U2.7.17 A question of cost

At a recent CET event, a member asked if a patient needing a toric contact lens, but who was unwilling to pay a higher price, could be fitted legally with a best sphere.

A patient attends for their contact lens check-up to be told that, as a result of their latest eye examination they now need a more complex lens to improve their vision to the same level as their spectacles. Perhaps the cyl component has risen to 1.00D from a previous 0.50D. This is not a huge amount, but with modern contact lens designs, such prescriptions are easily fitted with excellent results. A higher amount of cyl might be more difficult to ignore and would warrant a discussion with the prescriber.

The problem is that the new type of lens is more expensive and the patient feels they cannot justify the extra cost when the contact lenses are used for social occasions only. May you continue to supply the simpler lens despite it not being the full prescription? Yes, you may, but the facts of the situation must be fully explained to the patient. If driving acuity is below the DVLA standard, for example, they must understand that they cannot drive with the contact lenses.

It is sometimes helpful to give the patient a trial of the complex lens to demonstrate the improvement in vision before they make a decision, which is then giving the patient an informed choice. If they still feel it is unjustified, the simpler lenses may continue to be supplied.

The facts of the discussion and the difference in acuity must be recorded on the patient’s notes in full. It might even be sensible to ask the patient to sign a disclaimer, confirming they have been warned of the reduction in vision, if you feel the situation has not been fully accepted.

The General Optical Council, in its Standards of Practice, states as its first point: ‘Listen to patients and ensure they are at the heart of the decisions made about their care’. The choice of lens, power or modality, has to be a joint decision between you and the patient. You must not encourage the patient to do anything to jeopardise their sight – but the final decision must be theirs.

As a caveat, I would not consider fitting a child with such a compromised prescription, as their developing vision needs to be fully corrected for their long-term welfare.