Breaking the Cycle of Contact Lens Dropout
To effectively prevent contact lens dropout, you need to manage the source of the problem.
By Chuck Aldridge, OD, MBA, FAAO
A few years ago, I read several studies discussing contact lens patients who dropped out of contact lens wear. What really got my attention was that all of the studies came to the conclusion that approximately 20% of our contact lens patients drop out each year (Weed et al, 1993; Pritchard et al, 1999; Young et al, 2002; Richdale et al, 2010; and others. Full list available at www.clspectrum.com/references.).
I thought this meant that my colleagues were doing a really bad job of maintaining their patients in contact lenses—because I knew that this couldn’t apply to me! But later, I saw another study that made me rethink this; it noted that most practices fit about 20% new contact lens patients each year (Morgan et al, 2015).
Could this mean that we aren’t noticing these dropouts because we have about the same number of new contact lens patients coming in as the number dropping out? When I starting digging a little deeper into my own practice statistics, I noted that the total number of contact lens patients really didn’t change much each year. With a more thorough analysis, I found that the patient names weren’t actually the same year after year. I had to face the facts; I was not immune to this contact lens dropout problem.
The next obvious question became, “What causes a contact lens patient to drop out after successfully wearing contact lenses for years?” The Tear Film and Ocular Surface Society (TFOS) hypothesized that contact lens discomfort is the key. TFOS notes that “such discomfort may be the leading cause of patient dissatisfaction with, and discontinuation of, contact lens wear throughout the world.” (www.tearfilm.org/tfos_cld_report.php).
To better understand why this contact lens discomfort is the leading cause of lens wear discontinuation, TFOS embarked on a very thorough study of this topic that culminated in the publication of The TFOS International Workshop on Contact Lens Discomfort. After reviewing the Executive Summary of this work (Nichols et al, 2013), I felt better able to analyze my practice and see how this impacted me. My goal was to continue my new contact lens fits at the current rate, while also significantly reducing my dropouts. Accomplishing this would not only be a win for my unhappy contact lens patients who are on the brink of dropping out, it would also create a real boost to my practice’s revenue and growth. Additionally, providing a solution that would allow these patients to continue wearing contact lenses would solidify their loyalty to my practice and prevent them from seeking care elsewhere.
I live in a very rural area where “everybody knows everybody.” This made it easy for me to review my records and find many of my contact lens dropouts. My first observation was that the majority of my dropouts were female patients in their late 30s or early 40s. I also noted that these patients had worn contact lenses successfully for a number of years before they dropped out.
I then began to talk with them when they came in for an eye exam or when I saw them in our community, asking them what led to their discontinuation of contact lens wear. Nearly all complained of “contact lens discomfort.” This discomfort got worse as the day progressed and led to fluctuating and/or blurry vision. When asked whether they used rewetting drops, nearly all confessed to multiple uses of such drops, but they quickly noted that these drops provided only temporary relief. A number even remarked that they found this unusual because in their earlier days of contact lens wear, they could go all day without even needing rewetting drops.
It struck me that what I was hearing from this demographic about their symptoms sounded a lot like patients suffering from dry eye disease. We know from the Women’s Health Study and the Physicians’ Health Study that dry eye is more prevalent in females than in males (3.23 million women versus 1.68 million men) (Schaumberg et al, 2003; Christen et al, 1998). We have also learned that some of the most common dry eye symptoms are blurry vision, fluctuations in vision, and degradations of contrast sensitivity (Begley et al, 2003; Bjerrum, 1996; Goto et al, 2002). But the most interesting information came from a university-based study in which dryness was the most common symptom causing contact lens dissatisfaction in 109 of 453 (24%) patients who discontinued contact lens wear permanently and in 119 current contact lens wearers who expressed contact lens dissatisfaction (Richdale et al, 2007).
Traditionally, we have considered dryness symptoms with lens wear as a classic chicken-or-egg dilemma: Is the contact lens the cause of the dryness, or is dryness creating the contact lens discomfort? I have been in practice for over three decades and have fit many high school patients and monitored them into adulthood. These young contact lens patients initially have no issues with lens discomfort related to dryness or to any other cause. But over time, a decrease in comfort unfortunately often leads to discontinuation of contact lens wear. These patients are mostly female. In many cases, after they graduate, they start jobs that require long hours in front of computer monitors. It is at this point that they usually come back to our practice and complain of contact lens discomfort, a discomfort that is consistent with the dryness complaints found in the university-based study.
So based on this anecdotal data, the answer to our chicken-or-egg dilemma is simple—these patients have developed dry eye disease. Yes, it could be argued that contact lens wear may have contributed to their dry eye; but, based upon epidemiology, I doubt it. Regardless, these patients are now dry eye patients attempting to wear contact lenses. They are trying to keep not only their ocular surfaces hydrated, but their contact lenses hydrated as well. If their dry eye is not addressed, these patients will add to the dropout statistics.
The Historical Management Approach
How have practitioners historically tried to solve this problem? I’ve had the privilege to be able to travel around the United States over the last decade or so and provide continuing education courses to my colleagues on dry eye and contact lenses. It seems that regardless of our background or training, our response to these patients suffering from contact lens discomfort related to ocular dryness has been to change the contact lens material.
I’m sure you’re familiar with the scenario. When patients complain of lens discomfort, even in contact lenses that they have worn successfully for years, we attempt to refit them in a more hydrophilic material. We may eventually find them a lens that provides a little better comfort and decide to dispense it. At this point, patients typically complain about paying “another contact lens fitting fee” and then ask about exchanging their remaining previous brand of lenses.
This process, which I have performed numerous times, is akin to Einstein’s saying that, “Insanity is doing the same thing over and over again and expecting different results.” We seem to forget, when employing this approach, that dry is chronic and progressive (International Dry Eye WorkShop Report, 2007). This means that even if we do find an alternative contact lens that provides enough relief from the dry eye symptoms, this success will be short-lived; it’s only a matter of time before such patients return again with the same symptoms, and we repeat the process again and again until we have no options left to offer.
How to Break the Cycle
Armed with this information and having witnessed many of my own personal failures in refitting these potential contact lens dropouts, I decided to change my management protocol.
Now when I encounter contact lens patients who are potential dropouts—or who have already discontinued lens wear—due to dryness, I explain that dry eye disease is the likely cause of their problem. I then explain that some testing is required to confirm this diagnosis and that if the problem is dry eye disease, it can usually be managed to allow for continued successful contact lens wear. I also inform patients that if the problem is dry eye, switching to another lens brand would only be a temporary solution because untreated dry eye worsens over time.
Patients who have successfully worn contact lenses for years are typically very motivated at this point to initiate treatment for dry eye. They do not wish to discontinue contact lens wear or to go through the hassle of trying other contact lens brands. If they agree to continue, we advise them that dry eye is a disease and that the visits to diagnose and treat dry eye are medical in nature and will be billed to their medical insurance.
I then set up a dry eye evaluation. Patients complete our modified version of the Ocular Surface Disease Index (OSDI) questionnaire, which helps me better understand the subjective severity of their dry eye. We then test tear osmolarity, evaluate the meibomian glands for evaporative dry eye issues, check tear breakup time to determine the integrity and stability of the tear film, and inspect the tear meniscus, ocular surface, and lash margins to ascertain the overall quality and quantity of the tear film. Because sodium fluorescein is already on the ocular surface at this point, I also look for any active staining of the conjunctiva or cornea. If staining patterns are suspicious, we may use lissamine green stain for further evaluation.
If dry eye is diagnosed, I recommend frequent lubrication with rewetting drops, and I prescribe 0.05% cyclosporine ophthalmic emulsion to be used twice daily. I inform patients that they may not see much improvement with cyclosporine use for at least one month; maximum effectiveness is usually achieved after three to six months.
For patients who have already discontinued contact lens wear, I advise them to stay out of contact lens wear while using the cyclosporine for at least two months before attempting to restart wear. Once they are ready to restart lens wear and for patients already wearing lenses, I instruct them to instill their morning dose of this medication and wait at least 15 minutes before applying their lenses. Likewise, they should not instill the medication again until the end of the day after contact lens removal. This obviously means that overnight wear is not an option when using this medication. For patients attempting to resume contact lens wear, I follow up with them in about six weeks.
I also make other recommendations at this time, including prescribing omega-3 supplementation, warm compresses, and lid hygiene. I also review lifestyle adjustments, such as reducing prolonged near work, smoking cessation if applicable, staying hydrated, and avoiding low-humidity environments.
The good news is that these patients want to stay in, or return to, successful contact lens wear and are highly motivated to comply. Best of all, in my experience, the vast majority of these patients are much more comfortable in their current contact lenses within 90 days.
Look Beyond the Contact Lens
Please do not think that I am ignoring, or abandoning, the idea of refitting patients into more hydrophilic contact lenses. I certainly feel that this option has a place. But my philosophy is that if dry eye is the etiology of the contact lens discomfort, then affected patients will be better served by treating this condition first. Successfully treating the underlying dry eye disease often allows patients to continue successfully wearing the contact lenses with which they were already satisfied.
Let me conclude by making this observation: If we do not diagnose and manage patients’ dry eye first when they experience contact lens discomfort, then we are doomed to practice “insanity.” CLS
For references, please visit www.clspectrum.com/references and click on document #240.
Dr. Aldridge is a graduate of Southern College of Optometry and practices in Burnsville, NC. He lectures frequently and has written numerous articles on ocular disease, contact lenses, and practice management. He is a consultant or advisor to TearLab Corporation and has received lecture or authorship honoraria from Alcon and Allergan.