The Law of Diminishing Returns and the Contact Lens Follow Up Appointment

So the standard way contact lens fitting works is this: we docs take all the appropriate measurements, grab a lens we think will work, check the fit and vision...and 90+% of the time it works great and we're done. Occasionally a patient (mostly astigmatism, monovision and multifocal wearers) will return a few days or weeks later with some complaints and we look at the fit (for rotation), maybe take some more measurements with the lenses on (over refraction), and make some adjustments and try a new pair of lenses. That takes care of another 5% or so. Well what about the final 5%? The ones who are not happy with their vision through the contact lenses after 2 distinct visits? IMO most of them are just not good contact lens candidates. Either their visual demand is too high (20/20 "not clear enough"...this is the vast majority of contact lens follow-ups) or they need too many distances to be crystal clear (driving, computer and reading, for instance, all equally crystal clear). It is at this point that I usually give up. Not because I'm "lazy" or don't want to fool with it but because in 15 years of doing this I have learned that the more contact lens follow ups you schedule, the *LESS* likely you are to find a Rx that the patient is happy with. You'd think we could just endlessly "fine tune" the Rx and get closer and closer to the "perfect" pair of contacts, but actually the reverse is true. More contact lens appointments past the 1st two generally yield zero improvement and sometimes it's WORSE. Some patients have this idea that trying endless materials, brands, designs and incremental changes in Rx will eventually get them to where they need to be, but the reality is...we are very, very good at fitting contacts. When we choose the first pair it is HIGHLY probable that it's "right" and that you'll see as well as you will ever see in contact lenses with that 1st pair. So if/when you're not thrilled with the vision out of the 1st pair, you may assume it's because we didn't get it "right" or it needs some "fine tuning", but reality is usually that your expectations are too high, either because you think we should be able to duplicate your glasses vision in contacts or you have some preconceived notion of how your vision should be in contact lenses, usually from remembering your contact lens vision from before you needed bifocals. The vast majority of contact lens wearers are myopes (near sighted people). As I have blogged before, myopes often see *INCREDIBLE* up close without glasses on, and they incorrectly assume that we are able to duplicate that up close vision in multifocal contacts, which is fantasy. One thing I have learned about people who are "thrilled" with multifocal contacts (and multifocal cataract IOL implants also, BTW) is that they are not very picky about their vision. They are willing to put up with some amount of blur in order to gain the convenience of not wearing glasses or reading glasses. But for people who need to see *incredible* at multiple distances and they're over 45, multifocal contacts are almost never the answer, and for everyone of every age: if we can't get it "just right" in 2 probably cannot be done, by anyone.


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