Combating Patient Noncompliance

Steps to help keep your contact lens patients on the right track
and increase compliance within your practice.

A Contact Lens Staff Report
DECEMBER 1999

If you're like most contact lens practitioners, one of your most frustrating patient issues is noncompliance with lens care and use. Compliance with the appropriate use of lens care products has been reported to range from only 26 to 46 percent (Collins, 1986; Chun, 1987; Sokol, 1990).

Although patients know they need to take care of their contact lenses and use them correctly, they often fail to do so, which may lead to eye inflammation, infection and unnecessary drop-out rates.

The reasons for noncompliance vary for each patient. For instance, some patients may not have been properly educated about lens care. "I think that with the competition out there and the variety of contact lens sources available, there are probably a lot of patients who don't get started on the right track," says Chris Snyder, O.D., professor at the University of Alabama, Birmingham, School of Optometry.

In addition, because of media advertisements and the fact that contact lenses are so easily accessible nowadays, people have lost sight of the fact that they are medical devices. "A lot of people think that contact lenses are just commodities," Dr. Snyder says. "They think they don't need to be taken seriously. The idea that there's even any risk with lens wear gets downgraded significantly."

"Other patients who are well aware of the risks may choose to take a chance anyway," he explains.

Common Issues

Although there are many types of noncompliance with contact lenses, several types occur most frequently.

Wearing daily wear lenses overnight -- "In this day and age of disposable lenses, patients think the word 'disposable' means extended wear," says Burt Dubow, O.D., senior doctor at Minnesota Vision Group. As a result, some patients wear their daily wear contact lenses overnight, which can create a hypoxic situation in the eye or even infection.

"Very often, patients can wear daily wear lenses that feel great, but they try sleeping in them and feel terrible," Dr. Dubow says. "Sometimes patients feel fine and don't realize that they're causing problems until much later. There are also a lot of 'closet' extended wear patients who wear their lenses overnight because it's convenient, but don't tell their doctor."

Wearing lenses too long -- Although the U.S. Food and Drug Administration (FDA) recommended several years ago that patients shouldn't wear extended wear lenses longer than six nights consecutively, there are still abuses. "Even when advised to wear them no longer than six nights or seven days in a row, patients will stretch that for two to three weeks," says Dr. Snyder. "If the lenses feel good and patients can see fine, they figure, 'Hey, I can do this.' And they do it almost regardless of what we recommend." However, such patients are only inviting problems. "The evidence in scientific literature shows that the risk of corneal ulcers increases dramatically with each consecutive night of extended wear, particularly with soft lenses," he says. Such complications could result in vision loss or, in extreme cases, loss of the eye.

Not switching lenses often enough -- Patients who wear disposable lenses or rigid gas permeable lenses (RGPs) often wear them long after they should have been discarded. "As we look at the statistics of when patients buy their lenses, unless they're not wearing their lenses on a full-time basis, they usually don't purchase enough lenses for the year to meet the number of days," says Bobby Christensen, O.D., who is in group practice with Heritage Park Vision Source in Midwest City, Oklahoma. He explains that these statistics refer to patients who purchase their lenses from the practice, rather than from alternate sources.

Many patients who wear RGPs formerly wore lenses crafted from other materials that lasted longer. "Most RGP-wearers seem to always want to have an endurance contest of how long they can make their lenses last," Dr. Christensen says. "A lot of times their lenses are worn out way before they seek care. They're coated with protein or they're warped or damaged in some manner." Often, these patients are also not caring for their lenses properly. "We see them come in with inflamed eyes, poor vision and sometimes with giant papillary conjunctivitis (GPC). They tried to make their lenses last two or three years when the lens will only last about one year."

"Patients don't understand why it's dangerous to over wear contact lenses when they are beyond their service life," says Dr. Dubow. "The lenses get dirty, full of bacteria, change in shape, and the surfaces get worn. Contact lenses are porous, especially soft lenses, and can create all kinds of problems when they get old. This is a major reason why people become uncomfortable, get red eyes and even drop out."

Improper cleaning -- Patients may also become complacent in caring for their lenses--not washing their hands, using solutions or cleaners improperly or not cleaning or throwing away their lens cases as recommended. Sometimes they choose generic products, believing that they are identical to the prescribed care system, and may have an allergic reaction. They may also mix incompatible system components. "It's kind of like going into a chemistry lab and starting to throw a bunch of chemicals together," Dr. Christensen says. "Every now and then you end up with something toxic or inflammatory."

Often, if a patient is having problems, they can be traced back to a simple solution incompatibility. Many times, the lenses are not a direct cause of the problem, but the patient may just not be compatible with their care products if they have chosen off-the-shelf products, says Glenda Secor, O.D., who is in private practice in Huntington Beach, California.

Other patients may opt not to use solutions at all. "Some patients gravitate back to using water and rinsing the lenses off," says Dr. Christensen. As a result, they may experience inflammation, infection or allergic reactions. "Probably the number one cause of patients dropping out of contact lenses is incorrect solution use," says Dr. Dubow. "It continues to be a major problem for us."

Not returning for regular examinations -- When patients fail to return for regular examinations, they lose touch with their practitioners and may forget how to care for their contact lenses properly. "When they come in and we catch that they're so far off what they should be doing, we can really get them back on track and reinforce why they need to be changing their lenses more often or doing what we're encouraging them to do," Dr. Secor says.

Some patients in their 40s and 50s may also experience difficulty with their lenses because of changes in their tear chemistry, causing them to cease lens wear. If they haven't seen their practitioners, they may not be aware of options that may help them. "Despite a high drop-out rate with this group of patients, all of them really want to wear contact lenses," states Dr. Christensen. "They just have become uncomfortable, and sometimes, they don't feel that there's a solution to the problem when there actually is." Practitioners can also take this opportunity to introduce bifocal contact lenses to patients who are having difficulty reading.

Taking other risks -- Practitioners are also concerned about people trying on other people's lenses. According to Dr. Snyder, this is particularly true with teens, who often swap opaque lenses. Some people also obtain lenses without a prescription. "I wish contact lenses would be respected more as medical devices available by prescription only and be purchased and worn under the care of a licensed practitioner," he says.

Getting Patients Back on Track

Although you can't live your patients' lives for them, here are some steps you can take to help ensure they comply with your recommendations and instructions for healthy contact lens wear:

Educate your patients -- Practitioners agree that a major key to patient compliance is education and re-education. "At every visit each patient should be continually educated about their health and safety, and about proper lens wearing and care systems," Dr. Dubow says. He explains that it's important to develop a good relationship with patients. "Spend time with them, understand their needs, personalities and situations," he says. "As you develop this relationship, you and your staff will become intimately involved in educating the patient about why these issues are important to successful contact lens wear." He emphasizes that practitioners should develop systems of education, including written materials and verbal training during patient visits.

"In addition to quizzing patients about their lens care routine, it's important that practitioners also monitor their patients' actions," Dr. Secor comments. "A lot of times patients don't know the brand name of the product they're using, but they'll recognize it by sight. You can figure out whether they're on target, and try to reinforce why they need to be on a recommended care system and use it properly."

"Once a year we ask our patients to bring everything in with them--their solutions, their cases, anything they use on their lenses," says Dr. Dubow. "During the work-up, the technician looks at every bottle and case to see whether it's clean or dirty, what the expiration dates on the bottles are, whether the tips of the bottles are clean, and again, retrains the patient on all the rules and reasons why being compliant is so important."

During these visits, Dr. Christensen advises that you tell patients about all of the potential problems they may encounter. "Explaining the risks is an important part of being a competent contact lens practitioner because, as with anything else, there are certain risks that are associated with contact lens wear," he explains. Patients must be advised to call their practitioner at the first sign of a problem so that it can be treated before it becomes more serious.

Dr. Christensen feels it's important to tell patients that one of the most important issues with contact lens wear is eliminating germs. "They need to be sure that the system they're using kills germs at the highest level that's available. The second part of that equation is to be sure that the system includes the ability to remove protein from the surface of the lens because it builds up and becomes an irritant to the conjunctiva and eyelids," he states.

"It's important for the doctor to recommend the solution and care system and for the staff member to reinforce them," Dr. Christensen says. If practitioners don't emphasize how important these systems are, patients will tend to buy the least expensive solutions or generic brands. "They look on the shelf and see a store brand box that's a similar color to the recommended solution," he explains. "They tend to think that they're all the same thing, but many of them have totally different preservative systems. Some of them contain preservative systems that can cause reactions and irritation in as much as 10 percent of the population that uses them." Also, when a practitioner emphasizes a specific care system, patients may be less likely to inadvertently try a product containing a component they reacted to in the past. To further reinforce which system a patient should use, Dr. Christensen provides them with a sample of the proper solution.

After instructing a first-time lens wearer on proper lens care and the potential risks associated with lens wear, many practitioners ask patients to sign a consent form indicating that they understand and accept the responsibilities involved. This is done particularly with extended wear contact lens patients.

Involve your staff -- In addition to educating your patients, it's important to communicate with your staff about compliance during day-to-day operations and meetings. "You need to have staff members who are concerned about educating the patient," Dr. Dubow argues. "They need to know exactly what ingredients all of the solutions contain, how they work and why one works better than another," Dr. Christensen maintains. "Be sure to inform them whenever a new solution becomes available and make the appropriate changes. Tell them which types of lenses it may work well on and which types of lenses it may not work well on. Making sure that your staff members know how to explain solutions and care systems and combine the right care systems with the right material is the best way to ensure compliance."

Dr. Secor's staff makes sure patients return for their visits and are scheduled appropriately. They must be trained on how to deal with noncompliant patients, she says. "The staff has to buy into the opinion that patients have to come in and that there are reasons for that," she explains. "They have to be able to convince these people on the phone that they need to come in." She emphasizes that it's important for the people answering the telephone to know as much as the contact lens technicians. "You have to communicate to your staff that what you're doing is important and let them know why it has to be done," she says. "They have to know why it's important to change lenses because the staff can head off a lot of problems before they happen. This way, they will know if somebody calls in two years later for replacement lenses when their lenses were only supposed to last them three months."

Schedule regular visits -- "Practitioners have to see their patients," Dr. Secor says, explaining that this connection is important in keeping patients on track. Even for patients who have been wearing lenses successfully for some time, she insists on annual visits at the least. "We laughingly call them 'blessing' visits," she says. "These visits assure the patient that everything is going okay, and they reassure me that nothing unexpected is going to creep up and surprise us. These visits allow us to touch base on how things are working out for our patients and also give us an opportunity if we want to try something new."

To be sure patients return for regular office visits, Dr. Secor's staff schedules appointments well in advance. "You need a recall system where you will catch people who don't come in," she remarks. "If you pre-appoint them and you realize they're missing appointments, it's easier for a staff person to stay on top of it. It's good patient management to make sure they don't get too far away from you."

Practice what you preach -- "Practitioners should develop a consistent philosophy of care and stick to it," says Dr. Dubow. "If you think patients should wear lenses only on a daily basis and never sleep in them, don't give your best friend extended wear lenses and no one else. Once you've broken your philosophy, your staff and your patients won't believe in it anymore. Cracks in the internal systems of the office create noncompliant patients."

Tailor lens care solutions to patients -- "Some practitioners try to use one solution for every patient. I don't think that's appropriate," Dr. Dubow asserts. "You can have your favorites, but you have to have knowledge of and be able to prescribe different care systems for different patients, depending upon their needs. I think doing this enhances compliance because if everybody gets only one thing, it may seem unimportant, whereas if you tailor your prescriptions for each individual patient, it may be taken more seriously."

Encourage patients to buy their lenses from your practice -- When patients turn to alternate sources for their lenses, it becomes more difficult for practitioners to be sure that they are using them properly. "Practitioners can monitor compliance schedules more accurately when patients are purchasing their lenses directly from the practitioner," Dr. Secor says. She explains that when someone calls the office for a new supply, the staff can pull the patient's chart to check the date of his last visit and schedule an exam if necessary. "You're more aware of what's going on with that patient and what they're doing if you're able to catch blatantly noncompliant patients with things like that," she explains. "To remain competitive, we've priced our lenses so that it's not unreasonable to purchase them from us," says Dr. Snyder. "This way we know they're using exactly what we prescribed. When they take the prescription elsewhere, we always write 'no substitutions allowed,' and yet these things still happen."

Encouraging patient compliance is an ongoing process, requiring practitioners to keep the lines of communication open. "You always have to talk about it and reinforce why it's important," says Dr. Secor. "If you really believe it, patients will sense that and they'll understand that it's not just verbiage, that there is a purpose behind encouraging them to do the things you encourage them to do. I still have compliant patients who get infections. You cannot completely eliminate these problems, but you can certainly help to make them less frequent, less severe and less of an issue for everyone involved."