Personalize Your Care System Recommendations
BY GLENDA SECOR, OD, FAAO
Over the past two years, we have seen a paradigm shift in prescribing solutions and care regimens for our contact lens patients. I have witnessed cycles in lens care regimens in my own practice. The recent contamination issues and solution recalls certainly have reinforced that solution efficacy is critical to success and that focusing on convenience alone may result in complications.
Effects of No-Rub Convenience
No-rub multipurpose solutions (MPSs) became popular as a convenient way to minimize a patient's responsibility for lens care requirements. Patients often reported that they were lax about their lens care habits, so it stood to reason that the introduction of a passive contact lens cleaning alternative could more aptly improve contact lens care in light of the known poor compliance with digital cleaning.
Patients adapted to no-rub lens solutions, which quickly became mainstream options. Unfortunately, the pseudo-relaxed attitude of practitioners and patients as well as material price wars may have contributed to the perceived commoditization of contact lenses and lens care products.
No-rub MPSs generally exhibit acceptable bactericidal activity during an overnight soak, but may not be the best disinfectant against fungi and Acanthamoeba. In my opinion, a dedicated rub-and-rinse regimen is the most effective way to achieve the best results with an MPS. Some patients may require a refresher course on how to properly employ a rub-and-rinse MPS care regimen for proper disinfection.
Now, more than ever, it is time to refocus our efforts as physicians, recognize the importance of our recommendations and prescribe contact lens care regimens based on patient needs. Emphasizing the importance of proper lens care is imperative these days, and it has been an easily acceptable direction for a majority of my patients.
Consider Peroxide-Based Care
Even with a rub-and-rinse regimen for MPSs, I still believe that hydrogen peroxide systems have a place in a busy contact lens practice. Despite the improved efficacy of MPSs with proper compliance, I believe a hydrogen peroxide-based solution remains the best option for contact lens care in terms of killing bacteria and disinfecting lenses properly. These systems offer antimicrobial efficacy without the use of preservatives. Additionally, research has shown that with ample exposure time, a hydrogen peroxide-based lens care solution is the most efficacious product in eradicating microorganisms, including Acanthamoeba.
Hydrogen peroxide disinfecting systems work by penetrating the hydrogel material, expanding the lens matrix and oxidizing microbes. The hypotonic nature and 4.00 pH of hydrogen peroxide-based systems have the ability to break protein and lipid bonds and help to remove trapped debris. They can also penetrate microbial biofilms and are effective against a wide variety of organisms such as bacteria, fungi (including spores and yeasts), viruses and some protozoa.
Patient Selection and Education
Although peroxide-based care systems would be a viable option for all patients, it may not be the best recommendation for everyone. These systems are an ideal option for patients who have hypersensitivities or dry eyes. I find that for these reasons, about 20-to-30 percent of my patients require a hydrogen peroxide-based system and respond extremely well to the daily regimen. For these patients, we have received feedback that the change to a hydrogen peroxide-based system improves comfort and allows them to wear their lenses longer.
Regardless, you need to be responsive to each patient's lifestyle and needs. Younger patients who may not be as attentive to details may not be the best candidates for a hydrogen peroxide-based solution. Patients may feel a burning or irritating sensation if they do not properly neutralize the hydrogen peroxide. Unneutralized peroxides can be toxic to the epithelium, but the discomfort will resolve with temporary discontinuation of lens wear and adequate neutralization of the lenses before reapplication.
Therefore, it's crucial to explain the importance of full neutralization of the peroxide by following the manufacturers' recommendation with adequate soaking time and proper compliance. We must also emphasize to patients that they can achieve this only with the (basket-like) case enclosed with their specific system.
After complete neutralization, the remaining solution is unpreserved saline. Patients can apply their lenses directly from the case. Re-rinsing with H2O2 is always contraindicated, although a separate sterile saline rinse is acceptable and may be encouraged.
I recently examined a 22-year-old college student who was wearing aqua tinted disposable lenses. She returned home for college break and I saw her for her annual eye examination. I found that her vision was fine with her contact lenses, but she complained of redness, less comfort and inability to wear lenses for the full two weeks. She was using a multipurpose solution and appeared to be fairly compliant with her replacement schedule and care products. She preferred the tinted lenses and declined my recommendation to be refit into a silicone hydrogel material to see if that would improve her comfort.
She was home on break only for a brief time, and the immediate resolution I decided to move forward with was to switch her care product to a peroxide-based system and see if that would provide her with more comfortable lens wear.
Within one week, the patient returned and was much happier. Her eyes appeared less inflamed, her lenses appeared cleaner and she was able to keep her aqua tinted lenses. She was very satisfied and compliant with the additional care needed to reduce her problems and keep her eyes more comfortable.
As MPS options have been the primary solutions that patients have been utilizing, what then are our options for hydrogen peroxide-based systems? We currently have two preservative-free systems available: Oxysept UltraCare Formula (Advanced Medical Optics) and Clear Care (CIBA Vision).
These peroxide systems use different methods to neutralize the hydrogen peroxide into saline. The Oxysept product requires patients to add a separate neutralizing tablet to the system before the lenses can be reapplied. The Clear Care product uses a platinum disc for neutralization that is attached to the lens holder of the case, which must be replaced every three months. In both systems, the lenses must soak for a minimum of six hours for adequate disinfection and neutralization to occur.
In contrast, an MPS system uses a single solution for cleaning and disinfecting and also typically requires a minimum soak time of six hours.
I feel it's very important for my patients to understand the importance of compliance with prescribed care products. With current MPSs, proper usage provides adequate disinfection for many patients. Discussing the need for a rub-and-rinse regimen prior to storage will certainly maximize the benefits of lens wear and reduce the risk of infections with these solutions.
Although most patients may do well with multipurpose care products, some require a peroxide-based system to maximize comfort. This ultimately may affect their long-term success and impact their retention value for our practices. Being aware of care product options and personalizing our recommendation for each patient will always result in maximum benefit for our contact lens patients. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #153.
Dr. Secor is in private practice in Huntington Beach, CA. A Fellow of the American Academy of Optometry and Diplomate of the Cornea and Contact Lens Section, she is the current Immediate Past Chair of the Cornea and Contact Lens Section.