continuous wear colloquy
Continuous Wear: Not All Patients are the Same
BY N. REX GHORMLEY, OD, FAAO
Hyper-Dk silicone hydrogel contact lenses have significantly increased our continuous wear patient population. I've found that three types of new continuous wear patients exist, and we need to manage them differently.
1. New contact lens patients who've never worn contact lenses or haven't worn them on a regular basis for several months.
2. Current daily wear (low-Dk) soft lens patients who wear conventional, two-week or four-week disposable lenses full time.
3. Current extended wear (low-Dk) soft lens patients who wear one-week extended wear or flexible extended wear.
Choosing a Wearing Schedule
After we fit a patient with new hyper-Dk silicone hydrogel lenses, what wearing schedule should we prescribe? New continuous wear patients immediately start continuous wear. Current daily wear (low Dk) patients wear new silicone hydrogel lenses for three days and then start continuous wear. Current extended wear (low Dk) patients discontinue the extended wear schedule for one week and then resume a continuous wear schedule.
When I refit a patient who is wearing a low Dk/t (28) soft lens into a hyper Dk/t (175) silicone hydrogel lens, I allow time for the cornea to adapt to the new oxygen environment. In 1989, Holden reported a rebound effect because of the return to the normal epithelial metabolism after discontinuing contact lens wear. In the past, I observed cases where an extended wear soft lens patient had a contact lens inflammatory event when refit into silicone hydrogel lenses. I now allow time for the cornea to stabilize, and contact lens inflammatory events are rare in our practice.
The stabilization period depends on the previous wearing schedule, daily wear or extended wear, and the contact lens power. For example, a patient who has a +5.00D lens needs a longer period of time than a 1.00D patient.
What follow-up office visit schedule should we use? Our routine office visit schedule for the new continuous wear patient is one week, three weeks, six weeks and six months. We see the new contact lens patient one week after the initial examination. With hyper Dk/t (175) lenses, it's unnecessary to see the patient at 24 hours or three days, which was the normal schedule for low-Dk soft lenses. If the patient has continuously worn silicone hydrogel lenses for one week without complications, we schedule three-week, six-week and six-month appointments. We dispense a six-month lens supply at the six-week visit, and patients must have an exam every six months after the initial fitting period.
Daily wear soft lens (low Dk) patients wear their new lenses daily wear for three days and then start a continuous wear schedule. They're seen in 10 days, three days of daily wear and seven days of continuous wear, and then are scheduled for three-week, six- week and six-month visits.
Current extended wear soft lens patients wear new daily wear lenses for one week and then resume a continuous wear schedule. This isn't a management problem if you properly educate patients. Patients return in two weeks (one week of daily wear and one week of continuous wear). I then schedule the three-week, six-week and six-month office visits.
Different Levels of Care
You shouldn't give all continuous wear patients the same level of professional care. We need to evaluate history of contact lens wear, lens power and ocular health before recommending the appropriate treatment.
Dr. Ghormley is in private practice in St. Louis, MO. He is a past president of the American Academy of Optometry and is a diplomate of its Cornea & Contact Lens Section. He is also the team optometrist for the St. Louis Rams (NFL) and the St. Louis Blues (NHL).