RUB VS. NO RUB
RUB VS. NO RUB: Skipping the Rub Leads to Dirty Lenses And Complications
By Randy McLaughlin,
Patients already don't comply with lens care. Chances are they won't comply with long rinse times either.
Rubbing reusable, non-daily disposable contact lenses is as logical as brushing your teeth or rubbing your silverware when you wash it. If the surface is not clean (organic or inorganic) it sure isn't likely to get disinfected. And microorganisms love surfaces. They make slime (glycocalyx) to help them survive on surfaces. We learned this in Microbiology 101.
We have also learned since the beginning of contact lens disinfection that cleaning lenses by rubbing them with clean hands with a cleaner (and later a multi-purpose solution), rinsing and soaking them in fresh solution in a clean case are all required for proper, safe, minimal bioburden lens care. Deposits from tear proteins and lipids can form on contact lenses in minutes and hours, not just over days and weeks. So even lenses that are disposed after only weeks still need ongoing cleaning. Rubbing is needed in the cleaning process to remove at least one log unit of bacteria from a contaminated lens before the rinsing step. Contact lens wearers could skip the rubbing step and use agitation in an ultrasonic cleaner or some other agitator, or they could rinse for an irrational period of time (that no rational human would ever do) to create agitation. But the function and purpose of simple rubbing is not difficult to teach or understand.
Patients are not aware that rinsing can replace rubbing, nor are they likely to comply with the longer rinse step associated with no-rub lens care systems. These long rinses, as long as 20 seconds, are not rational for the common patient. Rinsing times are rarely if ever emphasized by practitioners, manufacturers or technicians, and it is logical that patients, who usually do not comply with lens care, will not comply with an unregulated rinsing step. Patients want to save solution, not use it. If rubbing is discouraged and rinsing is not emphasized, one wonders if vision, comfort and inflammatory complications are the likely consequence. The FDA approved no rubbing. If no-rub solutions are not supplemented by heavier rinsing as recommended by the FDA-approved protocol, more lens contamination may result.
Educating the Patient
Some statistics claim that 50 percent of patients don't rub their lenses. Eyecare practitioners should not allow advertising and promotion of no-rub regimens to discourage our patients who do rub their lenses, thus compromising their lens cleaning. Some advertisements promote lens care and lens care systems that I do not recommend. First of all, contact lens practitioners need to be educated, and then we need to educate our patients. They need to understand and be re-educated regularly about proper, complete lens care. They need to understand that they should not change their lens care products or procedures unless their practitioner advises them to do so. This is just good medical and eye care. Patients should never change their lens care without the practitioner's advice. I find too many patients switch products at mass merchandisers, pharmacies and grocery stores. They are induced to switch by print advertisements, coupons, price and TV advertisements. At every office visit, contact lens practitioners should review proper lens care with patients.
Some patients come in complaining of lens discomfort. I ask if they have switched from the recommended solutions. Most patients have switched, and almost all patients improve after I change them back to the original solution. If the contact lens is not clean, it's hard to disinfect. Microbiology 101 again.
In the new millennium, the increased disposability of contact lenses used with convenient all-in-one solutions have greatly minimized contact lens-induced complications. Patients must continue to complete the FDA-recommended minimal contact lens maintenance schedule to maintain successful contact lens wear. Complete treatment plans include not only careful examination and fitting but proper lens disposing compliance and a full dose of:
- Clean hands (don't contaminate what you're disinfecting
- Clean cases (to avoid biofilm)
- Cleaning with rubbing (like in the shower)
- Rinsing (bugs don't like flow)
- Fresh storage solution each day
Further uneducated "shortcuts" in lens maintenance may only lead to an increase in contact lens-induced complication such as giant papillary conjunctivitis (GPC), contact lens-associated red eye (CLARE) or other infiltrative or infective conditions. This could lead to contact lens dropouts and an increase in refractive surgery as the method of choice in vision correction.
Remember that good compliance depends upon good patient instruction and education, bonding with your patient through good communication, simplicity and ensuring patients understand why compliance is important.
Dr. McLaughlin is an assistant professor of clinical ophthalmology at The Ohio State University Department of Ophthalmology He is the optometric and primary contact lens consultant to the 39-sport OSU program.
Looking at MPS Care
Patients and Practitioners Want No-Rub Solutions
no-rub contact lens care solutions protect non-compliant patients.
For years, contact lens practitioners have longed for a one-step solution that didn't require a rub to clean soft contact lenses. We have been given many new solutions from manufacturers, but the common denominator was the rubbing step necessary to ensure a clean lens. We accepted rubbing as a necessary step. However, it wasn't long after each new solution came to market that we realized that patients weren't performing the rubbing step that the regimen required. At this point, we realized that no matter how easy the manufacturers made compliance for our patients, patients always found an easier way.
It has been said that compliance to any health care regimen or drug is only 50 percent at best. In a study at Washington University School of Medicine some years ago, researchers found that compliance to a given regimen of life-enhancing heart medications was no more than 50 percent under controlled conditions. I would postulate that compliance to far less life-enhancing products such as contact lens solutions is not even 50 percent. All of us have a tendency to say, "My patients listen to my instructions, and they comply at a high rate." A hard look at reality, however, shows this not to be true. In fact, if all contact lenses fitters would simply go over what solutions or regimen patients are currently using and how they are using them, I am certain that the compliance rate would be significantly less than 50 percent maybe 20 to 30 percent.
Therefore, my argument is that if we were given a contact lens multi-purpose solution that performed superior anti-microbial disinfection, cleaned well and enhanced comfort, all without rubbing, wouldn't it be logical to embrace this concept ? Given the level of compliance that our patients already have, the best product would be an MPS that patients could use without rubbing lenses, instead only rinsing them off for a few seconds before and after storing. Theoretically, the non-compliant patients would become more compliant due to ease of use. However, even without compliance, such a product would go further than products requiring steps they are skipping to ensure that their non-compliance did not harm their eyes.
In general, I believe no-rub solutions will become market leaders, as patients want easier, more convenient lens wear. If we are perfectly honest, it is what the practitioners want as well. We have always complained about systems that were far too complicated or had too many steps. We also complained about products that were not as efficacious as we would have liked for our patients to use. We now have multi-purpose solutions that aren't complicated and don't require too many steps. These contact lens solutions are efficacious and what our patients want. Why do contact lens practitioners have difficulty embracing this concept? I am always amazed that so many of us believe that "more is better." While this may be true for some things, it is no longer true for some multi-purpose contact lens solutions.
Switching to No Rub
Some science is necessary in choosing a no-rub product. I realize that just because our patients don't want to rub doesn't make enough of a compelling reason to convert all contact lens practitioners. However, when you consider that a no-rub product has been shown to keep lenses clean without rubbing for most patients in clinical studies, such as Allergan Complete and CIBA Vision AO Sept Clear Care for 30 days and Alcon Opti-Free Express for 90 days, contact lens practitioners can be certain of a high rate of cleaning performance whether the patient rubs or not. In other words, no rub becomes a safety net for non-compliance, and these studies have proven that to be true. Concerning disinfection, MPDS (multi-purpose disinfecting solutions) like Opti-Free Express and Bausch & Lomb ReNu MultiPlus have been shown to kill microbes without rubbing or rinsing. Only Opti-Free Express has FDA labeling for stand alone as well as no rub.
Does prescribing a no-rub MPS ensure compliance in every case? The answer is still no. No-rub products come closer than any other product on the market today. We know certain patients will not comply with written or verbal in-office instructions. But with no-rub solutions, even without total compliance, I am comforted to know that my patients are not at risk for microbial, fungal or amoebic infections. I am also comforted to know that these products, such as Opti-Free Express, have been clinically proven to be as effective in cleaning soiled lenses as an MPS used with rubbing. Though fungal and acanthamoeba infections are rare, they can be devastating.
Although the no-rub concept appears to be relatively simple, years of research and development were needed to achieve FDA approval. Manufacturers performed many studies to ensure that safety and efficacy have been met for my patients without compromising comfort in addition to the safety net for non-compliance. Years from now, we may have something even better, but now we embrace the concept of no rub in our office as the best and easiest way to care for contact lenses today.
Dr. Schachet is in private practice in Englewood, Colo. He lectures widely in the United States, New Zealand and
Contact Lens Spectrum, Issue: September 2001