Optometrists today have many unique and different career paths available to them. In this article series, we’ll be engaging with optometrists from various common (and not-so-common) practice modalities to get a firsthand perspective on what optometry is like in their setting.
Today, we’re interviewing three optometrists who have extensive experience with specialty contact lens practice: Anita Gulmiri, OD, FAAO, Stacy Zubkousky, OD, FSLS and Caitlin Morrison, OD, FAAO, FSLS.
Dr. Gulmiri is residency trained in cornea and contact lens and is an assistant professor of clinical optometry at the New England College of Optometry, specializing in fitting and managing both routine as well as specialty design lenses.
Dr. Zubkousky is residency trained in cornea and contact lens, and has extensive clinical experience fitting specialty contact lenses. She is an assistant professor in the contact lens department at Nova Southeastern’s College of Optometry.
Dr. Morrison is residency trained in cornea and contact lens and is the owner of In Focus: Specialty Contact Lens & Vision Solutions, a private practice in Scottsdale, Arizona specializing in contact lenses for advanced ocular conditions and comprehensive care for difficult visual cases.
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What advice would you offer optometrists considering a career path in specialty contact lens?
Dr. Gulmiri: If you are a student in your optometry career path, begin seeking opportunities to deepen your knowledge and experience in the field of contact lenses. Your college will most definitely have some type of contact lens club, so join the club or even go as far as becoming an executive member! Let your CL faculty know you’re interested in pursuing the career path so that they keep you in mind when student contact lens opportunities come up! Contact your clinical education department at your college to discuss your interest and volunteer for any extra clinical contact lens sessions that might be available to you. Attend contact lens webinars specifically geared for students. There’s a fantastic student webinar that is hosted by gpli.info and other specific webinars that are industry sponsored, find these and attend them. Try to gain as much understanding of this field as a student and then consider a Cornea and Contact lens Residency if you continue to be seriously interested.
If you’re a new grad interested in this field but have relatively low levels of clinical experience, you may have to work extra hard to gain the knowledge and clinical skills to specialize in the field. You may choose to go back to pursue a Cornea/CL Residency. This will be your fastest and most efficient path to gaining the expertise. However, it is not the only path. You can learn to fit specialty contact lenses without a Residency, but the path will be longer and you will need to be disciplined and committed to self-teaching and self-learning. More on this coming up! Keep reading!
Dr. Zubkousky: Shadow a specialty contact lens ECP. The daily routine and typical patient base are vastly different from a primary care ECP. Utilize that time to see if it is the right fit. If you get that indescribable feeling when you help a patient see clearly for the first time, that will motivate you to put in the extra work that comes along with specialty lens fitting.
I would also advise them to utilize the many resources available. One of my favorite resources is GPLI. I refer to their website often, as they offer webinars, coding and billing resources, etc. Attending specialty lens conferences like GSLS, can immerse you into the world of specialty lenses and keep you updated on the latest technologies and research.
Dr. Morrison: Become a lifelong learner! Although doing a residency program gives you a wealth of knowledge, some of the most influential contact lens specialists are those who were in practice for years and just decided to start learning.
Ways you can begin to become a specialist include: attending specialty contact lens lectures at Academy meetings, attend the Global Specialty Lens Symposium, become active in specialty contact lens Facebook groups, listen to specialty contact lens webinars, incorporate new technology into your practice, attain Fellowship in the Academy, Fellowship in the Scleral Lens Society, and work towards your Diplomat in the Cornea, Contact Lens & Refractive Technologies Section.
If you commit to learning and improving your skills daily, you will be successful.
What is the most rewarding aspect of practicing in a specialty contact lens setting?
Dr. Gulmiri: How can I choose just one? For me, the most rewarding aspect has been patient appreciation and gratitude. Specialty contact lenses, including scleral contact lenses, corneal GPs and prosthetic contact lenses, amongst other designs, treat the irregular corneal surface. For patients with these conditions, not only are we dealing with inadequate levels of visual acuity and visual quality, but as a result of the poor vision, we are also dealing with inadequate levels of quality of life. Most of our patients are functioning within the severe category of the low vision classification scale. Some of our patients have stark levels of ocular pain, photophobia, and others have very low self-esteem due to cosmesis and yet others will demonstrate signs of depression as a result of a combination of these factors. I truly believe we have the capacity to change patients’ lives with the use of our contact lens designs. If you’ve ever been in an advanced contact lens clinic, you may have experienced this first hand, where a patient is so overcome with emotion that they break down into tears right in your exam chair. These patient cries really do resonate deep into our soul and they remind us of the many reasons we chose this profession in the first place. This outpour of emotions is understandable because for the first time in years, these patients feel hope for the future. Providing that glimmer of hope, however small, is the most rewarding experience of practicing in this field.
Dr. Zubkousky: In the daily life of specialty lens ECP, it is not uncommon to change someone’s quality of life in a relatively short period of time. While specialty lens fitting involves patience and an extensive fitting process, the turnaround time for life changing results is short. If having a rewarding practice is a huge motivation for you, specialty lens fitting is a good fit.
Dr. Morrison: The most rewarding aspect of specialty contact lenses is the relationship you form with your patients. Because patients return multiple times during the fitting process, you develop a real friendship with them, instead of seeing them briefly once a year. Also, improving a person’s vision from 20/200 best corrected to 20/20 with a lens is the best feeling in the world.
What is the biggest challenge?
Dr. Gulmiri: To take a very practical turn on our discussion, the biggest challenge is from an insurance and payment standpoint. As you can understand, there is a lot involved with accurately fitting and assessing these very specialized lens designs. A lot of our patients fall into the “medically necessary” contact lenscategory. Sometimes the provider definition and insurance definition of medical necessity are well aligned. When we have that alignment, it is a fairly simple process in terms of billing and getting paid for our services. However, when these two ideas within the two parties don’t align, this is when things can get complicated and where the challenges arise. As a provider, we always want to strive to provide what is best for our patients, however we’re left to determine how to bill for our services understanding the patient may not have the appropriate insurance coverage to cover our services. Again, a very practical and real challenge to fitting these types of contact lens designs.
Dr. Zubkousky: I feel that the biggest challenge in a specialty lens practice is navigating insurance coverage and uninsured patients. As a provider, you are faced with a challenging decision when the best lens for the patient may be the most expensive lens.
I recommend that if you have an interest in growing a specialty lens practice, you attend or watch as many lectures or webinars on coding and billing. However, even with the savviest billing knowledge, there will be many plans that do not cover the lenses or uninsured patients who need lenses. It is so important to have a plan for those patients who can’t afford the lenses out of pocket. Some options are financing programs, grants, referring to local academic programs, industry workshop events and utilizing specialty lens company’s programs available for disadvantaged patients.
Dr. Morrison: In the specialty contact lens world, the biggest challenge is the design work itself. You may think a fit looks absolutely perfect, but then issues arise that you have to address. Every person’s ocular anatomy is completely unique. It is fun to have to think creatively, but also frustrating to not achieve “perfection” on your first try.
Is further education recommended/required for optometrists to successfully work with specialty contact lenses?
Dr. Gulmiri: This is a great question but also a very loaded one! As I currently work in an academic setting, I get this question from students time and time again. I’m also the coordinator of the Cornea/Contact Lens residency program at NECO, so I am partial to residency programs. Also, having gone through a Cornea/CL residency program, I’m also biased from that perspective. I will be the first to announce that completing a residency program at NECO completely changed my career path and I couldn’t be more grateful for the opportunities I’ve received and continue to receive as a result.
So, my short answer will be yes, I would and will always recommend additional training and the best type of training to gain more specialized experience will come in the form of a residency training. During residency, you will likely encounter far more specialty contact lens fittings and patients in one year than you may see 3-5+ years combined in a private practice setting (with the caveat that it doesn’t already have a strong specialty CL patient base). To give you an idea of the types of numbers you might expect to see in a residency program, I’ve included an excerpt from our annual residency review for the academic year 2018-2019.
|Type of Lens||Resident 1||Resident 2|
|Keratoconus Design (Corneal GP)||120||113|
|Corneal GP (RC)||131||177|
|Corneal S/P Corneal Surgery||50||22|
|Ocular Surface Disease||275||298|
Further, a residency program provides endless networking opportunities. You are trained by experts in the field and you’re introduced to those individuals leading the field. You develop a network of mentors and colleagues and you’re introduced to an elite group of practitioners equally as passionate about the field of contact lenses, so what could be better?
I will say though that I understand a year of residency training is a sacrifice: no doubt! There are tradeoffs: of time and money. You are foregoing the seemingly promised six-figure salary for a year of a dramatic pay cut coupled with a year of blood, sweat and tears. Kidding about the blood and sweat but probably not the tears. I understand a residency program is not for everyone for so many reasons, and I can almost always respect the decision that leads an OD to forego that option. If you are still committed to specializing in the field of contact lenses without first pursuing a residency, there are so many resources out there to further deepen your knowledge. Our contact lens industry partners have unlimited resources on their websites in the form of detailed fitting guides, webinars- archived and ongoing, to say the least. www.GPLI.info is another website committed to educating Optometrists in the field of specialty contact lenses, with or without having completed a residency program. Further, as you start your path on fitting these more complex designs, the manufacturer lab consultants are available to guide you through your fittings. Lastly, you can join groups on Facebook, where experts in the field post their cases and discuss steps in their fitting process. There are a lot of valuable resources out there. As I mentioned above, you will just need to commit to self- teaching and self-learning but I’m here to tell you, it is 100% possible.
Another question I often answer is in relation to the types of equipment that may be needed to start a specialty contact lens practice. Besides your typical equipment that you can find in almost every practice, such as a retinoscope/autorefractor, phoropter, slit lamp biomicroscope, it would be extremely beneficial to have a corneal topographer. Yes, an autorefractor or keratometer- will provide central keratometry readings- to get a full scope understanding of the corneal power and shape, you will need a corneal topographer. An anterior segment OCT will be nice to have if you are first starting out with fitting scleral lenses, as it can provide you with quantitative date of corneal-scleral sagittal height and fluid vaulting under a scleral lens as well as qualitative scleral lens alignment data.
Dr. Zubkousky: In optometry school, if you know that you have a strong interest for contact lenses, I would highly recommend a contact lens residency. Personally, my contact lens residency gave me the knowledge and confidence needed to tackle the most challenging cases as I entered my first position outside of residency at a busy hospital.
With that said, you do not need to have a residency in contact lenses to successfully fit specialty lenses. In this scenario, I would recommend reaching out to the specialty lens community, utilizing the many resources available, attending conferences and getting to know your contact lens lab consultants - they will be your best friends!
Dr. Morrison: To be a skilled specialty contact lens clinician additional education is absolutely necessary, but it does not have to be from a residency program. You can attend meetings, courses, and wet labs to develop your skills. Because the technology and research in the specialty lens sector changes frequently, the only requirement is a commitment to continued learning.
How is your clinic time allocated during the week? Can you briefly walk us through a “day in the life” of your typical work routine?
Dr. Gulmiri: Currently, my clinical time is divided between two settings. I am in the Contact Lens Clinic at NECO’s owned and operated site called New England College of Optometry Center for Eye Care and I’m also practicing one day a week in a hospital-based setting in Boston Medical Center’s Advanced Contact Lens Clinic. At both locations, I have the pleasure of working with NECO students and residents, so my experience is just that much more colorful. The patient demographic differs between the two sites as well. At NECO, I see a combination of routine contact lens patients, patients wearing corneal gas permeable contact lenses for both regular and irregular corneal conditions, such as Keratoconus. My students, residents and I manage a fairly high volume of patients wearing scleral lens for a variety of different conditions including severe ocular surface disease. I’m also part of NECO’s Myopia Control clinic where I currently do all of the orthokeratology and multifocal soft contact lens fittings. This has been a fairly new service for us and within the past two-three years, this clinic’s growth has been extremely interesting to observe.
At the hospital-based setting, which is a safety net hospital, I manage a high volume of severe corneal and ocular disease and serve patients from a diverse set of cultural backgrounds. Many of these patients do not speak English and come from lower socioeconomic backgrounds. This is an advanced CL clinic and mostly every patient is funneled through the Ophthalmology Cornea service to our CL dept. I manage a high volume of scleral lenses, corneal gps, and prosthetic contact lenses at this location.
I also teach in the Contact Lens Course at NECO as a lab instructor and as I mentioned above, I am the coordinator of the Cornea/CL residency program.
Dr. Zubkousky: A specialty contact lens practice has a lot of variety in your daily routine; that’s one of the reasons why I love it. In addition to any primary care exams, it consists of new lens consultations, dispensing visits and follow-up exams.
I typically allot 1-hour slots for my new lens consultations. At these consultations, I will perform the standard vision testing and slit lamp evaluation, but also will obtain corneal topographies, corneal-scleral profilometry, apply a trial lens and perform anterior segment OCT. I will also reserve enough time to discuss with the patient why they may benefit from specialty lenses, their lens options and the fitting process. I find the process moves more smoothly when I spend more time upfront thoroughly explaining these topics as well as setting expectations. The patients who present for these consultations also vary, ranging from pediatric patients with high myopia or traumatic scarring to elderly patients with severe ocular surface disease.
During my first dispensing visits, I will have the patients watch a video on application and removal options, and then will then have them sit down with me or a trained technician to find the best technique for them. It is important that they feel comfortable and not rushed, as the first dispensing visit can be quite overwhelming. We will also go over care systems and supplementary products. It is important to set your follow-up visits later on in the day, so you can see how the lens fits as they wear the lens throughout the day.
As the day comes to a close, I will place any new lens orders. I do this in a variety of ways, including online ordering systems and emailing and calling consultants directly. I will conclude the day with writing any letters to any of the referring cornea specialists or optometrists.
Dr. Morrison: A day in my private practice includes arriving about an hour before my first patient to open the office and read through each patient’s chart and referral notes. Ninety percent of my patients are new specialty contact lens patients and follow ups, and ten percent are comprehensive exams who come in for concierge-style eye care where we spend a full hour together addressing issues.
My typical new patient is a referral from ophthalmology. I see a lot of patients with keratoconus, corneal transplants, and radial keratotomy. Pediatric patients are referred for myopia control, aphakia and pseudophakia. An interesting portion of my practice involves prosthetic contact lenses for irretractable diplopia, post-traumatic complications, and corneal disfigurement, as well as other conditions.
After seeing my patients for the day, I will finish charting, answer emails and voicemails, and write letters to the patient’s referring providers. I try and leave one day a week free for purely administrative work, but this is difficult as I see more patients.
There are numerous specialty contact lens residency programs available to ODs today. What are some unique advantages/clinical skills these residency programs offer?
Dr. Gulmiri: I’ve touched on a lot of the advantages of completing a residency program in my answers above, but let me provide a brief summary. I cannot stress the extensive volume of specialty CL patient encounters and the depth of growth you will experience in one single year during your residency program. You will learn to diagnose, and manage complex corneal and ocular surface disease. You will learn to fit “difficult to fit” and advanced contact lens designs and your approach to lifelong learning and teaching will also expand and strengthen during your residency year. Coincidentally, this is that time of the year when I really come to terms with the level of growth a residency program can achieve. My current residents are graduating from their program June 30th and the incoming, fresh Cornea and Contact Lens residents will begin July 1st. The difference in the incoming and outgoing residents’ level of confidence and skill set, to say the least, is outstanding and frankly underrated. Further, our outgoing residents are leaving with life-long connections with colleagues, mentors and experts within the field as a result of their networking opportunities provided during the residency program. They also have a unique skill set that can be extremely beneficial and serve as an advantage to them as they seek practicing opportunities in a setting looking to expand their scope of medical contact lenses and or myopia management.
Dr. Zubkousky: After completing a contact lens residency, you will have the knowledge to fit a large variety of types of lenses on a wide range of pathologies. This is an invaluable skill as it allows you to enter your career with confidence to tackle any case that may come your way. It will set you apart in that you will be able to provide any patient who may need a contact lens an option. It will also give you the opportunity to work with many different lenses and technologies, so that when you enter your career, you can choose among the tools that work best for you.
Dr. Morrison: You will gain extremely valuable knowledge in completing a residency. You will also form connections with other Doctors and Industry leaders who can give you advice and guidance throughout the years. By completing a residency, you will be able to fit almost every style of specialty contact lens and troubleshoot complications.
You will also gain skills on how to write a paper of publishable quality, as well as submit for poster and oral presentations at annual meetings. Without the help of my mentors, I would have felt overwhelmed at this process and likely wouldn’t have continued after residency.
The specialty contact lens community is actually pretty small and we mostly all know each other. If you are deeply committed to this area of expertise please reach out to me, and I am happy to help you with your career aspirations and provide guidance on the process!
Optometrists interested in specializing in cornea and contact lenses have the option of starting their career path immediately after graduation through one of the many unique residency programs available. Seasoned ODs also have the option of learning to fit specialty contact lenses later in their career by acquiring the necessary skills through CE courses and workshops. Fitting specialty contact lenses is a niche largely exclusive to the optometric profession. It can offer a unique clinical experience, as well as provide life-changing results for patients.