In this episode, Dr. Harbir Sian welcomes Dr. Jennifer Lyerly, a self-proclaimed optometry nerd, a successful blogger, a pioneer in the optometry podcast world, and a passionate practitioner in myopia management and specialty contact lens. True Vision Optometry, where Dr. Lyerly works, was recently awarded one of the practices of the year in 2023 by CooperVision. Dr. Lyerly shares her expertise in myopia management, how she started her ultra-successful blog, and her journey in the optometry podcasting world. She also shares advice on dabbling in myopia management and gives her insights on the vision insurance plan. Tune into today’s conversation and gain awareness about the world of myopia management.
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Optometry Nerd And Podcast Pioneer, Dr. Jennifer Lyerly
Thank you so much, as always, for taking the time to join me here to learn and to grow. As always, I’m going to ask you one quick favor right off the top. If you get any value out of this episode, please do share it. Take a screenshot, put it on Instagram, tag me and my wonderful guest, Dr. Jen Lyerly, and let us know what you took away from this. Send a link to a friend, and let them know we are having these conversations.
I am so excited. Honestly, I have been wanting to have Jen on the show for so long. It’s my fault for not getting her on sooner. I’m so grateful to Jen for being impactful on my career and my journey into podcasting. She’s been so helpful to me. Thank you, Jen, right off the top, for being here and for being so helpful in doing everything you have done to support me in my journey. I wanted to get that out of the way.
In case you don’t know Jen, she is the Cofounder of Defocus Media with Dr. Darryl Glover. She’s also the author of a very successful blog called the Eyedolatry Blog, which gets over 50,000 page views a month. In previous months, it has hit even 100,000 page views a month, which is massive. In case you are not familiar with blog numbers, that’s pretty impressive. She is a self-proclaimed contact lens enthusiast and myopia management enthusiast. That’s the type of stuff we are going to dig into in this conversation. She is also the mother of a beautiful three-year-old daughter. Thank you so much, Jen, for being here. I’m so grateful.
Thank you so much for having me. I love your show. I’m a big fan and a first-time caller. It is an honor to be here. I am so excited to have this conversation because I know you share a lot of the same passions that I do in optometry. I think we are going to get to nerd out together on this journey.
Yes, because you are also a self-proclaimed optometry nerd, right?
Yeah. Darryl was trying to help me find it. He’s like, “I’m the favorite optometrist.” I’m like, “What is your brand?” He was like, “You are an optometry nerd.” I was like, “Is that me?” He was right, so that has stuck.
It’s okay because I am a little bit too. I’m more than happy to geek out as much as we can. The main arc of the conversation is going to be myopia management and practice management. That type of discussion. Honestly, I don’t do a whole lot of clinical conversations myself on the show, but I do like to get into these conversations offline with colleagues all the time. It only makes sense for us to start to have this conversation here. Why don’t you tell us a little bit about what you are into at work? What gets you up in the morning and what gets you excited to go to work daily?
Since I had my little girl, I have been a part-time associate doctor at a private practice in North Carolina. It’s called TrueVision Eye Care. I work for a good friend of mine that I first started working with several years ago. She left the practice we were jointly at to open up her place. She had always said like, “One day I’m going to call you and I’m going to say you need to come to work with me.” That was a joke for a long time. One day, she did call me and I have been very happy with her for several years now.
As part of that, she needed a very part-time doctor three days a week and that was exactly where I was at in my life at the moment. We can probably talk about this a little later on. I feel like being one of these part-time young females in optometry, I hear so many conversations around what the new face of optometry has meant to reduce patient care hours and this demand for more optometrists, even though we should theoretically have plenty of optometrists.
I’m on the back end of that. My response to that is, this was the promise that I was told when I first applied to optometry school. This is a great career for someone who might, when they start a family, want to do something part-time when that’s the right time in their life to do part-time work. Maybe as things change for them and their schedule allows for more days to add back in, that might happen too. That was our promise when we first applied. This is a great job for women because it gives you work-life flexibility when you need that.
That’s a very good point. It is true. That is the promise of optometry. It’s a very flexible career. Also, I suppose, to be honest with you, I’m sure I have heard it, but it didn’t click for me that that is part of the reason that we have this demand or this lack of supply potentially. It still feels weird to me that there’s a lack of supply of optometrists. I still feel like even with all of the women who want to take the time and have the flexible career, there probably should still be enough ODs out there, but maybe I’m missing something. I’m hearing it across all of North America that there’s a shortage.
We have more optometry schools than ever before. Many of the major optometry schools have bigger classes than ever before. We are graduating more optometrists than we ever have. Patient demand has greatly skyrocketed because there are more people that are aging that need more access to eye care. Our rural communities are going underserved. There might be larger urban centers that do have enough eyecare providers, but in rural areas, there’s still a shortage of doctors because young people aren’t moving to rural communities and the numbers that they had in the past.
I do think it’s not just young women who are being part-time doctors, which is often how the conversation gets framed. Many older doctors are looking to take some steps back to enjoy more work-life flexibility. There are retiring doctors, and there are people who have sold to private equity. In doing so, they have gone down to a few days a week because it’s no longer the practice that they own. Across all age demographics, you are probably seeing doctors, in many cases working slightly less because of different changes that have happened in our world and in the climate of healthcare where practice ownership isn’t necessarily the path that everyone is doing.
There’s been a change in that overall as well. I’m one of those people too who likes to do a little bit of work-life balance and flexibility. We were talking about it. I haven’t publicly spoken about this, but right now, I’m in the middle of a three-month parental leave as well. That affects how many patients we are able to see in our practice and that type of thing.
It’s not just women. It’s everybody. I’m one of those people too. We could definitely dive more into that a little later if we want to. I want to share something and celebrate something first about you and the practice that you are in. You were awarded one of the best practices in the United States by CooperVision. Can you explain a little bit about that and what that means?
For the past years, CooperVision has run this great program where it recognizes eight practices across the United States with a focus on practices that are involved in their community and focus on exceptional eye care. You submit your application online. It’s very easy. They will probably be accepting applications for 2024 very soon because the 2023 winners were just announced. They also have a student program where they recognize students who are excelling in community education and building those skills for incredible practice and patient care.
It’s a great thing too. I wanted to apply because I felt like we worked hard as a practice. The doctor who founded our practice, my boss, Alecia Barnes, needed recognition. Our staff needed some recognition because they are in the trenches every single day. It can be a thankless job. To get any person on our team, that moment would be like, “Great job.” More than me saying, “Someone is recognizing us from the outside. You guys are doing great.” I feel like that’s powerful for our whole practice and our staff, especially.
Congratulations to you, the business owner, and the practice as a whole. It’s only eight practices across the country that are honored with this and awarded this. That’s pretty incredible. 1 out of 1000 practices across the country. You are right. Probably more than anybody, the staff deserves that recognition because they often maybe don’t get it, or they might not feel like they are so involved in the greater growth of the practice. It’s great that you all get to celebrate that. Congratulations. Tell me a little bit about what you think separated TrueVision and made it one of these practices that were awarded this award. I feel like I have some powers here.
Honestly, it’s been our focus on specialty care from the very beginning. When I was coming out of optometry school, I didn’t have a specific passion. Medical optometry, I guess you would say, but contact lenses I didn’t think twice about, honestly. I started working side by side with Alecia in a group practice that we were at. She was very passionate about two things, especially contact lenses and myopia management. Two things that, honestly, I didn’t get a ton of exposure to in optometry school. Her passion was contagious. I found it in working alongside her and learning with her because the first time I fit a scleral lens was her first time fitting a scleral lens. We did it together.
She was like, “I don’t know what I’m doing,” and I also don’t know what I’m doing, so we can learn this at the same time. This was several years ago. There weren’t a lot of resources available for how to do it. I found like learning beside her was specialty care was contagious. We continued to learn together, go to conferences together, educate ourselves, and she built this practice on the mission of these special things that had captured her passion. She’s a person of many talents that included neuro optometry and vision therapy.
We have a lot of toes in multiple specialty areas, but the other doctor, Dr. Brendan Wyatt, and I, that’s been a mutual focus that we all care about. We want to provide great general primary care and great medical care, but where can we go above and beyond and not just say, “You need to see someone else. We can’t help you with that.” We can help you. There’s no reason that we can’t take on that to help you with the very best clinical skills and technology available.
In my practice, we are earlier on that journey, so we are trying to carve out some of these specialties within our primary care. We do draw a lot of dry eye, and we are leaning quite heavily into myopia management now. This is the progression, but the next step is the specialty contact lens. I have not fit a single specialty contact lens in my life. No scleral or no Ortho-K.
That’s why I’m so happy now that we are having this conversation because I’m going to take that enthusiasm you have, and I’m going to start to draw it. We have just purchased a typographer, so we are starting to get into that now, but I’m going to call you. The same thing as what you just said right now, I will offer a parent all the options for my opioid management.
If they pick Ortho-K, then I say, “Here’s where I’m going to send you.” I’d like to say, “I’m going to pass you on to this doctor who does it in her practice, or cones, or whomever patients who need those scleral. I’m sending them off, and I’d like to keep them in-house.” We are just starting that. It’s cool to hear that that’s gotten you to this point where your practice is honored with an award like this because you kept that passion going and growing that way. It’s cool.
I want to ask you my elevator pitch for why people should consider specialty contact lenses. When was the last time a patient asked for you to hug them or cried because they were so happy by what optometry care brought to them?
It’s happened. I don’t know if I could tell you the last time. It was probably a dry-eye patient.
My patient and I cried together. It’s emotionally a lot, but I have never felt more purposeful in providing specialty contact lens care. The moment she was in her 60s, she had corneal scarring from an HSK infection. This has been a multi-year journey to get everything healed to a stable point, 20/200 vision in that eye. Her ophthalmologist referred her over to trial specialty contact lenses. She has a lot of scarring. Honestly, we had no idea how clear vision could potentially be.
She put on the scleral lens, and I overcorrected. She saw 20/20. We both cried. It was incredible. Not every single patient has these incredible results. Sometimes we don’t get any vision improvement with the specialty lens because it is too much. I never promise like, “These will change your life.” When the lens can achieve something like that, you are like, “I am so thankful that I get to help you with this technology. This is such an incredible opportunity for me to be a part of this with you and to see the improvement that’s going to make for your life.”
That’s profound, honestly, to have that impact on somebody’s life. I know that that’s possible. We have patients of ours that we know we can help like that. I have told them they can get scleral and they can go somewhere, but they are hesitant. I know if I offer it here in-house and I will be the doctor to provide this, they would do it. I feel like I have personally been limiting their potential because I haven’t been able to offer this. I can’t wait to bring it in. I’m sure at some point along the way I will have those types of experiences with some of our patients. That’s exciting.
Thank you for giving me that extra little nudge. I’m going to lean into it. I’m going to a meeting by CooperVision on scleral down in Arizona. That’s going to be my real push. I look forward to getting to it. I’m going to have you back on, Jen. Within 2024, I’m going to have you back on, and I’m going to share one of these powerful stories. I know it.
I know you will. These patients are in your care, and they are ready for you to wow them with the possibilities of optometry.
It’s official. It’s been said in public here on the show. This is going to happen. I’m excited about that. Let’s talk about myopia management a little bit more. This is a super-hot topic right now, a lot of awareness around it. You are driven by some of the industry players but also conversations with colleagues. How we have been able to help our young patients, and how we have been able to reduce the progression of myopia. When I have a conversation with someone like you, it’s obvious. You have been doing it for years. I have been doing it for years. It’s part of our practice now.
There are still a lot of people out there who haven’t done anything with myopia management. I’m not trying to speak poorly of anybody. Sometimes, you are too busy to implement a specialty, or sometimes you are not sure, “Do I want to put a young child on a pharmaceutical agent?” I’d love to encourage our colleagues and talk about what it takes to start. Talk about things like fee structures and things like that. These are important things that are on top of people’s minds. Tell us a little bit about what you do right now day-to-day as far as myopia management goes.
My first piece of advice for people, if this is something you even want to dabble in, start with the FDA-approved options because that’s going to make everything so much easier. The conversations are so much easier. We are going to get into some things that are not FDA-approved that I offer in my practice, and maybe one day will be. I think my myopia management with the FDA approval of CooperVision’s MiSight lens, and then there’s been subsequent lenses. That’s been the game changer and why so many more people are ready to at least consider embracing it in their practice.
In my everyday practice, our goal as an office, you will listen to people. Some people would be like, “Every patient’s going to do myopia management. I’m going to prescribe myopia management to every child that has myopia.” I completely understand that mindset, and that makes total legitimate sense. It’s just not the way that I necessarily practice. I’m not one of those “I prescribe” people. I have found that I have better success thinking or defining my success as, “Have I provided education? Does the patient know about their options? Have I provided a well-rounded discussion of what those options are? Have I empowered them to make the best decision, hopefully for their family or their self?”
I cannot define my success whether a parent or a patient decides to pursue the treatment option that, maybe in my heart, I feel like is personally what I would do if I was in their shoes. At the end of the day, the patient’s always going to be needing to be the one that’s on board with that treatment plan. I’d like to tell you, for every single one of my children that are myos or in a myopia management program, that is not the case. Every single one of my myopic children, their parents, knows about myopia management, and I have provided the education and some take-home information that exists. No one in my practice doesn’t know that it was not an option for them.
At the end of the day, the patient is always going to be the one that’s on board with the treatment plan.
That’s step number one. I was telling you I’m developing a lecture called The Myopia Startup. I’m giving you a five-step plan for getting into myopia management. Step one is to talk about it and educate the patient and parent. If they leave your office and nothing else happened, at least they are not going to go somewhere else and learn about it and say, “My optometrist never told me.”
It’s a good way to start to gauge interest and learn what parents are saying in return. You can streamline your conversation. It’s very important to do that. The options that are available here in Canada, what’s Health Canada approved is not the same as what’s FDA-approved right now, but the MiSight lens, I know, is one of the big ones there. I imagine you do a lot of that.
Our big three are MiSight, Orthokeratology, and atropine.
Do you do all three of those?
I don’t want to offend anybody, but do you have a preference or one that you lean towards? Let me ask you a question the way that I get asked, and I’m sure you do. If this was your child, what would you do? When somebody asks you that question, how do you answer that?
Parents ask me this all the time like, “Which one do you think is the best? Which one’s going to be most effective?” The truth is there’s no study comparing them. I cannot, with any science, tell my patient that one therapy is better than the other. In my personal opinion, each of them has pros and cons. I have a three-year-old. If she was showing signs of myopia, to me right now at her life, atropine would be the only thing that I would be considering.
If I have an eight-year-old patient that’s playing a lot of sports and they are -150 already, this is potentially a very good contact lens patient. Atropine and still wearing glasses might not be as good of an improvement to their overall lifestyle and ease of daily life. If I do have them in a contact lens, whether that’s an overnight contact lens, like Ortho-K, or a daily disposable contact lens. I talk to parents about lifestyles, their kids’ responsibility level, and cleanliness habits. Where are we at as far as handwashing, brushing teeth, and organization? That’s why instead of me saying like, “I prescribed this solution.” I’m like, “Let’s talk about pros and cons. Let’s find the right fit for you through our conversation.”
That’s the most effective way to get to a solution that everybody is happy with. Just saying, “You should use atropine, end of the story,” doesn’t help everybody get on board. It has to be that evaluation of all the needs, age, myopic progression, and all those things. That sounds like a lot. Now, you have said all of that and that can sound like a lot to somebody who’s like, “I want to get into it, but now I have to have such a lengthy conversation with parents.”
You are able to have that conversation because you already know in your mind, “This is an eight-year-old child who’s a -3 who likes to play sports.” That calculation has already happened in your head. You can rank your recommendations accordingly. That happens when you are going into myopia management. I will say it’s important to set some system, algorithm, or protocol in your head about how you are going to offer treatments and then what happens next. What happens when you are off Ortho-K? Where do they go next? You don’t have to think about every single step as you are doing it because then it feels like it’s a lot of work.
I feel like this is where I had a big learning curve too, because this is easily a conversation that can go down a black hole. It’s an hour-long conversation about peripheral defocus if you are not careful with how you frame it. I have tried to put some groundwork. This is my comprehensive exam, for example. We also screen the axial link, which, in my opinion, it’s not 100% necessary if you want to provide myopia management, but it is a fabulous tool that I found helpful to be able to provide good myopia management. If you are able to do that for your practice, I think you will find it even easier to have these conversations.
We will talk about the normal stuff like, “This is a glasses prescription I’m finding.” I want to let you know that in the past, we always said, “Your child’s vision got worse. Here are the new glasses.” We know next year it’s going to get worse by, on average, 0.5 to 0.75 every year until you are done growing. We don’t have to let it keep getting worse every year. Though we have FDA-approved treatment options to slow down how quickly this worsening is happening. We keep the prescription as low as possible and eyes as healthy as possible. I then give them the pamphlet of information to take home. I don’t want them to make a decision right then and there, honestly.
Maybe some parents are like, “Let’s talk a little bit more about this.” I will, but trying to keep within my comprehensive exam slot time, I know there are certain things that we need to have as this is a first-time conversation. Just lay some groundwork, and then we are going to have a staff member that I have got that’s dedicated to this discussion to call and follow up with parents.
Usually, an interested parent is going to be following up with us pretty immediately. If they are interested in any of the contact lens-related options, I always bring them back for some additional contact lens measurements. A corneal topography, it’s essential if we are even considering orthokeratology. I always do corneal thickness too, because personally, if you have a thin cornea, I don’t want to do orthokeratology on that. I feel like there are some risk factors. You will be surprised at how many kids you start screening that do not have keratoconus.
I will have seven-year-old -2 myopes, a pretty normal-looking case. I will do topography, and there’s some irregular steepening. I do pachymetry. They are 470 to 480 thickness. Now, our conversation has gone from myopia management to also discussing there may be some risk factors for keratoconus that we want to make sure we are not rubbing our eyes hard. It’s pretty essential to do some of these screenings that you probably won’t do at your general comprehensive exam before you make consideration for what contact lens might be safest.
There’s a lot of stuff that we could start to dive into once we got the ball rolling, and you are starting to have these conversations with the parents of the patients. You want to start offering more solutions like the MiSight, the Ortho-K, or atropine, but then you need to have some of these adjunct tests that are going to be helpful. You just can’t do it every time as screening obviously, like topography and corneal thickness. That’s the 2nd or 3rd level now when you are starting to dive into it more. Do you do anterior seg OCT then? I imagine you have that if you are fitting scleral and stuff.
We do that for our scleral fits all the time. I haven’t been doing it for any of my myopia management stuff.
I was wondering about the corneal thickness.
I am measuring that. You are right. That’s how I’m doing pachymetry reading.
We don’t have anterior seg OCT yet, but I think that’s going to have to be one of our next purchases. Axial length is very important as one of the measurements. As you said, I don’t think it’s vital. You don’t need it to start doing myopia management. We still don’t have it, but that’s part of the process now as well. There are always new things to buy and new toys to get. You get the meibographer, and then you got to get this thing. There’s so much stuff.
A little tip we were able to purchase old IOL. Master from an ophthalmologist who performed cataract surgery and upgraded his technology. This is a very old piece of equipment. It’s not fancy-looking. All I needed it to do was a scan. It takes a great axial link. He sold it to us for a dollar. You may find an older ophthalmologist with a piece of equipment sitting in a closet collecting dust. He is not looking for a lot of money to sell it to you.
It’s quite the bargain. I’m going to start looking. Was it on Facebook Marketplace? Where are you shopping for this?
Crazily enough, we called around to ophthalmologists to be like, “Do you have a piece of equipment that you don’t need anymore that we could buy from you?” He was like, “I will just give it to you.” I’m like, “No, we should buy it.” We don’t want any weirdness. He was like, “$1,” he said.
I’m going to call my staff after this conversation. I’m going to get him to start calling all the ophthalmologists in our area. “What are you trying to sell right now? What can we take off your hands?” It’s a great idea.
Investing in axial links doesn’t have to be cost-prohibitive. There’s way better, like the pieces of equipment that can do a whole lot more.
Anyone from Topcon or someone reading this right now is going to be like, “No, don’t do that.”
You are going to do a topographer. If you can get everything all in one, then that’s great too.
There are lots of different ways to go about it. For anybody who’s reading who’s thinking about getting into myopia management, or who is already dabbling and wants to go a little deeper. In any specialty that I have made a decision to go into, most of the time, the decision is determined and decided by the conversations I have with colleagues like Jen and people who are ahead of me in that. I highly encourage you to go do that. Speak to other people and see what mistakes they have made and what’s worked well for them. You can skip past a bunch of stuff by speaking to someone, hearing what worked and what didn’t work, and speed up your process a little bit or smooth your process out a little bit as well by doing that. Please do that.
We are talking about myopia management. We want to start implementing this more in our practice, but we know it’s going to take chair time, it’s going to take multiple visits, and it’s going to cost the practice money. How do you start to develop management fees and things like that when you are bringing in a specialty?
First off, you have to decide how many times you would be seeing this patient. For us, the way we have outlined things is we have got your general comprehensive exam, then scheduling a myopia management consultation where we would be devoting a time slot to talking about the program in full. Taking these additional measurements that we were talking about to see if you would truly be a good candidate for any of these options. Sometimes we rule out certain options based on the results of our pachymetry and topography. We will do the myopia management calculator from Brien Holden Vision Institute, so I can give the parent a good idea of what are our risk factors here and does the technology suggest we would accomplish by implementing a program plan?
Let’s say you are slower. You could potentially do all of this at the time of their general comprehensive exam, but if you are a busy practice and you are afraid this is going to bog you down, I think having a separate appointment is a great way to offset that. For us, we have got that appointment, and then let’s say they enroll in a program. With orthokeratology, you might see these patients back a number of times. You need to factor that chair time into designing lenses.
Let’s say you do a MiSight, that’s a soft contact lens. It’s going to be no different than fitting a soft contact lens where you have got that INR that you are doing. You need to see them back for a 1-week to 2-week follow-up. Depending on how quickly their myopia has been progressing, you want to see them back at three months to repeat measures. I always see my patients back at minimum at the six-month mark to check in and make sure that we are achieving good control.
The last thing you want to do is under-correct your patient. I think we are all familiar with that study. If you have got an under-corrected myope as a child, they are going to change much faster than if they were fully corrected. You have always got to make sure that you have got a full correction to get your best myopia management effect.
The last thing you want to do is under-correct your patient.
These are a lot of additional visits that you need to calculate. What is your chair time for expenses for your office, your rent, your staff pay, and any equipment you are leasing? Do all of these numbers to know what does each appointment slot costs you. My boss always has a good reminder for me. She’s like, “It’s not just the chair times or times however many visits you are going to be seeing those patients back, because then you are breaking even, and we will still go out of business.” We do have to make sure there’s some profitability.
Another thing to look at is, if you are going to see a general exam or a comprehensive exam, what’s your average exam return for that patient? You are eating up an exam slot to be providing myopia management care. Every time you see a myopia management patient back at a no-charge visit, that’s one less comprehensive exam where you would have generated $300-some, maybe $400-some, depending on your clinic. You got to factor in your potential loss by offering your specialty care. That’s how you get how much you should charge.
That number is probably bigger than what most people are initially thinking. It can be a little concerning or a bit of a deterrent sometimes. That’s the point of offering specialty care. It’s not something that patients will be able to get everywhere they go. There’s got to be some value assigned to it as well that differentiates it from the average services that they are receiving.
I know that in my mind I would be afraid to charge $1,000, $2,000, or whatever number for specialty care. It’s because I say, “The patients are going to get upset that it’s expensive.” That’s one of those things that we have to change and shift our mindset on. We don’t necessarily have to talk about what that number is, but once you established that number, did you have difficulty implementing that? Did you feel like, “This is what I’m worth, I’m good to go?”
I know there are all these rules. We can’t talk about numbers because that’s price fixing. That’s why we are not talking about numbers here because, legally, we can’t. When I was first talking about implementing an atropine program, I used to do like, “You want to do atropine? I will write you a prescription.” I charged nothing.
We are like, “We need to come up with a fee because you are going to see them back for a follow-up visit.” I was like, “Okay, $100.” That seemed like to me, as a parent, I would still be okay with that cost. My boss was like, “If you do the math on it, if you are going to see them back two additional times, you are losing us a lot of money. You might as well see regular exams and not offer atropine.” It took her explaining it to me. I was like, “You are right.”
Once I understand the calculations behind why we need to charge what we charge, I don’t have any trouble defending it because I know that’s what we have to do in order to provide this care. There’s no way for me to do it for less and still be able to provide this for you. I have looked at the numbers. I think if you are having trouble justifying it to yourself that a patient be willing to pay for this. If you do the math and you understand why that’s got to be, you will stop having that trouble.
Did you, in the past, ever find yourself justifying it to the patient? Overexplaining, I know I have done that in the past, “It’s this much money, but it’s because,” rather than like, “It costs this much for the service,” end of the story. Where did you find yourself in that case?
Especially something that’s a bigger expense option like orthokeratology, I will have parents ask like, “What discount can you provide?” I get it. I do. It’s not inexpensive. I will say to them, “We have looked at every way we can cut expenses to you to offer the most competitive pricing, but these lenses are extremely expensive. The care we are going to provide for you, we are going to be seeing you many times. I can, without a doubt, say that there’s no way for us to provide this care at any less dollar amount than this number. If this isn’t the right time in your life to do this, we understand. We have got these other options that we can support you with. Choosing orthokeratology is a choice that you would make, but there’s no way to do it for less expensive than this.”
That’s fair. That’s a good way of putting it. Going back to a bit of the conversation we were having before stepping away from the price conversation. Is there anything else you want to say about the price conversation?
I guess my only other thing is there’s always this discussion, and this is in the States at least about using insurance and vision insurance plans. There’s no vision insurance plan that recognizes myopia management as a covered service. I want anybody reading to feel very confident in saying that and saying that to patients, a contact lens fitting in a myopia management program is not the same thing. You don’t need to feel in any way apprehensive about saying like, “This is not a covered service by insurance.”
It’s totally up to you if you want to do a program. Some people will bundle the lenses and the service of myopia management together. Some people will separate their professional fees for myopia management and the lenses as a separate product, in which case you could potentially build lenses into insurance theoretically. That is your personal choice, and you have to be well-versed in how your insurance reverses contact lenses to make sure that even makes sense. Some plans do not reimburse you in full for your contact lenses. You can start to easily decide like, “I’m losing money on this,” if you are accepting a plan that doesn’t cover the cost of the lenses.
That stuff is tricky. Once you guys start talking about vision plans and insurance down in the States, I am immediately so grateful that I live in Canada. There are pros and cons, don’t get me wrong, but that’s one thing I’m glad I don’t have to deal with. It is very important for those who are down in the States to look at that. That’s important. If you have any other wisdom in that area, please do share it because I’m learning more that providers could be pretty clear make or break if you don’t understand what the vision plan offers and what you are giving to the patient. That’s very important information, so thank you.
This is why many practices in the United States that choose to offer specialty care, you will see them often talk about dropping vision insurance and coverage. It creates this point of contention where a patient’s like, “I want you to use my insurance.” You are then saying, but the insurance doesn’t cover this service. Never going to work out. If you are not accepting the plan, then that removes that whole issue. In many cases, you can reduce the costs that you are providing to the patient because you are not having that middleman of insurance interfering with things and siphoning money off the top.
Being from Canada and being naive to that whole world of vision plans and insurance, every time I come down to the States or I talk to friends down there, I always want to say, but then I stop because I’m like, these guys are going to be like, “You don’t know anything.” I always want to say, “Just drop the vision plans. Just charge cash. It’s fine.” I know it’s not that easy. It’s a lot easier said than done, but it seems like that is the path to success.
We have carefully selected the few vision insurances that we participate in and choosing ones that we feel like do reimburse us fairly for the services that we provide. When you make a decision as a small private practice to drop a plan, it does hurt you. You will notice an immediate drop in patient care volume. What we have time and time seen is given 1 or 2 years, patients start to realize like, “The care I was receiving at that office was a different level.” We find many patients actually will choose to come to us out of network even though that first year, they might try somebody else.
That’s human nature.
Be prepared for that first year to hurt when you do it.
It’s important for us to put ourselves in the patient’s shoes. Sometimes I will go on a tangent here, but we talk about the pains of eCommerce and things like that. I’m like, “Don’t you shop on Amazon?” When you are sitting on the couch at 9:00 PM, and you need to order something, where do you go? We all do it, so let’s realize where the patient is. Let’s try to meet them there. If you are dropping a vision plan, you have to understand if you were the patient, you’d probably say, “Let me see what it’s like this year to get my exam covered and see what happens.” Hopefully, your services were good enough that they will want to come back to you. It’s nice to hear from your perspective that does slowly happen over time.
It does, but it does mean you have to be exceptional. You can’t be mediocre and expect people to remember that they should come back. There’s constant pressure on you to be the absolute most amazing eye exam at every level of customer service.
That’s important. That’s what we have to do in general, the way the industry’s going with all the disruptors, the players in the market, and the way things are changing. The only way for us to thrive is to be exceptional. We can’t be mediocre. That mediocre, the middle of the bell curve, that market is going to get gobbled up. We don’t want to be there anyway.
I do want to talk quickly about atropine. That’s what I wanted to change the topic back to. I was telling you offline that the first time I heard about the LAMP2 study was something that you posted very recently. We have been using atropine as a treatment for myopia management for years. It’s been working well, 0.05% is what I have been mostly on for years now.
You have posted about the potential use of atropine as a preventative measure for potential myopic patients or pre-myopic patients, however you want to phrase it. I’d love for you to share a little bit about that, please. I want to open our eyes a little bit to the power of what’s available to us and how atropine can help our patients.
This is the recently reported LAMP2 study. It was published in the Journal of the American Medical Association. The LAMP studies are these ongoing studies happening mostly in Asia about atropine for use in myopia management. This is the first time they broke down atropine as a potential for prevention. What they did is they enrolled 474 children between the ages of 4 and 9 that had no myopia at the time when the study was initiated. They split them into three groups. One group got a placebo eyedrop, I could never figure out from looking with the placebo. It wasn’t atropine, but I guess like maybe saline or whatever drop.
One got 0.01% atropine nightly, and one got 0.05% atropine nightly. At the end of the 2-year time period, 53% of the kids using the placebo drop developed myopia, and 45.9% of the kids using 0.01% atropine did. Of the kids using 0.05% atropine, only 28.4% of them developed myopia. It significantly reduced their risk of myopia development at the end of that two-year mark.
This was only over two years and I’m sure they are going to continue to look at this study’s results going on, but this is just one more check mark for 0.05% atropine as the most effective control. It at least opens the door for consideration. Let’s say you have got a kid whose parents are highly myopic, and they are very motivated to prevent it. I have these parents in my practice. They are like, “What can we do now? I know they are fine now.” All I have been able to tell them is, “Try to get outside a whole lot. Try to limit screen time.”
This is, potentially now in my opinion, on the table. I have never had any child develop side effects from atropine use besides light sensitivity. That has always been managed for me at least in my practice by lowering their concentration to a tolerable level. I do have patients on 0.01% atropine, and I know the study data says that’s not as nearly as effective. Some of my patients were that’s all they can tolerate, but I still have been able to achieve good results with the concentration that they could stand.
For me in practice, it’s the same way of parents are coming in. I start the conversation before the patient is myopic, especially if I see the risk factors. Siblings are myopic or parents are myopic, things like that. I will mention it, “Normally at his age, I would say he’d be good to go for a long time. With the trends, the prevalence of myopia, and the way we are on digital devices all the time, there’s still a chance that potentially, he or she may become myopic, and we want to keep our eye on that.”
If a parent is myopic, I’m having that conversation a lot more. Now, I can offer this as a potential preventative measure. I’m excited because parents, many of them, are very motivated. I would want to echo exactly what you said about the side effects. Light sensitivity. I have had a couple of patients who mentioned a little bit of near blur. The near blur is usually pretty tolerable. The light sensitivity on occasion is less so. I have dropped it down to 0.02, I do that for 6 months, and then I put them back on 0.05.
They can tolerate it better?
They tend to do okay. I guess that’s been working pretty well. Anyways, like you said, another check mark for low-dose atropine, especially 0.05. Just in case there’s somebody out there who’s a little hesitant to put their young patients on a pharmaceutical agent. Lotus atropine has been studied for so long anyways and has been shown that overall been quite useful. A lot of people ask questions about, “When do I stop, and what’s the rebound effect?” There’s data on that too, so check that out. I will taper patients now, and I have found that that’s been quite good, and over the last few years, I have been seeing quite stable results.
You know what’s so interesting is, in the States, this is an off-label treatment. It’s not FDA-approved. That’s the biggest conversation I have had around atropine with parents. I’m trying to explain and discuss that. We are still providing all of the great amount of scientific data behind atropine, and why I feel very comfortable in prescribing it, and I would use it in my child. I think not more than one company, there may be multiple companies who are currently undergoing FDA clinical approval process. It’s going to be a 0.01% concentration. That’s my understanding. That’s going to be very fascinating when we get the clinical data readouts.
Before LAMP got published, I was prescribing 0.01% atropine routinely as my concentration because I think the earlier Adam study data looked very favorable about that. I had, within my practice, a lot of success with that low concentration. After the LAMP2 data came out with the 0.05% being their most efficient dosage in that study, I tried to make that switch over, but I have had people who have been on 0.01% for their entire childhood with no real progression. I was like, “I don’t see a need to increase your strength.” I think if that study data looks strong, I think practitioners will embrace whatever the FDA approves.
At least that will open the doors to them prescribing something, which is where we are at right now. Encouraging our colleagues to start somewhere. We dove a little deeper than maybe I was planning to on some of the stuff that we talked about, which is great. Ultimately, the message that I’m going to be sharing quite a bit throughout the show is, “Just get started. Give it a shot. You are not going to harm the patient if you stick with 3 or 4 options that we know are proven and work well. You are not going to do any harm, which is always the number one thing we want to make sure of. You can help so many people. There’s the potential for improving the bottom line. If you do the fee structure and everything correctly, you can help boost the business, which we want to do as well.”
We all have those patients that are -10 with myopic maculopathy or retinal detachments, or glaucoma. My father-in-law has severe stage glaucoma. He never had eye pressure over eighteen. Highly myopic. The super myopic nerve. This is a classic example of how myopia can be the biggest risk factor for your patient. From seeing this happen to my own family, it’s like, whatever I can do to protect my patients from this. I’m trying to treat myopic-related glaucoma is extremely difficult because high pressure is not the problem here. It’s almost like a normal tension type of glaucoma. The tissue is stretched and damaged. It is tough. I know, as doctors, we want to help protect our patients from having that in their future.
As humans, we always have trouble looking forward that many years to understand this is the reason why we don’t work out as well as much as we should or eat healthy as much as we could. We have trouble understanding 30 to 50 years from now what the impact of our current decisions is going to be. That’s our job as doctors. It’s to at least let our patients and our parents know how we can help them. Thank you, Jen. How can people find you? Where can people find you whether it’s blog, social media, or however you’d like them to get in contact?
My blog is EyedolatryBlog.com. I’m on Instagram quite a bit. I have not made the TikTok transfer. As a mom of a three-year-old, I probably won’t be. I need to do less social media and more real-life time. I’m @Eye.Dolatry on Instagram because Eyedolatry was already taken, believe it or not.
The Eyedolatry was already taken?
Yeah, there’s another account with that already, so I have a weird period in mine.
@Eye.Dolatry is the Instagram handle. What’s the blog?
Who are these people? What are they doing with their lives?
They are internet squatters.
I’m telling you, they are not getting 50,000 page views a month, that’s for sure.
You make these mistakes early on. I started blogging in 2011, and so of course, I used a free blog spot account. The point of those accounts was for you to have someone else recognize it was getting big and then poached the URL. You live and learn. I did a lot wrong. If you want to know what not to do, probably send me a message. I have done it already.
I got AboutMyEyes.com was the website I decided I was going to go with years ago, so I have kept that one.
That’s your URL from the beginning?
Yeah. I purchased that a while back.
Nothing is for free.
That’s not going to be as in demand as Eyedolatry.com I imagine.
I probably would buy it from whoever that person is. I just don’t want to.
Don’t give them satisfaction. It’s out of spite, you won’t. Jen, I ask two questions at the end of every episode for every single guest, and I want to ask those of you now, please. The first of those questions is if we could hop in a time machine and go back to a point in time that was difficult, it was a struggle, whether you were younger or generally when you were younger, feel free to share that moment if you’d like to, but more importantly, what advice would you give to young Jen in that moment of struggle?
My darkest time was when I wanted to have a family, and I was struggling with fertility. I know a lot of people had been there. There is nothing that I can say that will help you go through that process, but I want to let you know that I was there too. Sometimes it works out and sometimes it doesn’t. It even hurts me to think about it because I know a lot of my friends are dealing with this right now. They haven’t had the success that they are so hoping for. There’s nothing that I can say that will help them. There are dark times for everybody. Just try to find love in the people around you that support you when you are going through that.
There are dark times for everybody. Try to find love in the people around you that support you when you’re going through that.
Thank you for sharing that. I can only imagine how difficult that time was. We know many people over the years, and we have been blessed to have our family. When you get to that age and you start to have kids and people around you are having kids or trying to, you start to see the challenges are mind-blowing. We didn’t realize when we were younger how difficult this process is. Even for people who have kids, how hard it is when they are going through that. It’s crazy. It’s a miracle. I think that message of finding love in the people around you, and talk to other people who have gone through it. Hopefully, that will help you to some degree. Those of us who have kids should take that as a sign to be more grateful for what we have.
I make no apologies about working part-time. I leave early and patients will call, “I need an appointment after 5:00.” I’m like, “Dr. Lyerly’s last appointment is at 3:30.” My patients will be like, “That doesn’t work for me.” They will get a little bit upset. I was like, “Just tell them she’s going to get to daycare.” I’ve got to pick up my kid. I want to spend time with my child. There’s nothing for me to apologize about that.
I am very thankful that I was able to have my daughter as part of my life, and I never apologized for putting my family first and spending time with them as goal number one. I love what I do. I love optometry. When I’m at the office, 100%, you have my full focus and attention. I am your doctor and I am not thinking about anything else, but I always make sure that my family is taken care of first before I get into the office.
Thank you for sharing that. I know that’s difficult, I can only imagine, for sharing that, and also I think hopefully, opening the door for others to share their story and their struggles so they can get a little bit of support and consolation also. Thank you. Jen, the last question is then everything that you have accomplished to this point in your career, how much of it would you say is due to luck, and how much is due to hard work?
I love it when you ask this question because I feel like there’s a universal theme. You have to give yourself the opportunity for lucky things to happen to you. There’s no way for one to exist without the other. There are doors open because you are in situations to meet people. I think many of us have seen, knowing people being in the same room and making friendships. That’s the stuff that luck is built on. Giving yourself the opportunity to be in the place for something good to happen to you, but that takes work to do that.
You have to give yourself the opportunity for lucky things to happen to you.
That’s a great answer. Thank you so much, Jen. Honestly, thank you again in multiple ways for being so supportive of me and my journey here. Thank you for being a mentor to other ODs and colleagues. Thanks for coming on to share your wisdom here on the show.
Thank you so much for having me. You all have a wonderful rest of your day if anyone tuned in.
There are so many people tuning in, Jen, just for you, I promise. Thank you to everybody who tuned in to the show, Canada’s number one optometry show. I hope you found so much value in this. Jen is such a lovely person. Again, make sure you give her a shout-out on Instagram, LinkedIn, or wherever. Let people know that we were chatting, and Jen shared all this amazing insight. I will catch you again in the next episode. Take care, guys.