Entering a New Age of Contact Lenses

The Contact Lens Spectrum
Decade Report

BY JOSEPH T. BARR, O.D., M.S.
JAN. 1996

The contact lens market is flat. Or is it? The very fact that manufacturers are still willing to put their R&D efforts into developing a contact lens with more deposit resistance, optimal convenience and continuous safety proves that the growth potential for the industry is huge. This year's decade report (to celebrate the 10th anniversary of Contact Lens Spectrum) provides a fresh perspective of the way things were and what we can expect in the future. We have a lot to be proud of and even more to look forward to.

Many of our industry consultants thought the availability of one-day disposable lenses was the most important event in 1995. Although only a small percentage of wearers will be prescribed this device, the debut of such a quality, inexpensive lens (whether it's worn every day, five days per week, one day per week or one day per month) changes the field again.

Mel Freeman, M.D., nominated the FDA approval of Summit Technology's excimer laser the "event of the decade." "The wise practitioner will offer PRK care and contact lenses and spectacles to a public interested in optimal vision correction for their needs," he said, and many others agree. James Aquavella, M.D., states that the contact lens industry will decline as PRK marketers target contact lens wearers and manufacturers cut back on their contact lens research.

REFRACTIVE SURGERY

As of mid-December, hundreds of FDA-approved PRK procedures were performed in the United States with hundreds more scheduled. Areas where excimer lasers are already retrofitted for PRK will see a multimedia advertising blitz aimed at the consumer in early 1996. Unless forward-thinking doctors and practice networks communicate their willingness to work with patients to obtain refractive surgery (or to make a mutual decision not to) then the risk of patient flight directly to refractive surgery centers will be substantial.

If five percent of the 60 million U.S. myopes elect to have PRK, that would be three million procedures. Distributed over three years, that's a million procedures per year compared to about one-third as many radial keratotomies in the past year. But preparation of laser centers takes time and even if there were enough lasers in place, that's still only about 20 procedures per U.S. eyecare practitioner per year or less than two per month. Many O.D.s will be trained in pre- and post-op care of the PRK patient but few will actually comanage and even fewer will profit from it. No one should underestimate that surgeons will be surgeons and, to their credit, refractive surgery will get better and better and become more and more commonplace.

Numerous experts agree that the media blitz associated with PRK will heighten awareness of all types of vision correction and increase contact lens use. Certainly, many of the patients who ask about refractive surgery but don't choose it (they'll outnumber takers by about 20 to 1) will opt for contact lenses. Perhaps 10 percent of younger patients will wear contact lenses after refractive surgery. Keep in mind that people don't want to wear spectacles and as Joe Goldberg, O.D., points out, multifocal or monovision contact lenses may increasingly appeal to the post-refractive surgery presbyope.

CONTACT LENS CARE

There is much debate about whether or not the practice of contact lens care will grow, stagnate or decline.

Internationally, there will be substantial growth in Latin America, the Pacific Rim and eastern Europe thanks to educational programs from the International Association of Contact Lens Educators, U.S. schools of optometry and perhaps from the Contact Lens Association of Ophthalmology. However, if education does not precede sales, the negative impact of contact lens misuse may be hard to overcome beyond the year 2000.

Half of the contact lens wearers on the planet live outside the United States, and this will likely decrease to one-third in the next decade, since population growth in the United States is not keeping pace with the rest of the world.

In the United States, practitioners faced with managed care, PPOs, HMOs and the like will be pressured to provide very efficient contact lens care to those who have contact lens care as part of their "plans." Indeed many believe that the pressure to do more for less in these plans will lead to poorer care and they argue that it would be better if fee-for-service and supply and demand were allowed to operate. Interestingly, this is likely to be the case with refractive surgery as it is in plastic surgery. Recent surveys show that where elective cosmetic surgery is not regulated nor a part of third-party coverage, fees are generally dictated by a free market and are stable. If managed care plans include contact lens care, they'll stimulate patient use; if they don't, they'll encourage the practitioner to provide contact lenses in the good old fee-for-service way.

The distribution of who provides contact lens care has changed little in the past years and it's unlikely to change soon. Optometrists will continue to emphasize contact lenses, ophthalmologists will continue to think of them as an add-on to their practices and until opticians gain political organization and better training, they too will see slow growth in contact lenses. Currently, about 12 percent of new fits are purchased through M.D. offices. Thirty-one percent of new fits come from retail chains with the remainder in optometry offices.

Regardless of who pays for the care, practitioners will need to measure outcomes and be prepared to document quality. In fact, with the high level of competency needed to manage advanced contact lens and refractive surgery care, the public may shift back to demanding more from their doctors and focus less on cost. Total quality management is a worldwide standard from private practice to the largest corporation to the government. To maintain successful contact lens practices, eyecare practitioners need to embrace it as well.

Yet, the lay press and retailers are likely to continue to trivialize contact lenses. Some groups will try to cripple the industry by encouraging stories like the Business Week attack on Bausch & Lomb and the DateLine attack on the contact lens industry. Certainly, lawyers will emphasize contact lenses' adverse effects and the FDA will keep them heavily regulated. But, as Dr. Neal Bailey always said, these horror stories and the continued misinformation about the risks of disposable lenses (really the increased risks of extended wear) will not deter future growth in contact lenses.

WHAT'S NEW?

We can expect to see more disposables such as PBH's Precision UV, Ocular Sciences' Biomedics 55 and B&L's Soflens 66 as well as the one-day disposable lenses from J&J and B&L. Interestingly, even though only a small percentage of patients wear 1-Day Acuvue, sales were beyond J&J's original projection. In fact, 1996 is expected to be the best year ever for frequently replaced lenses. Don't be surprised if contact lens manufacturers find a way to capitalize on the wait-and-see group who want more data on PRK or second generation laser vision correction. Manufacturers will expand their disposable lens lines.

The following developments are indicative of the vast improvements in contact lens manufacturing and distribution in the past decade:

• Direct to patient delivery by major manufacturers and distributors grew in 1995 and will continue to do so.
• Biocompatibles, Norfolk, Va., entered the U.S. market (from England) with its Proclear, phosphorylcholine material, lens.
• Wesley-Jessen, Chicago, changed hands and is now owned by the Bain Capital Group. It celebrated its 50th anniversary while releasing FreshLook Colors lenses in 6-packs.
• PBH, San Diego, sold Paragon to Summit Partners (not the laser company) and its solution business to Allergan.
• Cooper/Coast, Fairport, N.Y., reported wider acceptance of its Preference toric for planned replacement and introduced a conventional wear tetrafilcon Cooper toric.
• CIBA Vision, Duluth, Ga., launched Pure Eyes, an improved hydrogen peroxide lens care system.
• Permeable Technologies, Morganville, N.J., led by Leonard Seidner, O.D., created the LifeStyle Company to market its RGP multifocal leader LifeStyle Highrider and its new Frequency Progressive disposable soft multifocal.
• OcuTec, Morrisville, N.C., changed its name to Novavision and offered Novawet Perception, a multiaspheric multifocal.
• Blanchard of Montreal planned to offer its Esstech soft multifocal, available as Esspheric II, in RGP material from MidFlorida Contacts.
• With its new program "Practical advice for Practice Renewal," B&L, Rochester, N.Y., joins a host of companies sponsoring contact lens practice-enhancement aids. Alcon and B&L are both expected to introduce new products in 1996.
• Conforma, Norfolk, Va., will introduce a VFL 4 lens and perhaps a World Wide Web site.
• CIBA Vision claims that Focus Toric is now the most often fitted toric soft contact lens.
• Allergan, Irvine, Calif., promoted its Complete one-bottle system and bottled the same for mass merchandisers. Other products similar to B&L's ReNu are expected.
• Benz Research, Sarasota, Fla., will market the Benz-G 55 glycerol methacrylate material.
• More bifocal lenses are available. To maximize presbyopic contact lens correction, more practitioners are offering two or three options after monovision (which is now FDA approved.) Paragon, Phoenix, Ariz., and numerous RGP laboratories such as TruForm, AC, Metro Optics and C&H emphasized bifocals in 1995. Menicon promoted its concentric and segmented bifocals with an efficient fitting system.
• Polymer Technology Corp., Wilmington, Mass., launched two new materials, Boston 7 and Boston ES, and two new lens care systems, Boston Advance Comfort Formula (to replace Advance) and Simplicity. The latter contains Neutraclens, which enhances cleaning while neutralizing potential surfactant irritation, the manufacturer claims.

One indicator of ophthalmologists' interest in working with optometrists was the on-again, off-again agreement with LensCrafters. Many will watch to see if Luxottica's purchase of LensCrafters prompts other manufacturers in the optical field to vertically integrate.

Though many claim that dropout rates are down due to frequent lens replacement, there's little compelling evidence that this is true.

Providers have combated the recent growth of mail-order contact lens flow by lowering replacement cost and sometimes raising professional fees. This discourages practitioners from recommending contact lenses since they think they're not profitable for good candidates. But they'll continue to be interested in keeping patients in their practices regardless of which device or procedure they use for refractive correction.

PREDICTIONS FOR THE NEXT FIVE YEARS

• Use of disposable and frequent replacement lenses will expand and be adapted to patients' needs and not to a certain day/week/month schedule. More toric and bifocal lenses will be available in this category.
• Lens cleaners will improve faster than rinsing/disinfecting solutions.
• Better extended wear lenses will be available but their safety will be challenged by the year 2000.
• RGP lens designs will improve with advanced aspheric technology but the number of wearers will stay about the same. Slow progress will be made in linking corneal mapping to RGP lens fitting of inventory and custom-designed lenses. As in the past, the experienced RGP fitter will do most of the work and profit most from those who need RGPs. RGP lens patients are 10 times less likely to order lenses from mail-order, which may motivate practitioners to consider prescribing this modality more often.
• Adjunctive therapies that allow more comfortable and safer hydrogel and RGP lens wear, such as drugs and punctal plugs, will grow.
• Increased understanding of myopia and orthokeratology may influence contact lens prescribing trends.
• Improved refractive surgery and better ablation methods and shapes will be developed.
• Concerns about mandatory prescription release and chaotic patient flight to mail-order providers continues to frighten contact lens practitioners. Is pharmacy a future analogy -- where drug chains have 25 percent market share, hospitals and independents each have only about 20 percent and mail-order and mass merchants each have about 7.5 percent?

Clearly, we've experienced a tremendous amount of growth over the past decade and many other changes, both positive and negative, are yet to come. But the continued interest in perfecting the ideal contact lens and contact lens care system proves that the industry has a tremendous amount of potential and will stand firm against refractive surgery, managed care and alternative distribution. CLS

The author would like to thank all of the companies, educators and private practitioners who contributed to this report.