Wrapping Up
Our editor offers take-home points to
help you bring about positive change in your contact lens practice.
By Joseph T. Barr, OD, MS. FAAO (Dipl)
About
10 million people in the United States have dropped out of contact lens wear since
the turn of the century. The number across the planet is probably two or three times
that.
Hopefully, we've
covered enough issues in this supplement to help turn the tide. But to be sure,
I'll list some goals to shoot for as you aim to improve your contact lens practice.
Change History
Reviewing early
studies on contact lens wear, I found that success during the first 6 months was
73% to 90%. But in retrospective reviews, I found a success rate of only about 57%.
Of course, those were the days when we had only PMMA. However, that number increased
to only 60% in a 1979 study out of the University of Alabama at Birmingham, which
included gas permeable and soft lenses.
Interestingly,
many of the issues cited then were the same as those we're experiencing now —
with discomfort the leading problem. Our challenge is to work harder than ever to
achieve and maintain comfortable lens wear.
Answer the Critical
Questions
Desmond Fonn
at the University of Waterloo found that 51% of 568 current and former contact lens
wearers discontinued contact lens wear. Of that number, 25% resumed wearing lenses
later, but 14% discontinued a second time. Can we reduce that number? Can we take
people who have discontinued lens wear, short-term or long-term, and turn them around
when they want to try again? With improved technology, we may be able to succeed
and satisfy them for years to come.
Value Your Patients
— and Practice
Patients want
to see clearly and comfortably without spectacles. Most have rejected refractive
surgery. And the contact lens patient is more profitable to your practice over the
long term. Successful contact lens management not only
meets
their needs, it improves your practice. Patients buy contact lenses from you and
return to you more often, typically every year, as opposed to the 2 years or more
between visits you can expect from spectacle wearers.
Manage the Dry
Eye — Now!
Dry eye begets
inflammation, which begets lacrimal gland damage, which begets more dry eye symptoms.
It's a vicious cycle. We must do everything we can do to avoid this problem.
Use
antihistamines and mast cell stabilizers for the allergy patient. Wash out the bad
byproducts with lens lubricants and eye drops before and after contact lens wear,
and in the morning or at night for patients in continuous wear.
We
should take aggressive steps to reduce inflammation and corneal damage from contact
lenses and solutions. Work to help keep patients more comfortable, avoid lacrimal
gland damage, and thus, achieve a wetter, healthier, more comfortable eye.
What Are We Really
Talking About?
Identifying and
eliminating complications is a diagnosis of exclusion. Rule out physiological problems,
such as hypoxia, tight lenses, deposits, solution toxicity and other sources of
inflammation, such as infection. Then listen carefully if the patient still says,
"My eye doesn't feel good when I wear my contact lenses."
Learn
to take a holistic approach. Consider all possibilities, such as changes in lenses,
changes in solutions, lid disease, allergies, hydration and underlying inflammation.
Here are some other key considerations:
►
Keep the lens clean. Use a lens care system that has minimal toxicity.
And remember that multipurpose solutions are all different in terms of compatibility
with different lenses, degree of wettability and interactions with a patient's eye.
The complications we see now are subtle. Look closer to see the staining —
and use fluorescein and a wratten filter!
►
Tell patients to use drops before and after contact
lens wear. If for no other reason, it will wash away the bad stuff. We have
a lot of new, very good components in these lubricants. Read the label for ingredients
and be mindful of compatibility issues. Use the drops in a step-wise fashion to
see what might work best for each patient, his lens and his lens care regimen.
► Tell
patients to avoid, if at all possible, medicines and other agents that dehydrate.
Alcohol comes to mind. They should also avoid smoke.
►
Use punctal plugs as a last option. Despite temporary short-term relief,
long-term results show that plugs may cause the inflammatory mediators to be retained
on the eye, causing long-term complications.
►
Consider the new silicone hydrogel contact lenses. Manufacturers claim
these lenses stay more hydrated on the eye and reduce inflammation by not causing
hypoxia.
Facing the Future
In
the future, we'll be seeing secretagogues that help secrete a good mucin layer or
help the lacrimal gland secrete a better aqueous layer. A number of products, such
as a mild steroid for dry eye, could help with secretion and possibly control inflammation.
And certainly, vitamins will be a logical choice to stabilize the lipid layer and
help the aqueous layer in general.
Questions
will continue, but I think we have many answers already. Now it's a matter of doing
something about it in practice.
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►
How much of a factor is wettability? We learned from David Meadows, PhD, that according
to Alcon's in vitro measurement, Acuvue Advance lenses demonstrate a high contact
angle. Yet many of us have had very good clinical results when using Acuvue Advance
lenses. So when we put a lens on the eye, the eye can wet the lens, as long as it
is put on the eye with a clean hand and it comes out of a good aqueous environment
and a conditioning care system. A lens can be biocompatible, even though it seems
to start with what appears to be a high contact angle. Further research is needed
to fully understand what these wettability measures mean relative to comfort in
vivo.
►
Do silicone hydrogels wet like hydrogels? Certainly not. Silicone will be exposed
to the surface, and whether the lens is inherently wettable, like an Acuvue Advance,
or whether it's been surface-treated, like CIBA Vision and Bausch & Lomb's lenses,
those surfaces are all different. They're going to react differently with different
eyes and different solutions.
►
Can multipurpose solutions change your success or failure ratio? Probably, but we
need more research.
—Joseph T. Barr,
OD, MS. FAAO (Dipl) |
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Dr. Barr
is associate dean for clinical services and professional program at The Ohio State
University College of Optometry in Columbus. He is director of the NEI-sponsored
CLEK Photography Reading Center, immediate past chair of the American Academy of
Optometry Cornea and Contact Lens Section, and editor of Contact Lens Spectrum magazine.
Contact Lens Spectrum, Issue: April 2005