In Contact - May 2007

Normal Service Has Resumed

Well almost.
A recent case is one I felt I should share with you. It highlights many issues surrounding contact lens care, patient management and understanding.
The young lady concerned has been a patient of mine for the past decade. She first came to see me on referral from her myopic father. He?d been impressed with my contact lens care in updating him to higher Dk, UV blocking, high-water Actifresh 400 disposables, over a decade ago. They performed way better than the traditional HEMA conventional lenses his previous optometrist had prescribed. Recently he switched to UV blocking 1 Day lenses for convenience.
When first seen by me his daughter was a thirteen-year-old complaining of distance blur. Examination revealed she?d developed -1.00D of myopia.
After a period of vision therapy I prescribed spectacles, however it wasn't long before she requested contact lenses. She took to them like a duck to water - as we often see in children of contact lens wearers. To them It's like brushing teeth.
Dad does it everyday and he doesn?t cry.
Within a month she?d adapted well and reported fifteen hours of comfortable wear with 6/6 R&L. In November ?99 I had a request to send her Rx to Wellington as she was now living there. By then she?d progressed to R&L 8.8/14/-1.75 Acuvue on AOSept disinfection.

Things Change

She saw me again in February 2000 with complaints of red, sore, blurry eyes. She?d progressed to -2.00D. We updated her to Focus Dailies and implemented hot compresses, meibomian gland massage and Vitamins A, C, E and Selenium, through dietary means. She was taking prescribed iron supplements, which supported my suspicions that the changes in her previously pristine lids and tears related to hormonal changes and puberty.
By February 2002 she was up to -3.25D, in Focus Dailies. In November 2002 she requested an Extended Wear trial. She did well on 7N EW in Purevision 8.6/14/-3.25 but by July 2003 I noted she was alternating Dailies with Purevision. In March 2004 I suggested lower-Modulus, high-DK daily wear in Acuvue Advance 8.7/14/-3.50. We soon saw rather dramatic deposits and ?greasing? with ReNu and Complete which the now discontinued, gimmicky Rapidcare ?washing machine? didn't resolve. A colleague tried O2Optix 8.6/14.2/-3.75 with AOSept while I was on leave. They were better. The deposits recurred when she tried her Advance lenses again.
O2Optix kept her happy during most of 2005 but in January she developed what was diagnosed at Greenlane Clinical Centre as bacterial conjunctivitis. It was treated with Chloromycetin and Ciloxan. When all was clear I refitted her into Acuvue Oasys 8.4/14/-4.00. She reported that these provided the best comfort and vision in ages and wore them sans problems for the next year.
By now she was a successful young lady living and working in Sydney.

Communication

I saw her Dad this past February: A stable myope of -4.25D for over a decade, he told me his daughter was flying over specially to consult me as she was having terrible problems and getting all sorts of confusing advice in Sydney.
She saw me in March ?07 and reported that she?d seen an Optometrist in Sydney who?d completely ?freaked her out?.
She was somewhat concerned and rather unhappy.
Apparently he?d told her she?d developed ?infections? and ?ulcers? and given her a recommendation for eye drops that were duly prescribed by a GP he referred her to. He also told her that she had to stop wearing lenses for ?at least six months? and she had to get new spectacles [in a $AU 584 frame that we had for $NZ 525]. He explained her eye condition was akin to ?glandular fever of the eyes?.
At our consultation she was wearing her Oasys lenses ?on and off?. Apart from mildly inflamed lid margins her eyes looked in reasonably good shape. On eversion her tarsal conjunctiva was pretty normal. NaFl exam showed no significant staining of the cornea nor any sign of healed ulcers, CLPU, SEALS, CLARE, IK or MK.
She was also very upset that she was going to be ?minus six by next year?. I asked her where she got that idea. Apparently this self same practitioner had told her that she would progress to that level in a year.
This optometrist had not contacted us nor obtained her Rx or history.
As you can see she progressed, over ten years, from -1.00D to a relatively stable -4.00D: Almost the same as her stable myopic father. In my book and by my maths that's a ?typical? myopic progression rate of around -0.30D per annum.
In the past two years she?d only changed 0.25D [i.e. 0.12D per year]. This, along with knowledge of her Dad?s Rx, is a good indicator the progression is slowing [or stopped.].
How did the practitioner in Sydney, with no benefit of hindsight, get to the deduction she will suddenly progress -2.00D in a year; an increase of fifty percent!?
It astounds me how many patients are emotionally scarred because some control freak optometrist or ophthalmologist told them ?get used to using a white stick? or ?learn Braille? as they'd be ?blind in ten years?. Many of these have been stable RGP wearers for twenty, thirty, forty years and more. Most are still 6/7.5 with CLs or specs; in some cases sans-Rx, following refractive cataract surgery.
don't these bullies have any compassion or understanding of the damage they do with such ill advised and mostly incorrect ?diagnoses? and statements?
The Sydney optom also told her she couldn?t wear Dailies. Apparently ?they don't allow enough oxygen to the eye? and he refitted her into the highest modulus silicone hydrogel that exists [Night & Day]. Apparently Oasys also didn't allow enough oxygen transmission.
that's how she explained it all to me.
Now we're talking Daily Wear here, not EW.
Maybe this chap needs to attend some CL related CPD and re-check the Holden-Mertz criteria?
1 Day Moist and Focus Dailies meet the DW, Dk/L criteria. Oasys easily exceeds both DW and EW levels.
Had he asked for a report he?d not only have known her Rx history but would also have learned that she?d tried practically every silicone hydrogel in the past eight years. The higher modulus lenses had not been her preferred option.
I refitted her into 1 Day Acuvue Moist 8.5/14.2/-4.00 OU.
As I write I can confirm she is now quite happy. She confirmed this by email and ordered a six month supply of Moist, along with her fancy new Face a Face hi-index spectacles which have been dispatched to Sydney.

Discontinuity in Globalism

One thing that's irritated us for many years is the disparity between markets, often for the same company, in different regions.
Recent examples are patients being referred directly to an online pharmacy that sells contact lenses from a link on the B&L website. I was told, very efficiently, that this is not an ANZ choice but B&L USA didn't bother to get back to me?
When are they going to realise that we live in a global economy with information accessible in milliseconds?
What a company does in one region is visible in any other?
Ditto for so called ?discontinuations? of products.
A recent post by Joe Barr in the CL Today newsletter stated Acuvue Toric was being discontinued. It was followed by a clarification a week later that this only applied in the US.
Acuvue Toric has been ?discontinued? in ANZ for at least a year!
It created some problems but we've mostly worked our way through that.
It just shows that sometimes the left hand doesn?t know what the right hand is doing. Someone gets dumped on. Even Joe and his team of CL Spectrum staff get confused.
I'm not surprised, as the clarification issued by J&J in the US contradicts the ANZ situation.
he's confused, I'm confused, we're all confused.
Argghhhhh
In researching this column I was amazed to find that the NZ Acuvue website also referred to the AV Toric. It also listed at least two other supposedly ?discontinued? lenses, some of which I've had no access to for at least a year but the site says ?introducing??
When I raised it with J&J ANZ I got an immediate answer that a new up-to-date site would be up and running soon. Apparently B&L will also have a new ANZ site soon, with some added functionality practitioners may find useful.
As far as I'm concerned manufacturers and suppliers must learn what semantics are all about and the definition and meaning of the words they use.
If they state something is discontinued then that should mean the lens [or product] is no longer manufactured in any plant on the planet and once stocks have been exhausted, that's it.
If however they are ?merely? deleting it from a price list in a specific region then that's what they must tell us.
It's been happening in the contact lens, solution and spectacle market for too long and causes no end of problems.
we're sick of it.
With the global economy and mobile patients we don't want to be caught with our pants down by a patient saying ?you lied to me? because the lens ?we? said was discontinued, is freely available in say, the UK.

Name the Game

we've also had the recent, confusing situation that SofLens66 Toric, one of the top selling soft torics, has mysteriously been renamed SofLens Toric in packaging so similar to the Purevision Toric that I and others have already been caught out.
It's just a matter of time until someone wears a 0.19mm thick, low-Dk lens for EW because they thought it was something else. It also causes havoc with our systems, statistics, trials and ordering. The weird thing is that if you click the above SofLens Toric link and then click ?package insert? what you get is the good ol? SofLens66 Toric. It is the same thing.
Again, what were they thinking?
If I had to hazard a guess I'd suggest that ?someone in marketing? with poor knowledge of the contact lens market made some ?branding decisions? to get all B&L products into nice, tidy little niches.
A big black hole is more like it.
Another situation is that the same CL solutions or lenses sometimes have different names in different regions, not to mention different recommendations for use and replacement frequency.
We recently had a walk-in requesting a SofLens Half-Year, [as per the labelling], for a lens whose NZ equivalent, parameter wise, is a monthly disposable. The immigrant patient got pissed-off with us because we said we could only order them in six-packs. She only wanted to ?buy? one. She thought we were nuts when we recommended one month replacement and would need to do an eye exam to refit her into another lens type. It also wasted fifteen minutes of my time while a pre-booked, fee paying patient was kept waiting.
Argghh x1099
The manufacturers are not doing the CL industry any favours with all this nonsense.
It's driving us nuts and certainly irritates patients - often immigrants or tourists - and adds significant cost to their tight budgets. More often than not we refit them into products from another company, as they lose faith in the one that screwed them around, as do we.
Check out the relevant threads on www.odwire.org for some vitriolic comment from other practitioners relating to these issues.
One more thing that also irritates many: Why, with the Kiwi Dollar at an all time high, do contact lens and solution prices go up? we've had a whole raft of price increases and new price lists in the past few months. Of course some suppliers will roll out the well worn excuse of ?buying forward cover? but it seems to me this only tends to work one way. Cameras and LCD TVs keep coming down with improved Kiwi buying power.
Why don't frames and contact lenses?
There are many aspects to the myriad of topics covered this month. It's a long discussion that we don't have space for in this edition but I'd be interested in how readers feel. No doubt we will revisit some of this in future editions.
In the meantime the Super 14 is certainly getting interesting.
Having the rookie Hamilton tied first in the Formula One Drivers Championship, with three podiums in his first three races, is a stunning effort.

 

 

For more information or any comments email Alan at incontact@optom.co.nz.