“The 45-Minute Contact Lens Fitting” Confessions of a Career Contact Lens Guy

By Christopher Miller, ABOC, NCLE

I’m not as important as I used to think I was. I know that may surprise some of you (especially if you know me well) and this realization came after having fit con- tact lenses for over 30 years in South America, the Caribbean and the U.S.

When I was younger I use to think that my patients had to know almost everything, as well as demonstrate to me a high level of handling proficiency, before I would dispense contact lenses. Having now worked in almost every kind of office environment; from a sales retail chain, ophthalmology and optometry practices, and currently with an HMO, as well as having had my own private practice for 18 years, I believed I was the biggest part of the equation for a successful fitting. I now realize that the patient’s motivation and expectations, and their lens comfort play a larger role in their success than what I was trained to believe.

BEFORE, DURING AND AFTER

Now this realization didn’t come all at once but gradually unfolded bit by bit. It took the experience of seeing the procedures used in different office settings and finding out what worked and what didn’t work and what was absolutely necessary for a successful fitting session. First, the patient needs to know a few things before the fitting can begin. They are:

1. The price they were expected to pay,
2. Insurance coverage, if any, and final pricing,
3. Arrive a little early for the first appointment without lenses on, (but with a box they are currently wearing if they didn’t get them from you), and
4. A parent needs to be present if the patient is under 18; best when working with a minor. Also, that we don’t have to answer questions more than once and we can get paid on the same day as the fitting.

The most important items that need to be covered during the fitting appointment are:

1. Take a good history,
2. Ask the right questions concerning any current lenses being worn,
3. Understand patient’s expectations,
4. Make use of all types of media for instructions and training, and
5. Above all, make sure the patient never feels rushed. The fitting process should also fit the time schedule needed for a healthy practice.

In addition, everyone involved (the doctor, receptionist and contact lens fitter) should work as a team. Contact lens fitting requires great handoffs and communication; letting each one know what has already been done. Of course, the need for privacy requires that some information is written in the chart or on a piece of paper rather than said out loud during the hands off. Minimally, it requires that the patient is introduced to the next person who will be helping them. This helps create a respectful and friendly environment in which the patient feels welcomed and cared for.

The after portion is the time between the fitting appointment and the doctor’s check. Assuming all went well, the patient will get the green light and become an ongoing contact lens wearer.

For example, my own technique changed in 1985. I had literally spent two days—that’s right, 16 full hours—working with a young man to insert and remove his lenses. After the first four hours I asked if he wanted to give up (I know I did) but he said that he really needed to wear contact lenses. So, we continued until he was successful. Now I use a training video developed by one of the contact lens solution companies to do this training while I chart at the same time. That way, I know that the instructions for handling and disinfecting the lenses properly are covered and I don’t have to worry if I left something out. In fact, as long as the patient can get one lens out, I usually will let them take the trial lenses home on the first visit and book a follow up appointment with the doctor.

Using a variety of your own personal pearls and experiences, you can gradually reduce your involvement until it takes approximately 45 minutes for most types of fittings. This includes new fits, refits, soft and RGP fits, as well as multifocal lens fits. The exceptions would be specialty RGP fittings such as for Keratoconus, which usually include topographical mapping that adds time. It’s not the intent of this CE to suggest that a patient be short served but that over time, an efficient and exacting fitting can be reduced to 45 minutes.

THE FITTING PROCESS

The ordering of your procedures may be different than mine as your office may be laid out differently or you may take patient information and chart it differently. But the key here is to have a procedure and stick with it, making small changes as needed. Time each part of your process then think about how certain areas could be shortened. See if there are printed or DVD materials that can cover the process. That way you could point to the different sections in your brochures noting what they need to know first to be successful. Stress the importance of reading the rest of the information when they get home. Online training materials can be used inoffice but relying on them as primary tools for the patient at home may be risky. It’s okay for review.

Record the fitting assessment on a template, which I copy into the patient’s record when preparing for the appointment. Many practice management programs, such as Officemate, supply them as part of the patient record screens. If not an outline provides all the sections that require testing, assessment or discussion.

To create your own template, consider a SOAP model. SOAP is an acronym, which stands for Subjective/Objective/ Assessment/Plan. This ensures that all the data needed is recorded for recommendations and a permanent record of the visit.

It is required that the patient’s history details are reviewed for any previous or recent eye problems, how long have they have worn lenses, does anyone in their household currently wear lenses should they have any difficulties, what their visual needs are, what their expectations with contact lenses are, when and how they plan to use them, do they have backup glasses, and what solutions they currently use.

Also note in bold the lenses dispensed so that anyone looking at the chart can quickly find the lenses the patient is wearing. This can help save dispensing the wrong lenses later or other mistakes that can happen in a busy practice.

The SOAP model can take many forms. Here, a patient record example suggests a variety of more detailed sections starting with a patient’s history. If a receptionist or technician can complete the history, it frees the contact lens fitter to see more patients or for other tasks.

A “NEW FIT TEMPLATE”

Some of the template can be filled in with information ahead of time such as which solutions are usually used or the wearing schedule. Most of the time it would be the same for most patients and can be changed as needed. Other areas will be personalized such as the trial lenses used, the solutions dispensed and the prescribing doctor’s name.

While reviewing the wearing history, save time by copying and pasting the doctor’s prescription and date into the file; add any special instructions. I always use a notepad to write down the doctor’s Rx and date, any insurance coverage and the suggested first trial lens. Follow with a slit lamp exam and take the “K” readings noting on the paper what to copy into the chart when back at the computer station. Record all information; leave nothing to memory. Excellent records are a requirement.

After all information is entered in the electronic chart, it is time to tell the patient which lenses they are being fit with, noting the reasons for using that lens. Add any initial instructions if any.

It might sound something like this:

“I will be fitting you with a one month replacement lens. This is a lens that you will not be sleeping in; you will need to remove it every evening, clean, rinse and store it in fresh solution in a case overnight to kill the germs.”

“This is a lens that (then list the benefits such as newest manufacturing technology, of a more breathable material for longer wearing times and better comfort, toric lenses to correct your astigmatism, multifocal for convenience, etc.)”

This is a crucial step since it is here that you may learn of some patient expectation that they’ve not yet mentioned. Many times a patient would not have said at the beginning of the fitting that they wanted both color and clear lenses, or had something else in mind. Frequently stating what’s been done or agreed helps keep the fitting going smoothly, within the allowed time slot.

Also, this is a good time to mention lens costs for a one-year supply and address any adverse reactions. Some patient’s get sticker shock. Some offices manage it using the cost reductions available when patients purchase a yearly or six-month supply. Sometimes, a less expensive lens type may be necessary. Regardless, try to assess this as soon as possible and take care of any objections at the beginning of the process. If they only wanted to try the lenses first before ordering, then you will know that they will need a follow up appointment (usually a week later) to decide the final outcome.

LENS INSERTION (YOU) AND REMOVAL (THEM); THE ORDER

Next, insert the lenses. It often helps to distract patients by checking their address and telephone number. This allows them a few minutes to adapt without sitting in silence thinking about the way the lenses feel. Next, turn on the DVD that explains insertion and removal, and while they watch, finish filling in their chart.

Complete the order, as it will be transmitted later and again review the pricing. Schedule a follow-up appointment with you as the fitter and/or the doctor depending on the office procedure and need.

Once the video is complete, ask the patient if they have any questions.

Answer all questions and ask whether your answers were clear.

Check the visual acuity and review the lens fit under the slit lamp. If something isn’t right then try a different lens having the patient insert them. Spend a couple of minutes reinforcing the need to rub the lenses while cleaning and the importance of keeping the case clean. If these lenses are the correct fit, ask the patient to remove one lens only and reinsert it. Watch the patient for about two minutes. Change the position of the mirror as needed or give any additional instructions that are not covered in the video. Then, have a seat.

This is where I have learned to back out of the patient’s way because they will take as much time as they require. For most patients, in my experience, it should not take more than five minutes. If it takes longer, provide suggestions after observing how they are doing. I don’t recommend letting a patient take more than 10 minutes.

If a patient can’t take the lenses out, remove the lenses for them; delete the order and book a follow-up appointment. To prepare them for the next appointment, show them how to hold their lids and touch the eye with clean fingers. Have them do this several times per day until you see them on the return visit.

If you have an extra room and they are motivated, you might give them up to a half hour to practice. Then check back in with them. If they are successful removing the lenses, have them demonstrate how lens cleaning is done and have them reinsert the lens.

Close the fitting with a discussion about the price of the fitting, the cost of lens solutions, the lens order and schedule a follow-up appointment. Once all this is done, send the order electronically. If the office phones in orders, it’s a good time to switch to electronic ordering. It saves time and reduces errors.

THE AFTER

The period between the fitting appointment and the follow-up check is the after. However, a significant change I’ve made over the years is that I don’t automatically book everyone a follow-up appointment. The real follow-ups are reserved for RGP fits, soft toric trials, which need ordering (or any other trials not in stock), all multifocal fittings or fittings where the patient seems to have high expectations or specialized needs. This can open a schedule tremendously. Of course, all patients must know that they can see you for any emergency or any further training needed. You can have more confidence in some patients. Much like the confidence that experience and having fit many patients builds in you, one can assess the patients that can be empowered sooner. Allow the ones who are ready to go through the process quickly to do so without putting any limiting time frame on them.

CONCLUSION

Remember, a process is designed to never short change the patient but add efficiency to the contact lens fitting process. In the end, what is important is a happy, satisfied patient whose expectations have been more than met by your careful attention to their visual needs and desires. It will be 45 minutes well spent.