Are doctors afraid of silicone hydrogels?

Discussion in 'Optometry Archives' started by Lothar of the Hill People, Oct 13, 2003.

  1. I just had my ophthalmologist discontinue me as a patient because I
    was insistent that I wanted to try Focus Night and Day contact lenses
    as an alternative to my Acuvue lenses. He told me I should go see an
    optician (not a doctor) he recommended who specializes in contact
    lenses.

    I remember him frowning when I first mentioned these lenses to him a
    couple of months ago because he didn't like the idea of any lens that
    could be worn for 30 continuous days. He does prescribe Acuvues for
    6-night extended wear, incidentally. I later told him that I had done
    a lot of research into these lenses and that I was convinced that
    silicone hydrogels were the only soft lenses that were safe to sleep
    in (I showed him the Dk numbers and mentioned a clinical study I had
    reviewed). I also told him that I had no intention of sleeping in
    them for 30 nights if he didn't prescribe that schedule for me, but he
    said something to the effect that he didn't want to deal with those
    lenses because they will require too much time to fit, and they take a
    lot of visits to make sure they're fit properly. I get the impression
    that he has no experience whatsoever with this lens and is only going
    by what he has heard.

    I am curious if any doctors out there agree with anything he said, or
    is this simply a case of a misinformed doctor? Are these lenses
    really that time-consuming to fit, thus taking up too much chair time
    for it to be worthwhile for the doctor? Is this a common attitude
    among eye doctors in the U.S. these days?

    Lothar
     
    Lothar of the Hill People, Oct 13, 2003
    #1
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  2. Lothar of the Hill People

    The Real Bev Guest

    A good enough reason in itself to switch. I asked the optometrist at
    Costco how many lens iterations he was prepared to deal with per
    patient, and he said three or four. The optician I went to this last
    time said he'd eaten up his profit on me after the third set of
    multifocal RGPs. My previous optician said 'that's the best you can do'
    after three or four. Must be a magic number...

    I have to wonder if the optician gets charged for each pair even if he
    returns them -- since I'm not taking up time he could be using on
    another patient (he has lots of holes in his working days), how does the
    profit disappear except on a theoretical basis?

    A problem I haven't had to deal with yet: The prescription the optician
    ends up giving you will probably bear little relation to the
    prescription the optometrist gave you to take to the optician. If you
    want a copy of your prescription, what do you do?

    When the time comes, I think I'll take my lens containers to my
    ophthalmologist, tell him that I've been happy using these for <however
    long> and it took nearly a year to arrive at this prescription, will he
    PLEASE write one out for me so I can order some more?
    --
    Cheers,
    Bev
    ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
    "Even Islamic terrorists don't hate America like liberals do.
    They don't have the energy. If they had that much energy,
    they'd have indoor plumbing by now." -- Ann Coulter
     
    The Real Bev, Oct 14, 2003
    #2
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  3. Lothar of the Hill People

    Dr. Leukoma Guest

    Complete and utter BS. They come in one diameter and two base curves.
    Most people do better in the 8.4 base curve, per Ciba.

    Does your ophthalmologist also perform LASIK?

    DrG
     
    Dr. Leukoma, Oct 14, 2003
    #3
  4. Lothar of the Hill People

    LarryDoc Guest

    Some of us were "afraid" of toric soft lenses when they came out: too
    much chair time, but ultimately got into it.
    Some of us were "afraid" of multifocal lenses, and some still are.
    And quite a few still don't want to mess around with RGPs.

    OK with me! That stuff is what makes MY practice interesting and
    profitable.

    All I can say is that he had better get on the horse because that's what
    is going to rule the race in the coming months. Meanwhile, the current
    available Ciba lens comes in one diameter and two base curves---and one
    of those curves fits about 85% of potential wearers. And about 90 % of
    potential wearers can use them. It just doesn't take that much smarts to
    get people into these things. The skill comes in to make sure the
    vision is right and the fit provides longer term eye health. And that's
    what we get paid for.
    Re-fitting si-hydros to someone who's been in other lenses, especially
    the "old" extended wear variety can indeed be chair-time consuming.
    That's mostly because as the cornea tissue "heals" and otherwise changes
    in response to the increased oxygen and the stiffer plastic, the
    prescription and fit can change. So we charge for our time.

    Anyway, that's what "trial fitting" is all about. That's what makes lens
    fitting interesting! Plopping (fill in some common lens brand name
    here) on a healthy cornea simple myope is not rocket science. Neither is
    fitting si-hydros----just a little more challenging and *interesting*
    and, in the best interest of the health and vision of our patieints.

    So yes, it is worhwhile for the doctor AND the patient lens wearer.

    And come this spring, with perhaps three companies marketting a host of
    designs, this IS goingto require "thinking different." What fun!

    --LB

    --
    Dr. Larry Bickford, O.D.
    Family Practice Eye Health & Vision Care

    The Eyecare Connection
    http//www.eyecarecontacts.com
    larrydoc at m a c.c o m
     
    LarryDoc, Oct 14, 2003
    #4
  5. Thank you, Larry, I found your attitude to be most encouraging, and I
    am now quite convinced that I am better off without my current (now
    former) ophthalmologist...

    I've been having that same thought ever since he told me yesterday
    that he doesn't want me as a patient anymore. I think he's going to
    be forced to get with the times very soon, and perhaps then he will be
    thinking back and regretting his attitude with me.

    Which one, the 8.4 or the 8.6? You may recall that my K readings are
    all around 42, so I am guessing the flatter base curve would fit me
    better (although my corneas are larger than average).
    That's a very encouraging statistic. My eyes adapted so poorly to the
    feel of RGPs when I tried them for 10 days that I have been afraid I
    would have the same issue with the relative rigidity of silicone
    hydrogels, especially compared to my Acuvues, which are *extremely*
    floppy and the only lenses that have really been comfortable in my
    eyes.

    I am curious if you've seen this effect in patients who wear such
    extended-wear lenses on a mainly daily-wear basis. I tend to remove
    my Acuvues every night except for occasional (perhaps once a week)
    evenings when I fall asleep in them. I'm trying to get a sense for
    what to expect if I try the Focus Night and Days.
    That's the bottom line for me--I feel that silicone hydrogels are the
    safest lenses for my eyes, especially since RGPs apparently don't work
    for me. My old doctor seems to be more concerned with resisting
    change and keeping chair time down, and so he is not for me any longer
    and I suppose I am glad that he forced me to move on. I still feel so
    rejected though!

    My main concern is that my tear film chemistry will not be compatible
    with silicone hydrogels, because I have read that they can be
    susceptible to lipid spoilation. Of the 4 lenses that I have tried so
    far (Acuvue, Acuvue 2, Biomedics, and Menicon Z), only the Acuvues
    have not had any noticeable accumulation of a greasy/oily film over
    the course of a single day, or even after overnight wear. Do you (or
    anyone else reading this) have any experience with the Focus Night and
    Days accumulating such deposits?

    Thanks, Larry.

    Lothar
     
    Lothar of the Hill People, Oct 14, 2003
    #5

  6. Not to my knowledge, but I have never asked him. I am curious why you
    asked that? If he does, then I would be afraid of having him operate
    on my eyes, fearing that he is not current with the latest
    technologies.

    Lothar
     
    Lothar of the Hill People, Oct 14, 2003
    #6
  7. Very interesting. I guess 4 was the magic number for my old
    ophthalmologist (he wouldn't go on to 5). When I first went to him
    expressing interest in contact lenses, I was told that my fitting fee
    would include as many office visits as were necessary to get the
    lenses properly fitted. I should have asked for the "fine print" that
    there was a limit to how many lenses he would let me try. The thing
    is, I would have been happy to pay him for the additional time it
    would take to fit me with silicone hydrogels (or if he had simply told
    me that there would have been an additional fitting fee after x
    different lenses), but he never allowed me the opportunity. He did
    try to charge me an additional charge for one of my visits, saying
    that my problem was not a fit issue, but he later admitted that he
    thought my whole problem was fit. I protested the charge and he ended
    up waiving my copayment.
    Fortunately I haven't had that problem, and my doctor has been willing
    to give me my prescriptions. I suppose this probably varies with the
    laws of each state.

    Lothar
     
    Lothar of the Hill People, Oct 14, 2003
    #7
  8. Lothar of the Hill People

    Dr. Leukoma Guest


    ....because your ophthalmologist's objection made no sense otherwise.
    Certainly 30 day continuous wear offers a more attractive alternative to
    refractive surgery.

    Fitting a silicone hydrogel is no easier and no more difficult than fitting
    any other soft lens. If anything, the patients seem to become less myopic
    if they have been sleeping in a conventional hydrogel prior.

    About the only people who seem to have problems with them on a consistent
    basis are those who have developed problems in their pocketbook as they are
    more expensive than other lenses ;^)

    DrG
     
    Dr. Leukoma, Oct 14, 2003
    #8
  9. Ah, I understand now. Yeah, his objection made no sense to me either.
    I suspect that he was thinking that I have already wasted too much of
    his time trying out different lenses, none of which really worked for
    me, and he was making no profit on me because he only charges a single
    fitting fee until the patient is successfully fitted. Well, I was
    never successfully fitted in my opinion, and I think he was losing
    patience with me (as if is my fault that the lenses he prescribed
    weren't working).
    That's an interesting observation.
    Yes, the cost has indeed been on my mind, but I would gladly pay more
    money (even a lot more money) for lenses that are significantly safer
    for my eyes. I would probably still be considering Focus Night and
    Days if they cost twice as much as they do (don't tell CIBA I said
    that!). Perhaps the costs will come down once the newer players
    emerge in the market next year.

    Lothar
     
    Lothar of the Hill People, Oct 14, 2003
    #9
  10. Lothar of the Hill People

    LarryDoc Guest

    You're welcome.
    Remember the cornea diameter vs curvature discussion. If you are into
    statistics, at 42D, there's a 35 - 40% chance you'll need the 8.6,
    cornea diameter not with standing. If you cornea is larger than 12.5mm,
    the lens may not fit at all. Once again, the only way to know is to
    plop them on and observe with the slit lamp/biomicroscope.

    And if the Ciba Focus N&D doesn't fit, hold on a few months until J&J,
    B&L, and Cooper come forth with their lenses. The parameter choices will
    expand, for certain. We really do need a larger diameter (and smaller!)
    version. (Or take a vacation to a more civilized country where other
    si-hydros ARE available.)
    And if you are in the 10%, that's 100% bad choice for you.
    Indeed I have had a couple of people who experienced excessive lipid
    deposits with N&D. Whether or not that is an issue with the N&D surface
    treatment that might not occur with Purevision or the other coming
    brands, I cannot say for sure. The fix, for now, is more regular
    cleaning and translates to potentially less lens longevity and higher
    costs to the patient. The overwhelming majority of wearers have no
    problems at all.

    Do also remember that there ARE some people who simply do not do well
    with contacts, any contacts. But at least if you are working with a
    doctor who has the smarts to work with you, (and perhaps if you move to
    Canada, Australia, Germany, Japan or UK), you will suceed.

    --LB

    --
    Dr. Larry Bickford, O.D.
    Family Practice Eye Health & Vision Care

    The Eyecare Connection
    http//www.eyecarecontacts.com
    larrydoc at m a c.c o m
     
    LarryDoc, Oct 14, 2003
    #10
  11. I'm a biologist, so yes, I am very interested in statistics! Thank
    you, that was very informative. Did you mean there is therefore a 60
    - 65% chance that I will need the 8.4, or did you factor in a
    percentage that they might not fit at all? Just out of curiosity, did
    CIBA give you these statistics, or are these your personal
    impressions?
    My corneas are about 12.6mm (I measured my HVID at 12.5mm), so that is
    potentially discouraging.
    Yes, that thought has been going through my head. I am trying to get
    a sense for how *likely* they are to work for me though, before I
    decide to pay the money to try them. To switch to a new doctor, I
    will presumably have to pay for another full eye exam, which I don't
    think my insurance will cover because I've already had 2 routine
    contact lens exams this year, and then I will have to pay another
    fitting fee on top of that. If there's a substantial chance that the
    Focus Night & Day won't work for me, then I wonder if I would be
    better off waiting until I see what appears on the market next spring,
    and perhaps have my fitting fee apply to trying out more than one
    available silicone hydrogel brand until I find one that fits (assuming
    the new doctor's policy includes this routine like my old one did).
    In the meantime, my corneas will continue adapting to my low-Dk
    Acuvues, and I wonder if that will make it even harder for me to adapt
    to silicone hydrogels later. It's a lot for me to weigh, and I
    appreciate anything you've been saying (or will say) to help me
    decide!

    That is probably the single most important issue for me, and your
    observations are most helpful. Can you tell me what form these lipid
    deposits have manifest in these patients? You told me a month or so
    ago that lipid deposits often take the form of "globby, bumpy
    individual or clustered jelly-like bumps." This is not what I have
    been seeing on my lenses--it is more of a uniform colorless
    oily/greasy film (which again, I have not seen on my latest trial pair
    of Acuvues). My deposits have looked very much like Figure 4 in this
    article:

    http://www.siliconehydrogels.com/editorials/previous_editorial_jones_senchyna.asp#p

    If I touch these deposits after removing the lens from my eye, they
    smear.
    I don't mind having to remove and clean my lenses frequently. What I
    do mind is not being able to sleep in my lenses for even a *single*
    night for fear of them being too filmy to see through the next
    morning, which happened to me several times before I switched to
    Acuvues. But above all, I mind sleeping in (even occasionally), or
    even simply wearing, a low Dk lens that is not safe for my eyes.

    Lothar
     
    Lothar of the Hill People, Oct 14, 2003
    #11
  12. Lothar of the Hill People

    LarryDoc Guest

    Personal, combined with journal articles and other doc's findings.
    Excellent article and discussion on the issue, by the way.
    If the deposits occur within an hour of wearing the lenses, I'd put your
    chances of an enjoyable successful experience at close to zero. If they
    occur mostly toward the end of the day and you are willing to remove
    them for cleaning with Miraflow (alcohol containing surfactant cleaner)
    once or twice each day, you'll be OK with daily wear but again, close to
    zero for overnight use.

    And that doesn't even address the issue of fit. That is a consideration
    based upon the use of your time and money.

    You might do better with daily disposables, cost not being a major
    factor. And waiting for si-hydros in larger diameters and alternative
    surface treatments/properties.
    A coated lower DK lens is even worse.

    I think your path is self evident, Lothar, from the top of the Hill, at
    least.

    --
    Dr. Larry Bickford, O.D.
    Family Practice Eye Health & Vision Care

    The Eyecare Connection
    http//www.eyecarecontacts.com
    larrydoc at m a c.c o m
     
    LarryDoc, Oct 15, 2003
    #12
  13. Yes, I was very impressed by that article too. I found the graphs on
    lipid deposition on Focus Night and Day vs. PureVision vs. Acuvue
    (Figure 2) to be most enlightening. I wish I knew which lipid I am
    depositing most prevalently on my lenses. If it's something like
    cholesterol, then it would appear that I wouldn't have much to worry
    about with Focus Night and Days. If it's oleic acid, then I could end
    up with a rather unpleasant experience with them. The extremely low
    levels of any lipid deposition (at least the ones the authors
    examined) on Acuvues pretty much goes along with what I have
    experienced with these lenses--I haven't yet noticed any oily deposits
    on them. As I think I mentioned to you a month or so ago, I'd really
    be interested in having a lab analyze one of my other lens brands
    after they get filmy. I wish I had saved one.

    I take it you agree with me that these deposits sound like lipids? My
    doctor never agreed with me about that. I have never noticed such
    deposits after an hour or two of wear. In fact, at my mid-morning
    ophthalmologist appointments, my doctor has always said that my lenses
    look perfectly clear, and I don't think he believed me saying that I
    was having abnormal deposits (he dismissed it saying that this was
    just my normal tear film). With my Menicon Z's, I would notice my
    lenses getting filmy after perhaps 10 hours of wear on some days.
    With my Biomedics 55s, it was usually upon awakening after sleeping in
    my lenses, but only on certain occasions; other mornings, I woke up
    and could see just fine. With my Acuvues, I've never noticed any
    deposits even after sleeping in them, and they feel fantastic upon
    awakening (maybe because my eyes are numb with hypoxia!). In fact,
    these lenses feel better when I sleep in them than when I remove them
    each night.

    I tried using MiraFlow, incidentally, as part of my nightly cleaning
    routine (mainly because of the recommendation in that article we are
    discussing). I stopped because my doctor warned me about
    simultaneously using cleaning products from different manufacturers,
    and when I called AMO and asked them about compatibility of their
    "Complete" solution with MiraFlow, they said they had never heard of
    anyone doing that before, and said they couldn't recommend it
    (although they had no specific reason to tell me not to, like buffer
    incompatibility). I guess I didn't use MiraFlow long enough to tell
    if it made a big difference.
    The cost is definitely a major consideration, but more important to me
    is the consideration that I know I will be falling asleep while
    wearing my lenses from time to time, and I want a lens that is rated
    for extended wear (at least on paper).
    That is definitely something that I have been considering--waiting for
    alternative surface treatments. I'm keeping my fingers crossed (with
    anticipation that's so thick I can almost taste it) that one of the
    pending crop of new silicone hydrogels will have improvements in that
    regard. I'm sure I will have to wait a long time thereafter though,
    before the first published studies that report any decreased lipid
    deposition.
    That brings up an interesting question--I wonder which is worse for my
    eyes for overnight wear--a low Dk lens that does not accumulate any
    noticeable deposits (i.e., Acuvues), or a high Dk lens that
    potentially accumulates significant deposits?
    Unfortunately the view isn't quite so clear from the top of this hill.
    Must be these pesky unidentified lipid deposits clouding my vision...

    Lothar
     
    Lothar of the Hill People, Oct 15, 2003
    #13
  14. Test
     
    David Robins, MD, Oct 16, 2003
    #14
  15. Lothar of the Hill People

    Mark A Guest

    1 or 2
     
    Mark A, Oct 16, 2003
    #15
  16. Lothar of the Hill People

    LarryDoc Guest

    Novartis/Ciba did not purvail in the patent suite in an EU court. What
    happens next in the USA will be quite interesting.
    My crystal ball is broken just now. I think you can count on torics,
    new diameters, surface treatments and more. FYI, the current Ciba
    product is aspheric and often works quite well as a multifocal to about
    1 or 1.25 diopters of plus power.
    I'll let you know when I know, but I'd guess there will be a pretty big
    marketing blitz when it happens.

    And, of course, I am personally needing a front toric, rear aspheric,
    double thin zone version, so I'm on the look-out! Hear me, J&J ?

    --LB

    --
    Dr. Larry Bickford, O.D.
    Family Practice Eye Health & Vision Care

    The Eyecare Connection
    http//www.eyecarecontacts.com
    larrydoc at m a c.c o m
     
    LarryDoc, Oct 20, 2003
    #16
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