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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 contact
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.
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Learning Objectives:
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Upon completion of this program, the
participant should be able to: |
1. Learn how to shorten your CL fitting time.
2. Identify what is important in the fitting process.
3. Which fittings need longer appointment times?
 Christopher Miller started at
SOLA Optical USA in 1977 as the
Quality Control Department lead
manufacturing CR-39 lenses.
After several optical courses,
Miller became an optician at a
chain retail, then passed both the
ABO and NCLE exams, managed
optical locations and then opened his own optical
boutique. In the Caribbean and South America he
helped several doctors open practices and ran the
government of Guyana’s optical business. In 2002, he
returned to California and now works at a busy HMO
as a contact lens fitter.
Credit: This course is approved for one (1) hour of CE
credit by the National Contact Lens Examiners (NLCE).
Course #CJMI016-1
This CE is also available online at www.2020mag.com
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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 in-office 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.
 Subjective — It’s what the
patient tells you. Did they
like their previous lenses,
how well can they see (visual
acuity) and lens comfort?
Objective — Are your
observations through the
slit lamp; i.e., movement, lid
alignment, tearing, centration
and the Keratometer readings.
Assessment — An overview
of their previous contact lens
history, a needs assessment and
their expectations. This could
be summed up in one or two
short sentences such as “good
soft contact lens candidate” or
“requires J1 near and 20/20 for
driving and computer at work.”
Plan — How it is all put together?
For example: “try modified
monocular-multifocal fitting” or
“SV lenses for best distance V.A.’s
with +2.00 reading glasses.” I list
this information at the end of the
history section.
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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 oneyear
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 followup
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.
Source: 20/20 Magazine.
Published here under license and reprinted with
permission of Jobson Medical Information.
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