Proactively Prevent Contact Lens Dropout
You'll find most of the information you need to help prevent contact lens dropout in the patient history.
The U.S. 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.
The 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
Two new 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
* Chief complaint: Wants to try contact lenses for the first time
* Past ocular history: Has worn glasses since she was 8 years old
* Contact lenses: Never worn
* Past medical history: None
* Known medical allergies/Known environmental allergies: Allergic to ragweed
* Medications: Claritin
* Social history: Running, tennis
* Rx: - 3.00D OU
* Age: 43
* C/C: Wants to try contacts again
* POH: Has worn glasses since she was 8 years old
* Contact Lenses: Wore 5 years ago; stopped
* PMHx: Depression
* KMA/KEA: None
* Medications: Zoloft
* SHx: Likes to read
* Rx: -3.00D OU
After 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.
Before we discuss how to fit these patients, let's first discuss the elements associated with taking a complete patient history.
Age 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.
Myopic 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.
As 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 more important.
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.
Refraction 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 hydrogel lenses.
Is the 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.
Always 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 solutions.
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.
Does a 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.
Allergies 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 settle down.
Medications 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.
Knowing 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.
Most people spend at least some time in front a computer or reading, where they blink less and experience more dry eye complaints.
Patients 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)
Taking 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 answer.
TABLE 1 Contact Lens Considerations for Patients 1 and 2
Some 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.
Dr. Kovacich graduated from Indiana University School of Optometry and completed a hospital-based residency at the St. Louis VAMC. In 1998 she returned to IU as a Clinical Assistant Professor, currently working in the Cornea and Contact Lens Clinic.