Article

INTERNATIONAL PERSPECTIVES

THE GREAT WALL OF CHINA
中国的角膜接触镜长城

In this series of articles, we explore different contact lens markets around the world and ask: Is contact lens fitting very different in various parts of the world, and can we learn from each other? To answer the first part of this question: yes, contact lens markets differ considerably. This series started with the German-speaking countries (van der Worp and Pult, 2017). This time, it looks at China.

This region accounts for a population of close to 1.4 billion people. It is a region that historically has been quite secluded and is still walled off to some degree when it comes to new contact lens products. However, China has also been part of the international survey on contact lens prescribing habits since 2006 (Morgan et al, 2017).

Walled Off

The Great Wall of China, part of which was built as early as the Seventh Century BCE to protect the Chinese states and empires, forms a line across the historical northern borders of China. In terms of contact lens sources, China generally has a “closed” market for contact lenses.

The rules and regulations for manufacturers are strict, and the Chinese equivalent of the U.S. Food and Drug Administration applies high regulatory guidelines and standards to ensure safety of products. There are, for instance, only a few orthokeratology (ortho-k) designs available in the country from foreign manufacturers, and it is not easy to “get in.” Scleral lenses have not yet entered the market in China.

Myopia Control

At the same time, myopia control is a hot item in Chinese culture. Sixty years ago, 10% to 20% of the Chinese population was short-sighted; today, up to 90% of teenagers and young adults are myopic, according to a trending article in Nature (Dolgin, 2017).

Interest in lenses that can help manage myopia have received above-average attention. Therefore, it may not be surprising that, according to estimates presented at the most recent 2016 Optometric Management Symposium, there are about 1.4 million ortho-k lens wearers in Asia alone—responsible for the bulk of ortho-k lens wear worldwide (Norman, 2016). Two dual-focus soft lens designs for myopia control, manufactured in Taiwan, were approved in China in 2016, but have not yet gained popularity in the Chinese market.

GP Lenses

The best starting point would be to look at the Eurolens Research survey data as published in the January 2017 issue of Contact Lens Spectrum (Morgan et al, 2017), which focuses solely on lens fits and refits (not on numbers of lens wearers in a region or on sales data). Rigid lens fits other than ortho-k are not particularly popular in China, according to that survey; although, the survey numbers vary tremendously over the last three years.

But, based on local representatives’ feedback, corneal GP lens wear is not exceeding the benchmark of lens fits worldwide (7%), and specialty lens fits (such as with sclerals) have not been available in China.

Ortho-k may be the exception to the rule—although the percentage of ortho-k as a portion of all lens fits varies as well, between 4% (2014) and 1% (2016) in China. As previously stated, surveys are very susceptible to who returns them. This is especially true when the general number of returns is relatively low, which can give a skewed outcome and/or create significant variance.

Gold Standard

It is probably fair to say that as 97% of new fits and 99% of all refits are soft lens fits, those lenses are the gold standard of lens fitting in China. Silicone hydrogel (SiHy) lenses over the last few years seem to be underrepresented; as an illustration, the 2016 data show that 16% of soft lens fits are with SiHy in China versus 55% in the rest of the surveyed countries. This is partly because local Chinese industry does not manufacture SiHy; all of the SiHy lenses available in the market are imported designs, making their price much higher. This prevents them from becoming the “gold standard” of materials to go to at this point in China.

Another interesting fact is the relatively low numbers of toric lens fits in China: 72% of lens fits in the last survey were with spherical lens designs whereas 11% were with toric lens designs. On average, these values in the international survey are 55% for spherical and 22% for toric; the United States is pretty much “on par” with that at 54% and 25%, respectively.

Given the fact that roughly 45% of all patients seem to have astigmatism of 0.75D or higher, the toric lens fit percentages in general, and in China particularly, show an underrepresentation. One reason why torics are underrepresented in China is that most of the soft lenses sold in China are not prescribed by doctors but rather by opticians, who may have fewer opportunities to be trained to fit toric lenses. Cost is also much higher with the limited designs available—about three times higher for a toric lens than for a spherical lens.

Lens Replacement Schedules

In terms of lens replacement, it is hard to get a good feel for the Chinese market. Differences between regions, as well as cities versus the rest of the country, may play a significant role. Monthly replacement is probably the benchmark, followed by six-month replacement and one- to two-week replacement. Although daily disposables are quite popular according to the survey data (representing 39% of fits), this does not seem to be representative of the entire country.

A number that is slightly different in the survey for China compared to other surveyed regions is the relatively high percentage of annual replacement in China at 11% (this is 1% in all other countries combined). This percentage has been consistently high (in relative terms) over the last few years.

Presbyopia

One interesting fact from the Eurolens survey that certainly sticks out is the underrepresentation of bifocal lens fits in China. That is really an understatement, as it almost doesn’t exist. One important reason is that most of the soft contact lens users in China are between 16 and 40 years old. Indeed, the survey data shows that China has the youngest age group of all 33 countries in the survey (average 25.5 years ± 8.5 years).

Also, even though some presbyopic designs are available in the market, they are not well acknowledged by the elders nor are they recommended by the practitioners, as they have not been trained to fit these lenses. Finally, another reason could be that the prevalence of meibomian gland dysfunction is greater than 60% among East-Asian populations older than 50 years, which has become the main cause for dry eye and could further retard the popularity of presbyopic soft lens wear.

Conclusion

It seems that the Chinese market is fairly secluded in some ways—not all lenses nor all lens designs or modalities are even available in China. Soft lens fitting is the bread-and-butter in the Chinese contact lens practice, but this is not necessarily SiHy based. Daily disposables are relatively popular, but toric lens designs are not—and presbyopic lens fits are basically nonexistent.

Most of these findings are in sharp contrast with the German-speaking countries explored in our last column; for instance, those countries focus much more on technical fits such as soft torics and corneal GP lenses, while daily disposables lens fits are trailing.

Needless to say, the Chinese market has huge potential given the high numbers of potential wearers and increasing wealth in the country. Internationally, we can probably learn a lot from China by looking at the developments in the myopia-control arena. In many ways, China seems to be on the forefront of both research and implementation of new instruments for children as well as in schools to manage myopia development, including optical intervention options such as orthokeratology and soft dual-focus lens designs. CLS

Special thanks to Dr. Kah-Ooi Tan from Singapore, representative for China in the Eurolens Research international survey, and to Ron Beerten for his valuable input.

For references, please visit www.clspectrum.com/references and click on document #259.