Nothing Like the Real Thing
Before patients buy “Compare to…” bottles of solution, make sure they know what you want them to buy and why.
Dr. Potter: Dr. Miller, you prescribe a solution along with each patient's contact lens prescription. Why is this important to your practice?
Dr. Miller: My primary goal with regard to contact lens wearers is to minimize dropouts and increase the positive experiences of new wearers, and that really starts at ground zero. Contact lens success not only includes good vision; lens comfort is just as critical. This starts with patient education. I teach my patients about proper wearing habits, not just with a recommendation, but also with a prescription. I have to explain that I'm not just prescribing a specific contact lens, I'm also prescribing a specific care solution, wearing schedule, and any additional treatments that will maximize and enhance their wearing experience. I want patients to have the best possible contact lens-wearing experience.
I use the Andrasko “staining grid” when I'm performing a new contact lens fit. I feel this optimizes my contact lens and care solution selection. Dr. Andrasko has stated that there are no bad lenses and no bad care solutions, but some combinations are less biocompatible. The grid (Figure 3) helps me prescribe the contact lens and solution combination that will minimize that corneal staining and enhance the wearing experience.
Dr. Potter: Dr. Miller, what does corneal staining (Figures 4 and 5) mean to the everyday practitioner—particularly those with a contact lens focus?
Figure 3. Results show percentage area of the cornea exhibiting corneal staining after two hours of lens wear using an acute exposure model.
Figure 4. When corneal staining is present, practitioners may consider recommending a different lens type and/or different solution for the patient.
Figure 5. Once staining is identified, the practitioner conducts a visual exam to evaluate the level of staining.
Dr. Miller: From my private practice view, I don't like to see any staining, no matter what the cause—dry eyes, a poor contact lens fit or solution-induced staining.
When a patient comes in for a follow-up appointment after their initial contact lens fitting, we often look for redness and irritation, but we should also consider checking the cornea for staining. Again, I want to improve the contact lens-wearing experience for my patients, and if I see significant staining, then I need to change something—the contact lenses, the solution or the wearing schedule.
Dr. Brujic: You said you prescribe contact lens solutions. Is that something you do for every patient?
Dr. Miller: I do it for every new wearer. I have a contact lens agreement form that details the contact lenses prescribed, the wearing schedule (including whether their lenses are approved for extended wear or not), fees involved and which solution the patient should be using. If there are any issues, I want them to call me, so the form also has my emergency contact number on it. All new wearers receive this form, but it's something I should consider giving to every patient—every time they come back.
Dr. Sindt: In my practice, to comply with the Fairness to Contact Lens Consumers Act, we provide a written copy of the prescription at every visit—after their fit, at their follow-up appointment and at any other visit. At the bottom of the prescription, we state the replacement schedule, the recommended contact lens care solution and any specific notes for the patient. It's printed and stored in the electronic medical record.
Dr. Potter: There's still a pervasive feeling that care solutions don't matter. Also, it's important to remember that consumer commitment to branded products declines over time (Figure 6). So, why aren't more practitioners clearly stating their care solution recommendations?
Figure 6. As users gain experience within a product category, they seem to “step down” in price and use of branded products.
Dr. Miller: With all the demands on the eyecare practitioner, it is probably not talked about as much with the patient. They assume that by providing a sample, they have given a recommendation. This may allow patients to perceive that care solutions don't matter. To some degree, they think that wearing schedules don't matter either. If we fail at education—if patients aren't prescribed a specific lens and care solution, told how to wear the lenses and why all of this is important—then experience shows patients are more likely to dropout of contact lens wear.
Dr. Brujic: One reason we started having patients bring in their contact lens care solutions is because some successful wearers were complaining about mild to moderate discomfort. We wanted to understand these vague complaints as much as possible. When we pinned it down and made these patients responsible, we realized they were switching care solutions, often using a private label. We saw firsthand how switching from recommended care solutions can impact the lens-wearing experience.
Dr. Potter: Am I correct that private labelers have no obligation to keep their care solutions consistent?
Dr. Sindt: That is correct. Retailers can change their private label care solutions as they desire. If the packaging looks similar to that of a branded product, most consumers assume they're the same and don't bother, or don't know how, to read and evaluate the ingredients.
Dr. Brujic: To clarify, we sometimes use the term “generic” to describe a store brand with the identical active ingredients of a branded product. For example, ABC Drug Store acetaminophen is still acetaminophen. But contact lens care solutions are different and that's confusing for patients and practitioners, too. In the care solution world, if you have two products that look the same, the item patients might call a “generic” isn't really a generic. It doesn't have to be exactly the same as the brand-name product.
Dr. Potter: The bottom line is that private-label formulations can change without warning and private-label packaging often confuses consumers.
Dr. Sindt: If you're using Dr. Brujic's approach, then a patient brings all of his care solutions and lens cleaners to his exam. If the patient has a generic or private-label care solution, but he is perfectly fine—nothing wrong with his corneas—do you recommend a change for him? Or do you let him continue with the product that he's been using successfully?
Dr. Mayers: I don't want my patients to continue using generic or private label care solutions, so I re-educate them about the importance of using a specific care solution with a specific lens.
So, going back to my original statement, we want to minimize adverse events and problems. We want to minimize what Dr. Miller was talking about with dropouts. We want to keep patients in that controlled environment with that branded care solution, so we know exactly what's in the product and what type of performance to expect.
Dr. Potter: We've been clarifying some facts about generics and private-label care solutions and talking about how they make patient education that much more important. Are we seeing patients who are confused about the care solutions out there?
Dr. Sindt: Well, when patients use generics, they don't necessarily know that they're switching their care solutions. They might have been using a specific product successfully for years. They're buying the same bottle, but the formula may have changed on them.
Dr. Miller: There's so much confusion from the patient's perspective and very little talk about proper compliance. They receive mixed messages. I don't think some patients even realize they're doing anything wrong. They come in and happily tell us they're using the wrong care solution and how they're over-wearing their current contact lenses. I hear it all the time, “I wear them until they feel uncomfortable. I can get 6 to 8 weeks out of these lenses.”
I think it's really important to take a few minutes to educate all of our contact lens patients every time they are in our offices. Reinforce good behavior and correct any misconceptions.
Dr. Potter: One reason patients don't think they're doing anything wrong is our own mixed message. We instruct them to use generic drugs, but it's a different message when it comes to contact lens care solutions. To be clear, I'm emphatic with my patients. I make sure that I know what I'm prescribing, and I tell them I don't recommend generic or private-label care solutions.
Dr. Miller: Our patients only see us every year or two. Clarity and emphasis are important because when they're not in our practices, they're out there receiving mixed messages from their friends, from advertisements and at the store.
I can see why our patients are confused when I look at the shelves and see what's out there. They're grabbing a bunch of groceries, and they're naturally grabbing the care solution that looks familiar and is conveniently located. It's so commonplace. We should take it a step further after educating our patients about what we're prescribing, by telling them why we want them to buy a specific product every single time.
Dr. Sindt: People purchase contact lens care solutions like they purchase their hair care products. They check the bottle for key words like “moisturizing” or “all-day comfort” and then they look at the price. I think it's because they generally feel that in the United States, the government keeps them safe. They assume that if the FDA has cleared a prodcut for use, it's safe. To them, that's a safety net.
And not only do they assume that all those products on the shelf are exactly the same in terms of safety, but they also perceive that the care solutions are equally effective based on the keywords used on the labeling.
If we don't tell patients in no uncertain terms that for the best chance for success with their specific problems and lenses, they must use the brand-name care solution and no substitutes, then we're leaving them open to confusion.
Rather than just saying, “I want you to use this product,” we have to tell them, “I want you to use this product because it affects you as an individual in these important ways….”
Dr. Mayers: I just want to make a comment, going back to the generics. When patients go to the store shelves, generic boxes say “Compare to” a branded care solution. It's no wonder they think that the care solutions are the same—it's very confusing. It doesn't say, “This is exactly the same solution,” it just asks consumers to compare it to the real thing. I tell my patients, “There's a big difference. Don't compare it. Stick to the prescribed care solution.” CLS
|Wetting Silicone Hydrogel Lenses|
|Dr. Potter: Silicone hydrogel lenses are obviously revolutionizing our field, but are they more comfortable? And are they more difficult to wet?|
Dr. Brujic: I think silicone hydrogels are a phenomenal addition to the contact lens world. We've seen people who were unable to wear contact lenses or were wearing contact lenses uncomfortably, and now they're able to wear contact lenses successfully.
But we need to respect that this technology is very different than its hydrogel predecessor. The surfaces are different, and they interact differently. This creates challenges for maintaining a moist surface.
As clinicians, we need to keep the differences in mind when we're selecting the care systems for patients wearing silicone hydrogel contact lenses. That's how we maximize success. One of the biggest things people associate with success is the idea that they can't feel their lenses on their eyes. Patients reporting, “I'm so comfortable that I don't know I'm wearing them” is really the ultimate goal. Thus, carefully selecting contact lens care systems to match silicone hydrogel contact lenses is paramount in my mind.
Dr. Miller: We need to choose a lens for a reason, as well as prescribe everything that goes into that contact lens wearing experience.
Dr. Sindt: In my opinion, surface wettability is essentially the key difference between emerging generations of silicone hydrogel materials. The lenses become more and more wettable, and manufacturers are continually striving for increased wettability. Wettability affects what binds to the surface of the lens–biofilms, lipid deposition, and to some extent, protein deposition (Zhao, 2009; Zhao, 2010; Young, 2009). All of these things may affect the health and comfort of the contact lens wearer.