LENS CARE AND COMPLIANCE
CONTACT LENS CARE AND COMPLIANCE: AN UPDATE
Practitioners, manufacturers, and organizations are all striving to help improve patient compliance.
ANDREW D. PUCKER, OD, PHD
Contact lens care and compliance has historically been one of the most challenging aspects of prescribing contact lenses because we must depend on our patients to follow a complex list of care instructions (Bui et al, 2010; Robertson and Cavanagh, 2011; Ramamoorthy and Nichols, 2014). Over the years, manufacturers have created innovative products such as daily disposable contact lenses to reduce the number of steps required to be a compliant lens wearer; nonetheless, compliance among the contact lens-wearing population is still inadequate (Sankaridurg et al, 2013). While most noncompliant patients remain unharmed, some unfortunate patients—even daily disposable contact lens wearers—contract vision-threatening conditions such as microbial keratitis (Sankaridurg et al, 2013; Morgan et al, 2013) (Figure 1). Because of this, contact lens care and compliance is still a highly relevant topic. The goal of this article is to address the many complexities associated with caring for contact lenses, and when possible, this article will discuss current trends within this arena.
Figure 1. An example image of contact lens-related microbial keratitis. Courtesy of Jared C. Cox, OD.
Over time, contact lens modalities have transitioned from conventional contact lenses that are rarely replaced, to daily wear contact lenses that are typically replaced within one month, to daily disposable contact lenses that are replaced daily. Market data from Contact Len Spectrum indicate that daily, two-week, and one-month replacement contact lenses comprise the majority of today’s market (Nichols, 2012, 2013, 2014, 2015, 2016) (Figure 2). These same data also suggest that one-month replacement contact lenses are holding a steady market share, while daily disposable contact lenses are increasing at the expense of two-week replacement contact lenses (Figure 2).
Figure 2. Market data collected by Contact Lens Spectrum over the past five years on prescribed contact lens replacement schedules.
The increased market share of daily disposable lenses (15% in 2011 versus 28% in 2016) is a great step toward better contact lens compliance because daily disposable contact lens wearers have fewer required care steps (lower risk of ocular infection) and are more likely to replace their contact lenses on schedule (Nichols, 2016; Dumbleton et al, 2010; Sankaridurg et al, 2013). Daily disposable wearers are also more likely to return for annual eye examinations on time compared to patients who use other replacement schedules—daily disposable wearers’ inter-examination interval is 14.7 months, whereas the inter-examination interval is 16.4 months for two-week replacement schedules and 15.9 months for monthly replacement contact lens wearers (Dumbleton et al, 2013). Nevertheless, 15% to 18% of daily disposable contact lens wearers fail to replace their contact lenses as recommended (Dumbleton et al, 2010).
While these benefits indicate that we should be suggesting daily disposable contact lenses to most of our patients, not all of our patients are good daily disposable lens candidates (e.g., patients who have advanced keratoconus), and other contact lens modalities will always have their place in the market (Bennett, 2015). This theory is supported by the recent growth in the specialty contact lens market (Bennett, 2015), and it reinforces the need to create healthier, simpler-to-use contact lenses, especially as daily disposable contact lenses still carry some risk for infection (e.g., 2 in 10,000 daily disposable contact lens wearers contract microbial keratitis [Sankaridurg et al, 2013]).
LENS CARE SYSTEMS
Tear film biomolecules, dirt, microbes, and numerous other environmental contaminants regularly foul your patients’ contact lenses during a wearing day (Butcko et al, 2007; Cho et al, 2009; Cheung et al, 2014; Pucker et al, 2010). Contact lens fouling is a normal finding, although it needs to be combated by replacing contact lenses daily or by daily cleaning with lens care systems (Lievens et al, 2016). Hydrogen peroxide and multipurpose (chemical) care solutions are currently the two primary systems for contact lens cleaning. Each category has maintained a consistent market share over the past five years, although Contact Lens Spectrum market data indicate that hydrogen peroxide solutions may be on a slightly upward trend (Nichols, 2012, 2013, 2014, 2015, 2016) (Figure 3).
Figure 3. Market data collected by Contact Lens Spectrum over the past five years on prescribed contact lens care systems.
Each solution category has advantages and disadvantages. Multipurpose care systems are typically employed by first rubbing the contact lenses; the lenses are then rinsed and soaked for a set period of time to finish removing/killing any unwanted materials (Cho et al, 2009). Some multipurpose care solutions are approved to omit the rubbing step, although evidence suggests that these solutions are more effective if the rub step is retained in the cleaning regimen (Cho et al, 2009; Tam et al, 2014).
Hydrogen peroxide care systems are employed in a manner similar to multipurpose systems, although a primary difference between the systems is that the hydrogen peroxide solution turns into water after it is neutralized by the system (Lievens et al, 2016). This quality is highly advantageous for patients who may have an allergic response to multipurpose solution preservatives (Lievens et al, 2016). A primary hazard of hydrogen peroxide care systems is that uninformed users may inadvertently introduce unneutralized hydrogen peroxide solution into their eyes, which could result in a serious chemical burn; therefore, patients should always be educated about this potentially painful complication (U.S. Food and Drug Administration [FDA], 2016A).
Similarly, the need for neutralization of the hydrogen peroxide solution is less advantageous for lens wearers who are learning how to use contact lenses for the first time and for people who frequently need to clean their contact lenses during the day (e.g., dirt removal). The potential need for midday lens cleaning may make it prudent to prescribe a multipurpose lens care solution that can be used on an as-needed basis in conjunction with the prescribed hydrogen peroxide solution.
Care systems are also complicated by the need for adequate contact lens case cleaning. Unfortunately, up to 80% of contact lens wearers fail to prevent contact lens case microbial contamination (Wu et al, 2010; Panthi et al, 2009), a problem that occurs about equally among multipurpose and hydrogen peroxide cases (Wu et al, 2010; Vijay et al, 2015). Case contamination can be reduced by instructing patients to properly wash their hands with soap and water before touching a case (Wu et al, 2015). Case contamination can also be prevented by avoiding the use of tap water to clean cases (Hickson-Curran et al, 2011). Rather, patients should clean their cases by rinsing them with care solution, wiping them out with a tissue, and air-drying them face down (Vijay et al, 2015). The likelihood of contracting a case-related complication could also be reduced by replacing cases at least every three months (Panthi et al, 2009; Stapleton et al, 2012). Recent research efforts to further reduce the probability of case-related complications include the incorporation of antimicrobial substances such as silver into products (Sankaridurg et al, 2013).
COMPLIANCE AMONG CONTACT LENS WEARERS
A compliant contact lens patient can be defined as one who correctly handles, cleans, and wears his contact lenses (Chun and Weissman, 1987). While this may seem simple, maintaining full compliance requires patients to regularly complete a long list of tasks that up to 90% of wearers fail to accurately complete on a regular basis (Bui et al, 2010; Robertson and Cavanagh, 2011; Ramamoorthy and Nichols, 2014).
Compliance rates are similar around the world, although there are some regional variations in rates (Morgan et al, 2011). Some of the more serious areas of noncompliance include failing to rub or rinse contact lenses, the use of cosmetic contact lenses without a prescription, unprescribed overnight wear, exposing contact lenses or cases to tap water, topping off solutions, and failing to wash hands properly (Robertson and Cavanagh, 2011; Ramamoorthy and Nichols, 2014; FDA, 2006). Hand washing can not only improve eye health, it can also help prevent disease transmission, which is why it may be worthwhile for healthcare professionals to remind their patients how to properly wash their hands (Trampuz and Widmer, 2004) (Figure 4). Detailed instructions on how to properly wash hands can be found at www.cdc.gov/features/handwashing. Noncompliance often occurs because patients are simply misinformed; the compliance of these patients can be corrected with patient education (Bui et al, 2010; Robertson and Cavanagh, 2011).
Figure 4. Hand washing with soap and water is a critical step in maintaining good contact lens hygiene and physical health.
A child’s ability to maintain adequate contact lens compliance has even greater relevance today than in recent years. While eyecare providers may have previously prescribed contact lenses for children as a means to improve their performance during sports or to improve their perceived aesthetic appearance (Walline et al, 2007; Walline et al, 2009), the recent promise of using center-distance multifocal and orthokeratology lenses as an off-label myopia control method has made contact lenses a potential medical treatment (Cho et al, 2005; Walline, Greiner et al, 2013). Thankfully, children between 8 and 12 years of age have a similar risk for contact lens-related complications as teens do (Walline, Lorenz et al, 2013). Early research also suggests that if contact lenses truly prove to be useful for myopia control, children should be able to use their contact lenses safely and adhere to treatment plans (Turnbull et al, 2016).
OBSTACLES ASSOCIATED WITH COMPLIANCE
Contact lens compliance can be affected by both patient factors, such as forgetfulness, trying to save money, perceived lack of harm, and lack of time, as well as by other factors, such as increased treatment frequency, treatment duration, and the practitioner-patient relationship (Collins and Carney, 1986; Davidson and Akingbehin, 1980; Newman-Casey et al, 2015; Dumbleton et al, 2010). Conversely, evidence also suggests that contact lens compliance is not associated with a patient’s intelligence, social status, or age (Ley, 1979; Davidson and Akingbehin, 1980).
Understanding these obstacles is the first step toward helping your patients overcome them; therefore, ask your patients questions about the demands that they face and the potential time or financial obstacles that they may regularly encounter. While eyecare providers should make an effort to educate their patients about all aspects of eye safety, some evidence indicates that patients are the least compliant with case cleaning, rubbing and rinsing, replacing contact lenses on schedule, and hand washing, which suggests that providers should focus on these areas first (Morgan et al, 2011). Overall, knowledge about individual patient obstacles can help you better select contact lenses and care products that will best suit your patients’ needs, and a better understanding of their obstacles can help you better tailor the education that you provide to your patients.
SOURCES OF COMPLIANCE INFORMATION
Patients obtain care and compliance information from a variety of sources, such as eyecare providers, product manufacturers, and local and national organizations that provide information about public health. Unfortunately, these sources do not always provide consistent information (Wu et al, 2010), although this may be because research quickly propels our profession forward. Therefore, it is your job as an eyecare professional to be fully up-to-date, to acknowledge to your patients that conflicting information exists among the various compliance resources, and to educate your patients about the best treatment plan for them.
Eyecare Providers The most important individuals associated with improving patient compliance are eyecare providers because they are typically patients’ first point of contact. In fact, patient compliance typically increases after a recent provider consult, which is likely because the information is fresh in patients’ minds and because they have yet to be lulled into complacency (Morgan et al, 2011; Ramamoorthy and Nichols, 2014).
The best way for providers to provide contact lens care and compliance instructions is to do so in a non-technical manner and to use pictures when possible (McMonnies, Oct. 2011). Patients will likely also benefit from a formal list of succinct instructions that are specific for their individual situation; these instructions should also be reviewed at subsequent visits (McMonnies, Oct. 2011A; McMonnies, Oct. 2011B). Unfortunately, some patients are intentionally noncompliant because they may not perceive a significant enough danger (Bui et al, 2010; McMonnies, Oct. 2011B).
While some patients may be resistant to all education attempts, others may be persuaded with peer-reviewed literature (McMonnies, Oct. 2011A). You may want to refer these and other patients to the Contact Lens Safety website that was created by the American Optometric Association in collaboration with the American Academy of Optometry (http://www.contactlenssafety.org). This resource is a referenced, in-depth, question-and-answer-based website that includes information pertaining to everything from wear schedules to contact lens purchasing to when a patient should call an eyecare professional for help.
Manufacturers Manufacturers typically provide directions on how to use their products, and practitioners and patients should generally follow these directions to achieve optimal outcomes (FDA, 2016A).
U.S. Food and Drug Administration Over the last few years, the FDA has issued a number of statements in an effort to improve contact lens care and compliance. Specifically, the FDA has released Consumer Updates on contact lens safety for children, on how patients can avoid hydrogen peroxide solution complications, and tips for how all patients can improve their contact lens habits (FDA, 2015; FDA, 2016A; FDA, 2016B).
The FDA has also changed its stance regarding cosmetic contact lenses; the FDA once considered plano decorative contact lenses to be cosmetic, while it now requires all contact lenses, even decorative ones, to necessitate FDA clearance and to be prescribed by a licensed eyecare provider. This change was made because decorative contact lenses carry the same risks as other types of contact lenses (FDA, 2006).
Centers for Disease Control and Prevention (CDC) The CDC has made recent efforts to make the public better aware of the importance of good contact lens care and compliance by implementing its annual Contact Lens Health Week (CDC, 2016A). The current and previous two campaigns have focused on “healthy contact lens hygiene habits,” “proper use, care, and storage of contact lenses and supplies,” and “regular visits to an eyecare provider” (CDC, 2016A). The CDC has implemented its initiative via a number of media (e.g., posters, newsletters, social media, etc.), many of which can be obtained for free from the CDC by mail or from its website (www.cdc.gov/contactlenses/contact-lens-health-week.html).
Contact lens product innovations will likely lead to better patient outcomes, but the need to educate patients about proper lens care and compliance will always have a prominent place in eye care. While the growth of daily disposable lenses will likely make the need for lens care systems less relevant, technological innovations will never remove the human factor associated with contact lenses (Nichols, 2012; Nichols, 2016; Ramamoorthy and Nichols, 2014). Patients will likely continue risky behaviors such as sleeping in their contact lenses, and they will still likely suffer from negative consequences such as microbial keratitis (Sankaridurg et al, 2013).
Therefore, it is important for eyecare providers, manufacturers, and public health-oriented organizations to communicate a clear and consistent message to contact lens wearers because this will provide patients the best opportunity to maintain healthy and comfortable eyes for a lifetime. CLS
For references, please visit www.clspectrum.com/references and click on document #252.
Dr. Pucker is currently an assistant professor at the University of Alabama at Birmingham. He has also received research funding from Johnson & Johnson Vision Care and Alcon. You can reach him at firstname.lastname@example.org.