Making a Case for PALs
Case studies in five categories demonstrate how ECPs act outside the box to solve challenges in the senior PAL marketplace
By Karlen McLean, ABOC, NCLC

Helping seniors find the right lens improves everyday life. Image courtesy of Vision-Ease

Natural aging of the eyes, combined with visual pathology that can arise later in life, makes enhancing vision a top priority for seniors. If you can help your senior patients see better at the tasks they most desire and often miss, like hobbies, reading, or driving, you've helped improve their quality of life. Here's how several successful eyecare practitioners address some senior patient needs with progressive addition lenses for all-around rewarding results.

SMALL FRAMES: SHORT CORRIDOR PALS

Shirley Enfinger, LDO, operations manager, Wilson Eye Center, Valdosta, Ga.

Typically, a senior who is fitted in PALs in our practice selects a slightly larger frame, enabling us to use a longer corridor PAL. However, some seniors want smaller frames, which pose several specific challenges.

Fitting seniors in short corridor PALs comes down to the proper frame selection, the ability of the optician, and clear understanding from the patient. We don't specify that they're going with a short corridor PAL unless they're currently wearing a longer corridor PAL. Then, we discuss eye movement adjustment and explain that the lens focuses their reading area sooner. We explain and show patients the differences between lens designs; a lens display unit aids in explanation.

Also, if their head and neck movement is inhibited due to arthritis, neck and back pain, or other physical conditions, we cover the importance of head movement in achieving success with a PAL, especially short corridors.

We let them know that if they're reading a large page, such as a newspaper, they may have to fold the paper and tuck it down to a standard reading level to alleviate neck strain.

A challenge is price resistance. Seniors on a fixed budget want to go with PALs, but the additional cost may prohibit them from doing so. With many insurance plans allowing a basic bifocal, the up charge is an option for them.

Discussing PALs' advantages, including variable focal length allowing more natural vision, no line to cause image jump, and younger, more stylish appearance also aids in defeating price resistance.

TAILORED VISION: FREEFORM PALS

Training seniors on seeing through PALs is important for wearing success

Kirk Harris, OD, Doctors Vision Center, Washington, D.C., with multiple locations in North Carolina, South Carolina, Tennessee, and Virginia

I haven't recommended flattop multifocals since 1991. I'll sometimes prescribe flattops, but prescribing and recommending are different things.

Our practice has made the commitment to dispensing PALs only; a high percentage of our patients wear them.

I only recommend a brand name freeform created PAL because I believe in customization. It's like off-the-rack clothing. A customized fit with anything means complete comfort and satisfaction. That's how I explain freeform PALs to patients.

Our entire staff is involved in educating patients about PALs. Each step of the way, from front desk to technician, doctor to optician, there is a consistent message and smooth flow from one to another.

One woman came in for follow-up on dry eye. She had received her freeform PALs about a month prior to the follow-up. She said, "I've never paid as much for a pair of glasses as I did these."

I replied, "No one else but you has this lens; it's unique to you."

She answered, "These are the most comfortable pair of glasses I've ever had, thank you."

This is a patient who has documented problems with nausea; she experiences no swim or sway with freeform PALs, which is a big thing for her.

After refraction and Rx calculation, I summarize my eyewear recommendation. After a technician has used the freeform fitting tool, I tell the patient, "This is a test that we've never had available before. It determines head and eye movement and posture. The way we move isn't all the same. So we're marrying my exam results with those of this new test to custom fit you."

Seniors appreciate the additional visual acuity that freeform PALs, combined with AR, gives them. We started dispensing freeform PALs in June and we're now dispensing two pairs a day.

BARELY THERE: PALS FOR RIMLESS

Eric Kinsella, dispenser-manager, Kingsley Optical, Dallas

We're a mom-and-pop kind of a place, and our clientele is around 70 percent people over 60 years old. We find many of our seniors want rimless frames because they want to look stylish. They also want PALs with no line for better appearance.

Two key things with seniors: One, tell them what to expect from PALs at the start, and reinforce it at
dispensing. This is a rule in our practice. I tell them that it's like learning to ride a bicycle. It may be a little challenging at first but once you've got the hang of it, it's useful and fun.

Two, we tell them about the warranty. Many places won't mention the warranty. But, in order to build trust, which results in patient retention, especially with seniors, we tell them to wear their PALs for a minimum of two weeks. Then, if they don't like them, we can put them back in a lined bi- or trifocal.

Our success rate with PALs is at least eight out of 10. We use Trivex material 7x2i trifocal or PAL options for thinness, lightweight, durability, and impact resistance. Offering the choice keeps us versatile. We also prefer Trivex over poly for rimless drillmounts, since Trivex has a better track record for lens fractures and splitting at the drill holes.

We do our surfacing on-site to help cut lab costs and have control over the process. Trivex may not be easy to process, but the end results are a longer-wearing, high Abbe value pair of lenses that our patients appreciate from an appearance, wear, and visual acuity standpoint.

Not many people take care of their eyewear, and senior citizens may be the roughest. Typically, they sit on them or fall asleep in them. We need to give seniors the best, most durable rimless and lens options.

Seniors generally require more explanation and reassurance than other patients. Winning their trust is key. If you don't win and keep their trust, they may never complain, but they'll never come back.

NEAR VARIABLE FOCUS: COMPUTER- USE PALS

John Gunning, OD, Family Vision Center, Chillicothe, Ohio

With more and more seniors utilizing the computer for work, hobbies, research, and to stay in touch with friends and family around the country and around the world, the need for near vision focus lenses in eyewear specifically for computer use in this patient segment is acute.

Although I prescribe near variable focus lenses for many senior citizens, the most rewarding situations have been NVF use for individuals with reduced acuity, such as early AMD patients with acuity ranging from 20/40 to 20/100.

In the past, our only answer for these patients was an Rx with increased magnification, such as reading glasses, high-add bifocals or trifocals, or even high-add PALs. Although these high-plus corrections would give magnification, they would cause disorientation and necessitate a close working distance.

Now we can design a lens system for patients which gives them significant magnification with a manageable near working distance.

My office uses a brand name NVF lens that allows us to design the lens for specific near point tasks. We use a software fitting program that makes designing the lens simple.

An example of a successful NFV lens fitting for a senior patient is: Distance correction of -1.00D in both eyes. Best near point acuity is 20/60 at 18 inches.

For her, I placed a +2.25D add at the center of the pupil and a +3.00D add at the reading zone. With this lens design, she has a useable near power range of +1.50D to +3.00D and a range of near point focus from approximately 26 inches to 13 inches.

At the reading zone, her acuity improved to 20/40. Functionally, this Rx assisted the patient to accomplish things she couldn't do before, like read a newspaper or magazine, find a telephone number and dial it, and work on the computer.

At delivery of NVF lenses, you must reiterate to the patient what the lenses are to be used for, and, if possible, demonstrate how to use the lenses for that specific task.

CREATING CONVERTS: FLAT- TOP MULTIFOCALS TO PALS

Michael Horan, Jr., retail manager, Eye Health Vision Centers, North Dartmouth, Ma.

We apply top-down selling, offering the best first. It's important not to pre-judge patient pocketbooks, especially seniors. While many senior
citizens have a fixed income, we're in an area where many also have above-average income, so we have a wide variety of clientele.

We have price books at every fitting table; each page is a different lens package. The dispensers ask what patients like and what they don't like about their current
eyewear, then we say, "Based on
your prescription and your input, I'd recommend..."

We ask how long they've been wearing bifocals or trifocals. When recommending PALs instead of flattops, our focus is to educate patients on their options and the new PAL technologies that are available.

If there's clear hesitation on the patient's part, or if they've tried PALs before without success, we don't force them into PALs.

But, we do mention that today's PAL technology is nothing like it was a couple years ago and that they might want to try again. Also, we tell them "the success rate is even higher now; less than one percent of our patients return with problems from
a PAL."

We have all three Os under one roof in a medical setting. We perform cataract surgeries on-site. In the dispensary, we see seniors after cataract surgery. They're usually thrilled with the surgery results and receptive to a change in their eyewear.

We use a demonstration tool to show patients a lined bifocal versus a PAL design. It helps explain that when their eye jumps across the line the image changes rapidly, but with a PAL, the eye travels smoothly up and down. It's all natural.

On pick-up, seniors are shown how to use their new PALs—the frames are properly adjusted and then a reading card is used to point out what we call the sweet spots of the lens as the patient views through the lens. Then we have a head adjustment training session where we show them that they may have to raise and lower their chin a little to find the sweet spot. While that adjustment may feel like they are tipping their chin all the way back, it's, in fact, just a slight adaptation. Sometimes, I'll even demonstrate this myself.

It's important not to get in the habit of thinking, "Oh, they're wearing a flattop lens. It'll be
easier and faster to just keep them in that."

Change is good. It's important to keep a positive attitude throughout the dispensing process, especially with seniors. We encourage patient feedback and foster willingness in our patients to try new technology. EB

"I only recommend a brand name freeform created PAL because I believe in customization. It's like off-the-rack clothing."

"We need to give seniors the best, most durable rimless and lens options"

Driving Senior PALs

Since many seniors equate being able to drive as their last bastion of independence, most want to do anything they can to remain competent at the wheel. If you can offer them a lens specifically for driving, you've gained at least a second- or third-pair sale, plus a loyal friend.

"Seniors may have trouble driving with PALs due to peripheral movement when turning their heads to change lanes and maneuver in traffic" notes Shirley Enfinger, LDO, operations manager at Wilson Eye Center in Valdosta, Ga. "When fitting a senior in PALs, it's important to have the PAL low enough so if the patient has a little head movement they won't be looking through the lens periphery when driving."

A new driving lens design featuring melanin polarized variable focus lenses was introduced at International Vision Expo West this year. Product designers specify that the lens allows a total view of the dashboard and road, day or night, with a wide far zone and
generous intermediate zone. The product helps maximize visual
perception and performance while driving.