This series of articles on international prescribing practices has previously covered the German-speaking countries and China. This time, we look at Scandinavia: officially including Denmark, Norway, and Sweden. Often, Scandinavia and “Nordics” are used interchangeably, but the latter would include Finland and Iceland as well. As these two countries were not part of the recent Eurolens annual survey on international contact lens prescribing (Morgan et al, 2017), this article will focus on the three Scandinavian countries; this region represents about 21 million people, a number of different languages, and a few different currencies. So how does this region differ from the rest of the world, and in what ways is it similar?
The first thing that resonates when looking at the region is the penetration rate of daily disposable contact lenses, which has been the case since the modality’s introduction. Denmark (45%), Norway (33%), and Sweden (26%) all report considerably higher rates of daily disposable fits using hydrogel materials; by comparison, the average of all 33 countries together in the survey is 19%, and the United States is trailing with 8%.
For silicone hydrogel daily disposables, the numbers are slightly lower, but Norway (17%), Sweden (12%), and Denmark (7%) are roughly in line with the percentage of all countries together (12%), and they are higher than or equal to that in the United States (7%).
It may not come as a surprise that Denmark overall has the highest number of daily disposable lens fits in the region, with Sweden just barely trailing, given that the introduction of frequent replacement lenses in 1987—which irrevocably changed the world of contact lenses—was based on an idea by Danish ophthalmologist Michael Bay.
Daily Disposables and Soft Lens Safety In a recent review article, Bullimore (2017) explores safety issues with soft lenses—particularly in relation to children wearing them, as interest in fitting soft lenses for myopia control is on the rise. The article states that overall, the incidence of corneal infiltrative events in children is no higher than in adults, and in the youngest age range (8 to 11 years), it may be markedly lower. Daily disposables are mentioned as an attractive option for children and teenagers, as they obviate the need for cleaning and storage. This message of safety regarding daily disposables seems to be well embraced among Scandinavian practitioners, being mentioned as a prime reason to fit them.
GP Planned Replacement
Talking about safety and contact lenses, GP lenses are the safest lens option out there. GP contact lenses are not uncommon in the region; the numbers are close to, but not exceeding, the benchmark global average of 7%.
Norway and Denmark were in the selected group of 15 countries that reported the most rigid lens fits in the survey. Looking at the data within this selected group, what stands out is that both countries do well above average planned replacement with rigid lenses: 84% and 76% in Denmark and Norway, respectively, whereas it was 50% on average among all countries that fitted enough GP lenses to be included in that analysis.
Orthokeratology, another modality that is becoming more common for children, also is “on par” in Scandinavia with the global benchmark, at 2% in the region.
Extended Wear and Silicone Hydrogels
An article on contact lens wear in Scandinavia cannot go without at least mentioning extended or continuous wear of lenses. The starting point of this modality, to a large degree, may have been when Klas Nilsson from Sweden developed a lathe-cut, soft, high-water-content lens based on a vinylpyrrolidone and methylmethacrylate material; this was launched in 1975 under the name Scanlens 75 (S-75) as a contact lens for day-and-night use (Dahl, 2002).
Extended wear is still relatively popular in Scandinavia, with Norway leading the way at 9%, followed by Sweden (7%) and Denmark (6%). In many European countries, extended wear is limited; for instance, in surrounding countries, the United Kingdom is at 2%, and Germany is rounded to 0%. The average soft lens extended wear for all countries is 9%, but this is heavily biased by a few “outlier” countries doing exceptionally high percentages of extended wear.
Coming back to silicone hydrogels, Scandinavia does not go beyond the general fitting trend for this lens type, with Sweden (55%) on par with the average number and Norway (46%) and Denmark (36%) just trailing when it comes to this material choice for lens fits in the Eurolens survey.
Potentially interesting is the relatively high age of contact lens prospects: the age of the patients fitted in Scandinavia is 36 to 38 years, while this is 31.5 years on average in the consortium of countries in the survey. Then again, this is not unusual, as most other matured contact lens markets in Europe, including the United Kingdom (37.9 years), Germany (37.5 years), and the Netherlands (37.6 years), also show above-average ages for contact lens fits.
But the higher ages automatically make us curious about the number of presbyopic contact lens fits; and indeed, multifocal and monovision lens fits in the Scandinavian countries are exceptionally high: 29% of contact lens fits in Sweden, 28% in Denmark, and 26% in Norway. In contrast, the average percentage for all of the countries together in the survey is 11%.
The ratio of multifocal versus monovision is also slightly different compared to the average numbers. Of all people aged 45 or older in the survey (all countries), the ratio of multifocal/monovision fits is 42% versus 8%. Both of these numbers are higher for the Scandinavian countries: 52%/21% in Sweden, 51%/9% in Norway, and 43%/20% in Denmark. It appears that the Scandinavians take their presbyopic lens fitting seriously.
Land of Lego, IKEA, and Strong Economies
The technical skills required to “go the extra mile” in presbyopic soft lens fitting can potentially also be applied to soft toric lenses. According to the Eurolens survey data, the Scandinavians do fit toric soft lenses more compared to average: Denmark (36%), Norway (35%), and Sweden (31%) outperform most other countries in the survey, in which the global average was 22%, and the United States reported that among all soft lens fits, 25% were with toric lenses. This higher technical skill may not come as a surprise given the regional heritage of building with Lego bricks and the self-build IKEA furniture.
Another explanation for the above-average fitting of presbyopic and toric lenses is that it’s not (just) about skill, but about recognizing patients’ needs and the fitting possibilities. In addition to this, the economies in the Scandinavian countries are very strong, which could have a positive impact on patients’ ability to afford multifocal and toric lenses in high frequency of replacement.
Cosmetic tint lenses are virtually nonexistent in the region, reported as less than 1% of soft lens fits in all three countries represented here. As reported earlier, the Eurolens survey provides data on lens fits (and potential trends in lens fitting), not on market share or on contact lens sales data.
In summary, it appears that the Scandinavian market is relatively universal, despite differences in culture, language, and currency. Generally speaking, it seems fair to say that the Scandinavians take their daily disposable contact lenses seriously, and they also outperform most other countries when it comes to advanced soft lens fitting such as presbyopic/toric soft lens fits and extended wear. Especially regarding extended wear and daily disposables, this may not come as a surprise, given the history of those modalities in the region. CLS
Special thanks to Ingebret Mojord from Norway, Anna Lindskoog Pettersson from Sweden, and Eurolens international contact lens prescribing survey representatives Magne Helland (Norway), Peter Gierow (Sweden), and Ole Ravn (Denmark).
For references, please visit www.clspectrum.com/references and click on document #262.