Contact Lens Options for the Non-Traditional Patient Shane R. Kannarr, O.D.

Non-Traditional Patients for Contacts

Dry Eye Sufferer Astigmatic Presbyope Young Myope Non-Compliant Patients

Benefits of Fitting the Patients

Patient Satisfaction Loyalty Practice Builders 34 Million current wearers 12 million new fits 11 million drop outs PROFITABILITY

Contact Lens Fits by Type Segment Trend Total Lenses +7% SVS +4% Toric +11% Multifocal +25% Colors +6% Specialty lenses are driving the category growth Higher margin --> higher profits Source: HPR 1H 2003

Comfort and Vision are Top Benefits for both Current Contact Lens Wearers and Considerers (% Absolutely Critical — Top Box) Key Communication Points: > Comfort is THE unmet need . . . > CL comfort has increased significantly in last 2 decades but still enormous opportunity for manufacturers and eye care practitioners to increase patient satisfaction Source: Vistakon Attitude and Usage Study of Vision Corrected Consumers 2002

Dry Eye

Today’s Choices… ACUVUE® ADVANCE™ with HYDRACLEAR™ Key Communication Points: > Todays current CL choices force a compromise: - comfort, handling & vision excellence of traditional hydrogel but with limitations in maximum O2 supplied - or increased oxygen of high silicone lenses with stiffer, less comfortable materials & designs > VISTAKON combined the best of both AND - incorporated HYDRACLEAR for silky smooth comfort that LASTS Creating a new generation of contact lenses, revolutionary technology that provides exceptional long lasting comfort ACUVUE® ADVANCE™ with HYDRACLEAR™ Revolutionary Technology Exceptional Long Lasting Comfort

ACUVUE® ADVANCE™ with HYDRACLEAR™ A new generation in DAILY WEAR The outstanding initial comfort of a hydrogel lens Exceptional end of day comfort that outlasts the competition Uncompromized visual acuity of theACUVUE® Brand Oxygen delivery and lens properties that help keep eyes as white as with no lenses

Acuvue Advance Silicon Lens Hydrogel Comfort High Dk/t=83 Daily Wear 2 Week Replacement Same Design as Acuvue 2

30 Day Lenses Not Just for Extended Wear Consider Low Water Contact Lenses Look at Systemic Medications (BCP and Antihistamine) Limit Wear Time Use Artificial Tears Consider Plugs

Astigmatics… Not Just for RGP’s Anymore

Expectations

Residual Astigmatism (RA) RA=Refractive Cylinder-Corneal Cylinder Example on Next Slide >1D consider RGP

Example: Refraction -3.00 - 2.00 x 180 K Readings 43.00 x 180 / 44.25 x 090 For Our Purposes: 2 – 1.25 = .75 (RGP probably not needed.)

“LARS RULE” Left Rotation Add Right Rotation Subtract From your vantage point Each clock hour = 30 degrees

Example Trial Lens: -3.00-1.25x090----OD rotates 20 degrees left -3.00-1.25x090----OS rotates 20 degrees right NEW TRIALS OD -3.00-1.25x110 OS -3.00-1.25x070

Fuzzy Math…..

Soft Contact Lens Options

A. Less than -3.00 D of Cylinder Acuvue Advance and Purevision are nice compliments.

Both are -0.75 to -2.25 Cyl in -0.50 Increments. Both are Axis 0 to 180 in 10 Degrees Increments. Good Stability. 2 Week to 1 Month Replacement. Avg. Sale Price/Box $42-45

Profit / Patient / Year =$93.00/$186 Let Patients See the Improved Vision for Themselves. Up to -3.25 D of Cyl use Spherical Equivalent for Remainder. (example on next slide) Other Options: Frequency 55 Toric/Vertex Toric

Example Refraction: -2.00 -3.25 x 090 Closest Lens: -2.00 -2.25 x 090 Uncorrected Astigmatism (UA) -3.25 – 2.25 = 1.00D Spherical Equivalent of UA -1.00 / 2 = -0.50 Add to Sphere of Refraction -2.00 – 0.50 = -2.50 New Contact Script = -2.50-2.25x090

Greater than -3.50D of Cylinder

UCL, Sunsoft Toric, and Preference Work Well Together Parameters Sphere:+20.00/20.00 Cylinder:7D Axis is in 5 Degrees Steps Educate Patient about Possible Fluctuations in Vision Order with warranty

**********IMPORTANT********** Charge for your TIME Can not use standard multiplier Patient Satisfaction=Practice Builder

C. Rigid Lens Options

Correction on the front of the lens Back Surface Toric: Front Surface Toric: Correction on the front of the lens Low Residual Astigmatism Back Surface Toric: Back of lens shaped to match cornea High Residual Astigmatism Excellent Vision Comfort is the Issue

Presbyope

No One likes Growing OLD

A. Monovision

Start the Patient Early in Presbyopia Educate the Adaptation Time Start with the Non-Dominate Eye as Near (may switch) Return the Patient in 7-14 Days Manage Expectations

Cost Effective for the Patient (any single vision lens will work) NO Contact Lens Salute Cost Effective for the Patient (any single vision lens will work) No Intermediate as Presbyopia Progresses Trouble in Low Light Conditions Trouble over 2.00 D of add

KEY POINTS Will require chair time Inexpensive to patient Easier to start early in presbyopia Patients are happy that lens cost doesn’t increase Works for the majority of the patient Decrease Depth perception (consider 3rd lens)

B. Soft Contact Bifocals

Usually Provides All Ranges of Vision Comfort Over Rigid Lens Maintain Stereo Vision Works at All Add Powers Can be Costly Some Report Constant Blur

Let Lens Settle Before Rechecking Manage Expectations Halos at Night Let Lens Settle Before Rechecking 10-15 minutes is good Manage Expectations Return to Check After Wearing Use Trial Lenses

** Great Options **

Multifocal Market by Brand Multifocal Shares Brand Share Share vs YAgo Acuvue Bifocal 40.7 (21.1) SofLens Multi-Focal 34.3 +34.3 Focus Progressives 12.1 (13.8) Frequency 55 Multifocal 5.9 +4.2 Dailies Progressives 1.9 (0.2) In only 9 months, SofLens Multi-Focal is the fastest growing product in the category. Source: HPR Q2:2003

Soflens 66 Multifocal Base Curve 8.8 / 8/5 Powers: Add: Low (< +1.75) High (> +1.75) Design: Watch Pupil Size in High Adds

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

Exceptional Visual Acuity Natra-SightTM Optics Broad near to distance power transition to provide crisp, clear, natural vision Aspheric center-near with broad add profile across optic zone Equalized Mass Distribution Facilitates lens centration essential for effective functioning of the aspheric optics

Natra-SightTM Optics Not all aspherics are the same Power Profiles SLMF Low ADD SLMF High ADD Power Profiles: Low vs. High The difference between SofLens Multi-Focal’s low and high ADD lenses is quite apparent in these 3-D power profiles. The power of the low ADD increases gradually as one moves from the lens periphery to the center. The high ADD is distinctly different from the low ADD design as while it also affects a gradual power increase from periphery to center, there is a distinct central zone, or plateau, of greater plus power. It is this distinct near zone that boosts the near ADD power. Some older, or more mature presbyopes who require higher ADD power will benefit from this design. Fitting older patients with modified monovision, using two low ADD lenses, or a combination of a high ADD and a low ADD may be as, or even more effective in providing the older presbyope with functional vision. One should note the visual performance of the high ADD lens is more dependent on pupil size than the low ADD design. As such, the high ADD lens may compromise the quality of distance vision in some individuals, especially if their pupils are small. Ciba Progressives Single Steep Add

Basic Fitting Tips Know the Distance/Near Demands Control Expectations Add power <= +1.75/Start with low add Add power > +1.75/Start with high add Always use 8.5 BC with high add Aspheric Design offsets low amounts of Astigmatism

Rule of Thumbs for Add Powers < 47 Low Add in Both eye > 47 Low Add in Dominate eye High Add in non Dominate eye Be a little Creative Tailor your fit to your patients needs

Fits for “Normal Demands/Distance Demands” Find Prescription Fit on Rx OU/Low Add OU Let Settle 10-15 Minutes Before Checking Aim for 20/25 at Distance/20/40+ at Near RTC 1 week (Patient to bring list of were lenses do and do not meet expectations)

Difficulties with Distance Difficulties with Near Dominate Eye Remains the Same Non Dominate Eye Distance is Rx + ½ of Add Low Add Difficulties with Distance Check Over Refraction with Trial Lenses Look at Base Curve

Example Refraction -3.00D—OU +2.00 Add—OU OD is Dominate Initial Fit------- -3.00/Low Add OU 1st F/U--------- -3.00/Low OD -2.00/Low OS

Excessive Near Demands Refraction Week 1 Fit on Refraction OU/Advise Readers Week 2 Dominate On Rx / Low Add Non-Dominate On Rx / High Add Week 3 Add + to Non-Dominate with Trial Lenses until Near is Adequate

Example Refraction -3.00 OU +2.00 Add OD Dominate Week 1 -3.00/Low OU/Readers Week 2 OD -3.00/Low OS -3.00/High Week 3 OR OS +0.50 OD -3.00/Low OS -2.50/High Think before you use High Adds OU

FREQUENCY® 55 MULTIFOCAL LENS DESIGN

FREQUENCY® 55 MULTIFOCAL PARAMETERS BC/Diam.: 8.7/14.4 mm Sphere power: +4.00 to -6.00D Add:+1.00 (NEW) +1.50, +2.00, +2.50 D Optical Design D lens for dominant eye N lens for non dominant eye Handling tint: light blue edge-to-edge Packaging: blisters in 6-packs, single blister trials Modality: recommended for monthly replacement

Determine Spectacle Rx and Best Vision Sphere. FITTING PHILOSOPHY Determine Spectacle Rx and Best Vision Sphere. ▼ Determine Contact lens power adjusting for vertex distance, if required. Determine the dominant eye. Consider fogging with a +2.00 lens test to determine dominancy. 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. Under normal illumination conditions, evaluate visual acuities for distance and near, first monocularly then binocularly

FITTING PHILOSOPHY Acuity expectations: “D lens” – Distance 20/20 Near 20/40 or better “N lens” – Near 20/20 Distance 20/40 or better Binocularly – Distance 20/20 Near 20/20

Acuvue Bifocal Ciba Progressive * Other Options * Acuvue Bifocal Ciba Progressive

C. Rigid Bifocals

Simultaneous Vision Concentric Design Translating Designs Is Great Vision Trade-Off for Initial Discomfort? Educate the Patient about Adaptation (It will get better!) Lots of Hand-Holding in the Initial Phases

In All Options, Charge Adequately for Your Time.

Non-Compliant Patients

Significant Neo or Corneal Edema Again Look at 30 Day Lenses DK / L Comparison “Poor Man’s LASIK” LASIK

Rapidly Progressing Myope

Young Child -4.00 or Above Changing More Than -0.50 D / Year Fit a Half of a Diopter Flat Return to Check at 6 Months / Watch Cornea and Comfort Inform Patient of Proper Expectations Patience, Patience, Patience!