Wrapping Up

Our editor offers take-home points to help you bring about positive change in your contact lens practice.

Wrapping Up
Our editor offers take-home points to help you bring about positive change in your contact lens practice.

By Joseph T. Barr, OD, MS. FAAO (Dipl)

About 10 million people in the United States have dropped out of contact lens wear since the turn of the century. The number across the planet is probably two or three times that.

Hopefully, we've covered enough issues in this supplement to help turn the tide. But to be sure, I'll list some goals to shoot for as you aim to improve your contact lens practice.

Change History

Reviewing early studies on contact lens wear, I found that success during the first 6 months was 73% to 90%. But in retrospective reviews, I found a success rate of only about 57%. Of course, those were the days when we had only PMMA. However, that number increased to only 60% in a 1979 study out of the University of Alabama at Birmingham, which included gas permeable and soft lenses.

Interestingly, many of the issues cited then were the same as those we're experiencing now — with discomfort the leading problem. Our challenge is to work harder than ever to achieve and maintain comfortable lens wear.

Answer the Critical Questions

Desmond Fonn at the University of Waterloo found that 51% of 568 current and former contact lens wearers discontinued contact lens wear. Of that number, 25% resumed wearing lenses later, but 14% discontinued a second time. Can we reduce that number? Can we take people who have discontinued lens wear, short-term or long-term, and turn them around when they want to try again? With improved technology, we may be able to succeed and satisfy them for years to come.

Value Your Patients — and Practice

Patients want to see clearly and comfortably without spectacles. Most have rejected refractive surgery. And the contact lens patient is more profitable to your practice over the long term. Successful contact lens management not only

meets their needs, it improves your practice. Patients buy contact lenses from you and return to you more often, typically every year, as opposed to the 2 years or more between visits you can expect from spectacle wearers.

Manage the Dry Eye — Now!

Dry eye begets inflammation, which begets lacrimal gland damage, which begets more dry eye symptoms. It's a vicious cycle. We must do everything we can do to avoid this problem.

 Use antihistamines and mast cell stabilizers for the allergy patient. Wash out the bad byproducts with lens lubricants and eye drops before and after contact lens wear, and in the morning or at night for patients in continuous wear.

We should take aggressive steps to reduce inflammation and corneal damage from contact lenses and solutions. Work to help keep patients more comfortable, avoid lacrimal gland damage, and thus, achieve a wetter, healthier, more comfortable eye.

What Are We Really Talking About?

Identifying and eliminating complications is a diagnosis of exclusion. Rule out physiological problems, such as hypoxia, tight lenses, deposits, solution toxicity and other sources of inflammation, such as infection. Then listen carefully if the patient still says, "My eye doesn't feel good when I wear my contact lenses."

Learn to take a holistic approach. Consider all possibilities, such as changes in lenses, changes in solutions, lid disease, allergies, hydration and underlying inflammation. Here are some other key considerations:

Keep the lens clean. Use a lens care system that has minimal toxicity. And remember that multipurpose solutions are all different in terms of compatibility with different lenses, degree of wettability and interactions with a patient's eye. The complications we see now are subtle. Look closer to see the staining — and use fluorescein and a wratten filter!

Tell patients to use drops before and after contact lens wear. If for no other reason, it will wash away the bad stuff. We have a lot of new, very good components in these lubricants. Read the label for ingredients and be mindful of compatibility issues. Use the drops in a step-wise fashion to see what might work best for each patient, his lens and his lens care regimen.

Tell patients to avoid, if at all possible, medicines and other agents that dehydrate. Alcohol comes to mind. They should also avoid smoke.

Use punctal plugs as a last option. Despite temporary short-term relief, long-term results show that plugs may cause the inflammatory mediators to be retained on the eye, causing long-term complications.

Consider the new silicone hydrogel contact lenses. Manufacturers claim these lenses stay more hydrated on the eye and reduce inflammation by not causing hypoxia.

Facing the Future

In the future, we'll be seeing secretagogues that help secrete a good mucin layer or help the lacrimal gland secrete a better aqueous layer. A number of products, such as a mild steroid for dry eye, could help with secretion and possibly control inflammation. And certainly, vitamins will be a logical choice to stabilize the lipid layer and help the aqueous layer in general.

Questions will continue, but I think we have many answers already. Now it's a matter of doing something about it in practice.



Key Questions ... and Answers

How much of a factor is wettability? We learned from David Meadows, PhD, that according to Alcon's in vitro measurement, Acuvue Advance lenses demonstrate a high contact angle. Yet many of us have had very good clinical results when using Acuvue Advance lenses. So when we put a lens on the eye, the eye can wet the lens, as long as it is put on the eye with a clean hand and it comes out of a good aqueous environment and a conditioning care system. A lens can be biocompatible, even though it seems to start with what appears to be a high contact angle. Further research is needed to fully understand what these wettability measures mean relative to comfort in vivo.

Do silicone hydrogels wet like hydrogels? Certainly not. Silicone will be exposed to the surface, and whether the lens is inherently wettable, like an Acuvue Advance, or whether it's been surface-treated, like CIBA Vision and Bausch & Lomb's lenses, those surfaces are all different. They're going to react differently with different eyes and different solutions.

Can multipurpose solutions change your success or failure ratio? Probably, but we need more research.

—Joseph T. Barr, OD, MS. FAAO (Dipl)

Dr. Barr is associate dean for clinical services and professional program at The Ohio State University College of Optometry in Columbus. He is director of the NEI-sponsored CLEK Photography Reading Center, immediate past chair of the American Academy of Optometry Cornea and Contact Lens Section, and editor of Contact Lens Spectrum magazine.