Contact Lenses & Vision
The Annual Report

BY JOSEPH T. BARR, O.D., M.S.
JAN. 1997

In our annual state of the industry report, we examine the issues and developments that impacted contact lens practice in 1996 and what to look forward to in the coming months.

Spurred by a good U.S. economy, nearly three million people started wearing contact lenses in 1996. Who are these new wearers? They're baby boomers who continue to want contact lenses, even in presbyopia, and their often myopic teen-age sons and daughters who are good candidates for contact lenses. Yet, as many people or more may have dropped out of contact lens wear last year. Apparently, we're not doing well enough at keeping presbyopes in contact lenses and at minimizing lens drying and lens care hassles.

1996 IN RETROSPECT

According to Bausch & Lomb's Trends in Lens Care 1996, beyond the dropout problem (as many as 3.5 million in 1995), there is a decline in the frequency of in-office lens care instruction and a rise in mail-order lens purchases.

It's possible that many practitioners don't offer contact lenses enough because they don't think they're worth the effort. They should be encouraged to know that contact lens failures (about 13 million in the United States) try an average of three times before giving up. Half of those who try again are interested in disposable soft contact lenses.

Sixty percent of new contact lens wearers are age 25 or younger. This explains why nearly every manufacturer is trying to help prescribers cater to these young patients. About one-third of teen-agers (ages 12 to 17) who need vision correction wear contact lenses, compared with about 20 percent of all patients in the United States. To capture and retain the teen population, it's important to encourage trusting communication (that teens don't perceive as condescending) and promote regular office visits (if you can get them to the office).

Estimates of the percentage of contact lens wearers who purchase contact lenses by mail-order range from one percent to about 15 percent. This figure may have more than doubled in three years. Most commonly these persons order disposable lenses. Thus, disposable lens manufacturers offer programs that allow doctor-determined shipping of lenses from the factory directly to the patient's home or workplace. Most practitioners like this system for patients who are already loyal to their practices. Most of the patients who order their lenses through mail-order do so for convenience once they're educated about the full price. Patients rarely acquire RGPs through mail-order.

Patients reported they are loyal to the lens care system their practitioners prescribe 60 percent of the time. This percentage is decreasing, perhaps due to poor in-office instruction or the patient's perception that disposable lenses need less care. This decline may also be due to contact lens solution manufacturers encouraging patients to switch at the shelf.

By mid-1996, 57 percent of care kits dispensed for new lens prescriptions were one-bottle systems, and this percentage continues to increase.

My conclusion? Baby boomers and their children need the convenience of disposable contact lenses and single-bottle lens care. If we can't deliver this convenience to some patients, then we must explain why we prescribe what we prescribe and we must provide superior service for these difficult-to-manage cases. Otherwise, they'll have trouble accepting why they can't have an easy-to-use system, too.

WHO PRESCRIBES WHAT & HOW OFTEN

Of the 150 million people in the United States who need vision correction, about 25 million wear contact lenses for which they spend about $250 per year. M.D.s dispensed about 12 percent of these lenses in 1996, corporate practices dispensed 30 percent and independent O.D.s, 55 percent. Opticians dispensed the remainder.

About 45 percent of new contact lens prescriptions (either new fits or refits) in the third quarter of 1996 were for disposable lenses (about two percent of those were for one-day lenses), about 20 percent were for planned replacement (one to three months) and 35 percent were for traditional replacement.

Of the current soft lens wearers, 35 percent wear disposables, 10 percent wear frequent replacement spheres and 39 percent wear traditional replacement spheres. About 15 percent of soft lens wearers wear torics and about one percent wear bifocals (Fig. 1).

About 10 percent of new wearers and refits in the United States wear RGP lenses, although one source estimates the total number at 20 percent.

In 1995, 65 percent of the people polled in a Louis Harris survey said they'd had an eye exam in the last year. Contact lens wearers had an exam every 14 months while spectacle wearers had an exam every 17 months.

ECONOMICS

Most of the contact lenses in the United States are prescribed by independent practice O.D.s. Many practitioners don't believe contact lens patients are as profitable as spectacles patients, a fallacy that has been disproved repeatedly. Some manufacturers fear that as optometrists become salaried, they will be less likely to prescribe contact lenses. Yet, chain prescribing is up, probably due to advertising that works.

And what about managed health and vision care? Vision care is incorporated into up to 45 percent of PPOs and HMOs, and contact lenses are included in about 50 percent of these plans. Often the 'plan' simply means that members are entitled to a discount (typically 15% to 20%). Some HMOs look at contact lenses merely as a value-added service, a marketing tool rather than a profit center. Others look at them as a way to make up for money lost in other areas. Most contact lens practitioners hope any new plan they join will not include contact lenses, or if it does, that the discount will be minimal. Optometrists are still struggling to get reimbursed for medical care from many third party providers.

In two recent reviews of large primary care optometry practices perceived to treat more than the typical amount of eye disease, 20 percent and 40 percent of the patients were contact lens patients. While the emphasis in these practices seems to be medical treatment of eye disease, their income centers seem to depend heavily on contact lens care. This is not likely to change.

Many successful practices are seeing many more patients, yet their incomes are flat. They have learned to use automated equipment and trained staff more effectively for all types of care, including contact lenses. If this trend toward having technical assistants deliver contact lens care in high volume practices continues, then either the special needs patients will get sub-par care or they will create an opportunity for the contact lens specialists.

Cole National (Sears Optical) purchased Pearle's 692 outlets, bringing its total to over 1,700. They feel this may make them more attractive to managed vision care and HMOs. Indeed, nearly every eyecare practice in the country is looking for networks that will suit them.

COMPANIES, LENSES & SOLUTIONS

In November, several sources reported rumors that Johnson & Johnson (owners of Vistakon) may be considering buying Bausch & Lomb. Meanwhile, in 1996, B&L featured its new SofLens66 disposable lens and remained the market leader with ReNu one-bottle lens care. The company cut costs and rearranged management while court settlements did not seem to distract doctors significantly.

Some wonder if B&L's incorporation of RGP leader Polymer Technology Corp. into the Rochester operation will change PTC's relationship with its customers or reduce its RGP emphasis. PTC's introduction of Simplicity one-bottle lens care solution had less impact than many expected, but its Boston ES material was well accepted. PTC's market share would indicate that the company is doing well.

CIBA Vision became part of Novartis as parent Ciba-Geigy merged with Sandoz. CIBA's Focus toric lens is the number one selling toric. Toric planned replacement accounted for 46 percent of all new and refit toric soft lens prescription in the third quarter of 1996. The company also introduced visitint NewVues. Another new lens care entry, Pure Eyes, employs a new cleaner/saline and peroxide similar to AOSept. The company also launched SOLO-care, a one-bottle lens care system.

Alcon, Allergan and CIBA Vision are selling their one-bottle lens care systems (Opti-One, Complete and SOLO-care, respectively) at retail under private labels. This is good business for them, but practitioners need to know what is in the bottles their patients are using for lens care. The best way to do this is to compare the ingredients listed on the labels.

Allergan also began manufacturing Claris RGP solution which is sold by Menicon. Menicon sells Claris to practitioners and not to large retailers and will ship directly to patients upon practitioner direction.

Alcon introduced and emphasized its daily protein remover SupraClens. The company introduced but did not emphasize its new Opti-One one-bottle lens care system which now includes a surfactant, unlike the previous Opti-One that was the same solution as Opti-Free and Opti-Free Express.

Wesley Jessen acquired Pilkington Barnes Hind and continued to emphasize its FreshLook and other designs in opaque and OptiFit colors and its (PBH) Precision UV disposable lens. WJ surveys indicate 90 percent of patients are interested in UV protection. The FTC required WJ to divest its Natural Touch opaque colored lens in the United States to assure competitiveness.

Biocompatibles emphasized the uniqueness of its Proclear lens material and seems likely to expand its line.

Sunsoft introduced Sunsoft Multifocal. Molded with Essilor technology, the two front-surface, concentric add designs may have an impact on the presbyopic market. Sunsoft and others need to enter the multipackage soft toric competition now led by CIBA and CooperVision.

CooperVision gained market share with its Preference Toric planned replacement toric lens.

The LifeStyle Frequency Progressive disposable multifocal was tried by many; marketing was transferred to Specialty Ultravision.

Specialty Ultravision introduced Specialty Choice A.B. frequent replacement lenses and Specialty T-FRP torics as well as the Specialty Progressive in blister packs.

Ocular Sciences-American Hydron gained share with its Biomedics brands. Larger firms watch as this company's price deals, private labeling, telemarketing and low overhead works for them.

Probably the most interesting RGP news is Paragon's plan to promote FluoroPerm 151 material for frequent replacement and extended wear. Although neither concept is common in practitioners' RGP treatment plans, this material has the transmissibility to improve oxygen delivery, and frequent replacement will provide added convenience. Time will tell if practitioners will adopt either RGP extended wear or planned replacement.

Rand Scientific introduced Transfocal back aspheric multifocals, Transvision back aspheric single vision lenses, Extra dark red lenses and PMMA Classic material.

REFRACTIVE SURGERY & OTHER OPTIONS

While Idaho optometrists were told not to perform PRK, O.D.s in Oklahoma waited their turn to test the courts. Most practitioners agree that the $2,000 per eye fee for permanent vision improvement makes most people wait or never undergo the procedure, especially since RK is often a more economical alternative. Others believe that many former refractive surgery candidates (the 'easier' cases) have already had RK or PRK in Canada. Increasingly, and for lower and lower Rx's (down to two and a half diopters), LASIK (laser assisted automated in situ keratomileusis or 'flap and zap') is the procedure of choice. As technology improves and surgeons and manufacturers learn how to market the procedures, other 'competitors' such as the intrastromal corneal ring, holmium laser thermokeratoplasty for hyperopia, and water pressure keratectomy will expand the refractive surgery market.

Still, refractive surgery promotion drives in patients who often end up in contact lenses. We need a better extended wear contact lens soon to offer an option to refractive surgery for those beyond their teens.

ON THE HORIZON

Bausch & Lomb hopes to bring its daily disposable lens (manufactured in Scotland) on line in the next year. CIBA will also deliver a one-day disposable product in the United States soon. B&L, CIBA, Vistakon and others are investigating silicone and other high Dk 'soft lenses' for better 30-day wear. Many forget that 30-day extended wear was once approved by the FDA. It is again the goal.

One recent study showed that ulcer rates are lower with current lenses, perhaps due to less extended wear and probably due to more frequent lens replacement. It's ironic that when patients don't throw away their lenses as prescribed and then present with the infrequent corneal infiltrates and ulcers, they are 'misusing' their lenses, but the noncompliant patient who does not develop complications is 'frugal.'

More and more, the price of disposable lenses to the practitioner is going down. Even Vistakon increased discounting to more accounts in 1996. This helps the practitioner's bottom line, while rebate deals on disposables help the patient's bottom line. But reduced profits for manufacturers will surely stifle progress in contact lens development. The glut of contact lenses continues.

Specialty Ultravision not only marketed soft lenses but sought FDA approval for its Ultracon semisoft, high Dk material for spherical lenses, and its EpiCon lens for keratoconus.

Corneaplasty has orthokeratologists and some corneal specialists excited. After injecting an enzyme into the corneal stroma, a rigid contact lens is used to reshape the cornea. Over a year of shape change stability is possible. A clinical study is underway.

A FORECAST FOR 1997

Even in regions where managed care has a strong foothold, word-of-mouth referrals based on good care will remain the best sources of new patients. Manufacturers will keep improving lenses slowly and many will assist practitioners with practice financial analysis. Our contact lens practices will be comprised of mostly the early- to mid-presbyopes (people we can keep comfortable enough with good enough vision) and teen-agers and young adults. It has become the norm for patients to own multiple pairs of lenses. Simpler systems for lens prescribing and care will prevail except in the few demanding cases that require special attention. RGP studies regarding myopia progression in children will take on added significance in the next few years. CLS

Thanks to all who provided information, advice and review of this report.

Dr. Barr is assistant dean for clinical affairs at The Ohio State University College of Optometry, a diplomate of the Cornea & Contact Lens Section of the AAO and editor of Contact Lens Spectrum.