Feedback
I'm amazed at the feedback we get from this column, often from far flung places. This results largely from the mass availability of information, fostered by the Internet revolution. In the ?dark ages? of print only publishing this column would only have reached a few hundred people, at best. Today It's available to anyone with Internet access. Granted the majority of people on this planet would never seek it, nor likely ever see it.
For those however that are interested in contact lenses [and eye care], there's a good chance they would find it in a search engine, through a variety of search terms and combinations. One could also arrive here from a number of websites that have direct links to this page, via an e-mail subscription, recommendation, referral or more conventionally through the print based version. Thus people all over the world now read this and we often get feedback from these offshore readers. The same applies to the NZSCLP and our practice websites.
It's reassuring to get supportive comments from practitioners and others in the eye care industry - from diverse backgrounds - who note similar observations and experience. Many of the challenges we face are similar.
We get the odd grizzle too.
The following e-mail is one of a number received regarding the subjects covered last month.
?You were right on the money with your comments about needing a large selection of contact lens types available. I have been an associate at a practice that is currently being sold. The new owner optometrist has refit all the patients, including those with no complaints or symptoms, to XXXX (a single brand). We have had a tripling of follow-up visits due to problems such as discomfort and dryness. The motivation for this O.D. is simply that a sales rep. for XXXX gave him a great deal, so the lenses cost less. He charges the same for them as he does for comparable lenses from other companies; therefore, he makes more profit, but we waste more chair time and lose formerly happy patients. This is not a retail chain, either, it is a private practice. The problem has led me to decide to leave the practice and seek associateship elsewhere. This narrow-mindedness in fitting has more far reaching effects than most practitioners realize, and it is killing the art of optometry here in the USA and impersonalizing this field of work.?
I have withheld the name of the practitioner and the contact lens company involved, as these problems could well have applied to any practitioner or ?practice? that changed to a single brand, one size fits all philosophy. Granted many new disposable lenses fit a greater range of eyes than the old style conventional soft lenses. We do however definitely need a broad range of lens types, curves and materials to successfully fit and manage the diverse range of patients we see.
There are many issues behind this example, many of which are being - and will continue to be - debated and discussed in this column and elsewhere.
It's also not uncommon to hear from optometrists that have tired of being human autorefractors for retail operators. Hence the high staff turnover and dissatisfaction seen in some of these operations.
It furthermore amazes me that there are even those who seek to gain licence to perform ?refraction only? examinations. One has to ask the question ?Why would anyone want to perform the least stimulating part of a visual examination??
Methinks there would have to be ulterior motives?
May as well use an autorefractor I reckon - as they do in some Asian countries and elsewhere.
We look at other aspects of these issues elsewhere in this column.
Case Report.
Patient John, born in 1970 consulted a colleague of mine in the practice in February 1997. My colleague immediately noted mild keratoconus as a result of slightly irregular ret reflex and irregular keratometer mires. A history of pollen and dust-mite allergy was also recorded. As it transpired he had also been rejected for PRK, based on the irregularity of the topography.
Refraction at this stage was:
R? -0.25/-0.75 x 130?? 6/6
L? plano/-1.25 x 75?? 6/6
I duly examined the patient and fitted him with custom tetracurve lenses in FluoroPerm 30 material. I have seen and managed him over the past few years with excellent results and tolerance with average wearing time of at least 12 hours per day and 6/6 vision R & L.
K readings were:
R? 43.37/45.25 - distorted and doubled
L? 43.87/46.00 - also distorted and doubled to a slightly greater degree
He had Grade I Vogt?s striae in the L eye and inferior sagging cones.
During 1999 I saw John and updated his lenses to Boston XO in the R and Paragon HDS in the L which he wore successfully.
After this John moved to Canada to take up a position in the IT industry. I supplied him with a detailed report and the exact prescription of his contact lenses. I started receiving a string of emails from John a few months after his arrival in Canada. He was reporting extreme difficulty with his eyes, in a new environment and with prolonged computer work. He was finding it difficult to see with either his contact lenses or spectacles, which up until then had provided excellent results. He had seen a number of people who have been unable to satisfactorily resolve his problems. To cut a long story short he spent approximately the next 12 months seeing at least four different practitioners, with at least five different contact lenses fitted. Some of the lenses took five weeks to supply, at a total of over two thousand New Zealand dollars in consultations, lenses and air tickets. I referred him to a colleague at Waterloo University and he was in turn referred to a keratoconus and contact lens specialist in Toronto. A recent email stated the following:
?Since we last talked I have had two left contact lenses, both unsatisfactory. I have had a Rose K lens in the left eye and It's a poor fit [slips off easily] also the eyes feel out of balance?.
As it transpires he had two practitioners fitting different lenses to either eye and thus never seemed to be getting a pair of lenses, at the same time, that were ?balanced? and/or provided good comfort, fitting or vision. At this point he decided it would be cheaper and more effective to fly to New Zealand to see me, update his specs and lenses and then fly back. What was still unresolved after all this time in Canada, we managed to sort out in ?lil ?ol New Zealand in just three working days. He flew in on a Thursday, I gave him two days to recover from jet-lag, saw him on Saturday morning and by the following Wednesday [three working days later] we had received a pair of lenses from CLC. These were fitted on Thursday and the patient reported excellent results.
For those of you with an interest in these things the latest CL Rx is as follows;
R 7.65w(7.7)8.20(8.1)9.35(8.5)11.00/9.1?/F= -2.75D??? Boston XO UV Violet
L 7.50w(7.8)8.20(8.2)9.35(8.6)11.10/9.2?/F= -2.37D??? Boston XO UV Blue
These lenses were produced with a 30% DAC ?machine? blend right and a 40% blend, left.
At the dispensing visit they fitted beautifully with just apical clearance, plano over-refraction and R 6/6 and L 6/7.5.
The Issues [Get out the Tissues]
This case brings to the fore many issues, but highlights the need to adequately deliver solutions to peoples problems in an efficient and coordinated manner. This chap had been used to efficient service that addressed his needs. Also one of the practitioners had automatically assumed that a Rose K lens would be the best option. In this case the small optic zone of the Rose K, coupled with the sagging cone and a lens ordered for this eye with ?peripheral curves 2.0mm flatter? was giving him problems with flare and also the aforementioned ?loose lens? problem. Also as you can see from my CL Rx, he has relatively mild konus and a Rose K lens, in my opinion is more suited to more advanced cones. The most recent lenses, a right from one practitioner and a left from another, were actually looking pretty good in terms of fit and vision, yet one appears to be an aspheric design and hence a ?tiny? optic zone with flare and ghosting. Another retrograde step was going from lenses with 50 to 100Dk back to Boston IV with its lowly 19Dk, a big step backward in my opinion. In fact he has never had lenses with less than 30Dk, and why they went for Boston IV beats me. One practitioner simply wrote ?CL: Softperm? on his prescription pad. I'd hate to think of the long term problems that lens might have caused.
He reports that everything is great with the new lenses I supplied.
In fact, just before returning to Canada he reported that he had worn the lenses the previous day for some eighteen hours which included a seventeen hour return trip to Cape Reinga of which he drove for nine. I saw him the next day for final aftercare and everything was looking great. VA was 6/6 OU, fit was stable and corneas were clear and healthy. The lenses must be working pretty well!
This particular case [and many others too] highlight the fact that New Zealand has a high standard of eye care, which has come to be through the vision, hard work and dedication of many people, over many years. It's of real concern to me, and many others, that there are an absolute minority of people who seem to be intent on destroying this fine reputation by deregulating and ?dumbing down? the eye care professions so that we will end up with very poor standards and a lack of legislative control.
It would seem that these ?individuals? seek to allow any Tom, Dick or Harry to sell a contact lens and that ?quickie? refractions and contact lens sales could be provided by operators whose main goal is retail profit. One just has to look at the issues that have been challenged over the past few years, [as well as forthcoming challenges] to get an inkling of what their goals may be.
The 1996 select committee ruling that deregulated contact lens supply, was in my opinion, brought about as a result of ?stirring? by parties with vested interests. It backfired on ALL the eye care professions. I don't see the consumer having benefited either.
Many of you are also no doubt aware of the massive waste of time, for the dozens of people involved in the Gates/Maher litigation, not to mention the hundreds of thousands of wasted dollars. Imagine what we could have rather done with the money as far as CE is concerned, or marketing and promoting safe contact lens wear, where everyone would have benefited? [To Access this link you will need to use your NZ Optics online password, or apply for one, log in and then select ?page 2? from the drop down menu]
It also seems that there are issues pending as to the ownership provisions of practices to try and eliminate the need for registered eye care practitioners to be majority owners [no doubt so that ?big business? and chains can take control?] Those seeking the right to perform ?refraction-only eye tests? are also stirring the pot and there are also other commerce commission investigations in the eye care field.
The motivation to ?deregulate? is often the same. ?THE CONSUMER WILL BENEFIT?, gets shouted for all who will listen. Sounds great in theory but do they REALLY? I think not. Not when standards and quality of product is lowered and when pathology may be missed.
The professions under attack are also slated as being anti-competitive, monopolistic, cartels. Nice emotive words that really play into the hands of politicians and consumer types who sometimes get sucked in and miss the REAL issues.
As I've pointed out in previous columns, we cannot deregulate everything. It also appears that my prediction of a reversal in attitudes and re-regulation of, for example, grey imports, new movies, music, computer software and other intellectual property, is happening. The rest of the world were not happy and we stood to lose in the long run, as the consumer surely will, if eye care standards are further eroded, dumbed down and deregulated.
You get what you pay for.
It's as simple as that.
We are however fighting an uphill battle as it seems the average Kiwi has still not learnt this lesson. I sure was surprised to see that ?The Warehouse? was rated as one of New Zealand?s most favoured brands - certainly not mine - but nevertheless this type of low cost operation appeals to the masses.
A recent news item highlighted the risks of the ?low cost?, deregulation philosophy. Apparently some staff of ?no frills? airlines in the UK have a little competition going to see who can take on the least fuel, and one presumes use the least. Apparently these fuel loads are often less than recommended by the computers for given loads and conditions. A plane could get into great difficulty if a sudden head wind arose or if the plane had to circle the airport before landing. There would be no reserve for emergencies and sooner or later we will see a plane fall out of the sky, with disastrous results!
Crazy, but reportedly true.
It was even more interesting to see what example dictionary.com gave for the word ?deregulation?. Click here and see for yourself!
When next are you flying low gas, ?no frills??
Rugby Anyone?
During the course of my eight years in NZ, I've had to endure a fair amount of ribbing on various rugby issues. There have been a few challenges and wagers too.
I suppose I shouldn?t be surprised then at the dearth of correspondence, banter and ribbing this season?
I suppose It's now up to my ?Jaapie mates? - and as a consolation ? for Laurie Mains? Cats to make sure those %$#@ Aussies don't take home the silver in the Super Twelve. About the only thing I hear from all my local rugby mates is that when NZ won the Super Twelve the All Blacks didn't perform?.
I await the Tri-Nations and other tests with interest!
For more information or any comments email Alan at alan@optom.co.nz.