There are many factors at play when a patient is selected to be fitted with contact lenses. It is sometimes easy to forget the complexity behind these small miracles of plastic and how they can change (and even “rock”) someone’s world—forever. Providing this form of vision correction, and in some cases even offering therapeutic effects, quickly becomes an everyday if not mundane occurrence in the life of an eyecare practitioner, whereas for wearers, they are facing a whole new beginning.
When neophytes embark on contact lens wear, whether for occasional or full-time use, they must receive clear instructions on the rights and wrongs of lens wear—not only to be successful wearers in terms of vision and comfort, but also to optimize their safety.
KEY PROBLEM AREAS
The scientific literature reveals the risk factors of various forms of contact lens wear, from daily wear through to continuous wear, in addition to the range of materials and replacement intervals (Dart et al, 1991; Dart et al, 2008; Houang et al, 2001; Inoue et al, 2007; and others. Full list available at www.clspectrum.com/references ). Epidemiological studies uncovered that some patients are associated with an increased risk of complications with contact lens wear, such as smokers and young males (Stapleton et al, 2007).
When reviewing risk, some factors are fixed (e.g., patient age and gender), whereas others are behavior-related and modifiable. Examining key areas of noncompliance that have proven associations with complications, and selecting from these those aspects that may be under the influence of eyecare providers, makes for both effective and strategic aims during the lens fitting and dispensing visits and ongoing aftercare appointments.
CAN WE MAKE A DIFFERENCE—AND WHY SHOULD WE CARE?
With patient care serving as the foundation of a successful eyecare practice, it is natural for practitioners to be concerned about any one of their contact lens patients having an issue—even worse, a sight-threatening complication. Whether the key driver is ongoing wearer success and patient care, or defensive practice, both aim to maximize compliance with contact lens-related products and their recommended use (e.g., correct lens replacement frequency, appropriate use of care products, and care of the lens case).
Research has shown that compliance is often very poor with hand-washing, rubbing and rinsing lenses (in the case of reusable lenses), and case care (Morgan et al, 2011); this article focuses on these aspects that are modifiable behaviors under the potentially powerful influence of eyecare practitioners. During a scheduled aftercare appointment, practitioners can bring these three key areas relating to compliance into sharp focus with strong evidence that enhancing compliance in these three areas should proactively serve to decrease the risk of complications. It’s a win-win situation. For practitioners, time is well-spent reinforcing behaviors that are known to be poorly adhered to; for wearers, the advice serves as a timely reminder to help them stay safe during lens wear.
THE FOUR STAGES OF COMPLIANCE
When patients start wearing contact lenses for the first time, everything is new to them. A theory, referred to as “the four stages of learning a new skill” (Burch, 1970), reflects on the ups and downs of the process of being trained in something new. Learning how to handle and look after contact lenses safely is no exception. It is the practitioners’ responsibility to ensure that patients receive all of the necessary instructions on wearing and caring for their lenses. It is useful to consider this educational journey across the four stages of competence and, for this purpose, switching out “competence” for “compliance.” Good compliance goes hand in hand with a competent wearer who knows exactly what to do and when to do it. Of course, some wearers believe themselves to be highly competent when they are not necessarily compliant. The ultimate aim for any new wearer is to achieve excellence in his or her lens wearing hygiene; this could be considered “unconscious competence” or, in this case, “unconscious compliance.”
Following are the four stages of compliance as they relate to contact lens wear and care.
Stage 1: Unconscious Noncompliance Virtually all new wearers have zero scientific knowledge about the importance of hygiene with lens wear unless they happen to be a fellow healthcare professional or their occupation or life experience has made them aware of infection risks (e.g., a microbiologist or a caregiver for an immunosuppressed relative). Eyecare practitioners and all staff involved in educating new contact lens wearers need to be conscious of this inherent ignorance. Microorganisms are, by definition, invisible to the naked eye. Therefore, awareness of hand, lens, and case contamination cannot be assumed. This stage is the educational starting point. All office staff must be conscious of the complete naivety of prospective wearers in this regard and must be ready to lead by example and to educate.
Stage 2: Conscious Noncompliance Following careful discussion with their prescribing practitioner and further education about wearing and caring for lenses, new wearers begin to appreciate what they did not know before. For many, generating this awareness forms an element of informed consent. At this stage, wearers now know that there is much to understand about protecting themselves against the microorganisms that present a potential risk of infection and that competence in lens wear and care must be gained to minimize this risk. Teaching new wearers how to wash and dry their hands is the first step to increasing their awareness that they have much to learn about their own hygiene practices to be safe with lens wear and to minimize the risks of contamination.
Stage 3: Conscious Compliance This stage may be the most vital when establishing good habits. New wearers continue to build confidence with the individual steps of correct lens wear and care, and they must consciously remember, check, and think about each step. Maintaining good contact and open communication with new wearers is vital during this phase to prevent any apathy toward following correct procedures and to move new wearers successfully onto Stage 4.
Stage 4: Unconscious Compliance Finally, new wearers form lens wear and care habits that include an unconscious “routine,” first before applying their lenses and then similarly unconscious steps immediately before and after removing their lenses. Once these habits are unconscious, it is self-evident that all appropriate hygiene steps are carried out according to the recommended protocol.
UNCOVERING LAPSED COMPLIANCE
During follow-up visits, practitioners should take time to question wearers with the goal of confirming compliance or uncovering areas of noncompliance. Patients are then made “conscious” of any habits that reveal them to have become noncompliant according to (or non-adherent to) the recommended instructions and advice. This is a necessary jolt to bring them out of their seemingly “unconscious compliance,” which in reality has fallen back to “unconscious noncompliance” (they had not realized that they were beginning to take risks that may have consequences)—or perhaps they are “consciously noncompliant” in that they know that they are skipping steps (e.g., not hand washing every time, not rubbing and rinsing after lens wear) and are knowingly/consciously taking risks.
HOW TO ESTABLISH OR RESTORE COMPLIANCE
How can wearers be persuaded to conform and adhere to the recommended advice in the three areas of hand-washing, rubbing and rinsing, and case care? Utilizing proven psychological methods may further augment practitioners’ impact beyond simply giving the correct advice. To affect the behavior, the way in which practitioners position the advice, along with the language they use, may support the behavioral outcome.
Utilizing the Principles of Influence and Persuasion Within the study and research of human behavior, Cialdini et al (2000) highlighted six key principles that are influential when persuading someone to do something. When providing contact lens wear and care advice, harnessing the power of influence and persuasion helps to serve patients better and delivers a more optimistic outcome for both wearers and practitioners.
The six key principles are:
- Social proof
It may not be immediately obvious how these principles can be employed with contact lens wearers. In addition, some can be used at any time whereas others may be selected according to the clinical scenario.
- Liking The old adage “Patients don’t sue the doctors they like” is a reminder that all steps taken by staff to communicate effectively with patients and create a friendly environment within the office is desirable. In turn, this may reduce the likelihood of litigation (Levinson et al, 1997). When a good relationship exists between a practitioner and a patient, advice is more likely to be taken and accepted. Some practitioners have a personality that is instantly likeable; they have a natural charisma or regularly have a natural smile. The simple act of smiling promotes likeability (Carnegie, 2006).
- Authority Advice is more likely to be accepted when it comes from an “expert” or from someone who is perceived to be an expert. Within an office, displaying certificates of the credentials of all staff members is one example of how to establish this element of influence.
- Social Proof Humans naturally copy the behavior of their friends and peers. Friends may not be experts about eyes, but if they happen to be a contact lens wearer, their influence is greater than you might expect, possibly even greater than the eyecare practitioner’s. This trait can be utilized when giving advice by positioning the advice as being for “most people,” or perhaps discussing patients who have a similar occupation or lifestyle and their experience of taking the recommended advice (i.e., recommended for people like you…).
- Consistency This principle is subtle yet powerful. It is based on that fact that people feel a need to act in line with previous commitments, whether verbal or written. For example, asking new wearers to sign a statement of informed consent detailing their need to attend scheduled aftercare visits assists with this requirement. Having signed the form, wearers feel more “duty bound” to be consistent and to adhere to their agreement and are more likely to comply with the advice (e.g., the simple act of verbally agreeing to tell someone that notice will be given if it is not possible to make an appointment makes it more likely that this will be the case as a result of the principle of consistency).
- Scarcity This principle may be under-utilized in clinical practice, but it is known to have a tremendous effect in the retail environment. A great example of scarcity is when a new product is made available—for example, the iPhone 7 Plus—and one of the available colors has only limited supply (e.g., Jet Black). The knowledge of rarity tends to impact increasing demand. In eyecare practice, signs displaying “Appointments available today” may not be sending the appropriate scarcity message. A sign saying “Only two appointments remaining today” has a completely different tone and may encourage those “few” appointments to be taken before someone else takes them.
Front-of-house staff can sometimes find it difficult to schedule contact lens wearers for their ongoing check-ups, especially when wearers perceive no direct need. Making the availability of such appointments apparently scarce—e.g., we have only two of these appointment per day—may make obtaining such an appointment feel of greater value to patients.
- Reciprocity A great example of reciprocity is in the social situation of someone buying you a drink and your inherent desire to return that generosity. This can work well in the consulting room. The simple act of instilling lubricating drops for a contact lens wearer by way of demonstration may be sufficient for him or her to want to buy some before leaving the office. While this “free demonstration” results in a small commercial outcome for the office, knowing that contact lens wearers are both aware of, and have access to, lubricating drops is positive for their overall contact lens wearing experience and success.
MOST BANG FOR YOUR BUCK: WHERE TO FOCUS YOUR EFFORTS
Time is limited, and not all risk factors are under the influence of eyecare professionals. Bringing hand hygiene to the consciousness of all wearers should be paramount at every contact lens aftercare visit, as this applies to 100% of wearers with respect to reducing their risk of complications (Stapleton et al, 2007). In the case of reusable lens wearers, it is important to listen carefully to how multipurpose solutions are being used, whether patients are rubbing and rinsing their lenses, and to review case care due to the known risks associated with case contamination (Gray et al, 1995; McLaughlin-Borlace et al, 1998); advice on the latter has changed over the past decade (Woo et al, 2010; Woo et al, 2011).
Hand Hygiene Hand washing is carried out by only 40% of wearers, which indicates that there is significant room for improvement in this area for the remaining 60% of wearers. Research studies have reported measurable improvements when patients have been educated on the importance of hand washing, both with regard to enhancing compliance as well as the technique itself (Larson et al, 2003; Macdonald et al, 2006). It is important to take new wearers from unconscious noncompliance (i.e., not even realizing that hand washing is important in reducing the potential microbial load on the lens during handling) to at least conscious compliance by explaining that not hand washing carries around a four-fold increase in risk of microbial keratitis.
Multipurpose Solution Use/Rubbing and Rinsing In caring for reusable contact lenses, compliance with the correct procedure for rubbing and rinsing is as low as 20%, with around 80% of wearers failing to carry out this aspect of lens care (Morgan et al, 2011). Any improvement of this behavior serves to increase the safety of wearers who make the change and adhere to the recommendations. Omitting the rubbing and rinsing step with multipurpose care solutions carries a 3.5x increased risk of microbial keratitis (Radford et al, 1995). Failing to disinfect lenses overnight carries around a 50x increased risk (Radford et al, 1998).
Case Care Lens case hygiene ranks as one of the worst areas of noncompliance, carrying with it a four-fold increase in microbial keratitis when this procedure is not properly performed by contact lens wearers (Houang et al, 2001). Explanations for why so few lens wearers properly care for their cases may include:
- Little or no advice on this aspect of lens care for new wearers.
- No discussion of/challenge to this procedure at aftercare visits.
- Outdated advice.
- Patients seeking information online (which may include the inappropriate yet recommended use of tap water for rinsing lens cases).
- Few wearers instructed to store their lens cases away from the bathroom.
- Few wearers advised to air-dry their case.
- Few wearers given the latest advice to wipe out their lens case with a tissue.
To help wearers successfully and safely use contact lenses and associated care products, a full history of current routines around lens application and removal must be ascertained at the start of the scheduled follow-up visit. Not only is it important to use open-ended questions, but also use the opening words “Tell me…” to gain the full picture from wearers about their typical routine, both at the start and at the end of their lens wearing day. It is prudent to listen to the full routine, as opposed to interrupting at each incorrect behavior. The latter risks closing the patient down and losing the opportunity to uncover all areas of noncompliance.
It can be helpful for both wearers and practitioners to ask why a patient does or does not do something. Gaining an appreciation of certain wearer beliefs or misconceptions in their routine may help to uncover any aspects that may have been misunderstood during the initial education visit. This may be checked with staff involved in those aspects of the initial education, especially if it seems to be a recurring issue. Much can be learned about wearers’ perspectives when discovering why they do things a certain way; sometimes it is simply for practical reasons.
For example, some wearers carry around their lens case containing the old solution from the night before in case of emergency. Their intent is purely to be ready should they need to remove their lenses unexpectedly. Of course, doing this means that the routine case hygiene procedure is not followed and that increased case contamination is at risk. Providing wearers with a travel-sized bottle of solution and a spare case to have either in their car or at work is all that is needed to restore their routine in this instance.
DELEGATION IS GOOD
Most offices delegate the role of patient education to clinical assistants or “contact lens hygienists.” This approach has many benefits. Patients are often more relaxed being taught by a member of the support staff compared with their eyecare practitioner. Support staff have greater flexibility with their schedule, which also can be more convenient for new wearers. Having front-of-house staff involved in this element of education gives patients an immediate point of contact in case of emergency or if they simply have additional questions—questions that could be important, but ones with which they may not want to trouble their practitioner. Support staff can schedule a friendly follow-up call to check on the progress of new wearers and to provide any additional lenses in case of loss; an eventuality that may cause new wearers to discontinue out of embarrassment for their carelessness.
With all delegated functions, it is important to check periodically on the quality of the information provided to patients. Recording an appointment with the agreement of a new wearer by way of internal auditing is a more subtle measure, as the staff member (and the patient) quickly forget the presence of the recording device.
DON’T SUGARCOAT THE POSSIBLE CONSEQUENCES
It is natural to speak to patients about contact lens wear in an encouraging and positive manner; otherwise, who would choose to wear them? But there has to be a balance, and we have to remember what informed consent means. The risks associated with lens wear are extremely low (Stapleton et al, 2008), yet those risks exist. It is certainly a positive step on the part of the practitioner to proactively question wearers on the steps involved in lens wear and care that help to minimize the risks.
What if poor compliance with case hygiene is uncovered during the visit? There is little positive to be said about that, as the wearer is taking unnecessary risks. Perhaps then is the time to discuss what those wearers stand to lose; not only might they lose a few days of lens wear, but in the worst case scenario, they may need to be hospitalized for treatment, which, if delayed, could result in loss of corneal transparency. Likewise, Acanthamoeba keratitis is a meaningless phrase to a contact lens wearer, but a photograph of an eye with an opaque cornea is a powerful educational tool. The desire to wear contact lenses and to prevent what is in the photograph exceeds the risk taken, which is why this is a positive strategy; it serves as informed consent, and it provides noncompliant wearers with a strong reason “why” they should change their behavior. No one wants a wearer to land in that kind of trouble and say “Nobody told me this could happen.” CLS
For references, please visit www.clspectrum.com/references and click on document #258.