In Contact - September 2005
Our Mate Nate?
In the beginning there was light. Everything stems from light. Our profession revolves around light.
In 2000 there was Nate.
Otherwise known as Professor Nathan Efron he, along with the likes of Hill, Holden, Brennan, Rengstorff, Saks [S.J.], and Fonn et al, is one of my gurus and was instrumental in forming my long held views regarding ocular physiology and corneal health. he's done amazing work in many aspects of contact lenses and produced some great resources.
Nathan did however make some comments - and followed it up in 2001 regarding the ?Demise of RGPs? - that I and others do not agree with. In essence he stated that RGPs would be virtually obsolete by 2010. I believe that some of his reasoning is in fact a non sequitur. There are other articles, commentary and letters published in the journals? Global Contact and Clinical and Experimental Optometry.
that's history.
Five years down the track Nathan has rekindled the debate in a kind of ?we're halfway there? scenario as published in Clinical and Experimental Ophthalmology 2005; 33: 341?342.?
In the editorial, stirringly titled The desperate last gasps of rigid contact lenses, it seems Nathan wishes to raise the ire of coal face practitioners who have real life clinical knowledge of the realities of contact lens practice.
Is Nathan, in his cloistered academic environment, out of touch with reality?
I acknowledge that soft lenses have come along way in the past few years. Oxygen is no longer an issue. Costs are coming down. Advanced designs are providing better soft lens vision than ever. We have more stable and more comfortable torics. We have multifocal designs that work ? sort of. I have gone on record and lectured on the application of, for example, SofLens 66 Torics in Abnormal Eyes, where indicated. Nathan was probably at that lecture in Berlin.
In many cases soft lenses may well be the ?best? option. I'd also agree that I do less new fits with RGPs than say fifteen or twenty years ago.?
I can however also quote the recent Survey of Contact Lens Prescribing in New Zealand 2004 as published in NZ OPTICS, July 2005 and presented by Geraint Phillips at the CCLS meeting in Napier, April 2005. This survey clearly states that 11% of NEW fits were RGPs, a significant increase from a similar survey conducted in 2000, that found only 6% of NEW fits were RGPs.
I'm no statistical expert and was never a maths wiz but this represents an 83% increase in NEW RGP fitting.
Hardly a last gasp or a clinical practice in ?decline??
Nathan states ?optometry students and ophthalmology residents are not being exposed to rigid lens fitting as part of their practical training because virtually all patients are demanding to be fitted with soft lenses??.
My patients on the whole take my professional advice and get fitted with what?s best for their ocular health and vision. Rarely do I have a patient specifically asking for a specific lens type or brand. Where some enquire if they can have a specific brand It's usually because a friend or partner wears them. These lenses may not even suit them. We have the odd patient asking us to supply them with, for example, ?more Acuvues? and they are emphatic this is what they wear. When we examine the lenses, one can immediately see they?re not Acuvue. This is usually confirmed when we get the Rx details or check out their lens packs. They?re often B&L, CIBA or Cooper and visa versa.
Maybe the ?demands for soft lenses? Nathan reports stems from the fact that he's probably been in the UK for too long?
As we know, Poms are generally a bit ?soft? and hence maybe they don't have the perceived ?toughness? they think one needs to wear RGPs? Soft people demand soft lenses?
We all know what happened to the Lions on the recent rugby tour?
Nathan hits the nail on the head with the comment ?students and ophthalmology residents are not being exposed to rigid lens fitting as part of their practical training? because, I would add, the academics are not teaching RGPs properly, nor providing the needed clinical exposure. I have written for many years about many examples of this abject failure in modern Optometry. In many cases the lecturers have little or no real world RGP experience and the insights and practicalities that this exposure creates.
Their apparent biased philosophy, ?anti-RGP? stance and possible lack of skill in RGP practice may in fact be the root cause of the problem!
It's clearly a failure in education and training that is in part leading to the fact that graduates of the past decade or so take the ?easy? option and try and ?get away with? soft lenses. Frankly they are dead scared of RGPs and don't know where the hell to start. They rarely have even the most rudimentary skills in RGPs and often cannot even measure the parameters of a simple lens design. A basic skill.
The reason?
They were never shown how. Never taught.
After spectacles, contact lenses are the second most prescribed item in the majority of practices. The modern eccentric-fixation with pathology and doctometry has attempted to relegate contact lens care to the rubbish heap.?
That seems like a soft option to me?
Virtual Obsolescence or Virtual Bias?
Out of interest I performed a quick analysis of a recent month?s worth of contact lens patients I saw.
The results are certainly interesting and are again contrary to Nathan?s opinion that RGPs are undergoing a last gasp or are in demise.
My figures show that Soft Lenses represented 52% of cases and RGPs accounted for the remaining 48%.?
In my book 48% is hardly indicative of ?virtual obsolescence?
Granted I may be regarded as a specialist contact lens practitioner but there were numerous spectacle exams, child vision and behavioural cases as well as geriatrics and computer vision cases.
Among the soft lenses, 38% were torics [split equally between high Dk silicone hydrogels and SofLens 66 Torics!]. 34% were dailies and 7% were multifocals with a few mid-water lenses and aspherics thrown in.
In the RGP group 16% were keratoconics, 8% were high minus myopes, 13% were long term wearers with between 20 and 42 years of successful hard/RGP wear. Most RGPs were either Boston XO or Optimum Extra [both 100Dk UV materials], with some HDS 50 and one Fluoroperm 30. There were no low Dk RGPs. Apart from two bifocal and one Quad Sym propriety designs, the rest were on the whole custom tetracurve designs with some torics, toric peripheries and lenticulars.
I am pleased to report that there was no HEMA or PMMA in these cases.
OK
The rest of the Nathan?s editorial deals mostly with orthokeratology and Nathan?s two word dismissal of this modality was ?Why bother?...
I?ll leave others who are experts in the field to respond to this.
Efron also briefly attacks the ?myopia control? claims often mentioned as benefits of RGPs. All I can say is that anecdotally I've seen enough cases where myopia control or stabilisation seems to have occurred. Countless other practitioners and patients would also vouch for this. That some academic research fails to back this up may in fact be due to poor study design?
I mean how can we ethically really prove such a thing over 10, 20, or even 50 years - the typical cases where we observe this phenomenon?
Do we have a child wear a -5.00D spectacle lens on one eye and an RGP on the other, for forty years, to prove such a thing?
Kapa o Pango
The Springbok ? All Black encounter at Carisbrook was always going to be a big one. So it was.
The rousing new Haka, Kapa o Pango, ended with a challenge that left no doubt about the All Blacks? intentions. We were treated to eighty minutes of hard rugby. Mealamu scored a great winning try in the last four minutes, finishing off a rousing scrum that had 100% commitment from the boys in Black. Even then the game could have gone either way.
The ABs prevailed in what I think will be rated as one of the all time epic AB-Bok encounters.
Just like the good old days.
I don't mind losing too much after such a great battle.
Rugby?s the winner.
What I do mind however is having to actually support the Aussies at Eden Park. For the Boks to win the Tri Nations the Wobblies have to beat the ABs.
I don't think they will and the ABs look set to wrest the Tri Nations Cup from the Boks. I?ll be there watching.
In Closing
I know what I want for my Birthday this month of my birth, election wise, but alas they tell me there are more sheep than people in NZ?
I?ll be sitting up the mountain at Cardrona far from the hustle and bustle of the election madness. Yeehah.
What?s going to happen will happen. That applies to elections, rugby and life in general.
C?est la vie!
For more information or any comments email Alan at incontact@optom.co.nz.