LENS CARE DISCUSSION
Contact Lens Care and Aftercare
Emphasizing the importance of follow-up visits can increase the chances of patients returning for care.
By Sarah L. Morgan, BSc(Hons), MPhil, MCOptom, FAAO, FBCLA
Many people are involved in facilitating successful contact lens wear. Various office staff members need to ensure that patients receive the most appropriate lens type together with correct advice and instructions to put them on the road to success. With all the interlocking cogs within the eyecare practice, and the inherent communication interactions this entails, let's approach this subject by considering the elements involved and how we and our staff can best influence a patient on the road to ongoing success with contact lenses.
Contact Lens Care
While in some European countries single-use daily disposable lenses account for around 40 percent of new fits (Morgan, 2010), most fits in the United States are reusable frequent replacement lenses, which means prescribing a care product. When viewed from a patient's perspective, lens care products typically have no smell (no lemon zest or bleach-type disinfectant odor) or color, which could be why patients think they're similar to water. From this standpoint, our patients may take some convincing that their small transparent circles of plastic, which look fairly clean on removal from their eye, require this rigorous cleaning and disinfection process overnight before they can be safely re-worn.
As most patients we evaluate are not professors of immunology or microbiology, it's vital that we give them familiar everyday scenarios as analogies to aid their understanding of why it's so important to follow certain procedures when they plan to re-use their lenses. Acknowledging and playing psychic to their likely thought patterns is also helpful. Try making an analogy.
"You'll probably remove your lens and see how clean it looks and wonder why it needs to be cleaned after every wear. For a moment, just imagine your contact lens as a breakfast plate that's had the most delicious breakfast: two eggs over-easy, bacon, hash browns, and lots of ketchup. You'd never just re-use that plate the next day without first using dish soap and giving the plate a good scrub and rinsing it thoroughly. Your contact lens is a miniature version of just that. In your tears, you naturally produce a wonderful ‘windshield' fluid that has moisturizing oils to keep your eyes comfortable and that washes over your eyes and your contact lenses with every blink. This same oil can build up on the surface of your lens just like oil on silk. You'll appreciate that this needs some specialist cleaning products to gently remove this daily buildup so your lenses are both comfortable and clear to wear the next day. This is why we ask you to rub and rinse your lenses after every wear and then store them in the disinfecting solution overnight, ready for wear the next day. You also need to know that the chemistry of contact lens solutions varies, so I'm recommending this one as I feel it's best suited to both your eyes and the specialized material that your contact lenses are made from."
Emphasizing Lens Case/Solution Hygiene
Most people are aware that we share our world with bacteria and other bugs, and we can utilize this knowledge when communicating the need for patients to keep tops on bottles and lenses in closed cases. Not only do we need to prevent unwanted microbes from tumbling into the bottle via its open top, we also don't want to affect the concentration levels within the solution via evaporation.
We can compare keeping the tops on the solution bottle to keeping something fresh and protected from the environment. Patients may be unaware of the aerosol effect when a toilet is flushed (Barker, 2005). My neighbor manages a large dental practice, and she once told me that your toothbrush should never be closer than 6 feet from a toilet. This is a good fact to introduce to a patient, as no one in their right mind would like to taste the spray of their toilet flushings! Somehow, this very vivid and unpleasant statement can help to sell the concept of not keeping the storage case in the bathroom. Many patients do, and this may be an important factor in microbial contamination. To help persuade patients around to this new way of thinking, talk toothbrushes before talking about contact lens cases! Once a patient understands the importance of case hygiene, if only from the viewpoint of where they keep it, detailing the daily rinsing and air drying with the tops off and face down on a tissue should be smooth sailing.
Once human beings have been educated with a reason why they should do something, this enhanced understanding and direct benefit to them for their efforts gives them a reason to do what they're asked. Most lens wearers are interested in only two things: "Does it hurt?" and "Can I see?" Eyecare practitioners have infection control/preventing microbial keratitis (MK) at the top of the agenda. Patients, however, take lens wear safety somewhat for granted, and they need to be fully cognizant of factors that help keep lens wear safe.
Prescribe a Rewetting Drop
It's my opinion that all wearers, and especially new wearers, should be provided with rewetting drops and, perhaps more importantly, should be shown proper instillation during application and removal training. Patients unfamiliar with eye drops may harbor a negative association with them and have the misconception that they sting, so having patients practice using them as part of their contact lens instruction is very helpful in allaying this potential concern. Additionally, when patients are left to their own devices with eye drops they frequently resort to the "head back, look up to the sky, and fire" technique in the vain hope that a drop might land randomly in their eye. The approach I recommend to my patients involves looking into the mirror and moving the head to their right or left so that the cornea is in an extreme nasal position. Then, patients can instill the eye drop in the temporal conjunctival sac with the lower lid gently pulled down (Figure 1).
Figure 1. Demonstration of the proper technique for instilling a rewetting drop.
Without correct and thorough instruction, creating both the awareness of rewetting drops and how best to instill them, patients are left to their own ideas—which commonly include saliva or tap water. Single-use rewetting drops are my preference, as they are readily carried in a pocket or purse.
Why You Must Discuss Sleeping in Lenses
Sooner or later, contact lens wearers will inadvertently sleep in their lenses. The scenario that follows can be one of sheer amazement as they stare in wonder at their almost clear and perfect world, as if a higher being has made their eyesight perfect once more—along with the realization and panic if they have not been through the "I'm your psychic optometrist, and I predict" discussion. By this I mean proactively talking to all patients about accidental noncompliant behavior, so that if and when it happens, they have the knowledge to handle the situation well.
Talking to patients about sleeping in lenses does not encourage them to do so, and it certainly provides the opportunity to discuss specialty lenses that are approved for overnight wear. In many ways, discussing continuous wear brings the whole subject out in the open, allowing you to evaluate whether a patient has a burning desire to use lenses in this way. When daily wear is the selected route, it is helpful to discuss what to do should they wake up with their lenses still in situ. Without advice, patients often rush to remove their lenses which, in some cases, leads to a corneal abrasion. It is important to explain that with overnight wear, soft contact lenses lose moisture and may have very little movement on eye opening. For this reason, instilling rewetting drops helps restore lens moisture and aids lens removal. Patients should attempt to remove lenses only after the lens is mobile once more, which may be after about 30 minutes.
Educating Patients About Adverse Events
Discussing the downside to contact lens wear with regard to risk can feel uncomfortable. But signs warning the public about imminent danger are increasingly common, for example when a floor has been recently mopped in a restaurant. All patients should be made aware of the key clinical signs and symptoms of an adverse reaction to contact lens wear and, in particular, those of MK so that they take the most appropriate action in the event of an emergency. Most of us would assume that we'd never need to use the life vest on an airplane, and this does not prevent the majority from flying; yet we have been made aware of what to do.
A card, similar in size to a credit card, with the key instructions on dealing with a red eye can be given to patients to ensure that they take the most appropriate action and seek attention when needed (Figures 2 and 3). This should result in minimizing the impact of such an unwanted and chance event.
Figure 2. The front side of an emergency card detailing signs of infection.
Figure 3. The back of the emergency card that lists the practice's detailed contact information.
What "Monthly" Replacement Means
Research has shown that the more frequently a lens is replaced, the more likely the patient is to be compliant with that recommendation (Hickson-Curran, 2009). In the United Kingdom, where monthly replacement is popular, compliance with lens disposal at the recommended interval is enhanced by the payment systems in place. Most frequent replacement systems in the United Kingdom are paid for by monthly automated electronic bank transfer. This means that both lenses and solutions are either collected in the office or mailed directly to the patient once every six months. There is little incentive on the patient's part to "make lenses last longer," as they have new supplies being delivered that they have already paid for over the preceding months.
Perhaps the trickiest question to answer is that of the intelligent part-time wearers who have been fitted with a monthly lens. Understandably, patients might ask if they can make use of the lens for the maximum number of times possible, i.e. 31 times.
Assuming that a daily disposable lens is not available in the required parameters for a given patient (e.g. unusual prescription, material of choice), as daily disposable lenses usually work out to be the more economic option for wearers who use their lenses less than four times per week (Efron, 2010), then educating the patient about the impact on overall lens wear satisfaction when wearing a single lens as few times as possible serves to optimize their lens wearing experience.
Clearly, the office must supply an appropriate volume of lens care products, and savings can be made if cost is paramount. Often cost is not the chief concern, and lens comfort and performance are key. Having multiple pairs of lenses, for any contact lens wearer, as opposed to going back to the dark ages of owning only one pair, has to be the most convenient way to wear modern reusable contact lenses. Even GP wearers can own two pairs of lenses and alternate them on a daily basis to avoid ever being without a lens. The reassurance of being able to discard a lens in case of damage or discomfort and to open a new lens packet is certain to maintain success and optimize patient satisfaction.
Different practitioners offer varying strategies to help patients remember when to replace their lenses. Daily and weekly is probably the easiest to remember. Two-weekly and monthly lenses may require a little more thought. A new countdown case has been developed that shows contact lens wearers how many days are left for a particular pair of lenses. This type of case is promoted to be especially helpful to pediatric patients.
When one lens of a pair has been lost or damaged, advise patients to replace the lenses as a pair and not to be too frugal, as incidental additional lenses are often offered to patients as part of the service.
Aftercare: Is It Really Necessary?
Front-line staff can sometimes find it difficult to persuade successful and happy contact lens patients to report for aftercare appointments because the patients see no benefit in spending the time attending. From the patients' perspective, they can see and their lenses are comfortable—period.
Educate patients at the outset about the requirement to return for periodic aftercare visits to maintain successful lens wear. A key driver for eyecare practitioners is to demonstrate that they are caring for patients by the very act of seeing them for an appointment.
A key driver for patient non-attendance is the concern that the practitioner will say contact lens wear is no longer permissible. In wearers for whom contact lenses have given them an entirely new persona, it is unsurprising that the threat of "no more contact lenses" is sufficient to keep them away.
One of the books I was fortunate to read very early in my career as an optometrist was Harvey M. Rosenwasser, OD, FAAO's Malpractice and Contact Lenses: A Guide to Limiting Liability in Contact Lens Practice. At the time, I worked in a busy office where contact lenses played a significant role in the clinic. We employed several assistants, and I noted some variety in the knowledge of patients returning for aftercare depending on which assistant had instructed them initially. The book was my savior, and I immediately initiated a checklist approach to the new patient instruction appointment coupled with the informed consent element, which the patient signed. There was a paragraph that explained that future contact lens supplies were contingent on the patient attending for periodic examinations.
Since their introduction, I've never faced a new patient complaining about having to attend for aftercare; it was the existing patients that gave me the trouble! Subsequently, I initiated a "cleanup" process, whereby patients who had not been through this rigorous education (even as a competent existing wearer of several years) were booked for an information appointment alongside their next aftercare visit to ensure that they received consistent advice and up-to-date instructions on lens wear and care.
I have never looked back from following this procedure. Additionally, this has been very important when fitting existing wearers who were new to the practice, as well as when refitting patients with a new lens type that might require subtly different handling and care instructions. Every patient received thorough instruction to avoid the "nobody ever told me" scenarios. In addition, we had a signature to prove it! (The need never arose.)
Re-Examining Our Communication
"Put your chin on here…look up…and look down…and now I'm going to turn your lid inside out…" Or perhaps, "…and now I'm going to stain you/put some dye in your eye."
We need to carefully listen to ourselves, and as familiar as we are with our procedures, it is imperative that we find patient-friendly terminology to explain what we are doing. With a good technique, a patient will barely notice that his lid has been everted. "Coloring" people's tears is much kinder to the ear compared to staining or dying. Not only does that sound permanent, but it certainly sounds like stinging bleaching agents could be involved!
Lid eversion can provide patients with insight on why they should be compliant with the recommended replacement schedule. I once had the good fortune to observe Wayne Wood, OD, in his office in Jacksonville , Fla., back in 1993. He had an experienced contact lens wearer in his chair who asked whether regular lens replacement was really necessary. She was used to the old hydrogel lenses and found lens disposal to go against the grain after years of preserving lenses for as long as possible. Dr. Wood offered to show her the photograph of contact lens-associated papillary conjunctivitis. "Oh no, not the shrimp picture again," she said. "Dr. Wayne, I'll keep replacing my lenses!" Dr. Wood used his picture to paint a thousand words, and while a clinical picture, it was suitably gross to reinforce the message that a smooth lid is preferable and can be more easily achieved with regular lens replacement.
Other Questions We Can Ask
As contact lens technology advances, ongoing aftercare becomes even more important; otherwise, how will our patients find out about the newer and better lenses? With all of my patients, I thank them for coming to see me and I explain that while they are currently wearing the best lenses on the market for them, we never know when something new and even more fantastic is on the horizon.
Clearly, aftercare visits have been shown to impact compliance as an opportunity to reinforce good behaviors and to correct misconceptions or poor compliance. Only recently have we introduced questions detailing contact lens comfort: "What's the comfort like with your contact lenses? You say you wear your lenses for 14 hours, and for how many of those 14 hours are your lenses really comfortable?" Advances in toric contact lenses have also highlighted the need to question astigmatic patients about the stability of their vision in everyday situations.
Modern contact lenses can dramatically enhance people's lives, but only when all the cogs fit together: the optimum lens program, education on how to achieve optimal lens wear, and substantive aftercare. It's all part of the service. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #180.
|Dr. Morgan is an optometrist and staff development consultant and is author of "The Complete Optometric Assistant." At the University of Manchester, UK, she teaches across all three years of the optometry program and holds the post of Visiting Scientist.|