Lens Care Noncompliance
Clues to Contact Lens Care Noncompliance
Sometimes practitioners need to become detectives to uncover risky contact lens behaviors
By Susan Kovacich, OD, FAAO
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 and is currently an associate clinical professor in the Cornea and Contact Lens Clinic. She has worked as a researcher and consultant for Allergan, Bausch & Lomb, and Vistakon.
During my childhood, I spent many rainy afternoons playing the classic detective board game, "Clue," with my siblings or friends. You might remember the game — who, where, and with what were the clues gathered to find the culprit (e.g., Colonel Mustard, in the library, with a wrench). Who knew that a childhood pastime could be helpful in detecting patient noncompliance? (Example: Patient X, in the Amazon River Basin, with no disinfecting solution.)
On the flip side, instead of playing "Clue," some of our patients play a game similar to "Risk." This game of global domination is characterized by bold and sometimes unwise moves which can make or break the final outcome. Unfortunately, contact lens wear is not a game, and by making poor decisions, patients can risk their ocular health and impair their contact lens wearing success.
Types of Noncompliance
When I think of contact lens noncompliance, I generally think in terms of wearing schedule, replacement schedule, and lens care regimen. However, our wily patients can come up with an ever-expanding list of noncompliant actions that are unanticipated by practitioners. Noncompliant actions can result in unwanted complications that can affect ocular health, vision, and comfort.
Because patients are usually not forthcoming with acts of noncompliance, we must be alert for clues in the case history and ocular exam and know when to ask more questions. More importantly, good patient education from the beginning — emphasizing that contact lenses are medical devices — can promote good habits and compliance from the start.
Wearing, Replacement Schedule Noncompliance
Patient #1: In the Office, With Monthly Lenses (After 18 Months) This patient came in for his "yearly" routine eye exam and said that he was having no problems with his monthly lenses. He said that he was compliant with his contact lens replacement schedule and disinfection, but he was on his last pair of lenses. Because the record showed that his last contact lens exam was a year and a half earlier, the information in the chart and the patient's statement did not seem to add up. When asked how old his current contact lenses were, the patient said, "I am not sure, maybe five months."
Patients often wear their lenses longer than recommended. When patients complain of decreased vision, poor comfort or end-of-day dryness, one of the first questions I ask is how old the lenses are or how often they replace the lenses to see if patients wear the lenses longer than recommended.
Patients also will often sleep in their contact lenses and not admit it. The question, "Do you sleep in your lenses?" may put them on the defensive. It may be better to ask, "How often do you sleep in your lenses?" Although the difference is subtle, now patients assume that you already know that they are sleeping in their lenses, and it is okay to admit it. If patients are sleeping in the lenses, recommend contact lenses approved for overnight wear.
Improving Wearing Schedule and Replacement Schedule Compliance
When you dispense the contact lenses, educate patients on the proper wearing schedule. Advise patients that they should not sleep in lenses that are not approved for overnight wear. This gives patients the opportunity to ask to be fit in a higher-Dk lens if overnight wear is an option.
Also educate patients on the replacement schedule of their lenses when you give them their annual prescription. Give patients helpful tips on how to stay compliant. For two-week disposable lenses, advise patients to replace them on the first and fifteenth of the month. If patients get paid every two weeks, they can use that as a reminder. For lenses replaced on a monthly basis, tell patients to replace them on the first of the month, or link it with a monthly activity such as paying the mortgage.
While some contact lens patients are noncompliant on purpose, most patients would be more compliant with their replacement schedule if they had reminders or a way of remembering when to replace their lenses.
There is a place on our written contact lens prescription for the recommended wearing time, replacement schedule, and contact lens solution. Newer computer applications can provide automatic reminders to contact patients via e-mail, text message, or desktop widgets (such as Vistakon's Acuminder, a free service that patients can use for different brands of contact lenses and that also reminds patients when they are due for their annual contact lens examination.)
Wearing, Replacement Schedule Noncompliance
Patient #2: In the Bathroom, With Flat Packs and Saline This patient came into the office wearing daily disposable contact lenses and claimed to be compliant with disposing of the lenses on a daily wear basis. However, during the exam it was noted that she had bilateral corneal infiltrates. Studies have shown that the daily disposable contact lens regimen has one of the lower rates of both non-severe and severe keratitis among soft contact lens wearers, so why was this patient having corneal problems? Upon further questioning, the patient admitted to "stretching" her contact lenses. She would wear them for two days, keeping the open flat packs of saline that the contact lenses were packaged in for storage overnight on the bathroom counter.
This patient's noncompliance in her wearing schedule led to additional noncompliance in the disinfection and storage of her contact lenses. This case demonstrates the domino effect of noncompliance, with each inadvisable action or poor choice increasing the possibility of additional complications. This case also reveals the importance of asking further questions when the examination findings do not line up with the patient�s history or with the expected findings.
Contact lens solution noncompliance can take many forms. Patients are bombarded with many choices when they shop for contact lens solutions and will often buy whatever solution is cheapest. Patients will also try to save money by "topping off" contact lens solutions. Occasional contact lens wearers can get into trouble storing lenses in the same solution for too long.
Contact lens case noncompliance can result in some interesting stories. I have had patients keep their contact lenses in drinking glasses, film canisters and even plastic sandwich bags. Recently, I heard of a patient keeping his contact lenses in a pair of plastic spoons in disinfecting solution on the bathroom sink. Storing contact lenses in spoons was a new one to me. Of course, this begs the question, would it make a difference if they were silver spoons?
Improving Lens Care Regimen Compliance
At each visit, review the importance of proper lens care with the patient. Recommend a specific contact lens solution. Reinforce this by prescribing the solution and advising patients that not all solutions are created equal. Educate each patient about the significance of rubbing the lenses, not topping off solutions, and cleaning and replacing the contact lens case. If a patient understands that ocular health, good vision, and contact lens comfort are affected by correct lens care, then that patient may be more compliant in the long run.
Patient #3: In the Examination Chair, With Multiple Lenses When we saw this patient in the office, he stated that he was running low on contact lenses but he was not having any problems otherwise. His entering acuities with contact lenses were good, but during biomicroscopy, it looked as if the patient was wearing multiple lenses. Upon further questioning, the patient admitted that, yes, he was in fact wearing two of his wife's −2.00D hydrogel lenses in each eye. Because he wore −4.00D lenses, and was good at addition, he figured he could stack two −2.00D lenses and see well enough until he could order more of his own prescription. His wife was tired of him ransacking her supply of lenses and had prohibited him from taking any more of her lenses, leaving him no choice but to get an exam. He would not admit to how long he had been "creative" with his contact lens wear.
I found it odd that the patient would not come clean at the beginning and admit to wearing multiple lenses when it would become apparent during the examination. This case is a good example of the lengths that patients will take to remain in contact lenses, even if these measures can result in problems. The advent of higher-Dk silicone hydrogel lenses has reduced corneal hypoxic complications and made piggybacking lenses a feasible option under the supervision of a doctor, but it an unwise choice when made by patients.
In addition, eyecare practitioners may have to combat poor information from unanticipated sources. In recent years there have been restrictions (unless for medical need) on the size of liquid-containing bottles in carry-on luggage. I read a "helpful tip" in some now forgotten ladies magazine urging travelers to transfer contact lens solutions into smaller bottles. I can't imagine that these smaller containers were sterile.
There is no way to anticipate and prevent all of the inadvisable actions that patients may take with contact lens wear and care, even with the best instructive efforts. Continually educating patients that contact lenses are medical devices and reviewing proper lens wearing and replacement schedules is the best way to avoid noncompliance.
Contact lenses are ubiquitous, relatively inexpensive, and seen as a commodity by many patients, not as medical devices. This cavalier attitude can lead to contact lens noncompliance and unwanted complications. Proper education from the beginning can help prevent patients from falling into bad habits.
Because studies show that contact lens noncompliance is prevalent in patients who have worn contact lenses for several years, each patient encounter is an opportunity to review and reinforce proper wearing and replacement time and contact lens care. Be on guard for clues of risky behavior and noncompliance, especially when elements of the examination don't add up. CLS
For references, please visit http://www.clspectrum.com/references.asp and click on document #168.