What lens replacement modality is healthiest for patients? I have asked this question all over the world, and regardless of where I am, I get exactly the response that you would think. Yet, why do daily disposable lenses account for only 31% to 39% of fits in the United States (Nichols, 2017) and only 38% of fits on average internationally (Morgan et al, 2017)? Over a tenacious four years of focused work, my office is happy to report that we have moved the needle and now fit 93% of our contact lens patients with daily disposables. Let me share with you why we moved in this direction and the mindset that we created to get us there.
Daily disposable lenses have come a long way over the past 10 years. Like many of you, we consider daily disposable lenses a great choice for our patients; however, years ago there were so few options, and the patients who “needed” them were few and far between. Within the last 10 years, our entire industry has gone through a unique stage of growth (as it does every 10 years); commoditization of contact lenses has hit a new high, internet sales of contact lenses have grown, and the available contact lens options have shifted substantially. Millions of patients want to see well without surgery or eyeglasses. Despite our challenges in the contact lens world, we believe that daily disposables are the best choice for patients, practices, and the industry.
CHALLENGES WITH FREQUENT REPLACEMENT LENSES
A few years ago, my Pacific University friends and mentors Pat Caroline and Mark André started challenging the eyecare community to bring forth cases of patients who have worn frequent replacement (monthly or two-week) lenses while using a chemical disinfectant multipurpose solution for a period of 20 years (they have since switched this duration to 15 years). Their belief, and now ours, is that these patients are nearly extinct. Such patients have mostly either switched to a hydrogen peroxide solution or to a daily disposable lens, or they have discontinued wearing contact lenses. As we have looked through our patient base and kept a watchful eye in our practice, we have seen that, indeed, these patients do not seem to exist.
If after 20 years of lens wear, patients are no longer able to wear contact lenses like they could before, it begs the question: Why? I believe that three concomitant theories exist: 1) chemical contact lens care solutions challenge the eyes; 2) contact lenses themselves are unhealthy; and/or 3) the tear film loses its ability to withstand contact lens wear.
Theory 1: Contact lens care solutions challenge the eyes. Despite millions of dollars invested into research, clinical trials, and U.S. Food and Drug Administration (FDA) approval, could it be that soaking a contact lens in a chemical compound and then placing it on the ocular surface, where the chemical slowly leaches into the tear film, may not preserve the tear film or the delicate ocular surface as well as we once thought? Is it possible that doing this daily over the course of many years may cause a physiological change in the composition of our tears and ocular surface, especially when the eye is exposed to challenging environments such as forced air heating/air conditioning or consistent computer use?
Contact lens solutions are some of the most biologically complex solutions that we have. Needing to be a cleaning, disinfection, and wetting agent, these solutions are very complicated. In addition, lens care solutions need to have a biocompatible preservative, and the entire compound needs to work synergistically with every variety of lens brand and type.
The tear film is a complex structure itself, and as we have all observed in clinic, it is highly variable. In my practice, we’ve seen that it can be altered by the slightest of humidity changes or by environmental factors. Adding any chemical to the tear film equation nearly always disrupts it in some way. Unless, of course, it is a chemical intended to enhance the natural tear film, which is the direction that some care solutions may be heading in the future—at least we hope. Even so, my feeling is that such care solutions may still contain chemicals that are not 100% compatible with the tear film, or at the very least are not capable of enhancing it.
Theory 2: Contact lenses themselves are unhealthy. We all would hate to think that contact lenses are unhealthy. After all, as healthcare providers, we prescribe them to our patients. But the fact remains: contact lenses reduce the lipid layer thickness, increase evaporation, and reduce the stability of the tear film (Faber et al, 1991). Could it be that over years of wear, contact lenses irritate the eyes to the point that they are no longer capable of being comfortable?
Theory 3: The tear film loses its ability to withstand lens wear. Have you ever had patients complain of contact lens discomfort that you are able to resolve by refitting them into new lenses or switching to a different care regimen, but then one or two years later they return with issues of discomfort again? If we solved their problems with a contact lens or new care solution, why is it that their discomfort issue has returned?
Could it be that their initial discomfort issue was not the fault of either the contact lenses or the care system, but rather was due to their ocular surfaces’ inability to hold up to contact lens or care solution use? Patients in our practices who do not wear contact lenses experience increasing dry eye over time. Why would it be any different for lens-wearing patients?
OUR APPROACH TO CHANGE THIS
It seems to me that these three issues are interrelated: the ocular surface becomes more compromised with time, and contact lenses and care solutions make matters worse. Over time, we want to give our patients as many victories as we can. To do so, it is helpful to eliminate as many variables as we can as early as we can to maximize their long-term success. We know that some patients need to wear contact lenses, and some patients are going to wear them regardless of what we say. As such, we want to ensure that they are wearing the best lens option available to them. To do so, my practice takes an aggressive approach:
- Switch all of our patients to daily disposable lenses unless inadequate vision reduces their ability to do so.
- Eliminate all chemically based solutions unless alternatives are not available.
- Treat all contact lens-wearing patients as having dry eye whether they have symptoms or not.
This is all well and good, and I am sure that if you are reading this, you probably already agree that most patients should be in daily disposable lenses. But how do we move more patients to daily disposable lenses?
Depending on where you are in the world, your daily disposable lens options may differ from what we have in the United States. However, I have been blessed to travel to many of the countries in which this publication is read, and I know that there is a wealth of daily disposable options globally as well.
Having so many great options is useless if we are not able to convert patients into the modality. To refit our patients into daily disposables, the team in my offices likes to use to our advantage the opinions of our patients (commoditization), the concerns over price, statistics from our market, and the fact that we are healthcare professionals.
COMMODITIZATION OF CONTACT LENSES
I believe that most patients see contact lenses as a commodity. Contact lenses all seem the same to them. The reason why this is so is our own fault. Whether you are an industry representative, a practitioner, or a lens fitter, we are the reason why patients feel this way. We have commercialized contact lenses as a luxury item. Telling patients to “ask your eyecare professional for a free trial” of a lens, or sending patients home with multiple trial lenses to “see which one works best,” only leads our patients to think that contact lenses are a choice rather than a medical device that requires a prescription.
Features and benefits are two factors that marketers use to promote their products. As an industry, whether through a commercial on television or a feature article in a publication, we provide the perception that contact lenses are a viable option for everyone. Like selling a new car or a fancy blender, we give patients the impression that contact lenses will solve their problems; we just need to refit them into the one that they saw on television. The issue with this is that patients’ “problems” may be medical conditions (such as dry eye disease) that require medical attention.
When patients come in with a specific coupon for a free lens trial or a comment such as “my co-worker wears these lenses and loves them,” our office addresses this issue immediately. We are medical providers. We provide medical devices to preserve long-term health first, make patients comfortable second, improve visual welfare third, and save patients money last. The order of this does not always align with patients’ preferences, but we swore the Hippocratic Oath in our first week of professional training. At our office, we would rather lose a patient than violate our oath to “first, do no harm.” We would rather look back at our career and realize that we stood by our principles rather than compromising by giving in to what patients wanted—which, in the long term, may have served to aid in the development of discomfort and possible disease (dry eye).
Therefore, we educate our patients about the choices we make for their eyes. We share our priority order for their long-term lens wear success and prescribe the lens that we feel will be most optimum for them (regardless of their coupon). Next, we explain that not all lenses are the same and that if they have any issues with their comfort or health, we would be happy to change our prescription after they have worn the lenses in their habitual environment. In reality, our first-choice lenses work around 85% of the time, but there are times in which either the material or the surface of the lens is not optimum for particular patients and their environment. If that is the case, we modify our prescription for those patients (and learn something about their delicate ocular surface). We do not contribute to the commoditization of contact lenses; we medicalize them.
As a clinician, I do not like having price discussions anymore than you do. In a perfect world, our medication prescriptions, contact lens options, and recommendations would be followed without concern for finances or compliance.
But, alas, we live in the golden age of the internet in which price transparency abides. The most common reason that I have heard from practitioners for why their patients cannot be moved into daily disposable lenses is because of the price. A box of daily disposable lenses is more expensive compared to an equivalent supply of frequent replacements lenses. In addition to this, we know that our monthly and two-week replacement lens-wearing patients will wear their lenses longer than prescribed. We find that daily disposable lens wearers, although not perfect, tend to have the best compliance. This also adds to the price of daily disposable lens wear compared to frequent replacement lens wear.
Of course, the missing link in all of our discussions is care solutions. We know that many problems in contact lens history have arisen from a lack of patient compliance. In our office, we have read the care solution bottles; we see that they often recommend a five-second, steady-stream rinse on each side of the lens, followed by completely filling the case with solution. We have done this ourselves and discovered that you can use a significant amount of care solution, nearly an ounce a day, when you follow these instructions properly. Performing the math on a 10oz bottle of solution would mean that a patient would use more than 30 bottles a year. We have never once met a patient who does this or a provider who recommends this, and yet our industry partners have indicated that this is the best way to clean lenses.
Let’s try assuming that both our patients and we as eyecare practitioners want healthy and clean lenses. Under this assumption, our patients will either be cleaning their lenses as mentioned above or, at minimum, with the healthy habit of a rub-and-rinse step. Without one of these cleaning regimens, our patients may be putting themselves at a heightened risk of infection or, at the very least, will have habitually soiled and dirty lenses that will invariably lead to problems over time. If patients clean their lenses with either of the aforementioned cleaning regimens, they will usually spend about the same amount of money annually on care solutions as the difference between what a daily disposable annual supply of lenses costs and what an annual supply of frequent replacement lenses costs.
This, however, may require you to do some math for your patients and, at minimum, requires a detailed explanation. After having fitted more than 90% of our patients in daily disposable lenses, we can say that the conversation becomes easier with time and usually is only required once. After patients have encountered and appreciated what daily disposable lenses can do for them, we have never once had a patient request to return to his or her previous lenses due to price (or to any other reason, for that matter).
STATISTICS FROM OUR MARKET
Statistically speaking, 70% of your contact lens patients will drop out of their lenses by the time that they are 45 years old, and 87% will have dropped out by the time that they are 55 (Nichols, 2015). I have found that most practitioners either do not believe these statistics or think that the reason for dropout is often the result of presbyopia.
The reality is that between 50% to 94% of contact lens-wearing patients present to their eyecare provider with issues related to their lens wear (Dumbleton et al, 2013). That is a large number of people complaining, and what are they complaining about? Seventy-six percent of them are reporting dryness, and 67% are reporting discomfort (Richdale et al, 2007). These are the two most common symptoms for why patients see their eyecare providers about their contact lens wear.
These are statistics that speak not only to our current patients, but also to our future patients. If that many wearers report experiencing problems with their lenses, and if that many wearers will drop out of their lenses by the time that they are in their mid-40s, then we need to take evasive action before patients become symptomatic. We need to be aggressive at protecting patients while they are healthy rather than waiting until they are having problems. Just like other healthcare issues (e.g., diabetes, hypertension, and heart disease), it’s all about solving the underlying issue early in the disease state, removing the causative agent, and changing patients’ behavior that brings about a healthy reversal. If we wait until the disease or the problem develops, it can become chronic and progressive and may never be resolved.
We share with patients what we have observed in our practices as well as what the statistics show us about their likely future in lens wear. We share with them that we have seen far fewer problems in patients who wear lenses that they discard daily. We hear from all of our patients that they feel more comfortable at day one with a lens than they do at the end of a two-week or monthly wear cycle. We ask patients to theorize why this might be. Interestingly, nearly all of them arrive at the correct answer. We share why we want to preserve their lens-wearing future, rather than waiting until problems develop.
WE ARE HEALTHCARE PRACTITIONERS.
Health care is always a choice for both patients and providers. If patients desire to obtain a medical device or medication, they can find a provider out there who will prescribe it to them. But just because patients want something doesn’t necessarily mean that practitioners have to meet that desire if they feel that a healthier option is available or that the option desired by the patient would be unhealthy for that patient. Providers have the prescribing authority to decide whether a medication or medical device is ideal or counterproductive for a particular patient.
I am not interested in prescribing only what my patients want, especially if it is counter to what is healthiest for them. As healthcare providers, we have a daily view of how patients’ choices work or do not work for their benefit. Our patients only have the view of an “N of 1.” They are thinking of themselves at the present moment. We have had the experience of seeing thousands of patients just like them over the entire spectrum of lens wear. Most of our patients come to see us because they trust us to make the choices that we find to be the best for their long-term health.
We are healthcare providers. We prescribe what is best for our patients.
Daily disposable lenses have changed my practice. I know that they can change yours as well. My practice sees far fewer problems in our patients who are wearing daily disposable lenses than what we saw when we were fitting more frequent replacement lenses.
So here is my challenge to you: Swing for the fences with your daily disposable percentage. Almost all of the current contact lens distributors can provide you with the percentages of your lens modality usage. Discover what your percentage of daily disposable fitting was last year, and see whether you can increase it by 25% or more. Just set a goal. Undoubtedly, you will not hit 100%; there will be some patients who just are not able to make the move for one reason or another.
Recognize the reasons why patients cannot move to daily disposables ahead of time, and be ready for the discussion. Create your own reasons for why they are your first choice and why you feel that they are the direction in which to move for every patient. Imagine looking back at yourself 10 years from now; will you be happy with your investment in the time and effort to move your patients into daily disposables, or do you really feel that it will have all been a waste? I assure you that your previous hindered growth with daily disposable lenses will bring about incredibly heightened opportunities. CLS
For references, please visit www.clspectrum.com/references and click on document #255.