contact lens market recently grew slightly, with 3 million new fits
and 2.8 million wearers dropping out. You can avoid many dropouts,
however, by taking a thorough history when fitting both new and
existing lens wearers and tailoring a plan that meets each
individual's needs. After assessing each case, look carefully for
potential problems (or red flags) and then select the best product(s)
to meet that patient's needs. Because comfort is the number one
reason patients discontinue lens wear, you need to make every effort
to make lens wear as free from irritation as possible. This requires
constant monitoring of new advances in lens materials (for example,
silicone hydrogel lenses are now available in spherical, toric, and
multifocal designs) as well as of the constant changes in lens
solutions and anterior segment medications.
history is particularly important for patients who have previously
dropped out of contact lens wear. By listening carefully to each
patient, you can hopefully avert or better manage past problems and
rehabilitate the patient into successful lens wear.
A Tale of Two Patients
patients arrive for an appointment. Both are adult females, - 3.00D
myopes and want to be fit with contact lenses. Will these two
patients be fit the same?
* Age: 35
complaint: Wants to try contact lenses for the first time
ocular history: Has worn glasses since she was 8 years old
lenses: Never worn
medical history: None
medical allergies/Known environmental allergies: Allergic to ragweed
history: Running, tennis
* Rx: -
* Age: 43
Wants to try contacts again
Has worn glasses since she was 8 years old
Lenses: Wore 5 years ago; stopped
Likes to read
reviewing the histories, it becomes apparent that these patients
need to be fit differently. Each patient has three red flags that
make contact lens fitting more of a challenge. If you don't address
these potential problems from the beginning, these patients will
have a higher propensity to discontinue contact lens wear.
discuss how to fit these patients, let's first discuss the elements
associated with taking a complete patient history.
Although age is not the critical issue in most contact lens cases,
you should pay careful attention with very young patients (under
10), with prepresbyopic/presbyopic patients and with elderly
patients. In young patients, is the child mature for his years or
will the parents be heavily involved in the application/removal and
care of the contact lenses? When contact lens wear isn't medically
necessary, is the child motivated to wear contact lenses or is it
the parents' idea? Patients who aren't internally motivated are more
prone to dropping out.
patients in the prepresbyopic years can find it more difficult to
read while wearing contact lenses than while wearing spectacles.
It's important not to overminus these patients, and also educate
them on the possible need for an add. If a myopic patient over 40
has been removing his spectacles to read, you'll need to instruct
the patient about expectations and the possible need for a bifocal
contact lens. You can remove any unrealistic expectations of a new
multifocal lens patient at the outset by explaining that the goal is
to achieve a correction that will allow him to do most of what he
wants to do most of the time. In addition, presbyopic patients,
especially hyperopes, are appreciative of a visibility tint.
patients get older, presbyopic progression may cause them to drop
out of contact lens wear. Aging can increase dry eye problems by
affecting the quality and quantity of the tears. Older patients also
have more systemic health issues and take medications (discussed
below) that can cause dry eyes, making lens and solution selection
Determine the Chief
Complaint Listen carefully and try to solve the
patient's chief complaint if possible. If the patient has
unrealistic expectations, work on an acceptable compromise of the
options that allows the patient to achieve most of his goals.
This is the time to evaluate the refraction, habitual prescription
and keratometer/corneal topographer results if possible. Note if the
patient has an unusual refraction, significant astigmatism or
irregular astigmatism resulting from corneal problems such as
keratoconus. Irregular astigmatism is usually best managed with GP
lenses or hybrid lenses such as SynergEyes (SynergEyes, Inc.).
Contact Lens Wear
Is the patient happy with his current lenses? (Keep in mind that
patients may not mention problems for fear that you'll take them out
of lens wear.) Even if a patient is happy, it's important to educate
him about newer technologies and options, especially silicone
patient compliant with wearing time? If you know or suspect that a
patient is wearing lenses overnight, educate him about higher-Dk
materials and lenses approved for overnight wear. Look carefully for
evidence of problems (hyperemia, encroachment, microcysts) that may
lead to dropout with the current lenses.
ask patients if they're compliant with solutions and note if a
patient is using a generic or store brand solution. Solutions are by
far the easiest variable to change, and some soft contact lenses may
be incompatible with certain solutions. If you don't think that
using a particular solution is important (just use anything), then
your patients won't think it's important either. Educate patients
about solution/lens incompatibilities and that generic and store
brand solutions may be older formulations of the current name-brand
Past Contact Lens
Wear As previously mentioned, of particular importance
is a past history of unsuccessful contact lens wear (dropout). Why
did it fail? What can we do differently now? Having a thorough
working knowledge of new lenses available is critical to not
repeating past mistakes. Again, silicone hydrogel lenses may be the
answer for previous contact lens dropouts that resulted from
complications of hypoxia and comfort issues. Peroxide systems or
newer solutions may also make a difference.
patient have systemic conditions that can affect contact lens wear?
This list isn't all inclusive, but possible problems can occur with
acne rosacea and autoimmune diseases (primarily Sj�gren's syndrome,
rheumatoid arthritis and lupus). Other conditions associated with
dry eye include menopause, sarcoidosis and thyroid problems.
Environmental allergies can have an adverse impact on contact lens
wear, but several options are available for allergic individuals.
Daily disposable lenses may be the best option for these patients,
although GPs can work well, too. If a patient wears soft lenses for
a longer period of time, peroxide solutions may help keep the lenses
as clean as possible and prevent solution sensitivity problems.
Antihistamine/mast cell stabilizer combinations with once or twice
daily dosing can help many allergic patients remain in contact
lenses. If a patient has seasonal allergies that flare up and make
lens wear difficult even with medication use during certain times of
the year, let the patient know that it's okay to discontinue lens
wear for a period of time and then resume wear when the symptoms
It's important to know which medications can cause dry eyes, and
it's helpful to know the names and ocular effects of as many
medications as possible. Medications that cause drying include
diuretics, anti-depressants, oral contraceptives, hormone
replacement therapy, beta-blockers, sedatives, anti-cholinergics,
antihistamines, tranquilizers, ulcer medications and Accutane.
Occasionally patients will mention a medication but neglect to tell
you what they use it for (or they may name a condition but omit the
treatment), so be alert for inconsistencies.
which contact lenses and materials are indicated for dry eyes (such
as omafilcon A, used in Proclear lenses and in some Biomedics
lenses, both from CooperVision) could determine which lenses you
should select. Silicone hydrogel lenses, which have less water
content than do hydrogel lenses, tend to dehydrate less and may work
well for a dry eye patient. (Also, if one silicone hydrogel lens
material doesn't work, another might). Trying to solve dry eye
issues is complicated, however, and lenses that work well for one
patient may not work for another. Take into consideration the role
of contact lens solutions in the contact lens-wearing dry eye
patient. While artificial tears are useful in mild to moderate dry
eye, severe dry eye patients may be able to continue in contact lens
wear only when managed with cyclosporine 0.05% (Restasis, Allergan).
Occupations, computer usage and hobbies are other factors to
evaluate when considering contact lens options. A patient's work
environment may be unsafe for lens wear (such as a chemistry lab) or
simply detrimental to successful lens wear (such as a dusty
warehouse). You can then counsel the patient about wearing lenses
for social occasions. Occasional wear is a great option for such
patients, and those who incorrectly assume that you have to wear
contact lenses all the time really appreciate the suggestion.
people spend at least some time in front a computer or reading,
where they blink less and experience more dry eye complaints.
who are invested in certain hobbies are also willing to invest in
contact lenses that make their avocations more pleasurable. Athletes
especially are interested in products that can improve performance.
Disposable lenses are perfect for athletes or for weekend athletes
who aren't interested in full-time wear.
A Tale of Two Patients (Reprise)
all of this information from a patient history into consideration,
what are the three red flags for each of our female -3.00D myopes
and how should we fit them for the best possibility of contact lens
success? See Table 1 for the
TABLE 1 Contact Lens
Considerations for Patients 1 and 2
patients will drop out of contact lens wear no matter what you do.
However, taking a careful history, listening closely to the chief
complaint and knowing what lens materials, solutions and medications
are available can make a difference. Borderline contact lens
patients might eventually drop out if you don't consider potential
problems from the beginning. A proactive approach to contact lens
fitting along with an up-to-date knowledge of existing options can
turn a problematic patient into a successful contact lens wearer.