CONTINUOUS WEAR
Getting Started with Silicone Hydrogel Contact Lenses
Your patients have heard about refractive surgery. But if they want continuous vision, why not give them a non-surgical option?
By N. Rex Ghormley, OD, FAAO

Our patients want the joy and convenience of continuous vision. Several times a day a patient will say, "Dr. Ghormley, tell me about that surgery that will correct my vision." What patients are really asking for is the ability to see continuously without wearing glasses or without the daily hassle of applying, removing, cleaning and disinfecting contact lenses.

Patients can achieve continuous vision through one of three ways: refractive surgery, orthokeratology and continuous wear contact lenses. Progressive practitioners offer several options to patients who ask about that "miracle refractive surgery." A new generation of soft silicone hydrogel contact lenses is now a viable option for patients who want continuous vision. Using the Focus Night & Day lens (lotrafilcon A, CIBA Vision) as an example, I'll explain why.

Nothing to Worry About

Many practitioners are concerned about the safety of continuous wear contact lenses. Personally, I don't think this is a serious issue as long as your practice does the following:

• Thorough pre-fitting exam
• Good patient selection
• Patient education program
• Scheduled follow-up lens care.

In my 30 years of practice, I've never had a patient permanently lose a line of vision from a continuous wear contact lens. Even with a low Dk/t contact lens, we've minimized contact lens-related complications by adhering to the aforementioned protocol. Now ask yourself how many radial keratotomy (RK), photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) patients in your practice have permanently lost a line of vision? With this new contact lens technology and proper professional care on your part, you should rarely see severe contact lens complications.

Keeping Tabs for Safety's Sake

Focus Night & Day will be one of the most monitored contact lenses ever released in the United States. CIBA Vision plans to sponsor the following studies on the Night & Day lenses:

• An FDA post-market study to monitor adverse events with 5,000 patients
• A post-market 36-month study beginning in January 2002 with 20 doctors monitoring 20 patients for three years
• Additional epidemiological studies looking at the current microbial keratitis (MK) rates for silicone hydrogels

Choosing Candidates

What patients are good candidates for new silicone hydrogel continuous wear contact lenses? Those who have a constant need for a vision correction and have a busy lifestyle. Moderate to high myopes are perfect candidates for this new modality. But don't rule out hyperopic patients, because the high Dk/t of silicone hydrogel lenses will allow many hyperopic patients to wear this lens successfully on a continuous wear schedule.

Remember that patients who ask about refractive surgery are really just interested in continuous vision, so you need to inform them that surgery isn't their only option. During your patient consultation, present all options that are available to achieve continuous vision. You should give all current patients who wear low Dk/t disposable lenses for flexible wear or for one week of continuous wear the option to "upgrade" to a newer lens that will allow them to expand their wearing period. During your typical day at the office, you'll find many patients who are excellent candidates for this new lens modality. So once you find a good candidate, what do you do next?

Taking Candidates to the Next Step

Perform a diagnostic trial lens fitting on all potential patients. Also evaluate visual acuity, lens comfort and the fit of the contact lens. A trial lens needs to settle on the eye for approximately 10 to 15 minutes. It's not uncommon for a patient to initially report a slight degree of "lens awareness" with this contact lens because of the increased modulus of the lens material.

Observe lens centration and movement with the biomicroscope. The push-up test should show between 0.1mm to 0.5mm in lens movement. Silicone hydrogel lenses do move more on the eye than most spherical soft lenses, and this is an important factor in successful continuous wear. A well-fit lens is centered, comfortable and has no edge lift or fluting. A flat lens will show excessive lens movement, edge lift, lens fluting and poor lens comfort. A tight lens may have little or no lens movement as well as vessel impingement.

Following Up

Because of the material's high degree of oxygen transmission, you can be aggressive in recommending a wearing and office visit schedule. I recommend that a new contact lens patient wear Night & Day lenses full time every day for one week. It isn't necessary to "build up" the wearing time. If the patient is adapting well, then I start him on continuous wear at the one-week office visit and schedule follow-up office visits for one week and 30 days. At the 30-day office visit, I give the patient a six-month supply of lenses. For patients who are current soft lens wearers, I skip the one week of full-time daily wear and start them immediately on a continuous wear schedule with a one-week and 30-day office visit. I see all patients every six months to evaluate vision, lens comfort and ocular health.

What You Can Expect

At the conclusion of its 12-month FDA study involving 1,316 eyes, CIBA Vision found the following average wearing schedule with the Night & Day contact lens:

• 6.9 percent of the patients achieved from eight to 14 consecutive nights of continuous wear
• 14 percent achieved 15 to 21 consecutive nights
• 67.2 percent achieved 22 to 30 consecutive nights

The average wearing time was 26 or more consecutive nights of continuous wear.

In my practice, I've discovered satisfied patients, increased patient referrals and contact lens practice growth. Patients want simple, "hassle-free" contact lenses that provide good continuous vision. Embracing this modality in your practice will re-energize your practice by exciting doctors, staff and patients.

Moving Ahead: Continuous Wear

Evaluate your business and determine if your practice is ready for the next generation of continuous wear contact lenses. You should develop a practice education program to educate your staff and your patients about this new technology. You need to eliminate the perception that sleeping in contact lenses is bad. It's even a good idea to fit your staff members with this new lens so they can share their continuous vision experiences with your patients. And, consider wearing them yourself.

I believe that silicone hydrogel soft lenses will become the contact lens of choice in this decade. Low Dk/t hydrogel lenses will go to the contact lens graveyard just like polymethylmethacrylate (PMMA) and low Dk/t rigid lenses did years ago. These lenses are comfortable, they provide excellent visual acuity, they're manufactured from a hyper Dk/t lens material and they satisfy patients' need for continuous vision.

Dr. Ghormley is in private practice in St. louis, MO. He is a past president of the American Academy of Optometry and a Diplomate of its Cornea & Contact Lens Section. He is also the team optometrist for the St. Louis Rams (NFL) and the St. Louis Blues (NHL).