We’ve been talking about Digital Eye Strain for years. In our world, it seems ubiquitous and obvious. But according to The Vision Council’s July 2018 VisionWatch survey, as reported in Vision Monday, the problem and its solutions are still not clear to many consumers.
Not surprisingly, digital device usage continues to take up a huge chunk of our days:
Almost 60% of adults report symptoms of Digital Eye Strain. The #1 symptom is neck and shoulder pain, followed by eyestrain, blurred vision, neck strain, headaches and dry eyes.
Among children, the most common symptoms of device use reported by parents are not strictly vision-related: short attention span, irritability, and poor behavior. These were followed by eye strain (9%), headaches (9%), and neck and shoulder pain (5%).
While symptoms of DES abound, awareness of these symptoms as an ocular health issue lags. About 51% of U.S. adults say they are aware of DES, which isn’t bad considering that most people spend very little time thinking about vision issues. But it still means that half the population needs to be educated. About 35% report that they aren’t concerned about the impact of digital device use on their eyes, and 25% of parents say they’re not concerned about the impact of DES on their children’s eyes.
Awareness of solutions for DES is also low. 70% don’t know that eyeglasses designed to treat DES symptoms are available. Disturbingly, half of those who had eye exams in the past year say that vision problems associated with digital devices were not discussed.
What We Can Do
Digital device use is nearly universal, and 8 in 10 adults have symptoms of DES. What’s more, there are lenses for nearly every type of wearer that are designed to treat the symptoms. Even for people who don’t need prescription eyewear, there are solutions like “gamer glasses” designed that address both DES and blue light effects. Given all that, there’s every reason to discuss DES and possible solutions with virtually every patient. Even if they don’t report symptoms of DES on their patient questionnaires, a conversation might cause them to think a little harder, or to start noticing the symptoms after the appointment. Even if the conversation doesn’t lead to a sale of DES lenses, the patient will know his or her options. A more informed patient is always a better patient.
In the 1950s, 10-20% of the Chinese population was myopic. Today, as many as 90% of children and young adults are. Over 96% of 19-year-old Korean men are nearsighted. And the problem is not confined to East Asia: 40 years ago, 25% of Americans aged 12 to 54 were myopic. Today the number has risen to 42%.
There’s no doubt that we are witnessing a huge increase in myopia around the world, and it’s not just a matter of more kids needing glasses. Early childhood myopia can lead to serious vision problems later in life, like glaucoma, macular degeneration and even retinal detachment. So what’s behind this dramatic increase in myopia?
Clearly, genetics are one factor. But genes alone can’t explain the very rapid increase in myopia, so environmental and behavioral factors must also play a role. Book work has long been considered a primary culprit. Centuries ago, Johannes Kepler, the astronomer and optical scientist, attributed his own nearsightedness to all the time he spent studying. And even today, people associate eyeglasses with intelligence (or nerdiness, especially if the bridge of the frame is taped together.) Kids who read and study more appear more likely to be myopic, and the pressure for academic achievement helps explain the high levels of myopia in China and Korea. But even before they can read, many children play with smart phones and tablets, which could be setting the progress toward myopia into motion even earlier.
However, some evidence suggests that up-close work is not the actual trigger for the eyeball to elongate. A study by the Ohio State University College of Optometry found that neither book nor computer work correlated to increased risk of myopia. The one factor that did appear to reduce the likelihood of myopia was spending time outdoors. If this is true, increased study time and is still a factor to the extent that it can mean less time spent outdoors. Other factors could include the reduction of PE programs in many schools, parents’ reluctance to let their kids play outdoors unattended, and the rise of video games as a preferred leisure activity among kids.
Results are preliminary, and more research is needed to confirm the link between outdoor time and myopia. The specific mechanism by which outdoor time prevents myopia also requires further study, but some researchers believe that sunlight plays a role. But whatever the causes, the increase in cases is real, and likely to continue.
There are a number of treatment options that have been effective in slowing the progression of myopia in children: atropine eye drops, soft multifocal contacts worn in the daytime, or rigid contacts worn at night (ortho-k). Some eyeglass-based treatments have also been developed or are in development. But none of these can compete with the natural solution – more outdoor time for kids, which of course has additional benefits for children’s health (and perhaps the mental health of their parents.)
The explosion in myopia shows that parents need to be more vigilant than ever before in detecting warning signs so the problem can be addressed through behavioral changes or treatment. These include squinting to see in the distance, holding books very close to the eye or sitting close to the TV, headaches and eye strain. Once elongated, and eyeball can never be made shorter, but it is possible to slow the progression.
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Your pretest room and refracting lane have all the sleek, high-tech equipment you need to measure every aspect of a patient’s eyes. But if you’re like a lot of practices, you’re using 4500-year-old technology in your optical. Yes, I’m talking about the ruler, the earliest known example of which was discovered in ancient Sumeria, and dates back to around 2650 BC. It is doubtful that it was used to measure PD, but the concept has never really changed. How do patients react when you take measurements for a customized lens made to .01mm tolerances with a 4.5-millenia-old tool?
Not that old technology is necessarily bad: when we eat we use knives, a tool developed by early humans about 2.5 million years ago and is still state-of-the-art, at least until laser food cutters hit the market. The main problem with PD rulers is they are prone to inaccuracy – slight lateral movements by either the patient or the dispenser can cause measurement errors of one to five millimeters. And, of course, they don’t make a great impression when you’re selling advanced lenses. Pupillometers are more accurate, but for the best accuracy and the greatest sophistication, nothing beats a digital centration system.
Digital centration systems take two basic forms: freestanding and tablet-based. Freestanding units make a distinctive, high-tech impression in the optical, but they tend to be expensive and they take up space that many offices don’t have. Tablet-based units are more affordable and can be used anywhere. And since they tend to be bundled with digital lens demos, they offer a complete solution for working with patients in the optical.
Digital measurement systems are easy to use and produce consistent results. Many of them just require just one photo to produce both standard and position-of-wear measurements, like pantoscopic tilt and vertex distance. A lightweight attachment to the patient’s frame provides reference points for the camera. When patients are measured this way, they know they’re getting a pair of advanced optical devices in their frames.
Digital centration instruments are available from companies like ABS/Smart Mirror and Optikam, as well as many lens manufacturers. If you’re not using one, check them out. You’ll discover how easy it is to make a 4500-year technology leap.
In the days before eye exams, the method for selling eyeglasses was very simple: the seller (often a jeweler) had a bunch of eyeglasses in various powers, and patients tried on one pair after another until they found the one that worked best. Clearly, it was an imprecise approach, and was limited to the inventory available in the store, or the travelling salesman’s wagon. On the other hand, it had one distinct advantage over the way we sell eyewear today: consumers knew exactly what kind of visual experience they were buying.
Today we can design and manufacture a lens based on specific individual parameters. Even so, patients don’t get the opportunity to try before they buy. They have to accept on faith that the new eyewear will work as well or better than what they’ve been wearing. That can cause anxiety, both for the patient and the dispenser, especially if the eyewear they are purchasing is more expensive. For that reason, many dispensers prefer to keep patients in the same lenses, however much they are surpassed by newer technology.
A true lens test-drive continues to be impossible, but new demonstration systems offer the next best thing, with animation and imagery that can bring the latest lens technology to life. Some of these systems are standalone, while others are bundled with try-on and measurement systems. Today, many are housed on tablet computers, which are both more flexible and less expensive than freestanding versions.
These systems can demonstrate aspects of lenses like the difference between standard and customized lenses, how AR reduces reflections and polarization reduces glare, and how photochromics work in various lighting conditions. These are all things lens manufacturers do with side-by-side photos on dispensing mats, but digital systems provide animation and interactivity that dramatize the demonstrations.
The most advanced systems, like ABS Smart Mirror, can show the wider visual field of a customized progressive using the patient’s own prescription. While this probably won’t be as dramatic as showing what the difference would be for a -4.00 Rx, it is much more realistic and avoids false expectations. Some systems use the tablet’s camera to show the difference as the patients looks around the exam room or the optical.
Most manufacturers and ECPs agree that these systems are best used as an enhancement to, rather than a replacement for, a consultation by a doctor or dispenser. Your word as an expert is always the most important element in helping the patient choose the best eyewear, but seeing is believing.
This blog entry was based on my cover story in the November issue of Vision Monday, called “Dynamic Demos.” For a rundown on the various types of demo systems available, and their use, check out the article at VisionMonday.com. I can’t honestly say the article is a masterpiece of journalism, but I bet my mom would.
According to patients, the most important factor in determining their satisfaction with an eye care practice is how long they have to wait for their exam. It somehow weighs more heavily than the thoroughness of the doctor’s exam, the care demonstrated by the staff, or the quality of the eyewear you sell. This tells us two things: first, life isn’t fair; and second, keeping wait times short is extremely important.
A Jobson Research survey shows that about two-thirds of patients think that a wait time of no more than 15 minutes is appropriate to see an Optometrist. The good news is that of all medical professions, Optometry has the shortest wait times – about 17 minutes on average. On the downside, patients don’t expect to wait as long for an eye doctor as they do for other types of doctors.
Every office tries to schedule appointments such that the exam chairs will always be full, but patients don’t have to wait long. But it’s not an exact science, and inevitably there will be delays. Patients who arrive early are content to wait until their scheduled appointment times, but once that time passes, they become increasingly impatient (there’s actually a name for this: appointment syndrome.) Here are a few of ways you can make long waits more tolerable.
Beethoven’s Seventh Symphony is a masterpiece, and since I love it, I want everybody else to love it. Suppose I want to share it with you, and to do so I hand you a copy of the printed score. Would you get anything out of it? I certainly wouldn’t.
Now suppose I give you a download link to a performance of Beethoven’s Seventh played by a great orchestra under a brilliant conductor, and you listened to it. You still might not like it, but at least you would have the opportunity to appreciate it. The music exists only potentially in the score. It takes talented musicians to realize it – to make it come to life.
Why am I talking about this, apart from the fact that I have a nerdy love of Beethoven? Because the same relationship exists between a prescription and a pair of glasses. The prescription may be brilliantly done, but the piece of paper itself doesn’t help a patient see better. It has to be brought to life in the form of eyewear.
A prescription, like the Beethoven symphony that I just can’t shut up about, can be realized well or badly. Draggy tempos and poor playing correspond to narrow viewing zones and excessive peripheral swim. The wearer can come away with a bad impression of the prescription, and the doctor who wrote it, just like a listener can come away from a bad performance wondering why Beethoven is such a big deal. Is there any other type of prescription subject to such wide variations in quality?
Some doctors like to write prescriptions and leave the selection of lenses to somebody else. But in doing so, they allow the possibility that the patient will get a poor realization of the Rx. That doesn’t just make the patient unhappy – it reflects badly on the practice and the doctor.
This is an argument not just for understanding what’s going on in the optical, but for recommending specific lenses in the exam room, and making a firm hand-off to a dispenser. A recommendation from the doctor will be stronger than one from anyone else in the practice. Only the doctor can make the recommendation in the medical context of the exam room. And that’s entirely appropriate, because it’s the best way to ensure that the patient gets the most out of the recommendation.
Doctors, if you’re not involved, get involved. Talk to patients about their lens options, and why you think one is better than the other. A recommendation from you may keep them in your optical and away from the budget retailers. It’s good for your practice’s bottom line, and it’s good for your reputation.
(By the way, the Deutsche Grammophon recording of Beethoven’s 7th with the Vienna Philharmonic conducted by Carlos Kleiber is really, really good.)
Practices owned by private equity firms are now part of the optical landscape, just like big-box and online retailers. About 7% of U.S. Optometrists are now backed in some way by private equity, and new acquisitions are so frequently announced in Vision Monday that they’re becoming background noise. Why is this happening? Because health care is the fastest-growing segment of the economy, and PE firms know it. They’ve decided that there’s money to be made in creating a hybrid of private-practice and corporate optometry. And there are a lot of practice owners who are more than willing to sell part or all of their practice to investors. What do they see in it?
For practice owners who are nearing retirement, PE can be like a reverse mortgage – you get cash for your business, but you still get to practice as long as you want. For others, it’s an opportunity to get rid of all the headaches of running a business and focus on optometry. PE groups usually promise that they will preserve the culture of the practice, while installing their own business systems and controlling the optical. The bottom line is that the seller gets to control whatever goes on in the exam lane, and the investors take care of –or control, if you prefer – everything outside of it.
Whether selling to PE investors is right for a practice owner, or not, largely depends on two things: how soon the owner plans to retire, and his or her desire to control the practice. Selling provides the opportunity to reduce stress levels and get back to basics – the doctor controls what goes on in the exam lane, and the investors take care of the rest. But for those who like to control their own destiny, who relish the challenge of making their business run smoothly and profitably, staying independent is the way to go. One thing is certain, though: once you make the deal, there is no going back.
Sometimes the things we know the most about are the hardest to explain. I once spent some time talking to a sales VP for a company that made highly sophisticated medical devices, and he said something that struck me: “Our best salesperson is the one who knows the least about the product.” It seems strange, but there’s a good reason for it: the sales rep didn’t get buried in the technical explanations of how the equipment worked; instead, he focused on what it did better than other devices of its type.
The same rule applies when we talk about eyeglass lenses. We may know exactly why this one works better than others, but explaining it to patients may cause their eyes to roll into their heads, or make them feel like you’re just trying to intimidate them into buying a more expensive pair. It may be obvious to us that a wider distance zone with lower peripheral astigmatism is a good thing, but it probably isn’t to them.
Instead, focus on top-line benefits and keep them as simple as possible:
Every now and then, of course, you’ll encounter a patient who wants to know how the lens or coating delivers the benefit. In that case, it’s good to have a sentence or two about the technology in your back pocket. But unless the patient asks, just stick talk about the benefit that the patient will experience.
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