. The power of the low ADD increases gradually as one moves from the lens periphery to the center. The high ADD is distinctly different from the low ADD design as while it also affects a gradual power increase from periphery to center, there is a distinct central zone, or plateau, of greater plus power. It is this distinct near zone that boosts the near ADD power. Some older, or more mature presbyopes who require higher ADD power will benefit from this design. Fitting older patients with modified monovision, using two low ADD lenses, or a combination of a high ADD and a low ADD may be as, or even more effective in providing the older presbyope with functional vision. One should note the visual performance of the high ADD lens is more dependent on pupil size than the low ADD design. As such, the high ADD lens may compromise the quality of distance vision in some individuals, especially if their pupils are small.