The Contact Lens Spectrum Millennium Report

By Joe Barr, O.D., M.S. and the Contact Lens Spectrum Staff
JANUARY 2000

This report provides a comprehensive review of the past revolutions in contact lens wear in addition to forecasting the future of the industry.

We estimate, using round numbers, that there are about 80 million contact lens wearers on the planet (according to Holden, et al.), with nearly 33 million in the United States alone. This nearly 12 percent of the U.S. population includes 50 percent of those who need vision correction between the ages of 18 and 34. There are more contact lenses for more purposes today that are safer and better manufactured than ever before. Investment in contact lens research, manufacturing and marketing is strong. In the early part of this century, the market for contact lenses worldwide will be $3 billion. The market for contact lens care solutions at the manufacturers' level will be approaching $1 billion. Nearly 90 percent of these sales are for soft contact lenses. Only about 10 to 15 percent of patients routinely use their lenses for extended wear, although perhaps twice this percentage occasionally sleep with their lenses on. Roughly five percent of contact lens wearers in the United States use daily disposables, and we estimate that 40 percent use one- and two-week disposables. Twenty-five percent use planned replacement, and 30 percent remain in conventional lenses. Table 1 shows you how a sample of our readers select contact lenses for their patients.

The Current Situation

Daily wear soft contact lenses recommended for disposing every two weeks are a commonly prescribed modality and cost the practitioner about $10 to $15 per six-pack. Extended wear lenses for monthly replacement cost about twice that amount. Fees for contact lens care have eroded and therefore, net profit to the practitioner for lens care is reduced per patient in most instances. Thus, efficient care is essential, even for complicated cases. If the average patient pays $250 to $300 per year for contact lenses and care products, then the practitioner has about $50 per patient overhead and nets about $100 per patient. This allows the patient to pay about $150 to $200 per year for goods including their common rate of poor compliance with lens care solutions and lenses. Of course, these are very rough estimates. It is also estimated that spectacles cost just over $100 per year, contact lenses cost $260 per year and LASIK costs about $2,000 per eye. Lower cost LASIK is increasingly more available.

Despite the higher risk of losing best corrected vision compared to contact lenses, LASIK continues to find an increasing following. Of the total approximated 140 million people in the U.S. vision care market, about 21 percent will be wearing contact lenses in the year 2000, and about 1.5 percent will have had laser vision correction (CL Spectrum Supp., May 1999). Forbes magazine estimated that one million people would have their eyes lasered in 1999 when it described the "what amounts to a commission" paid by surgeons to the "referring optometrist."

Disposable contact lens unit sales have increased about 30 percent per year in the 1990s. We are approaching 75 percent of contact lens wearers in the United States who use disposable or planned replacement dispensing, including growth of one-day disposable lens use. This percentage of one-day disposable contact lens use should grow even further as it has in the United Kingdom, where debit card use is more accepted and there is more fear of contact lens solution problems.

Substantial growth of specialty soft disposable lenses including torics, colored lenses and bifocals is in action. New fits for soft toric contact lenses have enjoyed double digit growth in the past few years because the lenses are better and available in planned replacement and disposable pricing. Most of us were wrong when we predicted bifocal contact lens growth would never happen. In early 1999, new bifocal lens fits were up about 300 percent primarily due to the introduction of the disposable Vistakon Acuvue Bifocal. Other planned replacement bifocals, such as Sunsoft's Additions, and disposables such as CIBA's Focus Progressive, have pushed this bifocal lens growth spurt even further. There is certainly a paradigm shift in the bifocal and multifocal area, such that now, rather than routinely saying bifocal contact lenses don't work, practitioners are trying them even before monovision.

Patients Want Contact Lenses

And why are contact lenses so rarely recommended by most eye care practitioners? In a recent survey in Australia, practitioners assumed patients were biased toward spectacles and patients were passive about contact lenses. Patients stated that they wanted advice from practitioners about contact lenses, but didn't get it or got negative comments.

How ironic is it that patients want to know about contact lenses but practitioners, fearing failure, don't want to volunteer that information? Patients want contact lenses. In fact, 66 percent or more of them want extended wear if their practitioner recommends it. But practitioners fear that complications, chair time cost and the price of some lenses, including extended wear lenses inhibit their use. At least 20 percent of current soft contact lens wearers occasionally sleep with their lenses in their eyes.

In the United States, about half of the vision care population between the ages of 18 and 34 wear contact lenses, but in most of the rest of the world, this figure is far smaller. Perhaps this is because, although U.S. contact lens practitioner education has been criticized recently, and despite the International Association of Contact Lens Educators' substantial efforts, the United States' education is still more complete. Certainly, cost is not a reason to not recommend contact lenses given the cost of spectacles these days and the low percentage of patients who drop out of contact lens wear due to cost.

Important 1999 and late 90s Events

Bausch & Lomb's introduction of Purevision (100 DK/t) silicone-hydrogel contact lenses in the United States for seven-day extended wear and CIBA Vision's introduction of their Focus Night and Day lens outside the United States was significant. While these lenses allow extended wear with no corneal hypoxia-induced complications, practitioners fear of extended wear ulcers, price and lack of consumer advertising will lead to limited acceptance of the new extended wear. It's expected that approval for 30-day wear in the United States, consumer advertising and the expected publication of fewer corneal ulcers with these lenses will spur increased use.

• The CCLRU reports in one study that five percent of spectacle wearers and 11 percent of one-day disposable lens wearers report drying symptoms and there is no increased adverse reaction rate for 30 versus seven days of extended wear with new silicone-hydrogel extended wear lenses.
• Fifty-six percent of contact lens wearers say their intimate relationships have improved since starting wear.
• The AOA established Clinical Contact Lens Care Guidelines.
• Vistakon launched and heavily advertised it's successful Acuvue 2 disposable contact lens.
• Mail-order companies sold more contact lenses and more Internet contact lens sources were introduced, as practitioners struggled to compete with them. Practitioners report lowering their lens fees, educating patients about the risks of using mail-order sources and using private label contact lenses.
• ANSI is proposing new in-office disinfection guidelines, which can be obtained from the AOA Contact Lens Section.
• Menicon, the first Japanese contact lens manufacturer to enter the U.S. market (in 1991), decided to temporarily reduce U.S. operations in early 2000. Their extended wear Menicon Z study goes forward.
• Black market sales and teenager sharing of cosmetic soft contact lenses caused Wesley-Jessen to ask e-bay (the Internet flea market) to discontinue contact lens sales. Many practitioners mentioned these illicit uses of contact lenses in 1999.
• Alcon's Opti-Free Express with Aldox demonstrated a new level of contact lens disinfection.
• CooperVision's Frequency 55 Aspheric and Specialty UltraVision's Choice A.B. reintroduced the concept of better vision with contact lenses.
• Unilens' EMA and Blanchard's Quattro added to their arsenals of presbyopic options.
• Akorn's D.E.T. (dry eye test) with a more carefully manufactured fluorescein strip, developed by Dr. Don Korb, et al., is said to allow more accurate fluorescein tear break measurement and 95 percent reproducibility.

According to a survey reported by Howard Purcell, O.D., of the American Academy of Optometry (AAO) Section on Cornea and Contact Lens Diplomates, the most important issues to contact lens practitioners are: managed care, the number of contact lens wearers, dry eye, patient compliance, refractive surgery, presbyopia, trivializing contact lenses, fees, specialty contact lenses and RGP contact lens prescribing.

Speculations

Soft toric contact lens manufacturer sales are expected to grow at a rate of 13 percent per year through the year 2,003.Bifocal and multifocal soft contact lens manufacturer sales are expected to grow from about $16 million in 1998 to $184 million in 2003. Cosmetic lens sales are expected to grow from $143 million in 1998 to $230 million in 2003.

Our consulting editors mentioned improved correction of presbyopia, including for refractive surgery patients, as commonplace with contact lenses in the future. They expect to dispense one-day disposable and extended wear contact lenses as well as the same products for astigmatic correction and the combined correction of astigmatism and presbyopia more commonly.

These experts expect improvements in contact lens comfort and reduced "drying" with improved contact lenses. Contact lenses which are antimicrobial or have surfaces that resist deposition and infection are expected. Some believe contact lens use will be the norm for teens and presbyopes, and refractive surgery will be more commonplace for those in between these age groups. Extended wear beyond one year is mentioned as well.

Randy McLaughlin, O.D., M.S., speculates an increase in the fitting of specialty lenses, especially for medical purposes and predicts a decline in simple spherical lens fits because of refractive surgery. Ed Bennett, O.D., M.S., predicts bifocal RGP fitting will increase due to consumer demand and as practitioners become more comfortable fitting them. Glenda Secor, O.D., expects growth in the extended wear toric and bifocal modalities.

Summary

The tension between soft toric and RGP lens use will continue into the next century. Whether there will be enough practitioners who believe in the value of RGPs or soft torics will prove even more successful as they have improved immensely over the past decades is yet to be seen. There will also be ongoing tension between one-day disposable and extended wear lenses playing out the ultimate in safe contact lens wear versus the ultimate in convenient contact lens wear. A revolution in bifocal contact lenses may even be underway.

We've tried to bring you the news and views of contact lenses on these pages for nearly 25 years. In the 1970s, a number of major corporations entered the industry which, in the 1960s and before, was not influenced by major international corporations. Since Contact Lens Forum started in 1976 and Contact Lens Spectrum was founded in 1986, there have been numerous major corporations and contact lenses which have come and gone.

Those who are gone include (just to name a few) Union Corp., 3M, Dow Corning, DuPont, Syntex, Revlon and others. Lenses which have not survived include Silcon silicone elastomer and silicone resin (Dow Corning), and the Advent perfluoroether lens (3M). The contact lens field is competitive and will remain so for the foreseeable future.

As we complete the year 1999, we know that contact lenses are better and safer than ever before. They have been successfully used in war, in outer space, in sports, for cosmetic use or for everyday use as an alternative to spectacles and refractive surgery, and in the care of patients who cannot see optimally without them. More people on the planet wear them than ever and there will be continued growth in the number of wearers. We have the best to date in safer extended wear with silicone-hydrogels pending 30 day FDA approval and the best to date in safety with one-day disposable soft lens use. Increasing numbers of patients must be fitted with these modalities if the contact lens wearer base is to grow. Keeping patients in contact lenses will require better understanding of contact lens comfort and "drying," in addition to a better basic understanding of dry eye in general.

Acknowledgements: Contact Lens Spectrum contributing and consulting editors, lectures by Sylvie Sulaiman and Brian Holden, Rick Franz, Yvonne Green and for Gretchyn Bailey's assistance in preparing this article.

Experts Speak of the Past and Future of Contact Lenses

There are many profitable years yet ahead in the contact lens field, but not with the pizzaz of the past decades. But I see the contact lens field shrinking by the year 2020 (how about that for a coincidence)?

-- Carl Moore, Chairman, RGP Committee, CLMA

The original hydrogel lenses were followed by many others with novel chemistry and ultrathin and high water content lenses catalyzed the development of many other lenses, including the recent silicone-hydrogels. The outcome of the current trend of increasing wear to one month or longer without removing the lens is difficult to predict.

-- Miguel F. Refojo, D.Sc., Senior Scientist Emeritus, Harvard Medical School

The growing attraction of interdisciplinary scientists to the field such as Irv Fatt, Steve Klyce, Brian Tighe, Buddy Ratner and Miguel Refojo adds scientific leverage to the contact lens enterprise. In the future, contact lenses will remain a significant option for the management of refractive error, but with greater compatibility.

-- Richard M. Hill, O.D., Ph.D., Dean Emeritus, The Ohio State University College of Optometry

The greatest advance in the last century was the use of soft gas transmissible materials. In the next century contact lenses will become obsolete except in special instances. But, there will be a period when surface wetting properties will advance with the newer materials.

-- C. Montague Ruben, FRCS, FRCOph. DOMS (England)

Our development of aspheric multifocal RGP and soft contact lenses and being mentored by Dr. David Volk were my most important events in the past decade. Lasik refractive surgery will not eliminate contact lenses just as contact lenses did not replace spectacles. Presbyopic patients will seek aspheric multifocal soft contact lenses to improve post-operative qualitative vision.

-- Joe Goldberg, O.D.

There will be greater growth in the contact lens field in the next century due to increased interest in vision correction driven by laser surgery and more extended wear due to safer materials and the customized fitting due to new instrumentation.

-- Carl Sassano, COO, Bausch & Lomb

The most important event to date has been disposable contact lenses. RGPs will become a specialty item and laser correction will replace most contact lenses. -- Duane Tracy

The introduction of disposable lenses was significant and lenses will become monthly replacement for all types including torics and multifocals. -- David Geffen, O.D.

In the next century, we will have near perfect extended wear and the demise of LASIK as it is performed today. -- Brien Holden, Ph.D.

After 10 or 15 years of daily disposable and continuous wear, I believe refractive surgery will replace contact lenses as an alternative to spectacles in more affluent cultures. RGPs will be used for special situations. Perhaps contact lenses will be the optical correction for the poor.

-- Craig Norman, COT, FCLSA

In the future, we will gain the knowledge and technology to make lenses that will be worn for months on end without removal and that will enhance vision to levels higher than are possible with today's contact lenses. -- Sheldon Wechsler, O.D., M.S.

If contact lenses are to continue as a main avenue of refractive correction, the development of a genuinely full-time wear lens which can be placed in the eye at the initial fitting and left there without necessary removal for a genuinely significant time, and the development of a soft lens material that permits sufficient movement without discomfort across the cornea so that a translating bifocal could be fitted will be required. -- Irv Borish, O.D.

In the next century, I think contact lenses will be accepted more and more. There's been a tremendous improvement in materials and techniques, and a new generation of lenses.

-- Newton Wesley, O.D.

The soft hydrogel lens transformed a limited group of wearers into about 30 million.

-- Mel Remba, O.D.

With the development of soft contact lenses, we were able to fit more people due to factors of comfort and oxygen transmissibility.

-- William Fleischman, O.D.

A major event is reduced cost specialty lenses including soft torics and bifocals.

-- Bruce Onofrey, O.D., RPH

In the next century, I look forward to a lens of hybrid material with high transmissibility, a biocompatible surface, the optics of an RGP and comfort of a soft lens, to be disposed of monthly.

-- Tom Quinn, O.D., M.S.

Soft lenses introduced many new materials. In the future, we'll have better 30-day materials and bifocals.

-- Leonard Seidner, O.D.