Choosing Lens Care Wisely
Unexplained red eyes, unaccounted for dropouts -- many can be traced back to a lens care product. Here's how to avoid them and grow your practice.
LaMar G. Zigler, O.D., M.S., F.A.A.O., Columbus, Ohio
How many times have you worked diligently to achieve the "perfect" contact lens fit only to be frustrated at a follow-up visit by a red eye. Suddenly, you're second-guessing yourself.
Is the red eye viral, allergic or bacterial? Is it due to complications from the lens fit, design or material? Could it be the result of lens overwear? Or perhaps it stems from a patient's improper use of the lens care system, or it could be a solution reaction.
Although many solution-sensitivity problems have been addressed and minimized by new formulations, don't be lulled into thinking they've been completely eradicated. In this article, I'll explain why we need to stay vigilant and offer some suggestions on how to avoid these problems.
It's frustrating when we learn patients aren't following our prescribed recommendations for their lens care. Maybe they've become lazy and are cutting corners in the care regimen. Or they may have switched brands or tried a generic brand to save money, unwittingly introducing ingredients that may not be good for them.
Most patients don't look at the care system formulation they're switching to. They read the label that says: "For Sensitive Eyes," "No Rub Formula," "Lasting Comfort," "Essential Electrolytes," "Healthy Lens Wear." It's no wonder patients are overwhelmed and confused when they look at the store shelves.
Usually, when you ask patients what they're using to clean and care for their lenses, they can't tell you the name. They look around your exam room until they see a bottle with the colors they recognize. Or they tell you "I use the blue box with the rainbow colors," "The blue box with the funny yellow logo," "The green box with the red and blue on it," "The orange box" or a store's generic brand, which may have a label and colors like the national brand.
Now add to this confusion the old formulations with similar names and colors that are still on store shelves. Whew! In their confusion, some patients even buy saline and not a disinfectant at all because it's labeled "For Soft Contact Lenses" and it's cheaper.
Not only are our patients confused but so are we. What does "No Rub" mean? What does MPS (not stand-alone), MPDS (stand-alone efficacy) mean? What do electrolytes, lubricants, surfactants, chelating agents, protein removers, large molecules and cationic charge do for these new care systems?
Some systems are approved for all contact lenses, some for 90-day replacement or less, or 30-day replacement or less, depending on whether or not the rubbing step was used. Soaking times vary from 5 minutes to 6 hours. Some allow lens storage in an unopened case for up to 30 days.
Eyecare practitioners and staff need to know the manufacturer's instructions for each product they dispense. These instructions must be emphasized to the patient at every visit. Not only does compliance ensure healthy eyes, it also factors into a patient's satisfaction with his overall contact lens wearing experience. In other words, noncompliant patients often stop wearing their lenses.
FROM NONCOMPLIANT TO DROPOUT
Current estimates show about three million new patient fits, 34 million current patients and 2.5 million dropouts per year. For every 10 new patients we fit, 60% to 70% will drop out.
Many dropouts leave your practice and seek eyewear, eye care or LASIK services elsewhere. They either believe you haven't met their needs, or they're embarrassed to return to you because of their own failure. They feel they've wasted time and money with you.
Therefore, it's critical for us to recognize why patients stop wearing their contact lenses and discover how to reduce the number of dropouts.
THE FOUR C's: COMFORT IS #1
Patients leave contact lenses because of issues with comfort, convenience, cost or compliance. Of these, comfort is the number one reason for failure. As eyecare practitioners, we need to determine if comfort problems are caused by the lens or the care system. Many times, it's difficult to tell.
Our usual approach is to change the lens design, material or brand first. Lens problems, typically, are mechanical in nature and manifest as symptoms of edge sensation due to excess movement or edge design. If the comfort issue is dryness, it may be remedied by changing the lens material or by aggressively treating the blepharitis or meibomian gland dysfunction with lid hygiene, antibiotics or nutritional supplements.
Astute practitioners also will consider contact lens care systems as a possible cause of discomfort and dryness. We need to be ready to prescribe care systems other than our "favorite" in order to treat the patient's symptoms. We must explain to patients that we've prescribed a care system for their particular lenses and emphasize the importance of compliance. We must prescribe care systems just like we prescribe medications to treat eye disease. Just as with eye disease, if our initial treatment fails, we must go on to the next option.
CONVENIENCE BRINGS 'EM BACK
Solution manufacturers have been working diligently on convenience because they know convenience sells products. They also know that convenient care will help keep patients from dropping out or switching brands.
How many times have you refit a dropout who hasn't worn contact lenses since the days of heat units and multi-product care systems (a.k.a. "miniature chemistry sets")? When you tell them that we now have disposable contact lenses that are thinner and more comfortable, and "one-bottle," no-rub
solutions, they're usually eager to try lenses again.
COMPLIANCE VERSUS COST
Compliance and cost usually are adversaries in contact lens care. Our job is to educate patients on the proper use of their contact lenses and lens care systems. Do your technicians use the words "prescribed a system for you?" Do they explain that it's important to stay with a particular care system and use it according to the manufacturer's instructions?
Too often, we give patients a care system without training them on its proper use or, worse yet, we give them a kit and say that all care systems are essentially the same. This encourages patients to shop around for the lowest price. Many patients end up with saline alone because it's cheaper than a disinfecting solution, or they buy generic disinfecting solutions that are older formulations with a different preservative than the system you prescribed.
When I have a patient with a red eye, I always ask: "Have you recently changed your contact lens care system?" Many times, the answer is yes.
Other cost-cutting measures can produce complications, as well. Beware of patients who:
- Don't rinse their lenses thoroughly
- Use minimal solution in their cases
- Reuse the solution in their case, topping off the old solution with new to save a few pennies.
You and your staff must be diligent. At follow-up visits, always ask patients how they're cleaning their lenses. Reeducate them on proper lens care and compliance to your prescribed regimen.
MANY PATIENTS ARE OVERWHELMED AND CONFUSED BY THE ARRAY OF CONTACT LENS CARE PRODUCTS THEY FIND ON THE STORE SHELVES.
LENS CARE EVOLUTION
In the past 5 years, the trend has moved to one- bottle, no-rub, multipurpose solutions. A multipurpose solution must be able to clean lipids, proteins and debris from the lens surface as well as the lens matrix. It must be capable of rinsing and be efficacious in disinfecting the lenses. The solution must enhance comfort and prevent lens dryness. The multipurpose solution must do all this without adverse effects on the ocular surface.
The solution manufacturers have been working diligently to create these wonderful "smart" solutions for our patients. We've come a long way from heaters and salt tablets, chlorhexidine and thimerosal, enzyme tablets and strong cleaners. Hydrogen peroxide systems also have evolved from multi-step systems to "one-bottle," no-rub formulations. This evolution in design has produced solutions that are convenient, efficacious and comfortable with minimal adverse effects to the contact lens and the ocular surface.
The newest hydrogen peroxide system is AOSept Clear Care, a "one-bottle," no-rub formulation. This is the only product that contains Pluronic 17R4, which is a cleaning agent.
Three percent hydrogen peroxide is an excellent preservative-free disinfectant. Thus, these systems are indicated for patients who are sensitive to preservatives. Many patients also report excellent comfort with these systems
The drawbacks include a rapid reduction in peroxide until it becomes saline, which requires repeated use if stored more than 24 hours. The other drawback is stinging caused by a chemical keratitis if unneutralized peroxide is placed into the eye by mistake.
LEADING MULTIPURPOSE SOLUTIONS
The leading multipurpose solutions are state-of-the-art "smart" solutions. They're carefully designed to clean, rinse, disinfect, remove protein, condition and store contact lenses.
Complete Moisture Plus has added electrolytes and the lubricant hydroxypropylmethylcellulose (HPMC). Solo-care Plus has added Aqualube for lubrication. Opti-Free Express and ReNu MultiPlus have MPDS stand-alone labeling for all lenses. In addition, Opti-Free Express has Tetronic 1304, a surfactant that treats the lens surface, lowering the wetting contact angle to zero. Poloxamer 237 in Complete Moisture Plus and poloxamine in ReNu MultiPlus are cleaners and surfactants, which help lens wetting. ReNu MultiPlus has Hydranate, a chelating agent that helps prevent protein binding.
All solutions contain the chelating agent EDTA, which is an antimicrobial preservative and an agent that may prevent lens deposits. All buffers keep the pH near that of natural tears and enhance microbial and cleaning effectiveness. Only Solo-care has a 5-minute express disinfection labeling for lenses replaced after 30 days, which requires rubbing, rinsing and soaking.
OTHER CARE SYSTEMS
Other care systems generally are older formulations of brand-name solutions. ReNu has less PHMB at 0.5 ppm than the newer MultiPlus formulation, which may help if a patient shows sensitivity to PHMB at 1 ppm. Only Opti-One has no-rub labeling, other than generics with this same formula.
Although it involves two steps, Quick Care is a nice system for patients -- swimmers, for example -- who need quick disinfection. It's an excellent solution for swimmers to disinfect their lenses immediately after swimming. It uses an alcohol-based cleaner and a finishing rinse and storage solution. The ABS/low-level peroxide system in the finishing solution makes it a good system for patients with sensitivities to chemical preservatives.
Eyecare practitioners usually don't give much thought to generic solutions, but we should. Twenty percent (1 of 5 bottles) of solutions sold each year are generic or private label.
Patients assume that generics are equivalent to the brand you prescribed for them. But most generic solutions are older formulations of brand-name products, so patients won't get the benefits of the new technology. Also, patients are more likely to have a sensitivity problem or complication, which has been addressed in the new formula.
Another problem with generic solutions is that patients don't read the ingredients list to see if they match those of the brand-name product. A generic solution may be made using a completely different formulation under the same private-label name, depending on who manufactured it at the time.
SILICONE HYDROGEL LENSES
Solution compatibility with silicone hydrogel lenses is being hotly debated. Practitioners are reporting complications in some patients using solutions containing PHMB, but manufacturers claim the complication rate is no different than with other lens materials.
Specifically, the claim is that patients wearing silicone hydrogel lenses and using ReNu MultiPlus are exhibiting diffuse superficial punctate keratopathy (SPK). It's been well-documented that diffuse SPK is most likely caused by chemical toxicity. Recent reports in the literature suggest a connection between PHMB and silicone hydrogel materials, producing SPK. According to these case reports, the SPK resolved when the patients switched to a care system without PHMB.
Both the solutions and the contact lens manufacturers are examining these reports and if they're substantiated, they'll seek a resolution. Opti-Free Express was the first solution cleared for use with silicone hydrogel lenses in its labeling.
Another incompatibility was reported a few years ago, when clinicians noted changes with some silicone hydrogel lenses. In this instance, UltraCare solution used with PureVision lenses caused surface changes, but tests on other hydrogen peroxide systems and other silicone lenses were inconclusive. More research is needed to determine the answer to these possible incompatibilities.
And finally, be aware that patients wearing Acuvue Advance contact lenses should not use Solo-care, as stated in the package insert.
GROWTH AND PROSPERITY IN A BOTTLE
As you can see, today's contact lens care systems are quite complex. It's critical to the success of our practices to understand the products we're prescribing and to educate our patients on proper lens care.
With increased compliance, we should see an increase in the number of lens wearers due to a decrease in contact lens dropouts. This will lead to happier, more loyal patients, which will keep our contact lens practices growing.
Dr. Zigler practices in Columbus, Ohio. He's a clinical instructor in the Contact Lens Clinic at The Ohio State University College of Optometry. Dr. Zigler has participated in the clinical investigation of several contact lens materials and contact lens solutions, as well as lecturing on the fit, design and modification of contact lenses, and patient problem solving.
|Lens Care System Vocabulary|
Here are some common terms related to lens care systems.
Cleaner/Surfactant: Removes mucin, debris, makeup
Disinfectant: Kills organisms, specifically three bacteria (Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus marcescens), and two fungi (Candida, Fusarium) used in FDA testing
Buffer: Keeps pH close to natural tears; helps the disinfecting and cleaning agents
Wetting Agent: Lubricates lens surface; decreases wetting angle
Protein Solubility: Reduces protein deposits on the lens surface by suspending mucin away from the lens
Chelator: Prevents calcium-bound proteins from depositing on the lens surface; enhances disinfectant
Multipurpose Solution (MPS): Cleans, rinses, disinfects and stores the lens according to a prescribed regimen
Multipurpose Disinfecting Solution (MPDS): Same as above with higher microbiocidal requirements (stand-alone criteria)
FDA Stand-Alone Criteria: No lenses are involved. After inoculation, the solution must show three logs kill for bacteria and one log kill for fungi
FDA Regimen Criteria (rub, rinse, soak, rinse steps): After inoculation of the lenses, the regimen must reduce the levels of bacteria and fungi from one million to less than 10 for the lenses in solution.
FDA No Rub Requirement: Must show both regimen antimicrobial and cleaning efficacy without rubbing.