Contact Lens Contact Lens Options for Options for

the Non-the Non-Traditional Traditional

PatientPatientShane R. Kannarr, O.D.Shane R. Kannarr, O.D.

Non-Traditional Non-Traditional Patients Patients

forforContactsContacts

Dry Eye SuffererDry Eye Sufferer

AstigmaticAstigmatic

PresbyopePresbyope

Young MyopeYoung Myope

Non-Compliant PatientsNon-Compliant Patients

BenefitsBenefitsof of

Fitting Fitting the the

PatientsPatients

Patient SatisfactionPatient Satisfaction

LoyaltyLoyalty

Practice BuildersPractice Builders 34 Million current wearers34 Million current wearers 12 million new fits12 million new fits 11 million drop outs11 million drop outs

PROFITABILITYPROFITABILITY

Contact Lens Fits by TypeContact Lens Fits by Type

SVS64%

Colors10%

Toric20%

Multifocl6%

SegmentSegment TrendTrend

Total LensesTotal Lenses +7%+7% SVSSVS +4%+4% ToricToric +11%+11% MultifocalMultifocal +25%+25% ColorsColors +6%+6%

Specialty lenses are driving the Specialty lenses are driving the category growth category growth

Higher margin --> higher profitsHigher margin --> higher profits

Source: HPR 1H 2003

Wearers ConsiderersTop Tier

Give me excellent vision 83 88Comfortable to wear all day long 81 87Designed to meet my specific vision correction needs81 85

Middle TierEasy to insert and remove 60 75Healthiest for the eyes 65 75Durable 58 67Convenient to care for 50 64Keep eyes moist 49 60Allow the most oxygen to reach my eyes 49 59Specially designed for those with sensitive eyes or allergies 22 48Provide protection against ultraviolet (UV) rays 30 45Reasonably priced 44 43A brand I can trust 35 43Recommended by my eye doctor 38 41

Bottom TierAvailable for purchase at many types of locations 25 33Can sleep in them without problems 25 32A well known brand 13 20Available in the best colors to enhance or change my eye color 9 15

Comfort and Vision are Top Benefits for both Comfort and Vision are Top Benefits for both Current Contact Lens Wearers and ConsiderersCurrent Contact Lens Wearers and Considerers

(% Absolutely Critical — Top (% Absolutely Critical — Top Box)Box)

Source: Vistakon Attitude and Usage Study of Vision Corrected Consumers 2002

Dry EyeDry Eye

Today’s Today’s Choices…Choices…

ACUVUE® ADVANCE™ with HYDRACLEAR™

Revolutionary Technology Revolutionary Technology Exceptional Long Lasting ComfortExceptional Long Lasting Comfort

HYDRACLEARHYDRACLEAR™™

ACUVUEACUVUE®® ADVANCE ADVANCE™™ with with HYDRACLEARHYDRACLEAR™™

ACUVUEACUVUE®® ADVANCE ADVANCE™™ with with HYDRACLEARHYDRACLEAR™ ™

A new generation in A new generation in DAILY WEARDAILY WEAR

The outstanding initial comfort of a hydrogel lensThe outstanding initial comfort of a hydrogel lens Exceptional end of day comfort that outlasts the Exceptional end of day comfort that outlasts the

competitioncompetition

Uncompromized visual acuity of theACUVUE® Uncompromized visual acuity of theACUVUE® BrandBrand

Oxygen delivery and lens properties that help Oxygen delivery and lens properties that help keep eyes as white as with no lenses keep eyes as white as with no lenses

ACUVUEACUVUE®® ADVANCE ADVANCE™™ with with HYDRACLEARHYDRACLEAR™ ™

A new generation in A new generation in DAILY WEARDAILY WEAR

The outstanding initial comfort of a hydrogel lensThe outstanding initial comfort of a hydrogel lens Exceptional end of day comfort that outlasts the Exceptional end of day comfort that outlasts the

competitioncompetition

Uncompromized visual acuity of theACUVUE® Uncompromized visual acuity of theACUVUE® BrandBrand

Oxygen delivery and lens properties that help Oxygen delivery and lens properties that help keep eyes as white as with no lenses keep eyes as white as with no lenses

Acuvue AdvanceAcuvue Advance

Silicon LensSilicon Lens Hydrogel ComfortHydrogel Comfort High Dk/t=83High Dk/t=83 Daily WearDaily Wear 2 Week Replacement2 Week Replacement Same Design as Acuvue 2Same Design as Acuvue 2

30 Day Lenses Not Just for 30 Day Lenses Not Just for Extended WearExtended Wear

Consider Low Water Contact Consider Low Water Contact LensesLenses

Look at Systemic MedicationsLook at Systemic Medications

(BCP and Antihistamine)(BCP and Antihistamine) Limit Wear TimeLimit Wear Time Use Artificial TearsUse Artificial Tears Consider PlugsConsider Plugs

Astigmatics…Astigmatics…

Not JustNot Justforfor

RGP’sRGP’sAnymoreAnymore

ExpectationsExpectations

Residual Astigmatism Residual Astigmatism (RA)(RA)

RA=Refractive Cylinder-Corneal CylinderRA=Refractive Cylinder-Corneal Cylinder Example on Next SlideExample on Next Slide

>1D consider RGP>1D consider RGP

Example:Example:

Refraction Refraction -3.00 - 2.00 x 180-3.00 - 2.00 x 180

K Readings K Readings 43.00 x 180 / 44.25 x 090 43.00 x 180 / 44.25 x 090

For Our Purposes:For Our Purposes:

2 – 1.25 = .752 – 1.25 = .75

(RGP probably not needed.) (RGP probably not needed.)

““LARS RULE”LARS RULE”

Left Rotation AddLeft Rotation Add

Right Rotation SubtractRight Rotation Subtract

From your vantage pointFrom your vantage point

Each clock hour = 30 degreesEach clock hour = 30 degrees

ExampleExample

Trial Lens:Trial Lens: -3.00-1.25x090----OD rotates 20 degrees left-3.00-1.25x090----OD rotates 20 degrees left -3.00-1.25x090----OS rotates 20 degrees right-3.00-1.25x090----OS rotates 20 degrees right

NEW TRIALSNEW TRIALS

OD -3.00-1.25x110OD -3.00-1.25x110

OS -3.00-1.25x070OS -3.00-1.25x070

Fuzzy Math…..Fuzzy Math…..

Soft Soft ContactContact

LensLensOptionsOptions

A. Less than -3.00 A. Less than -3.00 D of CylinderD of Cylinder

Acuvue Advance and Acuvue Advance and PurevisionPurevision

are nice compliments.are nice compliments.

Both are -0.75 to -2.25 Cyl in -Both are -0.75 to -2.25 Cyl in -0.50 Increments.0.50 Increments.

Both are Axis 0 to 180 in 10 Both are Axis 0 to 180 in 10 Degrees Increments.Degrees Increments.

Good Stability.Good Stability. 2 Week to 1 Month Replacement. 2 Week to 1 Month Replacement.

Avg. Sale Price/Box $42-45Avg. Sale Price/Box $42-45

Profit / Patient / Year =$93.00/$186Profit / Patient / Year =$93.00/$186 Let Patients See the Improved Vision Let Patients See the Improved Vision

for Themselves.for Themselves. Up to -3.25 D of Cyl use Spherical Up to -3.25 D of Cyl use Spherical

Equivalent for Remainder.Equivalent for Remainder. (example on next slide)(example on next slide) Other Options: Other Options:

Frequency 55 Toric/Vertex ToricFrequency 55 Toric/Vertex Toric

ExampleExample

Refraction:Refraction: -2.00 -3.25 x 090-2.00 -3.25 x 090

Closest Lens:Closest Lens: -2.00 -2.25 x 090-2.00 -2.25 x 090

Uncorrected Astigmatism (UA)Uncorrected Astigmatism (UA)

-3.25 – 2.25 = 1.00D-3.25 – 2.25 = 1.00D

Spherical Equivalent of UASpherical Equivalent of UA

--1.00 / 2 = -0.501.00 / 2 = -0.50

Add to Sphere of RefractionAdd to Sphere of Refraction

-2.00 – 0.50 = -2.50-2.00 – 0.50 = -2.50

New Contact Script = -2.50-2.25x090New Contact Script = -2.50-2.25x090

B.B.Greater than Greater than

-3.50D of Cylinder-3.50D of Cylinder

UCL, Sunsoft Toric, and UCL, Sunsoft Toric, and Preference Work Well TogetherPreference Work Well Together

Parameters Sphere:+20.00/20.00Parameters Sphere:+20.00/20.00 Cylinder:7DCylinder:7D Axis is in 5 Degrees StepsAxis is in 5 Degrees Steps Educate Patient about Possible Educate Patient about Possible

Fluctuations in VisionFluctuations in Vision Order with warrantyOrder with warranty

********************IMPORTANTIMPORTANT********************

Charge for your TIMECharge for your TIME

Can not use standard multiplierCan not use standard multiplier

Patient Satisfaction=Practice Patient Satisfaction=Practice BuilderBuilder

C. Rigid Lens C. Rigid Lens OptionsOptions

Front Surface Toric: Front Surface Toric: Correction on the front of the Correction on the front of the

lenslensLow Residual AstigmatismLow Residual Astigmatism

Back Surface Toric:Back Surface Toric:Back of lens shaped to match Back of lens shaped to match

corneacorneaHigh Residual AstigmatismHigh Residual Astigmatism

Excellent VisionExcellent Vision Comfort is the IssueComfort is the Issue

PresbyopePresbyope

No One likes Growing No One likes Growing OLDOLD

A. MonovisionA. Monovision

Start the Patient Early in Start the Patient Early in PresbyopiaPresbyopia

Educate the Adaptation TimeEducate the Adaptation Time Start with the Non-Dominate Eye Start with the Non-Dominate Eye

as Near as Near (may switch)(may switch) Return the Patient in 7-14 DaysReturn the Patient in 7-14 Days Manage ExpectationsManage Expectations

NO Contact Lens SaluteNO Contact Lens Salute Cost Effective for the PatientCost Effective for the Patient

(any single vision lens will work)(any single vision lens will work) No Intermediate as Presbyopia No Intermediate as Presbyopia

ProgressesProgresses Trouble in Low Light ConditionsTrouble in Low Light Conditions Trouble over 2.00 D of addTrouble over 2.00 D of add

KEY POINTSKEY POINTS

Will require chair timeWill require chair time Inexpensive to patientInexpensive to patient Easier to start early in presbyopiaEasier to start early in presbyopia Patients are happy that lens cost doesn’t Patients are happy that lens cost doesn’t

increaseincrease Works for the majority of the patientWorks for the majority of the patient Decrease Depth perceptionDecrease Depth perception (consider 3(consider 3rdrd lens) lens)

B. Soft Contact B. Soft Contact BifocalsBifocals

Usually Provides All Ranges of Usually Provides All Ranges of VisionVision

Comfort Over Rigid LensComfort Over Rigid Lens Maintain Stereo VisionMaintain Stereo Vision Works at All Add PowersWorks at All Add Powers Can be CostlyCan be Costly Some Report Constant BlurSome Report Constant Blur

Halos at NightHalos at Night Let Lens Settle Before Let Lens Settle Before

RecheckingRechecking 10-15 minutes is good10-15 minutes is good

Manage ExpectationsManage Expectations Return to Check After WearingReturn to Check After Wearing Use Trial LensesUse Trial Lenses

** Great Options ** Great Options ****

Multifocal Market by Multifocal Market by BrandBrand

In only 9 months, In only 9 months, SofLens Multi-Focal is SofLens Multi-Focal is the the fastest fastest growing growing product in the product in the category. category.

Multifocal SharesMultifocal Shares Brand Brand ShareShare

ShareShare vs YAgovs YAgo

Acuvue BifocalAcuvue Bifocal 40.740.7 (21.1)(21.1)

SofLens Multi-FocalSofLens Multi-Focal 34.334.3 +34.3+34.3

Focus ProgressivesFocus Progressives 12.112.1 (13.8)(13.8)

Frequency 55 MultifocalFrequency 55 Multifocal 5.95.9 +4.2+4.2

Dailies ProgressivesDailies Progressives 1.91.9 (0.2)(0.2)Source: HPR Q2:2003

Soflens 66 MultifocalSoflens 66 Multifocal

Base Curve 8.8 / 8/5Base Curve 8.8 / 8/5 Powers:Powers: Add: Low (< +1.75)Add: Low (< +1.75)

High (> +1.75)High (> +1.75) Design:Design: Watch Pupil Size in High AddsWatch Pupil Size in High Adds

Consider Modified MonovisionConsider Modified Monovision Cost / Box:$31.25Cost / Box:$31.25 Avg. Price / Box: $60.00Avg. Price / Box: $60.00 Profit / Patient / Year:$119.00Profit / Patient / Year:$119.00

Exceptional Visual AcuityExceptional Visual Acuity

Natra-SightNatra-SightTMTM Optics Optics Broad near to distance power Broad near to distance power

transition to provide crisp, clear, transition to provide crisp, clear, natural visionnatural vision

Aspheric center-near with broad add Aspheric center-near with broad add profile across optic zoneprofile across optic zone

Equalized Mass DistributionEqualized Mass Distribution

Facilitates lens centration essential for Facilitates lens centration essential for effective functioning of the aspheric effective functioning of the aspheric opticsoptics

SLMF Low ADD

SLMF High ADD

Natra-SightNatra-SightTMTM Optics OpticsNot all aspherics are the sameNot all aspherics are the same

Ciba ProgressivesSingle Steep Add

Power Power ProfilesProfiles

Basic Fitting TipsBasic Fitting Tips

Know the Distance/Near DemandsKnow the Distance/Near DemandsControl ExpectationsControl ExpectationsAdd power <= +1.75/Start with low addAdd power <= +1.75/Start with low addAdd power > +1.75/Start with high addAdd power > +1.75/Start with high addAlways use 8.5 BC with high addAlways use 8.5 BC with high addAspheric Design offsets low amounts of Aspheric Design offsets low amounts of

AstigmatismAstigmatism

Rule of Thumbs for Add Rule of Thumbs for Add PowersPowers

< 47 Low Add in Both eye< 47 Low Add in Both eye > 47 Low Add in Dominate eye> 47 Low Add in Dominate eye

High Add in non Dominate eyeHigh Add in non Dominate eye

Be a little CreativeBe a little Creative

Tailor your fit to your patients needsTailor your fit to your patients needs

Fits for “Normal Fits for “Normal Demands/Distance Demands/Distance Demands”Demands”

Find PrescriptionFind Prescription Fit on Rx OU/Low Add OUFit on Rx OU/Low Add OU Let Settle 10-15 Minutes Before Let Settle 10-15 Minutes Before

CheckingChecking Aim for 20/25 at Distance/20/40+ at NearAim for 20/25 at Distance/20/40+ at Near

RTC 1 week (Patient to bring list of were RTC 1 week (Patient to bring list of were lenses do and do not meet expectations)lenses do and do not meet expectations)

DifficultiesDifficultiesDifficulties with NearDifficulties with Near

Dominate Eye Remains the SameDominate Eye Remains the Same Non Dominate EyeNon Dominate Eye

Distance is Rx + ½ of AddDistance is Rx + ½ of Add

Low AddLow Add

Difficulties with DistanceDifficulties with Distance

Check Over Refraction with Trial LensesCheck Over Refraction with Trial Lenses Look at Base CurveLook at Base Curve

ExampleExample

Refraction -3.00D—OU +2.00 Add—OURefraction -3.00D—OU +2.00 Add—OU OD is DominateOD is Dominate

Initial Fit------- Initial Fit------- -3.00/Low Add OU-3.00/Low Add OU

11stst F/U--------- F/U--------- -3.00/Low OD-3.00/Low OD

-2.00/Low OS-2.00/Low OS

Excessive Near DemandsExcessive Near Demands RefractionRefraction

Week 1 Fit on Refraction OU/Advise ReadersWeek 1 Fit on Refraction OU/Advise Readers

Week 2 Dominate On Rx / Low AddWeek 2 Dominate On Rx / Low Add Non-Dominate On Rx / High Add Non-Dominate On Rx / High Add

Week 3 Add + to Non-Dominate with TrialWeek 3 Add + to Non-Dominate with Trial Lenses until Near is AdequateLenses until Near is Adequate

ExampleExample

Refraction -3.00 OU +2.00 AddRefraction -3.00 OU +2.00 Add OD DominateOD Dominate

Week 1 -3.00/Low OU/ReadersWeek 1 -3.00/Low OU/ReadersWeek 2 OD -3.00/Low OS -3.00/HighWeek 2 OD -3.00/Low OS -3.00/HighWeek 3 OR OS +0.50Week 3 OR OS +0.50

OD -3.00/LowOD -3.00/LowOS -2.50/HighOS -2.50/High

Think before you use High Adds OUThink before you use High Adds OU

FREQUENCY® 55 MULTIFOCAL LENS DESIGN

BC/Diam.: 8.7/14.4 mmBC/Diam.: 8.7/14.4 mm Sphere power: +4.00 to -6.00DSphere power: +4.00 to -6.00D Add:+1.00 (NEW) +1.50, +2.00, +2.50 DAdd:+1.00 (NEW) +1.50, +2.00, +2.50 D Optical DesignOptical Design

D lens for dominant eyeD lens for dominant eye N lens for non dominant eyeN lens for non dominant eye

Handling tint: light blue edge-to-edgeHandling tint: light blue edge-to-edge Packaging: blisters in 6-packs, single Packaging: blisters in 6-packs, single

blister trialsblister trials Modality: recommended for monthly Modality: recommended for monthly

replacementreplacement

FREQUENCYFREQUENCY®® 55 MULTIFOCAL 55 MULTIFOCALPARAMETERSPARAMETERS

FITTING PHILOSOPHYFITTING PHILOSOPHYDetermine Spectacle Rx and Best Vision Sphere.Determine Spectacle Rx and Best Vision Sphere.

▼▼Determine Contact lens power adjusting for vertex distance, if Determine Contact lens power adjusting for vertex distance, if

required.required.▼▼

Determine the dominant eye. Consider fogging with a +2.00 lens Determine the dominant eye. Consider fogging with a +2.00 lens test to determine dominancy.test to determine dominancy.

▼▼Place the “D lens” on the dominant eye and the “N lens” on the Place the “D lens” on the dominant eye and the “N lens” on the non-dominant eye. Wait 10 minutes for the lenses to equilibrate.non-dominant eye. Wait 10 minutes for the lenses to equilibrate.

▼▼Under normal illumination conditions, evaluate visual acuities for Under normal illumination conditions, evaluate visual acuities for

distance and near, first monocularly then binocularlydistance and near, first monocularly then binocularly

Acuity expectations:Acuity expectations:

““D lens” – D lens” – DistanceDistance 20/2020/20

NearNear 20/40 or better20/40 or better

““N lens” – N lens” – NearNear 20/2020/20

DistanceDistance 20/40 or better20/40 or better

Binocularly – Distance Binocularly – Distance 20/2020/20

NearNear 20/2020/20

FITTING PHILOSOPHYFITTING PHILOSOPHY

* Other Options ** Other Options *

Acuvue BifocalAcuvue Bifocal

Ciba ProgressiveCiba Progressive

C. Rigid BifocalsC. Rigid Bifocals

Simultaneous VisionSimultaneous Vision Concentric DesignConcentric Design Translating DesignsTranslating Designs Is Great Vision Trade-Off for Is Great Vision Trade-Off for

Initial Discomfort?Initial Discomfort? Educate the Patient about Educate the Patient about

Adaptation Adaptation (It will get better!)(It will get better!) Lots of Hand-Holding in the Initial Lots of Hand-Holding in the Initial

PhasesPhases

In All Options,In All Options,

Charge AdequatelyCharge Adequately

for Your Time.for Your Time.

Non-CompliantNon-CompliantPatientsPatients

Significant Neo or Corneal Significant Neo or Corneal EdemaEdema

Again Look at 30 Day LensesAgain Look at 30 Day Lenses DK / L ComparisonDK / L Comparison ““Poor Man’s LASIK”Poor Man’s LASIK” LASIKLASIK

RapidlyRapidlyProgressingProgressing

Myope Myope

Young Child -4.00 or AboveYoung Child -4.00 or Above Changing More Than -0.50 D / Changing More Than -0.50 D /

YearYear Fit a Half of a Diopter FlatFit a Half of a Diopter Flat Return to Check at 6 Months /Return to Check at 6 Months /

Watch Cornea and ComfortWatch Cornea and Comfort Inform Patient of Proper Inform Patient of Proper

ExpectationsExpectations Patience, Patience, Patience!Patience, Patience, Patience!