PUTTING VIAGRA BACK INTO RGP LENS PRACTICE TONY PHILLIPS

PUTTING VIAGRA BACK INTO PUTTING VIAGRA BACK INTO

RGP LENS PRACTICERGP LENS PRACTICE

TONY PHILLIPSTONY PHILLIPS

THE DEMISE OF RGPs????THE DEMISE OF RGPs????

In the 1990s, Nathan Efron forecast In the 1990s, Nathan Efron forecast the demise of RGP lenses by the year the demise of RGP lenses by the year 2,0002,000

Then 2001, 2002, 2003, 2004 etc, and, Then 2001, 2002, 2003, 2004 etc, and, at the latest count, 2010at the latest count, 2010

Horror of horrors, could he actually be Horror of horrors, could he actually be correct?!correct?!

PHILIP MORGAN - WORLD PHILIP MORGAN - WORLD SURVEY Of PRESCRIBING SURVEY Of PRESCRIBING

HABITSHABITS The number of RGPs prescribed in The number of RGPs prescribed in

the USA is 7%, 8% in the UK and 5% the USA is 7%, 8% in the UK and 5% in Hong Kong.in Hong Kong.

In Australia, the figure is also 5% In Australia, the figure is also 5% with 27% of these being prescribed with 27% of these being prescribed for Ortho-k and around three for Ortho-k and around three quarters of the rest being for refits or quarters of the rest being for refits or where RGPs are essential e.g. where RGPs are essential e.g. keratoconus, post-grafts, trauma, etckeratoconus, post-grafts, trauma, etc

So have we effectively already stopped So have we effectively already stopped prescribing RGPs? Again, has Nathan’s prescribing RGPs? Again, has Nathan’s prediction already come true?prediction already come true?

Yet in New Zealand the prescribing Yet in New Zealand the prescribing rate of RGPs is 23% and in Holland is rate of RGPs is 23% and in Holland is 39%39%

So what is it that they know that we So what is it that they know that we don’t?don’t?

Are we right - or are they???Are we right - or are they???

WHAT I WANT TO COVERWHAT I WANT TO COVER

To remind ourselves why we should be To remind ourselves why we should be prescribing RGPs - and not lose the prescribing RGPs - and not lose the art!art!

Understand why the current situation Understand why the current situation has arisenhas arisen

Finally give you twenty-one ways in Finally give you twenty-one ways in which to improve your RGP practice!which to improve your RGP practice!

THE REASONS FOR THE REASONS FOR PRESCRIBING RGPsPRESCRIBING RGPs

Refitting of existing RGP wearersRefitting of existing RGP wearers Some conditions can ONLY be fitted Some conditions can ONLY be fitted

with RGPs e.g. karatoconics, post-with RGPs e.g. karatoconics, post-grafts, corneal trauma, etc.grafts, corneal trauma, etc.

RGP lenses may be easier to handle RGP lenses may be easier to handle e.g. narrow VIPs, enophthalmics, e.g. narrow VIPs, enophthalmics, babies, etc.babies, etc.

Easier to maintain and last longer Easier to maintain and last longer than many soft lenses.than many soft lenses.


Some patients will get better acuity with Some patients will get better acuity with RGPs e.g. irregular astigmats, uncorrected RGPs e.g. irregular astigmats, uncorrected small cyls in soft lens wearers, etc.small cyls in soft lens wearers, etc. But is this no longer applicable since aspheric But is this no longer applicable since aspheric

SCLs are now available????SCLs are now available????

Nathan Efron - “Modern approaches using Nathan Efron - “Modern approaches using aspheric optical designs result in vision with aspheric optical designs result in vision with soft lenses that is just as sharp as that soft lenses that is just as sharp as that which can be achieved with soft lenses”which can be achieved with soft lenses” Is this true?Is this true?

RGPs and V.A.RGPs and V.A.

The results of one 2008 study stated:The results of one 2008 study stated:

“… “…the fitting of aspheric design soft the fitting of aspheric design soft contact lenses does NOT result in superior contact lenses does NOT result in superior visual acuity, aberration control or visual acuity, aberration control or subjective appreciation compared with subjective appreciation compared with equivalent spherical soft lenses” and –equivalent spherical soft lenses” and –

“…“….all indicate that the aspheric abberation-.all indicate that the aspheric abberation-controlled design actually reduces vision”controlled design actually reduces vision”

And who said this????And who said this????

The man himself!The man himself!

RGPs and VARGPs and VA

In conclusion on VA and the aspheric lens debate, In conclusion on VA and the aspheric lens debate, Trusit Dave stated in the BCLA journal, 2008:Trusit Dave stated in the BCLA journal, 2008:

““If the patient has a high refractive error, spherical If the patient has a high refractive error, spherical aberration will play an important role in visual aberration will play an important role in visual blur. However, in higher prescriptions also be blur. However, in higher prescriptions also be aware that other factors such as lens movement aware that other factors such as lens movement and rotation will also play a significant role in and rotation will also play a significant role in vision quality. vision quality. Currently, lenses that are designed Currently, lenses that are designed to correct spherical aberration have to correct spherical aberration have notnot been been shown to be more effective than conventional shown to be more effective than conventional spherical lensesspherical lenses””

By implication, RGP’s will provide better visual By implication, RGP’s will provide better visual quality than most soft lensesquality than most soft lenses

VA and RGPsVA and RGPs

Refractive Surgeon, Dr B Allan, writing in the Refractive Surgeon, Dr B Allan, writing in the UK journal ‘Optometry Today’ (2008) stated:UK journal ‘Optometry Today’ (2008) stated:

““The best qualitative approximation of what The best qualitative approximation of what patients can expect from their vision post-patients can expect from their vision post-LASIK is what they can see in soft contact LASIK is what they can see in soft contact lenses. Most post-LASIK patients do not have lenses. Most post-LASIK patients do not have zero refractive error and it is important to zero refractive error and it is important to emphasise that some sharpness may be lost. emphasise that some sharpness may be lost. This is particularly important for RGP This is particularly important for RGP wearerswearers””

REASONS FOR PRESCRIBING REASONS FOR PRESCRIBING RGPsRGPs

RGP lenses perform better RGP lenses perform better physiologically because there is:physiologically because there is: Less corneal coverageLess corneal coverage Better retro-lens tear flowBetter retro-lens tear flow Often greater oxygen permeabilityOften greater oxygen permeability

Often better and sometimes the only Often better and sometimes the only alternative in cases such as GPC, alternative in cases such as GPC, recurrent SEALs, marginal dry eye, recurrent SEALs, marginal dry eye, etc.etc.

RGPs & ADVERSE RGPs & ADVERSE REACTIONSREACTIONS

Annual incidence of microbial keratitis in different Annual incidence of microbial keratitis in different lens typeslens types

RGPs & ADVERSE RGPs & ADVERSE REACTIONSREACTIONS

Insight, September, 2008:Insight, September, 2008:““Online/mail order purchase of contact Online/mail order purchase of contact

lenses carries five times the risk (of lenses carries five times the risk (of microbial keratitis): 2 Studies”microbial keratitis): 2 Studies”

Nathan Efron - textbook: “The Nathan Efron - textbook: “The incidence of virtually all forms of adverse incidence of virtually all forms of adverse physiological events is lower in RGP lenses physiological events is lower in RGP lenses versus soft lenses”.versus soft lenses”.


RGP wearers appreciate the skill involved RGP wearers appreciate the skill involved and become loyal, happy patientsand become loyal, happy patients

Alan Saks writing in Insight, September, Alan Saks writing in Insight, September, 2008 wrote:2008 wrote:

““Most days I see at least one long-term RGP Most days I see at least one long-term RGP wearer with at least thirty to forty years of wearer with at least thirty to forty years of very successful hard/RGP wear. They are very successful hard/RGP wear. They are generally some of the most trouble-free, generally some of the most trouble-free, loyal and happy patients one can ever loyal and happy patients one can ever hope to see. They make going to work a hope to see. They make going to work a pleasure”pleasure”


RGP wearers rarely, if ever, reorder RGP wearers rarely, if ever, reorder through the internetthrough the internet

RGP bifocal and multifocal lenses RGP bifocal and multifocal lenses generally give better results in terms generally give better results in terms of clarity.of clarity.


RGPs can be repolished or modified in RGPs can be repolished or modified in power within small limitspower within small limits

A good knowldge of RGPs is essential if A good knowldge of RGPs is essential if you contemplate doing ortho-k workyou contemplate doing ortho-k work As ancillary to this, if ortho-k is shown to slow As ancillary to this, if ortho-k is shown to slow

down or stop the progression of myopia it will down or stop the progression of myopia it will hugely take off.hugely take off.

Holden - approximately 30% of the world’s Holden - approximately 30% of the world’s population are myopic (1.92 billion)population are myopic (1.92 billion)


RGPs are less affected by dryness and RGPs are less affected by dryness and blinking:blinking:

Edwards (2008)”The current investigation Edwards (2008)”The current investigation showed that the tear film evaporation with soft showed that the tear film evaporation with soft contact lenses in situ is significantly higher than contact lenses in situ is significantly higher than that from the bare optical surface”that from the bare optical surface”

Tomlinson (1994) “The reduction in visual Tomlinson (1994) “The reduction in visual performance induced by the blink during soft performance induced by the blink during soft toric lens wear appears to last longer than that toric lens wear appears to last longer than that produced in RGP lens wear”produced in RGP lens wear”

SO WHY HAS THE PROBLEM SO WHY HAS THE PROBLEM ARISEN?ARISEN?

Inadequate University teachingInadequate University teaching Difficulty in Universities getting Difficulty in Universities getting

appropriate patientsappropriate patients Laboratories like volume and the Laboratories like volume and the

simpler lens type the bettersimpler lens type the better Optometrists’ fear of charging Optometrists’ fear of charging

reasonable fees for their timereasonable fees for their time The longer adaptation period for The longer adaptation period for

RGPsRGPs

SO WHY HAS THE PROBLEM SO WHY HAS THE PROBLEM ARISEN?ARISEN?

Patient pressurePatient pressure

Perceived as quicker and easier for Perceived as quicker and easier for practitioners and, particularly,:practitioners and, particularly,:

if their own RGP knowledge is rather if their own RGP knowledge is rather mediocre and/or they don’t have mediocre and/or they don’t have appropriate fitting sets and appropriate fitting sets and equipment.equipment.

FEESFEES

In Jim Kokkinakis’s excellent In Jim Kokkinakis’s excellent article in Mivision (March, article in Mivision (March, 2009) he pointed out that the 2009) he pointed out that the sales economy is hour glass sales economy is hour glass shaped:shaped:

The top 60% of the market The top 60% of the market seek quality over costseek quality over cost

The lower 37% are cost driven The lower 37% are cost driven andand

3% are internet purchasers3% are internet purchasers Very few are in the middle!Very few are in the middle!

FEESFEES

The bottom part of the hour glass is divided The bottom part of the hour glass is divided between the large corporations since all they can between the large corporations since all they can advertise is how cheap they are. The quality of advertise is how cheap they are. The quality of

the eye examination is the eye examination is not vital to most patients.not vital to most patients. Volume is paramountVolume is paramount The larger, top end of The larger, top end of the hour glass expect athe hour glass expect a high standard of carehigh standard of care and represent a golden and represent a golden opportunity for specialist, opportunity for specialist, professional imageprofessional image practice including RGP fitting.practice including RGP fitting.

SO WHAT CAN BE DONE TO SO WHAT CAN BE DONE TO IMPROVE THINGS?IMPROVE THINGS?

More help/enthusiasm from the Universities with More help/enthusiasm from the Universities with undergrad and post-grad courses. More RGP undergrad and post-grad courses. More RGP clinical workclinical work

More help from the CCLSA e.g. travelling post-grad More help from the CCLSA e.g. travelling post-grad courses on RGPscourses on RGPs

Development of better wetting materials etc. by Development of better wetting materials etc. by labslabs

Awareness by practitioners that it is their own Awareness by practitioners that it is their own interest to learn more on the subject e.g. CCLSA interest to learn more on the subject e.g. CCLSA Fellowship, and to acquire the necessary Fellowship, and to acquire the necessary equipment and fitting sets equipment and fitting sets

IMPROVING YOUR RGP IMPROVING YOUR RGP PRACTICEPRACTICE

WHAT YOU CAN DO WHAT YOU CAN DO NOW!!NOW!!

1. Improve your knowledge!1. Improve your knowledge!

How many of you have read a recent How many of you have read a recent text-book or current paper(s) on RGP text-book or current paper(s) on RGP fitting?fitting?

There are several good text-books on There are several good text-books on the market (well, at least one!)the market (well, at least one!)

2. Understand how to write a 2. Understand how to write a prescription properly!prescription properly!

Please supply:Please supply:

R. C3/7.80:8.30/8.50:8.80/9.90:9.80 -6.50DR. C3/7.80:8.30/8.50:8.80/9.90:9.80 -6.50D

Green XO ct 0.15 FOZD 7.40 Green XO ct 0.15 FOZD 7.40

et 0.16 – 018et 0.16 – 018

VWB Engrave ‘R’ and ‘XO’VWB Engrave ‘R’ and ‘XO’

3. Understand how to 3. Understand how to manipulate the ‘numbers’ to manipulate the ‘numbers’ to

achieve what you wantachieve what you want

With very little practice you can With very little practice you can understand how to change the curves understand how to change the curves and diameters to achieve what you and diameters to achieve what you want.want.

Those attending the workshop will be Those attending the workshop will be experts by the time they leave!experts by the time they leave!

4. Reject the obvious potential 4. Reject the obvious potential failures in the first place!failures in the first place!

High cyls but spherical corneasHigh cyls but spherical corneas

Those with corneal cyls but little or no Those with corneal cyls but little or no refractive cylrefractive cyl

Those who work in very dusty Those who work in very dusty atmospheresatmospheres

Those who spend a great deal of their time Those who spend a great deal of their time doing contact sportsdoing contact sports

Those who want intermittent wear onlyThose who want intermittent wear only

5. Use the Correct 5. Use the Correct TerminologyTerminology

The correct or incorrect use of wording can The correct or incorrect use of wording can have a major effect on the patient’s have a major effect on the patient’s perception.perception.

Andrew Hogan in Optometry Pharma, 2008:Andrew Hogan in Optometry Pharma, 2008:

“… “… practitioners who see patients with practitioners who see patients with central serous chorioretinopathy should central serous chorioretinopathy should consider recommending that they cease consider recommending that they cease taking sildenafil (Viagra) which will, of taking sildenafil (Viagra) which will, of course, be a hard decision”course, be a hard decision”

Use the Correct Use the Correct TerminologyTerminology

Imagine if you said to a patient:Imagine if you said to a patient:

““Your first choice is a soft lens. Compared to the Your first choice is a soft lens. Compared to the alternative, these are:alternative, these are:

Rather slippery, somewhat slimyRather slippery, somewhat slimy Will give you a slightly poorer standard of visionWill give you a slightly poorer standard of vision Will be more expensive to wearWill be more expensive to wear Will significantly increase your chance of a serious Will significantly increase your chance of a serious

infectioninfection Are more difficult to handle than the alternativesAre more difficult to handle than the alternatives Will tend to dry out more easily,” etcWill tend to dry out more easily,” etc

How many would go for them?!!!How many would go for them?!!!

Use the Correct Use the Correct TerminologyTerminology

Avoid the word ‘Hard’Avoid the word ‘Hard’

Even avoid the use of the word ‘Rigid’Even avoid the use of the word ‘Rigid’

Just talk about ‘Gas Permeable’ or ‘GP’ Just talk about ‘Gas Permeable’ or ‘GP’ lenseslenses

If necessary, just say that GP lenses are like If necessary, just say that GP lenses are like soft lenses but just a more rigid material soft lenses but just a more rigid material and with specific advantagesand with specific advantages

6. If in doubt?6. If in doubt?

Start with an RGP lens first. It’s much harder going Start with an RGP lens first. It’s much harder going from a soft to an RGP than vice versa!from a soft to an RGP than vice versa!

Also, most RGP wearers, if they are going to fail will Also, most RGP wearers, if they are going to fail will usually fail in the first month whereas SCL wearers usually fail in the first month whereas SCL wearers may take many months to show up as failures (e.g. may take many months to show up as failures (e.g. from mediocre VA, marginal dry eye, unstable from mediocre VA, marginal dry eye, unstable toric, etc)toric, etc)

Better to start with an RGP and fail quickly than Better to start with an RGP and fail quickly than have problems cropping up along the way over the have problems cropping up along the way over the next two years with soft lenses before they give upnext two years with soft lenses before they give up

7. Use an anaesthetic at the 7. Use an anaesthetic at the fitting appointmentfitting appointment

The urban myth is that this gives a false The urban myth is that this gives a false impression and can lead to corneal damageimpression and can lead to corneal damage

Purslow et al, BCLA Jnl 2008 concluded that ;Purslow et al, BCLA Jnl 2008 concluded that ;

“ “The use of Proxymetacaine prior to lens fitting The use of Proxymetacaine prior to lens fitting had no significant effect on redness or had no significant effect on redness or corneal staining compared to a placebo drop corneal staining compared to a placebo drop and subjects prefer its use for the procedure”and subjects prefer its use for the procedure”

Use an anaesthetic at the Use an anaesthetic at the fitting appointmentfitting appointment

Ed Bennett and Cristina Schnider, CL Ed Bennett and Cristina Schnider, CL Spectrum 1993:Spectrum 1993:

““A study performed at the Pacific University A study performed at the Pacific University College of Optometry showed that… no College of Optometry showed that… no significant physiological problems resulted significant physiological problems resulted from the use of one drop of Proparacaine from the use of one drop of Proparacaine prior to lens application at the fitting visit. prior to lens application at the fitting visit. In addition, subjects who received the In addition, subjects who received the anaesthetic seemed to adapt more rapidly anaesthetic seemed to adapt more rapidly to their lenses to their lenses and to display a more and to display a more positive outlook throughout the first month positive outlook throughout the first month of lens wearof lens wear.”.”

8. Generally, go larger in Total 8. Generally, go larger in Total DiameterDiameter

Initial comfort is often better with a Initial comfort is often better with a larger TD lenslarger TD lens

Choice of diameterChoice of diameter

Lindsay and Bruce recommend choosing the TD Lindsay and Bruce recommend choosing the TD according to the lid positionaccording to the lid position

As most eyelids cover the upper part of the cornea As most eyelids cover the upper part of the cornea and are level or slightly below the lower limbus, and are level or slightly below the lower limbus, most corneas allow a larger TD to be selected.most corneas allow a larger TD to be selected.

Choice of Total DiameterChoice of Total Diameter

As stated before:As stated before:

Go for the largest TD possibleGo for the largest TD possible Aim for lid attachment if possibleAim for lid attachment if possible Consider the effect of the eyelidsConsider the effect of the eyelids

9. Fitting Sets9. Fitting Sets

From the foregoing it will be essential to have:From the foregoing it will be essential to have: at least three TD sets e.g. 9.50, 10.00 and at least three TD sets e.g. 9.50, 10.00 and

10.50mm diameters10.50mm diameters Toric sets e.g. 0.4 mm toricityToric sets e.g. 0.4 mm toricity With time, sets of different BVPs and e valuesWith time, sets of different BVPs and e values

And, most importantly:And, most importantly:

Know Know ALLALL the lens parameters and check the lens parameters and check them for accuracythem for accuracy

10. Ensure the lens edge 10. Ensure the lens edge shape is optimalshape is optimal

The ideal edge should be rounded with a The ideal edge should be rounded with a tapered front surface (Donna La Hood, tapered front surface (Donna La Hood, 1988).1988).

A rounded front surface is more important A rounded front surface is more important than a rounded back surface or squarethan a rounded back surface or square edgeedge

Ensure the lens edge shape is Ensure the lens edge shape is optimaloptimal

A very simple quick way to check an A very simple quick way to check an edge is with a piece of plasticene edge is with a piece of plasticene pressed into a cube and your slit-pressed into a cube and your slit-lamp on the highest magnification.lamp on the highest magnification.

Ensure the lens edge shape is Ensure the lens edge shape is optimaloptimal

11. Specify and check the 11. Specify and check the centre and edge thicknessescentre and edge thicknesses

Look up ct in tables and check!Look up ct in tables and check!

12. Don’t err on the tight 12. Don’t err on the tight sideside

Go for alignment or slightly steep Go for alignment or slightly steep (but not a ‘tight’ edge!)(but not a ‘tight’ edge!)

Don’t err on the tight sideDon’t err on the tight side

Remember, a steep lens is not Remember, a steep lens is not necessarily a tight lens!necessarily a tight lens!

13. Get the correct Axial Edge 13. Get the correct Axial Edge ClearanceClearance

Garry Andrasko in C L Spectrum (1989):Garry Andrasko in C L Spectrum (1989):

Tricurves with narrow peripheral curves Tricurves with narrow peripheral curves are more comfortable than bicurves or are more comfortable than bicurves or tricurves with wide peripheral curvestricurves with wide peripheral curves

Lenses with high axial edge lift (> Lenses with high axial edge lift (> 0.15mm) are less comfortable than lenses 0.15mm) are less comfortable than lenses with a low edge lift (0.08mm)with a low edge lift (0.08mm)

Blended lenses are more comfortable than Blended lenses are more comfortable than non-blended lensesnon-blended lenses

14. Lenticulate14. Lenticulate

As a general rule, lenticulate all lenses over As a general rule, lenticulate all lenses over + and – 5.00D+ and – 5.00D

A lens of TD 9.80mm and BVP +7.00D would A lens of TD 9.80mm and BVP +7.00D would be 0.41mm in ct if non-lenticulated but be 0.41mm in ct if non-lenticulated but 0.26mm ct if ordered with an FOZD of 0.26mm ct if ordered with an FOZD of 7.00, i.e. 60% thinner.7.00, i.e. 60% thinner.

This is significantly more comfortable and This is significantly more comfortable and provides significantly better oxygen provides significantly better oxygen transmissiontransmission

15. Mimic any former lens 15. Mimic any former lens designdesign

It is often tempting to go to a ‘modern’ It is often tempting to go to a ‘modern’ fitting or your favourite design when fitting or your favourite design when refitting an existing RGP or PMMA wearer.refitting an existing RGP or PMMA wearer.

By all means try to head in that direction but By all means try to head in that direction but generally speaking try to mimic what they generally speaking try to mimic what they already have.already have.

Bear in mind the effect of improved oxygen Bear in mind the effect of improved oxygen transmission on corneal shape however!transmission on corneal shape however!

16. Don’t get them back for 16. Don’t get them back for the first after-care too quick!the first after-care too quick!

Warn patients that there IS an adaptive Warn patients that there IS an adaptive periodperiod

Warn them that this can be very variable Warn them that this can be very variable between individualsbetween individuals

That That initialinitial adaptation will take two or three adaptation will take two or three weeks and sometimes a little longer to weeks and sometimes a little longer to completely forget that they’re in their eyescompletely forget that they’re in their eyes

Whilst telling them to report any obvious Whilst telling them to report any obvious symptoms, don’t get them back for after-care symptoms, don’t get them back for after-care in under two weeks. All they’ll do is whinge!in under two weeks. All they’ll do is whinge!

17. Stress hygiene and 17. Stress hygiene and cleaningcleaning

Good hygeine is, of course, essential Good hygeine is, of course, essential with any form of contact lens.with any form of contact lens.

The pitfalls of soft lens wear (dryness, The pitfalls of soft lens wear (dryness, GPC, etc.) can be avoided by good GPC, etc.) can be avoided by good cleaning and, particularly, the use of cleaning and, particularly, the use of Progent, say monthlyProgent, say monthly

18. Consider surface treated 18. Consider surface treated lenseslenses

The use of surface treated materials is The use of surface treated materials is equivocal but may help in certain equivocal but may help in certain cases.cases.

Remember that they cannot be Remember that they cannot be repolished or changed in power in repolished or changed in power in most cases.most cases.

19. Do over K’s where 19. Do over K’s where necessary to check for lens necessary to check for lens

flexureflexure

This can affect VA’s and may indicate This can affect VA’s and may indicate the need for a toric design, especially the need for a toric design, especially in against-the-rule corneasin against-the-rule corneas

In with-the-rule corneas go slightly In with-the-rule corneas go slightly flatter if the lens flexes flatter if the lens flexes

In both cases the lens ct may need to In both cases the lens ct may need to be increased slightlybe increased slightly

20. Fees!20. Fees!

Charge an appropriate fee for all your Charge an appropriate fee for all your time, skill, equipment, ancillary staff. time, skill, equipment, ancillary staff. You’re worth it!You’re worth it!

And remember, soft lenses wearers And remember, soft lenses wearers are for now, RGP wearers are for are for now, RGP wearers are for ever!ever!

20. Fees20. Fees

Remember that poor fitting fees is one Remember that poor fitting fees is one of the main reasons for the low of the main reasons for the low recommendation of contact lenses in recommendation of contact lenses in this countrythis country

You need to cover the fitting session, You need to cover the fitting session, the instruction session and at least the instruction session and at least three after-cares i.e. around $3 - three after-cares i.e. around $3 - 400400

21. Don’t pre-judge!21. Don’t pre-judge!

Keith Edwards (BCLA Jnl. 2002) tested a new Keith Edwards (BCLA Jnl. 2002) tested a new B & L RGP design on 51 subjects:B & L RGP design on 51 subjects:

96% wore the lenses successfully96% wore the lenses successfully

Two drop-outs were former soft lens Two drop-outs were former soft lens wearerswearers

Two dropped out for visual problems Two dropped out for visual problems (lenticular astigmatism - but the research (lenticular astigmatism - but the research protocol did not prevent their exclusion)protocol did not prevent their exclusion)


Johnson and Schnider (1991) Int. C L Clin. Johnson and Schnider (1991) Int. C L Clin. carried out a cross-over study where one carried out a cross-over study where one group of new patients were fitted with RGP group of new patients were fitted with RGP lenses and the other half with soft lenses. lenses and the other half with soft lenses. At the end of six weeks they were swapped At the end of six weeks they were swapped over.over.

In a forced choice, 60% preferred the soft In a forced choice, 60% preferred the soft lenses and 40% the RGPs. However, 35% lenses and 40% the RGPs. However, 35% also wore the RGPs quite successfully in also wore the RGPs quite successfully in terms of vision and comfort and could have terms of vision and comfort and could have worn either. In other words, 75% of the worn either. In other words, 75% of the group could have successfully worn the RGP group could have successfully worn the RGP lenses and 40% actually preferred themlenses and 40% actually preferred them


They further noted:They further noted:

That all subjects preferred the RGPs for VAThat all subjects preferred the RGPs for VA

That all subjects preferred the RGPs for That all subjects preferred the RGPs for handling and cleaning simplicityhandling and cleaning simplicity

That the preference figure for RGPs of 40% That the preference figure for RGPs of 40% would undoubtedly have risen if the trial would undoubtedly have risen if the trial had extended beyond six weekshad extended beyond six weeks

IN SUMMARYIN SUMMARY

Improve your knowledgeImprove your knowledge Understand how to write prescriptions properly - Understand how to write prescriptions properly -

and do it!and do it! Understand how to manipulate the numbersUnderstand how to manipulate the numbers Reject the obvious in the first placeReject the obvious in the first place Use the correct terminology with the patientUse the correct terminology with the patient If in doubt, start with an RGPIf in doubt, start with an RGP Use an anaesthetic at the fitting appointmentUse an anaesthetic at the fitting appointment Use a largish TD where possibleUse a largish TD where possible Make sure you have adequate and known fitting Make sure you have adequate and known fitting

setssets Ensure the edge shape is optimalEnsure the edge shape is optimal

IN SUMMARYIN SUMMARY

Specify and check the ct and etSpecify and check the ct and et Don’t err on the tight sideDon’t err on the tight side Ensure the correct aecEnsure the correct aec Lenticulate where appropriateLenticulate where appropriate Mimic any former lens designMimic any former lens design Don’t get them back too quickDon’t get them back too quick Stress hygiene and cleaningStress hygiene and cleaning Consider surface treated materialsConsider surface treated materials Do over-k’s where necessaryDo over-k’s where necessary Charge appropriate feesCharge appropriate fees Don’t pre-judgeDon’t pre-judge

CONCLUSIONCONCLUSION

So is it really worth going to all this trouble?So is it really worth going to all this trouble?

van der Worp (2002) stated:van der Worp (2002) stated:

““Even small improvements in Even small improvements in RGP fits influenced comfort of RGP fits influenced comfort of wear significantly. It shouldwear significantly. It should be noted that this could be noted that this could potentially lead to drop outpotentially lead to drop out among patients among patients with acceptablewith acceptable but not optimal fits”but not optimal fits”

CONCLUSIONCONCLUSION

Brad Giedo in CL Spectrum, 2008Brad Giedo in CL Spectrum, 2008

““If you are truly an advocate of GP lenses and you If you are truly an advocate of GP lenses and you believe the positive things that you tell your believe the positive things that you tell your patients about them, then you need to be willing patients about them, then you need to be willing to present GPs as a to present GPs as a firstfirst option. In my experience option. In my experience this is not how most of you practice so I challenge this is not how most of you practice so I challenge you to make a conscious effort to include GPs you to make a conscious effort to include GPs when you consider your initial lens selection. when you consider your initial lens selection. Resist the urge to simply default to soft lenses. Resist the urge to simply default to soft lenses. You will find that there are many more You will find that there are many more opportunities to fit GP lenses than you thought opportunities to fit GP lenses than you thought possible and you and your patients will be better possible and you and your patients will be better for it.”for it.”

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PUTTING VIAGRA BACK INTO RGP LENS PRACTICE TONY PHILLIPS