EMPOWER - Optimizing Contact Lens Wear

Dr. Jacob Lang:
Hi, everyone. I'm Jacob Lang, and welcome to a special episode of The MOD Pod. This is the second installment of our new 2025 Empower Series, aimed at advancing optometric knowledge to help elevate our practices and our patient care. Today's episode will specifically focus on optimizing contact lens wear. I'm going to introduce my guests, really honored to be here with our experts, Dr. Ashley Tucker and Dr. Jessica Yu, thanks for joining me. We really appreciate having you on Empower.

Dr. Ashley Tucker:
Hey, everyone. Yes, I'm Dr. Ashley Tucker. I'm so honored to be here as part of this wonderful podcast. My practice is Bellaire Family Eye Care down in Houston, Texas.

Dr. Jessica Yu:
Hi, everyone. I'm so glad to be here with you all today. My practice is Connecticut Contact Lens Institute. We're in the southwest corner of Connecticut in Fairfield County. And I specialize in all types of contact lens fits and keratoconus specialty lenses, as well as myopia management.

Dr. Jacob Lang:
Obviously, renowned contact lens experts, so really honored to have you here. Do you guys wear contacts? Ashley, do you wear contacts?

Dr. Ashley Tucker:
Oh, my gosh. Yes. I'm a specialty contact lens fitter, so I wear all specialty designs. And my favorite one, though, is a hybrid, which I know is the underdog for many specialty contact lens fitters out there. But I love a hybrid lens. I'm mostly still, so it neutralizes my cylinder perfectly without having to worry about the rotation aspect. I'm a big proponent of this lens.

Dr. Jacob Lang:
And you'll actually switch? You're like, "I'm going to wear sclerals today"?

Dr. Ashley Tucker:
Yes, yes. Depending on [inaudible 00:01:54]. Yes. Sometimes I'll wear a scleral, like if I'm watching my daughter play volleyball and I want laser sharp vision, my scleral is amazing. If I'm on vacation, I'll wear a daily disposable that I'll deal with a little bit of rotation, but it's still quite good vision. But the best of every world is my hybrid.

Dr. Jacob Lang:
That's awesome. That's really interesting. You play in the field here with all the contacts.

Dr. Ashley Tucker:
Equal opportunist.

Dr. Jacob Lang:
Yeah. Jessica, how about you? Do you wear contacts?

Dr. Jessica Yu:
I do, yeah. I actually wear daily disposables. I'm also a lot of still but more myopia, so I like to test everything on the market. I've tried pretty much everything out there, but my go-to is still a daily disposable, soft toric lens. But I'm glad to hear Ashley say what she did about the hybrid. It's amazing, because not enough people promote and advocate for the hybrid lens and it is an underdog out there for sure.

Dr. Jacob Lang:
That leads us into the next part of this, knowing your options. Choosing the right lens and the right fit for our patients. Knowing our options. Let's talk about materials, like silicone hydrogel versus standard hydrogel, the SiHy versus just Hy. If we think back years ago and still in pediatric practices, we had the SilSofts by Bausch, I think it was, and still is. Where they were 100% silicone. And they got away from that, moved into hydrogels, and then back to silicone hydrogels. Where are we at now and when do you think about silicone in your lens and when do you say, "This is not a patient that should be dealing with silicone"?

Dr. Ashley Tucker:
Hydrogel lenses are hydrophilic, they're well known for being made of polymers that love water and they rely on water to transmit oxygen. But with that, the lens tends to dehydrate over time. When I was in school, we were taught that hydrogel lenses are where it's at for patients that have dry eye. But like I said, that lens tends to dehydrate. And where do you think it's getting the rehydration from? It's from our tear layer.

Silicone hydrogels, on the other hand, are made of silicone and they don't require a ton of water to have good oxygen transmission. There's more silicone, less water, so it doesn't really depend on our tear layer to rehydrate. I tend to lean on SyHys in practice for the most part. I only steer clear of them when the patient has a known silicone allergy or I've put them in a SyHy and they're having some sort of weird reaction. That's where I'm at material-wise. What about you, Dr. Yu?

Dr. Jessica Yu:
I would agree with you, actually. I think that I definitely lean into the SyHy category, but not forgetting the hydrogels as well. I think sometimes they do get bashed upon a little bit just because of their lowered oxygen transmissibility and what we know about the benefits of oxygen and health to the eye. But I definitely lean into the silicone hydrogels as well. And I think that, for most people who are not sensitive, they can offer such a great benefit for corneal health as well as just comfort. And it's been a really nice advancement in all of the different modalities for contacts for us.

Dr. Jacob Lang:
Jessica, talk to me about daily disposable versus reusable lenses, that wear schedule, where your mind goes with programming. What are your thoughts now with extended wear in contact lenses?

Dr. Jessica Yu:
Well, I don't fit a lot of extended wear or reusable lenses. My practice is probably about 90, 95% daily disposables. So, I definitely promote that. And as far as a fit strategy, that's the way I'm introducing contact lenses to most patients, especially children, teenagers, even new wearers, because a lot of the new technology is in that realm of contact lenses.

Dr. Jacob Lang:
Why have you evolved? I assume it wasn't maybe always 90 plus percent, but why did you evolve towards that or what was the journey to get to that point?

Dr. Jessica Yu:
I think it's just the convenience and also the health benefits of it. When I graduated from school, it was still the era of pure vision, night and day, and even the older yearly hydrogel lenses. But over time, the increased replaceability of lenses has really just made contact lens wear such a nice convenience for patients and also offering the health benefits. But also, saying lenses get dirty, they rip, they get makeup on them. People just have a little bit of a hard time maintaining that pristine surface for X amount of months. So, having a more reusable lens just makes more sense. It makes travel so much easier, like what Ashley was saying. So, it just makes sense as far as all that, provided that the economics make sense for the patient as well, of course.

Dr. Jacob Lang:
Yeah. I really feel like it's the best option for your patients, it's really the best way to set them up for success. Ashley, are there any patients where you're like, "I need to do something different" or that, "Maybe I would talk about extended wear in these certain patient types, certain patient lifestyles"?

Dr. Ashley Tucker:
I do want to reiterate, I'm with Jessica, daily disposable are my go-to. That's what I open the conversation with, that this is the best option. But yes, realistically speaking, there are going to be people that are going to push back on daily disposables. The biggest thing is cost, unfortunately. That can be prohibited for some patients. And then, the other big issue is waste. Patients nowadays are very conscientious of plastic waste and how that impacts the environment. So, the way to mitigate that is to have patients recycle their blister packs, their lenses and the little boxes that they come into. There are plenty of programs that will recycle. We actually ask patients to bring in all of their waste to us and we recycle it for them. That's one thing.

And then, you have patients that are just not going to be adherent to our recommendations for disposability. If they're going to sleep in lenses, even though we're telling them not to. If they're going to reuse their daily disposables for a week or two weeks or for, god forbid, a month, I then will talk about extended wear. But that is very, very reluctantly. That's last resort after educating ad nauseum.

Dr. Jacob Lang:
It's good to keep options in mind and realize not everyone's going to fit into the mold, but it's nice to hear that if you talk about good, better, best, you're saying best is daily disposable, better is daily disposable, and good, well then we'll talk about it. How about our dry eye patients? Especially meibomian gland disease being a very prominent form of dry eye, 80 some percentage of patients having some form of meibomian gland dysfunction in their pathology with dry eye disease patients. How do contact lenses interact with our meibomian gland, with our eyelids, with our ocular surface?

Dr. Ashley Tucker:
Contact lens, even though we all love them, they disrupt the tear layer, they bisect the tear layer. There's going to be a post-lens tear film, and then a pre-lens tear film. It's disruptive. So, we have to be cognizant that if a patient already has dry eye issues or already has MGD issues, this could potentially exacerbate that. The best way to get around having a patient have worsening symptoms is to address these issues ahead of time.

I rarely, rarely ever will start a patient on contact lenses if there is any compromise to their ocular surface. We need to be cognizant of that and we need to let patients know that we're taking this as a stepwise approach and not just jumping two feet in to [inaudible 00:09:52] prior to mitigating some of these issues.

Dr. Jessica Yu:
Yeah, of course. I think that, for sure, patient education is one of the most important pieces we can do as their eye care providers. And a lot of times I think patients love hearing this, right? They may not want to hear a 10-minute spiel about their meibomian glands. But of course, if we're providing them a stepwise function of say, hey, you got to do warm compresses three, four times a week, you have to do a little bit of lid hygiene. We know you want to succeed in the contact lenses as much as we want to see you succeed as your doctor, but it's going to require a little bit of TLC to be able to get to that point just because of your underlying issues.

And I think if we outline this for them and make it easy and present it in a way that's manageable, that it can make a lot of sense and it will improve their success rate and also keep their vision stable, especially in multifocals, which the optics really require that kind of nice surface for it to happen.

Dr. Jacob Lang:
That's a great point. These presbyopic patients are at much higher risk for ocular surface disease, and we're trying to put them into a complicated or at least higher and more advanced optic lens. If we don't support that higher level optics, we're going to fail. And I think that was great, Ashley, about addressing ocular surface disease on the front end. We talk so much about that in preoperative care, before LASIK, before cataract surgery, address the ocular surface, get better biometry. And so, it'd be really interesting. I think we see that in contact lenses as well, right? We're going to get better keratometry readings, better corneal topography if we're addressing the ocular surface on the front end.

The other big thing that I think about is messing with your eyes all day. Are we washing our hands? Are we getting all the soap off? Are we putting soap in our eyes? And the chemicals, the chemicals in... You guys already beat it to the punch by going to daily disposables. But the chemicals and solutions, especially more generic solutions, might be pro-inflammatory. Anything that can be causing inflammation, whether it be makeup or contact lens solution, is probably going to drive that ocular surface disease and make our patients less comfortable in their lenses. So great to educate, like you said, Jessica, on all these things and the consequences of everything that you're putting in your eye.

Awesome. I'm going to get off my ocular surface disease soap box here now. But on the same thread here, let's talk about dropout and complications. Why do patients stop putting in their contacts and why do we not let patients put their contacts in? Why do we say, "Hey, you can't wear your contacts", even though the patient might want to. And vice versa. When do the patients come back to us and they're like, "We're not doing a contact lens check today. What happened?" So, what are the things you see causing that? And then, what are your strategies for addressing those things?

Dr. Jessica Yu:
Sure. Yeah. I always like to understand, during my patient history portion of the exam, why the patient... Well, if the patient is wearing the lenses as much as I think they are, or as much as I last saw them wearing. And if they're not, then usually to understand why. Is it the vision part of it stopping them? Are they not getting every piece of the vision that they want for their daily needs? Or is it something stopping them more like comfort, the lenses drying out, or they feel like they have to put in drops, or if they're just feeling like the lens isn't staying comfortable in my eye for more than five, six hours and it's annoying to have to stop what I'm doing at work and just have to take them out and then put on my glasses?

Because as much as we hate to admit, we're all human beings that love convenience and love ease. And so, if something interrupts our flow, we're not as likely to do it. So, depending what the response is, usually I'll target the exam a little bit, gearing it towards that direction and trying to understand and see if I can figure out the underlying issue. And if so, then of course they're a great candidate for either a refit for a contact, if it's something that's material driven or comfort driven or convenience driven. And of course, with costs, there's different strategies we can discuss with patients. Are they social wearers, part-time wearers? Are they taking advantage of rebates? Are there things that we can help to mitigate so that we can enhance their contact lens wearing experience?

Dr. Jacob Lang:
And by that, enhance their quality of life. Right?

Dr. Jessica Yu:
Exactly.

Dr. Jacob Lang:
That's great. Yeah. Good to be open. It's okay for patients to tell us the reason why. And sometimes they're a little hesitant, too, for multiple reasons.

Dr. Ashley Tucker:
I would just like to mention, and this happens to me, unfortunately, more often than I would like, is that fit a patient in a contact lens one year, and then I see them back for their annual follow up on why they aren't coming in wearing contact lenses today. And they'll mention, "Well, you fit me last year, and I didn't particularly like that lens" for some reason or another. And they're not understanding the fact that the fitting includes follow up. And I'm committed. And so, to get them to a point where they can wear contact lenses comfortably.

But patients have this... They don't want to disappoint you. They don't want to tell somebody in your office or you that they failed. They don't want to be a reflection of your relationship with them. I love to make sure patients know, during the fitting process, that I'm committed, I want them to come back if there's any issues. So, just the importance of follow-up care. I just want to make sure our listeners know that patients don't necessarily understand that that contact lens fitting isn't a one and done sort of effort.

Dr. Jacob Lang: 
Yeah. Yeah. I'm here for you. That's awesome. What about complications? What sort of things do you see where you're like, "I'm a little worried about things. Let's delve into your habits or your wear schedule. Or we need to pivot on this lens"? What sort of complications have you been seeing? Lots of fungal keratitis and Acanthamoeba or maybe something a little more common?

Dr. Ashley Tucker:
Yeah. Thankfully, I don't see that very frequently. The biggest thing, especially here in the south, is just allergies. Allergens just being such a problematic issue. And that is actually a good selling point for daily disposables. I have lots of patients that I've been working for a while trying to get them into a daily disposable. So, it's very easy conversation. They come in with itchy eyes, not being able to wear their lenses for as long as they would like. And the solution for a lot of these patients is just to simply switch them to a daily disposable. I would say allergies right now, and the complications from that, are the biggest thing that I see on a regular basis.

Dr. Jessica Yu:
Yeah. We've had a bad allergy season here, so I'm with Ashley on that one. The allergies definitely play a significant role for us come spring and fall. Another big thing that I tend to see is people who just, I think not intentionally per se, but just by ease of use, is that they get a little cavalier about their habits. Maybe the solution they're using, they're starting to drift towards generic or something less compatible because it just may be a little bit less expensive or it's a little easier to find. Or people who might start developing a little bit of bad habits with their contacts.

And we find that they can sometimes get some problems from it, from contact lens, not so much true abuse, but a little bit of that. And also just misuse of them. Those uncertain moments they have where the eye's a little irritated, but they might just persist in wearing that contact a few extra hours, or an extra day or two. And it does end up causing them a few days of problems, whether it's an abrasion, an infection, an infiltrate. And so, that's re-educating patients who have been in contact lenses for decades, that these regular simple habits of hygiene are super important.

Dr. Jacob Lang:
Yeah. Especially college kids that I see sometimes. College kids sometimes live a rowdy lifestyle, and with that lifestyle comes some rowdy complications. The other thing, do you guys think, allergies... Do you feel like more patients have more allergies than we did like five, 10 years ago? Or is it just that we blame everything on allergies more? We understand how much stuff is in the air and how much of a role where we used to maybe put up with it?

Dr. Ashley Tucker:
Gosh. I sure feel like it is. I have never been an allergy person myself, and I'm having trouble this season. So, that's a great question, Jake. I don't know the answer to that, but it sure feels like I'm seeing more allergic responses just to the environment than I ever have.

Dr. Jessica Yu:
Yeah. I feel like I see a lot more kids and teenagers with allergies than I remember when I was a kid or teenager. And friends, it didn't used to be a thing, so to speak. And now, it's very common people getting allergy shots and going through these different issues with their allergies.

Dr. Jacob Lang:
Yeah. Probably enough for a whole nother podcast. Presbyopia, it's not my favorite word these days as the birthday candles on my cake are increasing. Are you guys each team multifocal or team monovision? Or is there a place for both? And if so, when are you like, "Oh, yeah. This is an ideal multifocal patient, this is an ideal monovision patient"? Jessica, what do you think?

Dr. Jessica Yu:
Well, I'm more team multifocal. I'm probably like 85% multifocal, lesser percentage monovision. I do think monovision has its place, that being said. I feel like, for some people, their brain is just wired in such a way that they process monovision better. They can deal with that separation and that combination using their binocular vision. But at the same time, I do advocate for multifocals because having that binocularity and having both eyes have that more or less equal distance, intermediate and close vision, just brings so much more to the table. And I really do think technology for multifocals has come a very long way since I first started seeing them.

Dr. Ashley Tucker:
100% agree. Team multifocal all the way. But of course, monovision has a place, especially in our emmetropic presbyopic patients, that's where I lean on monovision the most. And just maybe on people that just don't have really significant near-demands, like someone that has a more active day-to-day that they're not staring at a computer all day long and they're not at a fixed distance, I lean on monovision for that. But I love monocularity. I think we were born that way, so I want to capitalize on that in every aspect of eye care. So, multifocals whenever possible.

Dr. Jacob Lang:
Yeah. I think of it like in monovision, you're trying to suppress one eye. You're either suppressing the distance eye or the reading eye. You're suppressing. Whereas, in multifocal, you're trying to enhance or to fuse or to build upon each other. I kind of agree with you. Binocularity is a thing. There's a reason we have stereopsis and binocularity. Why do we want to poke that bear, so to speak? Or take that away from patients? So, I agree wholeheartedly.

Dr. Ashley Tucker:
For those of us that wear contact lenses, we don't want to stop wearing them. As a contact lens wearer myself, I am trying to create new options for myself as I am becoming presbyopic. And so, I understand the struggle that I've been talking to my patients about for years and years. But I don't want to come out of contact lenses, I want my doctor to figure out a way to keep me in them. So, we need to do that for our patients, just put ourselves in their positions and understand that it's a big shift to go from contact lenses to glasses.

As a younger doctor, I took that for granted. But now I realize that we need to do all that we can within our power to keep our patients in them for their own happiness and for our practice to maintain those patients and maintain the revenue. Because contact lens patients also need glasses. That's another aspect of contact lens retention that is really helpful to the practice sustainability.

Dr. Jessica Yu:
I think that it's important for us to always showcase the technology that's been made available to us, emphasize the importance of the fitting process for contacts and why we're doing what we're doing, why we're selecting and fitting a patient with a specific lens, communicating with and educating them about these different finer points. Because ultimately, they generate more successful fits, which will generate referrals for the practice and ultimately growth for us.

Dr. Jacob Lang:
Yeah. Word of mouth is powerful. I see that in my practice a lot. I'm seeing a lot of, "My sister told me I had to come see you" or, "My neighbor..." or, "I'm a nurse and the nurses on my floor told me I got to come see you." Word of mouth is probably underestimated, I think, that we realize that... Especially when people are happy and they're doing better, their friends recognize that like, "Hey, your eyes look so much happier" or, "Why aren't you wearing your glasses?" People notice these things, and when they get noticed, they get recognized. Awesome thoughts again.

In summary, we talked about daily disposable, multifocality, being there for your patients, connecting with your patients, asking questions about why they're not wearing lenses or would you like to wear contact lenses? Is there an opportunity for you to be a contact lens wearer? Let's wrap up with one kind of golden ticket. If you could give one piece of advice to the listeners to make them a better, more successful optometrist with regards to contacts, what would it be? And then, we'll wrap it up. So, what's your golden ticket to the optometrist listeners?

Dr. Jessica Yu:
I would say to really try to... And I know we all do this so well, but to really listen to what the patient is trying to tell us and really take that into account as we're trying to prescribe whatever it is we're prescribing. It could apply to glasses, but obviously in the contact lens world, no one contact lens works for everybody. And there's a lot of different strategies to make a patient happy. And the communication portion is so important to really let them know why we're doing what we're doing and how we're trying to solve their needs.

Dr. Jacob Lang:
Beautiful. Eye doctors need to have big ears. Is that what I'm hearing?

Dr. Jessica Yu:
Exactly. Exactly.

Dr. Ashley Tucker:
I would say go that extra mile for your patient. If they need a torque lens, fit a torque, don't fit spherical equivalent. If you know in your heart that binocularity with a multifocal would be better for the patient, put them in a multifocal, don't go to the easier out, which I consider monovision. Just take a moment and put yourself in the patient's position and give them what you would want as the consumer, as the patient. So go that extra mile, take a little bit of extra time to fulfill their requests and their needs.

Dr. Jacob Lang:
Yeah. There's no shortcuts to success, is there? There are no shortcuts to success. I love it. I love it. Well, awesome. Thank you, Dr. Yu and Dr. Tucker, for such a wonderful, complete discussion. Again, I'm Dr. Jacob Lang. And thank you for listening to the special episode of The MOD Pod. Please stay tuned for another installment of the Empower Series coming your way soon.