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Finding your Niche – Alan Saks

There’s no doubt in my mind that finding a speciality niche in practice is one of the best, most rewarding things you can do in developing and safeguarding your career.

The tentacles of commercial optometry are spreading ever wider. The competition for bums on seats and discounted sales of spectacle frames and lenses is reaching ridiculous proportions. Although one can implement strategies to counter such things and compete, simply trying to match or beat a price point involves a race to the bottom. Although optometry has a fairly unique combination of medical professionalism and retail commercialism the good old days are no more. Medical aids also create some less than satisfactory commercial pressure. There’s also not much job satisfaction in churning out a spectacle prescription every 20 minutes.

So how do we fix it?

Most cornea and contact lens specialists would agree that this speciality niche provides massive levels of satisfaction. Providing life changing eye care is so much better than fretting over whether we give someone 30% off their glasses, barely scraping a decent margin out of it from all the time and effort. Not to mention fighting for every cent with the medical aids and the overheads associated with such things. It may also amount to wasted time: After all your effort, the end result might be a patient simply requesting their Rx and heading to the nearest chain store for an assumed deal.

When it comes to a specialty contact lens niche, I am not talking about simply churning out generic 8.6/14.2 disposable soft lenses, where the Internet will almost always beat you on price. Although this is not yet a rampant issue in South Africa it is creating major headaches for contact lens prescribers around the world and in time it will have a greater effect on South African practitioners too. I guess there is an upside to random theft and non-delivery of Internet purchased goods in South Africa…

Small Steps

Developing a true speciality contact lens practice takes time but is well worth the effort. It starts with the basics. A thorough optometric examination is the cornerstone. Understanding the oculomotor and accommodative systems, assessing the ocular surface, lids and lashes while knowing about underlying pathology – from the anterior tear film right through to the occipital cortex and everything in between. If there are signs of lid disease, dry eye or meibomian gland dysfunction, treat it before you try contact lenses.  Having a contact lens dropout from another practitioner in your chair, with signs and symptoms of dry eye, and chucking in another one of the cheapest, generic 8.6/14.2 disposables and expecting a different result is futile.

Measure everything and record it. Things like palpebral aperture height (PAH), horizontal visible iris diameter (HVID) ocular shape, topography, K readings, the ocular Rx, corneal staining etc are all invaluable in determining the best lens for a given patient. Such strategies will dramatically improve your first-fit success rates and reduce dropouts.

Implementing treatment for the lids and ocular surface is yet another sub-speciality niche and for a contact lens specialist this represents a niche within a niche. Savvy practitioners are setting up speciality dry eye clinics with great success: Do you go all in with an intense pulsed light (IPL) instrument, a LipiFlow machine and a meibographer, or all three, or start more simply? It’s probably best to start simply, gauge the market and returns and build up a referral network. There are many simple inexpensive tools, lotions and potions that can get you great results with simpler or less advanced dry eye patients. As demand picks up, start adding the bells and whistles. So long as you charge decent fees and can fund the fancy toys, you’re on a winning ticket. Use lid cleansers, Omega 3 supplements, home treatments for MGD, lubricants and so on, and don’t give out free samples. Such things provide another revenue stream. Over time you’d be surprised at what they add to turnover. My colleagues were always impressed at how much my ‘accessory sales’ brought in. In some ways it’s easier to sell a bottle of fish oil supplements than it is to sell a similarly priced 6-pack of contact lenses!

Most fancy instruments we need in optometry and ophthalmology can be funded through a lease, where the costs are covered by using the instruments just a few times per week.

Myopia control is another niche within a niche in contact lenses and clinical practice. Like the rest of the world, South Africa is also on the rampant myopia epidemic highway.

There are yet other speciality niches within contact lenses like keratoconus, corneal grafts, post LASIK ectasia, radial keratotomy, high astigmatism and ametropia, aphakia, paediatrics, strabismus and so on.

Take Off the Training Wheels

In order to further evolve your contact lens speciality development, make sure you have all the basic skills and instruments in place along with a broad range of trial sets with a wide range of parameters and combinations. In soft lenses one needs at least two astigmatism and multifocal trial sets, (a combination of centre distance and centre near lenses), two premium silicone-hydrogels (Si-Hy) and a speciality non-hydrogel for those rare, sensitive patients who cannot tolerate Si-Hy lenses.

Don’t get involved in a price debate or be dictated to by the patient who wants Brand X because their friend has it and gets it cheap, online. Place a trial lens of the very best performing daily on the eye. Tell your patient this is what you recommend and that it will give them the best results. They’re in your chair, you are the expert. They will often say, “Wow, that feels amazing. In fact, I can’t feel it” Problem solved. Job done. Almost…

Give them a few trial lenses along with revenue stock of 3, 6 or 12 months and book their aftercare visit. Break lens costs down to X rand per day. Many of your patients will be spending more on booze, cigarettes or other things they can cut down on. Four coffees a day instead of five, will probably fund their contact lenses.

We go beyond being contact lens practitioners. We are personal trainers, budget advisors, personal brain care specialists (psychology) and make up and cosmetic experts (manage those nasty cosmetics that mess up contact lens success). Should someone occasionally not succeed with your initial trial, then merely swap the revenue stock for the lens type that does work. If contact lenses are a total bust (very rare), then refund them the cost of any unused, sealed lenses supplied and credit this towards their new, necessary spectacles. Never argue over money. Sometimes you just need to suck it up. Any loss you take now will be repaid, over and over again, from the patient loyalty thus gained. This however rarely happens; by pre-treating and managing dry eye or allergies and providing the best lens we should get at least 90-95% success.

The next step on the pathway to speciality practice is to take on the high prescriptions, complex cases and provide presbyopes with contact lens options that satisfy their needs. Fit lenses to accommodative esotropes and anisometropes and at the same time delve into the subspecialty of behavioural optometry and binocular vision, which are other great niches.

Much of the above can usually be achieved with the amazing plethora of disposable contact lenses we have in our armamentarium and that includes myopia control. Extended ranges of Si-Hy disposables, like torics up to -5.75DC, can work a treat in grafts and less severe keratoconics while toric multifocals and high spherical powers cover much more of the bell curve than we ever could in the past.

All for relatively low cost or overhead.

Learning to Fly

Once you are cruising, get involved in more complex corneal RGPs, Ortho-K and scleral lenses. This is best achieved through mentoring and hands on experience. The best place to start on that road is by attending conferences or joining a speciality practice with a view to buying into the partnership over time. Of course, there is valuable support available by email, tutorials and YouTube. Join the contact lens society where you can network with successful colleagues and find a mentor.  Most speciality lens manufacturers have a team of consultants able to walk and talk you through a given complex fit, often by Skype or webinars. You will need a few trial sets. Ask around as to what lenses provide the best results. In my case I had access to many great trial sets, but I had a few that I would go to for most cases. Make sure you verify every trial lens, patient’s worn lenses and those you are ready to dispense.  A radiuscope should be used by all on every lens, or else you will have comebacks, incorrect end results, refits and other surprises. Examine every lens with a 7X loupe and do a full in-office laboratory clean with specialised lab cleaners and the like.

If you are on the road to speciality contact lens practice and simply want to refine your skills in contact lenses, the cornea and the ocular surface, or take it to the next level, you would be hard pressed to beat the range of specialists and world experts who are attending and presenting at Contact Connect at SPIER in the Cape during September. There will be great lectures, hands on workshops and much else in an amazing location. If the last Contact Connect is anything to go by this one should be even better, and that’s saying something.

I look forward to seeing you there and being back in the amazing Cape.

Check out and register for Contact Connect at www.contactconnect.co.za

If you feel like some overseas travel or want to do a post-election LSD trip, we’d love to see you in Noosa, Queensland, Australia in October for the renowned International Cornea and Contact Lens Congress (ICCLC) which is arranged by the Cornea and Contact Lens Society of Australia (CCLSA).

Check it out and register at www.icclc2019.com.au

Like the Contact Lens Society of South Africa (CLSSA) and the Cornea and Contact Lens Society of New Zealand (CCLSNZ), the CCLSA remains one of the longest running societies of its type in the world. I’ve been fortunate to be a member of all three, a President of two, and now serve as the CEO of the CCLSA and have arranged conferences for all three bodies. It’s really great to be part of a collegial society so if you’re not a member join the CLSSA now at http://clssa.co.za/

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