Patients with disfigured eyes used to have limited options. They could wear sunglasses or comb their hair over the damaged eye. Or they could try to find an eyecare practitioner who was willing to undergo the long process of ordering a prosthetic lens.

That perception still lingers. Today, however, the ordering process has become nearly as efficient as prescribing most other contact lenses. In this article, which is based on an exclusive roundtable discussion of prosthetic lenses at the 1999 Contact Lens Association of Ophthalmologists (CLAO) in Las Vegas last January, we’ll discuss how you can better meet these troubled patients’ special needs.

Why so few fits?

One of our roundtable panel members was Peter Kastl, M.D., Ph.D., professor of ophthalmology and biochemistry at Tulane University School of Medicine, New Orleans. He elaborated on the biggest obstacle discouraging many doctors from fitting patients in prosthetic lenses.

"I think a lot of practitioners feel that it’s the old way, where they think, ‘Oh, we’re going to have to take a photograph and send it off to Germany somewhere and someday we’ll get a lens back, maybe a year from now.’ That’s the way they still think it’s being done."

Today, however, the ordering process has become nearly as efficient as prescribing cosmetic colored lenses. In large part, a more streamlined approach has been made possible by Wesley Jessen’s 1997 acquisition of the Narcissus Medical and Research Foundation, which until the acquisition was responsible for arranging most prosthetic lens fits.

After the transfer in ownership, Wesley Jessen created the nonprofit Wesley Jessen Special Eyes Foundation, now the nation’s leading maker of prosthetic lenses. Dr. Kastl and three other practitioners who sat in the prosthetic lens roundtable said the new foundation had the resources to customize lenses quickly and relatively inexpensively, using Wesley Jessen’s cosmetic lens technology.

Today, using a menu-like selection sheet, you can check off color, pattern, size and pupil size. Then a Wesley Jessen Special Eyes Foundation consultant will walk you or your staff member through the ordering process. Within 8 weeks, the custom-made prosthetic lens is in hand.

Finding the hidden patients

Researchers are still working to pinpoint the number of people who could benefit from prosthetic lenses. At this point, however, one thing is clear — a significant number of people with disfigurements aren’t even aware of prosthetic lenses.

"It turns out that probably less than 10% of major eye trauma is referred for prosthetic needs," said panel member Timothy T. McMahon, O.D., director of the Contact Lens Service, University of Illinois, Chicago Eye Center. "If you can then back track and extrapolate it for the country, you probably are talking about a relatively small patient base that has benefited from prosthetic lenses."

Because so many disfigurements are associated with eye trauma, doctors affiliated with or located near trauma centers could attract the largest number of these patients. However, prosthetic lenses can also benefit patients with opacification of the cornea secondary to ocular disease, or from congenital ocular conditions.

Fitting more patients in prosthetic contact lenses won’t necessarily enhance your revenue stream. But it will do wonders for your sense of professional fulfillment.

Still, many doctors wonder how they can incorporate prosthetic lens fitting into their practice routines without sacrificing time away from revenue-generating activities. The roundtable panelists addressed this issue, saying they charge a global fee or an exam fee equivalent to what they would charge for a keratoconus patient or other complex fits.

Because most patients have a need for only one prosthetic contact lens, Dr. Kastl said he charged prosthetic lens patients 60% of his specialty contact lens fitting fee.

Michael A. Ward, FCLSA, Director of Contact Lens Service at the Emory Eye Center in Atlanta, said that he didn’t offer the same contact lens guarantee to prosthetic lens patients as he would regular contact lens patients. That protects his practice from patients who continually want to tweak the color of the lens.

Many doctors also have patients sign a waiver that says the practice will try to help them gain reimbursement from an insurance company, but that the patient will ultimately be responsible for payment. Patients often need to pay the cost of either the procedure or the materials — or both.

The real benefits of prosthetics

By organizing your approach to prosthetics in a comfortable, risk-free fashion, you’ll enhance what Dr. McMahon describes as the "secondary gain" of prosthetic fitting. "It enhances our referrals and allows us to give back to humanity," he said.

Leroy G. Meshel, M.D., Daly City, Calif., Medical Director of the Wesley Jessen Special Eyes Foundation, echoed that sentiment as well.

"There’s nothing you’ll ever do in contact lens fitting that will give you or your patient more satisfaction than fitting prosthetic lenses. The derivatives have been great. With the ability to prescribe comes secondary gain in the community."

Ward added that you’ll feel even more satisfied with the ultimate outcome — helping patients who suffer emotionally and physically as a result of the trauma to their eyes.

"A prosthetic lens fitting can be of tremendous value to a patient’s abilities to overcome depression," he added.

Patient motivation is a key to success in prosthetic lenses, because the process does require additional chair time. Karen K. Bator, NCLC, Clinical Coordinator for the Wesley Jessen Special Eyes Foundation, Des Plaines, Ill., said that "motivation to wear prosthetic lenses is higher with the traumatized patient who was normal and wants to be normal again."

Panel members estimated that, once they’ve determined color by using trial lenses, they only need an additional 15 minutes to get ready to order the lens. Some of the practitioners maintain control of the patient throughout the ordering process. Others have technicians work with the patient to achieve a color match.

Dr. Meshel opts for the latter. "The technicians love it. It gives them a kick because it’s an important task, so I see it as an employee management enhancer. I like to get the technicians involved."

Getting started

The roundtable panelists offered these suggestions if you want to fit prosthetic lenses.

• Begin with the easiest cases — dark-eyed patients.
• Obtaining a favorable match for light-eyed patients is getting easier, but success with fitting dark-eyed patients still comes much faster. Also, keep in mind that congenital disfigurements with small children can be more difficult because children’s eyes are smaller.
• Review expectations with the patient.
• "It’s important that the patient understands that you can make his or her eye look better, but that it’s not always a perfect match with the unaffected eye," said Ward. With traumatized eyes, you can’t turn back the clock."

• Dr. McMahon suggested using "diffuse terms when talking to patients about the lenses." He offered this script: "We can improve the appearance or function of your eye." Don’t be specific and say, "We can match your other eye."
• Introduce prosthetic lenses without reservation — and suggest to your referring practitioners that they do the same.
• "You can be pretty direct when asking patients if they’re interested in a prosthetic," said Dr. Kastl. "They’ve gotten used to the scars and have learned to ignore them. While you’re examining the patient, say ‘You know we can get a contact lens that will cover up that scar.’ They’ll respond to that."

• Dr. Meshel agreed, adding that practitioners can’t assume that a patient is bothered or not bothered by a disfigurement.

• "We see patients with horrible problems who are not bothered at all," he said. "Others have a very minor problem and feel like it’s a pimple on the end of the nose that everyone can see. I say to the patient, ‘We have something that might be useful for you’ (whether it’s cosmetic or photophobic). Then I’ll present the prosthetic lens-design options and let the patient make the decision."
• Make an initial trial with a commercially available cosmetic lens.
• Use of a cosmetic colored lens is less expensive and more readily available. If that doesn’t work, move on to a special order lens.
• Encourage all monocular patients to wear polycarbonate spectacles at all times.
• This will protect the good eye. Plus, a spectacle prescription can add value — such as providing astigmatic correction or a minimizing effect.
• Use discretion.
• Patients will sometimes request a prosthetic lens when it’s not indicated. The panelists provided these examples:

• -"In blind eye disease, if we can’t obtain an adequate match by fitting the blind eye, on occasion we fit bilaterally with the same pattern. I’m philosophically opposed to that because I don’t like putting a lens on a one-eyed patient," said Ward.

• -"I’ve had long-time cataract patients who have had the cataract taken out. As a result of double vision, they’ve asked for an occluder lens, but that’s inappropriate," Dr. Kastl said.

• -A prosthetic lens would also be inappropriate if a patient doesn’t have enough ocular structure remaining to support a lens, added Dr. McMahon.

Explore all applications

As you get more involved in fitting prosthetic lenses, you’ll find out that their use isn’t restricted to trauma cases. You can fit these lenses for sighted eyes in cases of photophobia, aniridia, and rod and cone dystrophies, for example.

"As we work with these patients, we’re finding expanding indications," Dr. Meshel said. For example, by providing color blind patients with red or green lenses, "you don’t give them the ability to see color, but you enhance the luminescence of red or green. We’ve found the biggest motivation here is with people who want to get their pilot’s license or who need to match colors in the electrical industry."

The panelists also advised you to recognize the limitations of fitting prosthetics. Dr. McMahon said patients had asked him to fit them with lenses to avoid embarrassment for failing employee color blindness tests. If that test is a requirement for an important responsibility, such as the inspector in a nuclear power plant matching color coded wires, "it’s more nefarious" than beneficial to the patient, Dr. McMahon said.

Finally, expect variation when fitting prosthetics. Trauma seems to come in spurts, and so do prosthetic lens patients. One year, you might not see one prospective patient; the next year, you might see a half dozen. But as practitioners and the public learn more about prosthetic lenses, the number of people who realize they can benefit from the specialty lens is certain to increase.

Spreading the Word

More than 3,000 patients in the United States ordered prosthetic lenses in 1998. However, that’s just a small portion of those that would — if only they or their eyecare practitioners knew the lenses were readily available.

To better inform potential patients, the Wesley Jessen Special Eyes Foundation has developed a new patient information brochure and will soon release a video press release. The foundation’s Web site, specialeyesfoundation.org, enables prospective patients to locate eyecare professionals in their vicinity who are known to have prescribed prosthetic contact lenses. To talk with a Wesley Jessen Special Eyes Foundation consultant on custom-designing a lens for a patient, call 1-800-488-6859.

Paul Gerber is a Chicago-based freelance writer who specializes in ophthalmic issues. He’s also a communications consultant with Wesley Jessen.