Compliance Realities and Care Solutions

Even if you're already pushing compliance, you may want to push harder

Compliance Realities and Care Solutions

Even if you're already pushing compliance, you may want to push harder.

Dr. Potter: We know that compliance is pretty poor in many of our patients. One study showed that 50% of our patients have no idea when they're supposed to return for follow up (Wu, 2010), and another showed that 50% of our patients don't wash their hands before handling contact lenses (Stone, 2007). When it comes to contact lenses and care solutions, what's your experience with patient compliance?

Dr. Brujic: It's been well documented that about 50% of people either top off or re-use their contact lens care solution (CLC Press Release, 2007). I thought that there was no way that this could be correct. So, for 2 weeks, I asked patients when they came in, “How often are you replacing your contact lens care solution in your case with fresh solution from the bottle?” Sure enough, about half of them told me that they reuse their care solution. These were people I thought would never do this!

They said they replaced their care solution “every few days,” which usually means they're waiting twice as long to replace their care solution. When I asked, “How do you know when it is time to replace it?” they answered, “When it's dirty.” I asked what they meant by “dirty” and they replied with, “When I see stuff floating around in there.” That's the reality. People are reusing their contact lens care solution.


Dr. Potter: How does your knowledge of patients' non-compliance affect your choice of care solution?

Dr. Brujic: Unfortuantely, there is significant non-compliance with our contact lens wearers. In light of this fact, I select care solutions with a high level of disinfection and I educate all of my patients about their lenses and their care solution. I drive home the brands they'll be using.

Dr. Potter: Your concern about branding rings true. For any type of product, people's use of branded products tends to decline as they get more experience with it (MSW Survey, 2008).

Dr. Brujic: When people are new to contact lenses, they do exactly what we tell them to, but as they wear contact lenses longer, they tend to deviate from our initial instructions. It may be our fault. It may be an education deficiency. Patients seem to believe that they don't really need to be careful because they have no problems. But non-compliance can affect comfort over time.

Dr. Sindt: I think it's human nature. The first couple times I tell my children to do something, they just do it. Then they start to test what happens if they just do it halfway or don't do it at all. Can we do less work without a negative result? What can we get away with?

It's human nature, and contact lens wearers are no different. When we see them, we just ask if they're having any problems. If they say “no”, we move on to the next patient. We're not asking the important questions. We're not reinforcing our message.

Dr. Brujic: Practitioners generally become more complacent with long-term contact lens wearers. We assume they're doing what we asked them to do initially, and patients may become more complacent with their contact lens wear.

Dr. Mayers: Yes, I think we tend to slack off with the existing wearers in private practices because we're busy and we assume our “experienced” patients know what they're doing. But we should never assume this is true. It's very important to take that time and re-educate patients every time they're in our office.


Dr. Potter: The habits we're talking about—for example, patients who don't wash their hands before they insert or remove their lenses—can introduce bioburden onto contact lenses. How big a problem is this?

Dr. Szcotka-Flynn: A major source of bioburden comes from the hands (Szczotka-Flynn, Eye Contact Lens, 2010). To a certain degree, the body can overcome the problem. In one study, researchers had patients handle their lenses, then they cultured the lenses (Mowrey-McKee, 1992). The patients also handled the lenses, then wore the lenses for 5 hours, and researchers cultured them again. After lens handling, the lenses were not clean, but the level of contamination after 5 hours of wear was 22-65 times lower than the initial contamination level induced by lens handling. The eye has a tremendous ability to kill those organisms.

Dr. Sindt: Prospective studies show that almost all wearers are non-compliant (Yeung, 2010). Furthermore, a study published last year concluded that 80% of patients understand the risks of non-compliance, but they continue to be non-compliant (Bui, 2010).

Also keep in mind that some of your problem-free and complaint-free patients may be non-compliant, too. So education helps, but we need to keep pursuing better products.


Dr. Potter: If talking about how non-compliance can risk patients' ocular health doesn't make a major impact on their behavior, what does? We're prescribing care solution to make sure they have the right one, but is there anything we can we say to make patients follow our instructions?

Dr. Brujic: We spend a lot of our time talking about potential adverse events because we have an ethical obligation to keep our patients both healthy and complication-free. But it's interesting to see what our patients find most important. Studies (Young, 2002; Dumbleton, 2010) show that about half of contact lens wearers are uncomfortable, and about half of dropouts cite discomfort as their reason for discontinuing contact lens wear.

Comfort hits home for people because it ultimately either enables or limits their ability to wear contact lenses.

If I talk to an established contact lens wearer who is over-using his contact lenses and not using the care solution I recommended, but he has never had any complications, I feel a discussion of adverse events won't be as effective as a discussion about comfort. It's also important to remember that patients experiencing end-of-day discomfort may minimize complaints because of a belief it may mean they have to stop wearing contact lenses.

For these patients, I don't talk about adverse events to reinforce compliance. I talk about comfort. “You know when your contact lenses feel dry and uncomfortable toward the end of the wearing period? That's not how they're supposed to feel,” I say. “I have patients in the practice who wear contact lenses like you do, and eventually they stop wearing them because they're uncomfortable. I want you to be able to wear contact lenses and never have comfort limit your ability to do so. That's why I'm going to ask you to do a few things. One, replace your contact lenses according to this schedule. And two, use this contact lens care solution.”

If the patient brings in a different care solution at the next visit, then I chart his non-compliance and write the prescription for the care system. I don't normally do that if I see that a patient is compliant.

Dr. Potter: It's interesting that you emphasize the recommendation. It's clearly what makes the difference. Our recommendations do carry a lot of weight. I also like that you take a comfort approach to your discussion with patients. I think talk about adverse events can get a little abstract for patients, but we can all relate to comfort.


Dr. Potter: Realistically speaking, we have a finite amount of time. As clinicians, we pick our battles. If you have a returning patient that's doing great, are you going to talk to him about care solutions again? This year, you have other things to discuss, so maybe that battle can wait until next year. We've talked about having that written prescription for a care solution. Do you have any other strategies for driving home compliance while keeping a realistic chair time?

Dr. Sindt: Doctors are pressured to see more patients at a faster rate. Conversations get shortened. And because of that, using supplemental written materials—for example, lid hygiene handouts—is very important. We can use support staff to deliver some information as well, so the compliance message comes from every layer of the practice, not just the doctor. Patients hear it from the technician. They hear it from the front desk staff when they call. It's a consistent message from everybody.

Dr. Brujic: The conversation takes a few minutes, but those minutes are in the best interest of the patient, and that ultimately will be in the best interest of your practice. CLS

Behlau I, Gilmore MS. Microbial biofilms in ophthalmology and infectious disease. Arch Ophthalmol 2008;126(11):1572-1581.
Bui TH, Cavanagh HD, Robertson DM. Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens 2010;36(6):334-339.
Carnt N. Daily Wear Adverse Events. July 2009. Available at: Accessed January 12, 2011.
Christie C, Meyler JG. Contemporary contact lens care products. Contact Lens Ant Eye 1997;20 Suppl:S11-S17.
Contact Lens Council Press Release; August 8, 2007.
Dumbleton K, Keir N, Moezzi A, Feng Y, Jones L, Fonn D. Objective and subjective responses in patients refitted to daily-wear silicone hydrogel contact lenses. Optom Vis Sci 2006 Oct;83(10):758-68.
Dumbleton K, Woods C, Jones L, Richter D, Fonn D. Comfort and vision with silicone hydrogel lenses: effect of compliance. Optom Vis Sci 2010;87(6):421-425.
Elder MJ, Stapleton F, Evans E, Dart JK. Biofilm-related infections in ophthalmology. Eye (Lond). 1995;9(Pt 1):102-109.
Hughes R, Kilvington S. Comparison of hydrogen peroxide contact lens disinfection systems and solutions against Acanthamoeba polyphaga. Antimicrob Agents Chemother 2001;45(7):2038-2043.
Imamura Y, Chandra J, Mukherjee PK, Lattif AA, et al. Fusarium and Candida albicans biofilms on soft contact lenses: model development, influence of lens type and susceptibility to lens care solutions. Antimicrob Agents Chemother 2008;52(1):171-182.
Khardori N, Yassien M. Biofilms in device-related infections. J Ind Microbiol 1995;15(3):141-147.
McLaughlin-Borlace L, Stapleton F, Matheson M, Dart JK. Bacterial biofilm on contact lenses and lens storage cases in wearers with microbial keratitis. J Appl Microbiol 1998;84(5):827-838.
Meadows D. Measuring wettability. Contact Lens Spectrum April 2005.
Miller J, Powell S, Espejo L, et al. Solution recommendations for soft contact lens wearers. Poster presented at AOA; June 2010; Orlando, FL.
Mowrey-McKee MF, Sampson HJ, Proskin HM. Microbial contamination of hydrophilic contact lenses. Part II: Quantitation of microbes after patient Handling and after aseptic removal from the eye. CLAO J 1992:18(4):240-244.
MSW attitude and usage survey, Market Performance Group, LLC. Survey of 1000 patients, November 2008.
Nichols J. Contact Lenses 2009. Contact Lens Spectrum. January 2010. Available at: www. Last accessed October 2010.
Patel JD, Ebert M, Stokes K, Ward R, Anderson JM. Inhibition of bacterial and leukocyte adhesion under shear stress conditions by material surface chemistry. J Biomater Sci Polym Ed 2003;14(3):279-295.
Personal communication between Loretta Szczotka-Flynn, OD, PhD, and Mahmoud Ghannoum regarding yet to be published laboratory work.
Rosenthal RA, Dassanayake NL, Schlitzer RL, Schlech BA, Meadows DL, Stone RP. Biocide uptake in contact lenses and loss of fungicidal activity during storage of contact lenses. Eye Contact Lens 2006;32(6):262-266.
Rosenthal RA, McAnally CL, et al. High capacity disinfection of contact lenses. Poster presented during the annual meeting of the British Contact Lens Association, 2001.
Schneider S, Woods CA, Fonn D. Hyper-reflective cells observed by confocal microscopy with staining caused by different lens-solution combinations. Optom Vis Sci 2009;85:e-abstract95912.
Stapleton F, Dart J. Pseudomonas keratitis associated with biofilm formation on a disposable soft contact lens. Br J Ophthalmol 1995;79(9):864-865.
Stapleton F, Dart J, Matheson M, Woodward EG. Bacterial adherence and glycocalyx formation on unworn hydrogel lenses. J Br Contact Lens Assoc 1993;16(3):113-117.
Stone R. The Importance of Compliance: Focusing on the Key Steps. Poster presented at BCLA, May 2007, Manchester, UK.
Sweeney DF. Clinical signs of hypoxia with high-Dk soft lens extended wear: is the cornea convinced? Eye Contact Lens 2003;29(1Suppl):S22-25.
Szczotka-Flynn L, Diaz-Insua M. Risk of infiltrates with traditional hydrogel and silicone hydrogel extended wear: a meta analysis. Optom Vis Sci 2007;84(4):1-10.
Szczotka-Flynn L, Lass J, Sethi A, et al. Risk factors for corneal infiltrative events during continuous wear of silicone hydrogel contact lenses. Invest Ophthalmol Vis Sci 2010;51(11):5421-5430.
Szczotka-Flynn L, Bajaksouzian S, Jacobs M, Rimm A. Risk factors for contact lens bacterial contamination during continuous wear. Optom Vis Sci 2009;86(11):1216-1226.
Szczotka-Flynn LB, Imamura Y, Chandra J, et al. Increased resistance of contact lens-related bacterial biofilms to antimicrobial activity of soft contact lens care solutions. Cornea 2009;28(8):918-926.
Szczotka-Flynn L, Pearlman E, Ghannoum M. Microbial Contamination of Contact Lenses, lens care solutions, and their accessories: a literature review. Eye & Contact Lens 2010. 36(2):116-29.
Wu Y, Carnt N, Stapleton F. Contact lens user profile, attitudes and level of compliance to lens care. Cont Lens Anterior Eye 2010;33(4):183-188.
Yeung KK, Forister JF, Forister EF, Chung MY, Han S, Weissman BA. Compliance with soft contact lens replacement schedules and associated contact lens-related ocular complications: The UCLA Contact Lens Study. Optometry 2010;81(11):598-607.
Young G, Keir N, Hunt C, Woods CA. Clinical evaluation of long-term users of two contact lens care preservative systems. Eye Contact Lens 2009;35(2):50-58.
Young G, Veys J, Pritchard N, Coleman S. A multi-centre study of lapsed contact lens wearers. Ophthalmic Physiol Opt 2002;22(6):516-527.
Zegans ME, Becker HI, Budzik J, O'Toole G. The role of bacterial biofilms in ocular infections. DNA Cell Biol 2002;21(5-6):415-420.
Zegans ME, Shanks RM, O'Toole GA. Bacterial biofilms and ocular infections. Ocul Surf 2005;3(2):73-80.
Zhao Z, Carnt NA, Aliwarga Y, et al. Care regimen and lens material influence on silicone hydrogel contact lens deposition. Optom Vis Sci 2009;86(3):251-259.
Zhao Z, Naduvilath T, Flanagan JL, et al. Contact lens deposits, adverse responses, and clinical ocular surface parameters. Optom Vis Sci 2010;87(9):669-674.