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PATIENT COMPLIANCE
Repairing
Contact Lens Care
Teaching
patients why proper lens wear and care are essential will encourage them to choose
adherence.
By Brian Chou, OD, FAAO
Dr. Chou is in group practice in
San Diego at Carmel Mountain Vision Care. He is the co-developer of EyeDock.com,
an online contact lens reference for doctors.
In
years past, patients did whatever their physicians instructed, without question.
Patients who didn't comply were deviants breaking the rules; people unable to follow
directions. Indeed, "compliance" implies a passive, one-way relationship wherein
a practitioner makes a demand for a patient to follow. In contrast, "adherence"
suggests an active interaction between patients and doctors wherein a patient voluntarily
accepts his practitioner's prescribed treatment.
The concept of
adherence is more applicable today. The reality is that practitioners are no longer
the stalwart and exclusive sources of healthcare information that they were in the
past. Today information comes from multiple sources, including direct-to-consumer
advertising, the Internet, the lay media and even friends and family. Some call
it patient empowerment. Yet which sources do patients believe when the information
is contradictory or incomplete?
So Many Choices
Suppose
you prescribe Mrs. Smith Brand X soft contact lenses. You instruct her to remove
the lenses daily and to discard them monthly while using a specific multipurpose
solution. After all, you know this regimen is best for her. In the compliance model,
you wouldn't need to explain your prescribing rationale.
However, in the
adherence model, you must have the real-life awareness that Mrs. Smith may question
it. Maybe she'll go off course after seeing a TV advertisement for Brand Y contact
lenses. Maybe it'll happen after she sees the labeling on the Brand X box that promotes
the lenses as FDA approved for extended wear up to one month. Or maybe it'll occur
when her best friend tells her that she can wear her contact lenses twice as long
before replacing them. Maybe it'll happen when she's in the drugstore aisle and
gets overwhelmed after seeing the large number of displayed multipurpose solutions
(Figure 1). Patient adherence requires practitioners to proactively educate patients
about the benefits and costs of the prescribed treatment for the enhancement of
therapeutic outcome.
The
recent events related to Fusarium keratitis have led some of us, including
myself at one point, to reflexively blame patient noncompliance as a significant
causative factor. But patient compliance hasn't suddenly gotten worse. Noncompliance
has existed for a long time. As early as 200 B.C., Hippocrates advised physicians
to consider noncompliance when the usual successful treatment didn't produce the
expected result (Carr, 1990).
Looking Through Rose-Tinted Lenses
Practitioners
may actually be poor judges of patient compliance/adherence. In one evaluation of
138 patients who had pulmonary disease, a significant disparity existed between
physician evaluations of patient compliance and corresponding patient accounts (Goldberg
et al, 1998). Another study compared 320 paired cases of patient-reported and physician-estimated
compliance to a specific type of HIV therapy (Murri et al, 2004). Physicians failed
to correctly estimate patient-reported compliance to the therapy in 111 cases, or
in more than one-third of patients.
The results of
these two studies suggest that physicians have difficulty accurately appraising
compliance in their patients. These results should also prompt us to consider how
our patients accept our recommendations on contact lenses and lens care. Maybe it
comes as no surprise that Castellano (2004) reported that roughly one-third of patients
follow our directions exactly, one-third follow some of our instructions and the
remaining one-third don't follow any of our instructions.
Looking
at the contact lens literature, Claydon and Efron described in a 1994 review article
that between 40 percent and 91 percent of contact lens patients are noncompliant.
Collins and Carney (1986) found that noncompliance with lens care correlated to
an increased incidence of corneal staining and lens surface deposits. Corneal staining
is important, even if asymptomatic, because it represents a breach in the barrier
integrity that can permit microbial invasion into the cornea.
Changing Tactics
Has our
industry adequately communicated that contact lenses are prescriptive devices that
require professional supervision and appropriate lens care? All of us in the industry
share some responsibility in supporting this message — from contact lens and
solution manufacturers to practitioners and staff and alternative distributors.
The partnership between manufacturers and prescribing practitioners is perhaps the
cornerstone in presenting a unified patient message.
Yet contact lens
manufacturers have sometimes created consumer perceptions that are at odds with
practitioner efforts. Direct-to-consumer advertising including free trial lens coupons
and sweepstakes promotions exemplifies how certain manufacturers drive new demand.
But if done without disclosing risks, these strategies may undermine practitioners'
efforts to get patients to adhere to proper contact lens wear and care regimens.
Free product coupons, promotional tie-ins with free MP3 music downloads and travel
sweepstakes are more typical for retail goods sold in department stores than for
medical devices. After all, when was the last time anyone could win an exotic vacation
for getting an artificial heart valve or replacement knee joint? The result of these
promotions is that some patients get the impression that contact lenses are non-prescriptive
and that lens care is irrelevant.
The
quandary practitioners now face is how to encourage patients to adhere to sound
contact lens wear and care regimens under circumstances like these. Of course, practitioners
can't directly control the marketing strategies of medical device manufacturers;
but they can tell their manufacturer representatives what will better serve the
interests of patients and will help improve patient adherence.
Meanwhile,
practitioners and their staff members remain at the front line for modifying patient
behavior through their direct interaction. What works to increase compliance? Clinical
psychologist Alan Carr has pointed out several key areas based on research in a
1990 article:
•
Don't keep your patients waiting. Patients seen promptly are more apt to follow
your directions.
•
Converse with your patients in a friendly and informal style. Doing so encourages
patients to share useful information.
•
Present the treatment regimen and rationale in easy-to-understand, memorable language.
Use short sentences and state the most important aspect of treatment first.
•
Evaluate your patient's understanding and expectations about the treatment. Compliance
is correlated with patients' beliefs about their vulnerability to illness, the seriousness
of illness and the efficacy of appropriate treatment.
•
Find out how much information your patient wants to know. Some want a cursory explanation
while others want to know it all. Tailor your discussion to meet each patient's
expectation.
•
Help patients appreciate the negative consequences of non-compliance and the benefits
of compliance.
•
Enlist the help of a patient's family or friends in following your advice.
•
Review compliance at each follow-up consultation.
Armed
with strategies for enhancing patient adherence, the challenge remains to encourage
our patients to develop proper habits for lens replacement, application, removal,
cleaning and disinfection.
Tackle Infrequent Lens Replacement
Regardless
of the intended lens replacement schedule, it's no secret that too many patients
make their lenses last too long. At the expense of eye health, some patients wear
lenses until they're torn, fouled with deposits or otherwise too uncomfortable to
wear.
Take for example
a patient who is a full-time contact lens wearer and makes a 12-month supply of
lenses last for two years. In such cases, our responsibility is to educate patients
about why they should more regularly replace their lenses. This is no different
than a primary care physician's obligation to act when a hypertension patient tries
to make 12 months of blood pressure medicine last twice as long.
Clean Hands and Clean Cases
In any
healthcare setting, good hygiene in handling contact lenses requires hand washing.
Hand washing before lens removal is important, but it's even more so before lens
application. Lens handling is the most likely source of contact lens contamination
(Mowrey-McKee, 2002).
A 2002 review article
by Montville indicated that hand washing reduces microorganisms by about 2 to 4
logs (100 to 10,000 times). Even with hand washing, an estimated 1,000 to 1 million
organisms get on each lens. Mowrey-McKee and co-workers (Mowrey-McKee 1992, Hart
1993) looked specifically at contact lens contamination from handling after hand
washing. Their results indicated that lens removal contaminated nearly organism-free
lenses from the eye with an average of 653 colony forming units per lens. Nearly
95 percent of lenses showed bacterial contamination and 11 percent showed contamination
with fungi including both yeasts and molds. Of note was the fungal presence in this
study, which was performed in Rochester, New York. A higher rate of fungal contamination
may have occurred had the researchers performed this study in the tropical Far East
or in southern Florida.
We've
all witnessed patients in our offices removing and applying contact lenses without
hand washing. Rather than pretending we didn't observe these behaviors, we should
take the opportunity to educate patients about the potential consequences of poor
hygiene and about the benefits of hand washing.
Finally,
an often neglected aspect of contact lens hygiene is the lens case. Most clinicians
have observed cases so filthy that words can't sufficiently describe them (Figure
2). In a Fusarium case-controlled study, Chang (2006) found no correlation
between the fungal infections and frequency of lens case replacement. Regardless,
it's prudent for patients to replace lens cases at least every three months. Between
those periods, proper lens case cleaning is necessary. In the past, a common recommendation
was rinsing the case with hot tap water and letting it air dry. It now appears that
rinsing the case with disinfecting solution and then air drying is a better course.
The Rub on Cleaning Contact Lenses
No-rub
multipurpose solutions entered the market in 2000. These solutions are intended
to minimize lens deposit formation without a rubbing step in lens cleaning while
also removing microorganisms. No-rub solutions have demonstrated that they reduce
the levels of the primary proteins on lenses (Hong 2005) and prevent the formation
of visible deposits.
Patients
frequently don't recognize that no-rub solutions require a rinse step to achieve
effectiveness. Houlsby (1984) found that rubbing alone with solution removed about
98 percent of lens microorganisms while rinsing alone removed nearly 99 percent
of microorganisms. These results suggested that the rubbing step may not be necessary
as long as rinsing is performed. However, Houlsby's study was limited to hydrogel
lenses of the early 1980s. Silicone hydrogel lenses may have changed the dynamics
of these observations because silicone hydrogels appear to deposit lipid at a greater
rate than do hydrogels (Jones, 2003).
In
the case-controlled study of Fusarium (Chang, 2006), 68 percent of control
patients failed to rub their lenses at least sometimes while 54 percent never rubbed
their lenses. The lack of lens rubbing was not a risk factor for fungal infection
identified in the study. Still, gently rubbing lenses is a prudent step unless future
evidence suggests otherwise.
Topping Off on Disinfection
Both patients
and practitioners confuse the disinfection/soaking step with cleaning. Disinfection
specifically relates to reducing the number of microorganisms on the contact lens.
It has nothing to do with lens deposit removal. For a multipurpose solution to earn
labeling as a disinfecting solution, the current FDA standard requires the product
to reduce 99.9 percent of colony forming units of bacteria and 90 percent of colony
forming units of fungi. For a lens care product to earn no-rub labeling, it must
reduce the inoculums of each challenge organism, both bacteria and fungi, by 99.999
percent using the labeled regimen.
What can go wrong
with lens disinfection? First and foremost is reusing solutions or "topping off."
This practice by patients is rampant based on reports of product consumption by
solution manufacturers. Chang (2006) found in the case-controlled study of the
Fusarium outbreak that patients who topped off were on average 3.2 times
(between 1.2 times and 9.4 times) more likely to be in the group who developed Fusarium
infections compared to controls. Another researcher has suggested that topping off
is like reusing today's dirty dish water for tomorrow's dishes. Reusing solution
is concerning because of the potential of the solution to lose disinfection efficacy.
Rosenthal (2002, 2006) has demonstrated that some solutions lose their disinfection
capacity after soaking certain types of lenses because the lens matrix absorbs some
of the active disinfecting compounds.
The
absorption of active biocides from disinfecting solutions into the lenses points
to a second issue: The application of lenses containing the absorbed biocide may
result in the release of high concentrations of biocide on the eye, resulting in
corneal staining. Papas at BCLA (2006) reported that patients exhibiting toxic corneal
staining were 4.02 times more likely to experience corneal infiltrates. Andrasko
(2006) has shown that certain combinations of lens materials and multipurpose solutions
are more prone to causing corneal staining. Andrasko's ongoing work is updated on
the website www.StainingGrid.com. His findings suggest that practitioners should
guide their patients to use specific lens care products depending on the prescribed
lens material.
A Paradigm Shift
Instead
of viewing resistance to change as stemming from only our patients, we must accept
that some of the resistance comes from the way we communicate with patients. The
old concept of compliance, where advice is doled out even when not requested, isn't
adequate to motivate patients to change their daily habits. Instead, practitioners
might consider a negotiation-based framework that harnesses patients' intrinsic
motivation to make their own decisions (Butler, 1996). This approach requires us
to accept patient decisions, even if those decisions run counter to current medical
wisdom. In this manner, we can make progress in getting patients to heed our recommendations
about lens replacement, maintaining good hygiene and proper use of lens care products.
CLS
To obtain references
for this article, please visit http://www.clspectrum.com/references.asp and click
on document #135.
DO Always
wash your hands before applying or removing your contact lenses.
DO After
taking the lenses out of their case, rinse the case with disinfecting solution and
let it air dry.
DON'T Don't
ever reuse the solution in the case. When soaking lenses, dump out old solution
from the case and use fresh solution. Expect to use 8 to 12 10-fluid-ounce bottles
per year.
DON'T Don't
switch brands or use generic alternatives without first consulting your eyecare
practitioner — always use the lens care products your practitioner recommends.
DO Although
most multipurpose solutions are "no rub," it's safest to gently rub the lenses —
especially the newer silicone hydrogel contact lenses.
DO Replace
your lens case at least every three months, even if it still looks clean.
Contact Lens Spectrum, Issue: February 2007