Article

INTERNATIONAL CONTACT LENS PRESCRIBING IN 2018

Our 18th annual report in Contact Lens Spectrum explores the variations in worldwide contact lens prescribing.

Since 2000, we have reported on worldwide contact lens prescribing trends in this journal. In that first year, five markets were summarized; in the intervening years, we have received data from 70 countries including 47 reporting in 2018. The database gathered contains information on more than 383,000 contact lens fits. The format of the project has remained constant—we aim to survey a representative group of contact lens practitioners in each market and request that they report generic information about the first 10 patients that they fit with contact lenses after receiving notification of the project each year. The precise method of distribution for the survey necessarily varies around the world. Many countries continue with a paper-based collection process, whereas others have moved to an online approach. Importantly, we have a large group of national coordinators who are able to ensure that a suitable range of practitioners are contacted so that a fair snapshot of each country is taken.

Specifically, we capture information about the age and gender of each patient fitted in addition to data detailing the material, design, replacement frequency, and wearing modality of the fitted lenses, anticipated weekly usage, and care system type. Each fit was weighted relative to the estimated annualized number of fits for each practitioner. The data are finally collated at both the University of Manchester and the University of Waterloo.

KEY WEARER INFORMATION

In 2018, information was received from 47 markets. In 14 countries, data was collected on a small number of lens fits (fewer than 100 fits). Data from those countries were formally added to the database, but are not included in this report. Of the 33 included countries, 24,131 contact lens fits were captured.

Overall, the age at fitting worldwide was 33.3 years ± 14.8 years (mean ± standard deviation), although this varied greatly from around 24 years in Saudi Arabia to two markets (Australia and the United Kingdom) in which the average age at fitting is older than 40 years (Table 1). In these latter two markets, the average age at fitting has increased by about 8 years over the duration of our Contact Lens Spectrum reports—a remarkable change that presumably relates to the general aging of the contact lens-wearing population in addition to increasing use of contact lenses for presbyopic patients. The survey dispels the previously-held notion that contact lenses are most widely prescribed to people in their early 20s; 24 of the 33 countries reported mean fitting ages in the fourth decade of life.

TABLE 1 DEMOGRAPHIC INFORMATION FOR ALL SURVEYED MARKETS
Country Total fits Mean ±SD age % female % new fits % part time (≤ 3 days)
United Arab Emirates (AE) 120 29.6 ± 8.2 73% 55% 0%
Argentina (AR) 564 35.4 ± 15.1 63% 32% 3%
Austria (AT) 100 37.4 ± 14.4 69% 23% 1%
Australia (AU) 381 40.2 ± 16.9 69% 32% 26%
Bulgaria (BG) 430 29.2 ± 11.3 65% 45% 9%
Canada (CA) 3186 35.9 ± 16.2 68% 29% 24%
Switzerland (CH) 200 39.5 ± 17.0 61% 46% 10%
Chile (CL) 120 35.4 ± 14.1 70% 15% 0%
China (CN) 120* 24.9 ± 12.5 62% 37% 2%
Czech Republic (CZ) 345 32.6 ± 14.3 62% 53% 20%
Germany (DE) 109 38.7 ± 14.7 66% 33% 8%
Denmark (DK) 263 37.7 ± 15.8 64% 38% 3%
Spain (ES) 772 33.0 ± 15.2 62% 59% 8%
Finland (FI) 551 36.0 ± 14.4 68% 39% 32%
France (FR) 410 36.6 ± 15.8 67% 39% 9%
Greece (GR) 744 30.9 ± 10.6 59% 21% 13%
Hungary (HU) 220 31.2 ± 14.1 63% 56% 6%
Israel (IL) 472 30.1 ± 12.6 61% 43% 7%
Italy (IT) 450 36.6 ± 15.8 59% 49% 11%
Japan (JP) 3762 31.1 ± 15.3 68% 42% 13%
Lithuania (LT) 594 30.8 ± 11.1 63% 23% 17%
Mexico (MX) 1536 31.0 ± 11.8 66% 42% 0%
Netherlands (NL) 914 38.7 ± 16.9 65% 26% 3%
Norway (NO) 564 37.5 ± 17.1 60% 25% 6%
New Zealand (NZ) 700 39.1 ± 17.2 64% 43% 15%
Philippines (PH) 2136 29.1 ± 10.3 71% 19% 2%
Portugal (PT) 108 31.4 ± 14.9 60% 60% 19%
Russia (RU) 608 26.0 ± 9.9 68% 30% 5%
Saudi Arabia (SA) 690 24.1 ± 3.7 81% 60% 17%
Sweden (SE) 967 36.9 ± 14.8 66% 20% 12%
Taiwan (TW) 627 28.4 ± 9.0 82% 50% 0%
United Kingdom (UK) 1176 40.1 ± 17.0 65% 47% 24%
United States (US) 192 34.7 ± 15.8 60% 28% 4%
OVERALL 24131 33.3 ± 14.8 67% 35% 8%
* Data from retail outlets only.

Most lenses are fitted to females—67% of fits overall. This metric is extremely consistent across the markets, with only eight countries reporting this demographic to be outside of the 62% to 72% range. Similar to previous years, 35% of fits were classified as “new fits” (patients receiving lenses for the first time or who have not worn lenses for a number of years), and most wearers (92%) were prescribed lenses for “full-time” use of four days per week or more.

Table 2 provides a summary of the proportion of contact lens types fitted in each market. GP lenses overall account for 9% of contact lens fits (7% with conventional GP lens types and 2% with orthokeratology designs), 27% of lenses prescribed worldwide are soft daily disposables, 57% are soft reusables, and 7% are lenses for extended wear.

TABLE 2 BREAKDOWN OF ALL LENS FITS INTO SEVEN KEY CATEGORIES OF LENSES
Country Rigid (non-OK) OK DD hydrogel DD SiHy Reusable DW hydrogel Reusable DW SiHy Soft EW
AE 19% 0% 3% 14% 31% 25% 8%
AR 6% 0% 7% 4% 31% 44% 8%
AT 32% 1% 11% 24% 8% 23% 0%
AU 5% 2% 11% 45% 10% 21% 6%
BG 17% 0% 2% 10% 14% 53% 4%
CA 3% 1% 13% 34% 5% 41% 2%
CH 41% 2% 7% 18% 8% 18% 6%
CL 2% 0% 3% 17% 6% 72% 1%
CN 19% 61% 6% 0% 6% 0% 7%
CZ 4% 0% 8% 20% 7% 50% 10%
DE 35% 12% 3% 6% 23% 18% 3%
DK 6% 2% 47% 15% 7% 18% 7%
ES 15% 8% 12% 11% 23% 16% 16%
FI 9% 0% 4% 52% 1% 21% 12%
FR 21% 13% 6% 22% 5% 34% 0%
GR 2% 0% 5% 20% 19% 45% 9%
HU 11% 25% 2% 22% 6% 33% 2%
IL 6% 0% 22% 22% 14% 32% 4%
IT 15% 2% 17% 21% 11% 33% 1%
JP 14% 0% 30% 18% 12% 25% 0%
LT 23% 0% 5% 13% 3% 32% 24%
MX 2% 0% 3% 2% 8% 84% 2%
NL 22% 5% 4% 5% 6% 56% 2%
NO 13% 2% 21% 17% 8% 14% 26%
NZ 23% 7% 7% 32% 4% 25% 3%
PH 1% 0% 0% 28% 5% 44% 22%
PT 4% 0% 20% 23% 13% 38% 3%
RU 2% 2% 4% 8% 14% 63% 7%
SA 0% 0% 19% 0% 74% 7% 0%
SE 2% 1% 16% 26% 6% 43% 7%
TW 1% 3% 38% 9% 44% 5% 0%
UK 4% 0% 19% 32% 4% 37% 4%
US 6% 0% 4% 19% 3% 62% 5%
OVERALL 7% 2% 10% 17% 10% 47% 7%
SEE TABLE 1 for country abbreviations. OK = orthokeratology DD = daily disposable DW = daily wear EW = extended wear

GP LENSES

The use of GP lenses, at around 10% of all lens fits (Table 3), has remained constant for more than 10 years. There is considerable variation in this parameter, however, with high use in markets such as Switzerland, France, the Netherlands, and New Zealand but very few GP fits in many countries (Figure 1 and Table 2). Japan has long been considered a bastion of GP lenses, but this market has seen an ongoing decline in fitting of this lens type, from a high value of 36% of new fits in 2003 to 14% in 2018 (Figure 2). We tracked 352 scleral lens fits in 2018, which accounted for a weighted value of 1.4% of all fits; this has been a similar figure for the past five years.

TABLE 3 DETAILED INFORMATION FOR ALL PRESCRIBED GP LENSES ONLY FOR MARKETS REPORTING > 35 GP LENS FITS
AR BG CA CH ES FI FR IT JP LT MX NL NO NZ PH SE UK OVERALL
Rigid lenses for new fits 5% 20% 6% 47% 23% 8% 41% 17% 6% 29% 1% 34% 18% 31% 3% 3% 1% 9%
Rigid lenses for refits 6% 13% 4% 40% 23% 10% 31% 17% 20% 23% 2% 25% 13% 29% 0% 2% 8% 9%
MATERIALS PMMA 16% 0% 0% 4% 0% 0% 0% 2% 1% 0% 11% 0% 0% 0% 0% 9% 0% 1%
Low-Dk (< 40) 11% 0% 4% 2% 2% 0% 0% 11% 7% 0% 36% 7% 2% 7% 2% 0% 1% 6%
Mid-Dk (40-90) 68% 0% 31% 32% 22% 16% 5% 43% 29% 4% 37% 42% 71% 13% 18% 34% 47% 27%
High-Dk (> 90) 5% 100% 65% 63% 76% 84% 95% 45% 63% 96% 17% 51% 27% 79% 80% 57% 53% 66%
DESIGN Sphere 63% 88% 26% 8% 34% 49% 28% 42% 79% 50% 83% 22% 34% 7% 34% 20% 25% 42%
Toric 18% 7% 12% 38% 28% 48% 5% 18% 2% 9% 6% 25% 17% 3% 1% 23% 14% 14%
Multifocal/monovision 16% 5% 19% 32% 1% 3% 10% 11% 12% 10% 6% 20% 16% 2% 4% 8% 35% 12%
Ortho-k 0% 0% 20% 5% 35% 0% 39% 9% 0% 0% 0% 19% 11% 24% 41% 37% 9% 15%
Myopia control 3% 0% 20% 12% 1% 0% 0% 1% 0% 0% 1% 8% 1% 31% 13% 0% 0% 5%
Other 0% 0% 3% 5% 1% 0% 17% 19% 7% 31% 4% 6% 20% 32% 7% 12% 18% 12%
Planned replacement 80% 100% 58% 65% 68% 88% 84% 64% 14% 100% 84% 42% 65% 37% 100% 61% 69% 60%
Extended wear 3% 0% 17% 12% 41% 0% 2% 3% 0% 27% 4% 4% 2% 40% 29% 10% 2% 15%
SEE TABLE 1 for country abbreviations. PMMA = polymethylmethacrylate

Figure 1. Proportion of GP fits for the 33 countries reported in the 2018 survey.

Figure 2. Contact lens prescribing in Japan from 2003 to 2018. EW = extended wear; DW = daily wear; Si-H = silicone hydrogel; DD = daily disposable.

Globally, most GP lens fits are with high-Dk (greater than 90 Dk) materials, and 12% of fits are with multifocal/monovision lens designs. Overall, 15% of all GP lenses are for orthokeratology use.

SOFT LENSES

Soft lenses accounted for just greater than 90% of lens fits (Table 4). Silicone hydrogel materials accounted for 76% of soft lenses prescribed and for more than 90% of fits in four markets. Figure 3 shows the use of silicone hydrogel materials since 2000. Very few fits were recorded until 2004, when the first products specifically for daily wear were launched around the world. For reusable soft lenses, there was a significant increase in the proportion of silicone hydrogel materials until 2013. After that, there has been a relative plateau. For daily disposables, the surge in the use of silicone hydrogels started in 2007 and has continued each year.

TABLE 4 DETAILED INFORMATION FOR ALL PRESCRIBED SOFT LENSES FOR MARKETS REPORTING > 100 SOFT LENS FITS
AR AU BG CA CH CL CZ DK ES FI FR GR HU IL IT JP LT MX NL NO NZ PH RU SA SE TW UK US OVERALL
Soft lenses for new fits 95% 87% 80% 94% 53% 99% 95% 92% 77% 92% 59% 99% 61% 93% 82% 94% 71% 99% 66% 82% 69% 97% 86% 100% 97% 100% 99% 93% 91%
Soft lenses for refits 94% 95% 87% 96% 60% 98% 96% 93% 77% 90% 69% 97% 67% 93% 82% 80% 77% 98% 75% 87% 71% 100% 97% 100% 98% 100% 92% 94% 92%
MATERIALS Low water content (< 40%) 19% 4% 0% 1% 1% 0% 1% 5% 10% 1% 3% 2% 0% 3% 1% 7% 2% 0% 0% 1% 2% 1% 9% 14% 1% 69% 1% 0% 4%
Mid water content (40-60%) 5% 13% 18% 8% 13% 3% 9% 34% 14% 3% 6% 10% 3% 10% 17% 10% 8% 4% 5% 19% 10% 5% 1% 8% 11% 5% 9% 4% 7%
High water content (> 60%) 20% 7% 2% 9% 15% 5% 8% 24% 33% 3% 7% 15% 8% 27% 15% 32% 5% 7% 8% 29% 3% 1% 10% 72% 12% 12% 15% 3% 13%
Silicone hydrogel 56% 76% 80% 81% 71% 92% 82% 38% 43% 93% 84% 73% 88% 60% 66% 50% 85% 89% 86% 51% 84% 93% 80% 7% 76% 15% 76% 92% 76%
DESIGN Sphere 46% 39% 68% 44% 19% 39% 57% 39% 42% 47% 40% 59% 44% 46% 31% 75% 55% 39% 29% 30% 31% 50% 82% 40% 43% 93% 34% 52% 47%
Toric 39% 18% 13% 31% 41% 59% 27% 27% 25% 28% 29% 27% 19% 34% 39% 17% 9% 53% 37% 29% 37% 20% 7% 3% 34% 4% 33% 23% 32%
Cosmetic tint 2% 1% 1% 1% 2% 0% 0% 3% 1% 0% 0% 2% 0% 1% 1% 3% 8% 5% 0% 0% 4% 10% 4% 55% 1% 0% 2% 0% 5%
Multifocal/monovision 11% 38% 15% 22% 33% 2% 16% 29% 28% 23% 29% 11% 37% 19% 27% 5% 11% 3% 33% 39% 24% 19% 2% 1% 21% 3% 31% 23% 15%
Myopia control 2% 4% 3% 2% 4% 0% 0% 0% 5% 1% 1% 0% 0% 0% 2% 0% 1% 0% 1% 1% 1% 0% 1% 0% 0% 0% 0% 1% 1%
Other 0% 0% 0% 0% 1% 0% 0% 1% 0% 0% 0% 0% 0% 0% 1% 0% 16% 0% 0% 1% 2% 0% 4% 0% 0% 0% 0% 1% 1%
REPLACEMENT Daily 13% 64% 15% 50% 49% 20% 33% 71% 37% 71% 41% 29% 37% 48% 46% 57% 33% 4% 12% 63% 57% 36% 13% 19% 46% 48% 56% 27% 32%
1-2 weekly 27% 5% 7% 6% 10% 43% 17% 3% 2% 1% 7% 16% 1% 19% 10% 41% 21% 12% 4% 8% 4% 1% 31% 5% 9% 4% 4% 30% 13%
Monthly 36% 29% 74% 43% 21% 36% 46% 25% 56% 27% 51% 52% 62% 30% 40% 1% 42% 83% 78% 26% 33% 51% 46% 41% 45% 47% 40% 41% 51%
3-6 monthly 4% 0% 2% 1% 13% 0% 0% 1% 3% 0% 0% 1% 0% 2% 3% 0% 2% 0% 6% 2% 5% 2% 9% 34% 0% 1% 0% 1% 2%
Annually 19% 1% 2% 0% 5% 1% 3% 0% 2% 0% 0% 1% 0% 1% 1% 0% 0% 0% 0% 0% 0% 10% 0% 0% 0% 0% 0% 1% 2%
Unplanned 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 1% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Extended wear 9% 7% 5% 2% 10% 1% 11% 7% 20% 13% 0% 9% 3% 4% 1% 0% 32% 2% 3% 31% 5% 22% 7% 0% 8% 0% 4% 5% 8%
EW with silicone hydrogels 63% 100% 85% 82% 100% 100% 93% 100% 33% 99% 100% 80% 100% 62% 100% 50% 99% 91% 80% 97% 100% 31% 98% 100% 97% 100% 93% 30% 64%
MPS 89% 87% 93% 75% 44% 96% 91% 85% 91% 99% 70% 96% 87% 84% 79% 84% 68% 100% 81% 91% 86% 95% 93% 96% 92% 99% 94% 94% 92%
Presbyopes multifocal/monovision 12%/12% 38%/30% 61%/0% 50%/13% 55%/14% 11%/1% 60%/0% 52%/8% 71%/1% 68%/10% 68%/2% 71%/1% 78%/17% 63%/12% 71%/2% 26%/1% 36%/0% 16%/0% 62%/5% 47%/24% 38%/15% 77%/1% 33%/0% 0%/0% 42%/11% 15%/15% 47%/19% 38%/35% 46%/9%
See Table 1 for country abbreviations. EW = extended wear MPS = multipurpose solution
The final row indicates the proportion of multifocal and monovision lenses prescribed when patients were over 45 years of age.

Figure 3. Prescribing of silicone hydrogel lenses for 14 markets for which we have at least 10 years of consecutive prescribing data.

In 2018, around one in three patients fitted with contact lenses were prescribed at least one toric lens in their contact lens pair; this figure jumps to 41% if multifocal, monovision, cosmetic tints, and myopia control lenses are disregarded. This is close to the optimal value for the proportion of toric lenses fitted given the prevalence of astigmatism in the population. For soft lens fitting, myopia control lenses accounted for 0.7% of lenses prescribed worldwide.

Most soft lenses were prescribed on a daily disposable (32%), one- to two-week (13%), or monthly (51%) replacement basis. The use of daily disposable lenses varies considerably, with around 70% of soft lenses prescribed on this basis in Finland and Denmark compared to 12% and 4% of lenses in the Netherlands and Mexico, respectively (Figure 4). The low uptake of daily disposables in the Netherlands—one of Europe’s most successful contact lens markets in terms of overall penetration—continues to be a fascinating data point in the international survey. Extended wear of soft lenses continues to be prescribed infrequently—around 8% of fits—but this trend is countered in Norway and Lithuania, which reported extended wear for more than 30% of soft lens fits. Forty-six percent of presbyopes fitted with soft lenses receive a multifocal lens design; a further 9% is prescribed monovision. Most patients (92%) are prescribed a multipurpose solution to care for their reusable soft lenses. CLS

Figure 4. Daily disposable lens fitting for the 33 countries reporting at least 100 lens fits.

Funding and/or assistance was provided for the following markets: Australia—Optometry Australia; Bulgaria—Vision Protect Ltd; Argentina, Chile, France, Greece, and Israel—Johnson & Johnson Vision; Mexico—Johnson & Johnson Vision, CooperVision, and Alcon; Finland—Finnish Association of Vision and Eye-care; Norway—the Norwegian Association of Optometry; Netherlands—Bausch + Lomb; Spain—Spanish General Council of the Colleges of Opticians-Optometrists; Switzerland—Swiss Society of Optometry and Optics SBAO/SSOO.

The authors acknowledge the administrative support of Eurolens Research at The University of Manchester and the Centre for Ocular Research and Education at the University of Waterloo.

INSIGHT INTO CONTACT LENS PRESCRIBING IN CHINA

For the first time in 2018, we received prescribing data for “optometric centers” in China (in addition to fitting information from retail outlets that form the basic information for China presented here). These centers are well equipped and are staffed by highly trained optometrists who have a medical device license that allows them to fit and prescribe orthokeratology lenses. Of the 1,128 fits reported from optometric centers, 98% were rigid lenses with the majority (85%) for orthokeratology. The centers mainly provided myopia management strategies to children (age 13.4 years ± 4.7 years), principally fitted for myopia control.

Many of the centers reported here are associated with the Aier Eye Hospital. This hospital screens 3 to 4 million children every year as part of its vision screening project for local communities and schools. The hospital is a key partner of the Our Children’s Vision project operated by the Brien Holden Vision Institute. It is also of note that although the retail outlets are not allowed to prescribe orthokeratology lenses directly, many patients are referred to the local optometric centers and hospitals for this sort of myopia management; this is reflected in Table 2.