KIDS AND DAILY DISPOSABLES

Fitting Tweens and Teens With Daily Disposables

A change in attitude could pave the way for increased practice profit as well as happier kids and parents.

By Joel A. Silbert, OD, FAAO, Dipl.

Dr. Silbert is a professor of Optometry and director of the Cornea & Specialty Contact Lens Service at The Eye Institute, Pennsylvania College of Optometry, Salus University, Philadelphia, Pa.

The use of one-day disposable contact lenses has markedly increased over the past several years. According to a recent HPR Contact Lens Report, there was a 15.2 percent increase between 2006 and 2007 for daily disposable lenses, with a slightly larger increase for monthly planned replacement lenses (+19 percent) and a decrease for two-week planned replacement lenses (–1.4 percent) for the same time period. Although these data apply to all contact lens wearers, the question arises: Who would benefit most from one-day disposable lenses? Practitioners have prescribed planned replacement contact lenses (two-week or monthly) for so many years that we've been generally slow to accept the one-day modality — until lately. Why, then, the change in attitude?

The one-day modality has been increasingly embraced not only for the overall health benefits it affords, but especially for improved patient compliance. Addressing concerns triggered by the nationwide solution recalls, practitioners and patients alike have begun to realize the benefits of a wearing modality that does not require a lens care regimen, as well as a modality that simultaneously provides excellent comfort and freedom from daily cleaning.

Who Would Benefit Most?

Given these overall advantages of ocular health and comfort, the population that would benefit most from one-day disposable lenses would logically be children and teenagers. For kids between the ages of 8-to-12, refractive correction typically means eyeglasses. Many teens between 13-to-17 years of age who require refractive correction are already wearing contact lenses but, like their parents, are using two-week or monthly replacement lenses. A practitioner's reluctance to offer contact lenses to children is often based on a perception of increased chair time as well as the potential for children to manifest greater side effects with contact lenses compared to teens.

These issues were laid to rest with the Contact Lenses in Pediatrics (CLIP) Study (Walline et al, 2001), which assessed 84 children (ages 8-to-12) and 85 teens (ages 13-to-17) who were thoroughly examined and fitted with planned replacement, daily wear lenses. The study clearly showed that the difference in chair time between children and teens averaged only 10 minutes longer for children for placement/removal training and only 15 minutes longer overall during the three-month follow-up period (for traditional planned replacement lenses).

The results also revealed that there were no serious adverse complications in either group during the three-month study and no significant differences in slit lamp biomicroscopic findings between children and teens. The study introduced a questionnaire for these patients that sought to survey quality of life (QOL) issues for children wearing eyeglasses. The Pediatric Refractive Error Profile (PREP) scores for children increased 23 percent (from 64.4 percent to 79.2 percent) and for teens increased 24 percent (from 61.8 percent to 76.5 percent). The CLIP Study gave real credence to the safety profile of soft lens wear when routinely offered as a treatment for refractive error for children, and also demonstrated that both kids and teenagers gained greater satisfaction with refractive correction as well as improved self-perception in both appearance and participation in activities while wearing contact lenses (French, 2008; Walline et al, 2007).

Identifying Perceptions and Attitudes

With this backdrop, then, I believe the question of one-day disposables for pre-teens ("tweens") and teens deserves an in-depth analysis. With lens safety having been established, we need to focus on attitudes and concerns of the patients (the tweens and teens), the parents who must give their approval and who likely will pay for the treatment, and the eyecare practitioners who must first recommend the option and then provide the fitting and aftercare. I'll review the perspectives of all three constituencies to determine whether one-day disposables should be more widely prescribed for young patients.

As the process generally begins with clinicians recommending treatment options for correction of refractive errors, we must ask whether one-day disposables figure significantly in these options. Unless a practitioner clearly believes in the modality's benefits for young patients, it may never be presented, thus losing not only practice income but also the opportunity to satisfy the needs of these patients. You need to be an advocate for young patients in getting approval from their parents. In addition, parents need to be informed of the advantages of one-day disposables over traditional planned replacement lenses and shown that they can also be cost-effective.

In 2007, a nationwide survey was conducted for CooperVision Inc. by the Rochester Research Group to explore the opportunities of daily disposable contact lens wear for the 10-to-18-year-old population. Although daily disposables logically offer simplified care and convenience, the question remains as to whether the three aforementioned "decision-makers" would agree in making this option work successfully.

The survey included 598 online interviews of parents who had 10-to-18-year-old children who need vision correction and who currently wear glasses and/or contact lenses. The survey was first directed to the parents who subsequently turned the survey over to their tweens or teens to answer the remaining questions. This technique afforded an analysis of household attitudes while at the same time allowing for legal access and interviewing of participating minors.

The survey also included 382 participating optometrists via the CooperVision OD Panel. Statistically robust, the parent and tween/teen samples were associated with a precision interval of ±4 percent, and the OD sample was associated with a precision interval of ±5 percent. Both had a confidence level of 95 percent.

What, then, are the attitudes and concerns of the tweens and teens who participated in this survey regarding daily disposable lenses?

Tweens' and Teens' Perspectives

Of the 585 subjects surveyed, 43 percent were male and 57 percent were female. The age distribution was 23 percent pre-teen (ages 10-to-12), 39 percent younger teens (ages 13-to-15), and 38 percent older teens (ages 16-to-18). Two-thirds of the subjects needed full-time correction, while one-third required only part-time correction. A little more than one-half of the subjects wore eyeglasses only, while 35 percent wore both eyeglasses and contact lenses and only 7 percent wore contact lenses exclusively. Subjects were asked to comment regarding their attitudes towards glasses or contact lenses. From the comments provided about the "best aspects" of glasses, the following themes emerged:

• Fashionable
• Require low maintenance compared to traditional contact lenses (planned replacement)
• Give eyes a rest after contact lens wear
• Easier to use when not at home

When asked about the "worst aspects" of eyeglasses, the following themes presented:

• Easy to lose, break, or scratch
• A hassle for sports and athletic activities
• Annoying, bulky, and uncomfortable
• Socially unacceptable; and peer ridicule: "nerdy"

The following themes emerged from the survey, when these subjects were asked about the "worst things" about wearing contact lenses:

• Discomfort and irritation
• Hassle to handle, clean, and maintain
• Risk of infection
• Cost

And finally, the subjects' overall attitudes about the "best things" about wearing contact lenses:

• Looks, appearance, and improved confidence
• Stable during physical activities
• More comfortable than glasses
• Difficult to misplace, break, or scratch compared to glasses

When asked what they preferred to wear at school, the overwhelming preference, regardless of age or gender, was contact lenses. This was also true for sports or for going out with friends. For the group who solely used eyeglasses, one in three expressed an identical preference. In surveying those who wear eyeglasses exclusively, contact lenses exclusively, or those who use both, the clear preference in every group was for contact lens wear within every usage context: school (52 percent), going out with friends (60 percent), sports (69 percent), special occasions (63 percent), and in general (43 percent) (Figure 1).

Figure 1. Tweens/Teens overall preference profile.

When asked about their familiarity with the difference between planned replacement soft lenses (PRP, two-week or monthly) and daily disposables, only 7 percent knew that daily disposables existed (n = 585). The responses to this question showed no gender difference, and varied by age as follows:

• Pre-teen: 57 percent familiar
• Young teen: 79 percent familiar
• Older teen: 88 percent familiar

When asked about the relative merits of PRP lenses versus daily disposables "for someone like you," the responses encompassing "great idea" and "good idea" totaled 59 percent for PRP lenses versus 71 percent for daily disposables. Comments from those favoring daily disposables included:

• Less hassles — no cleaning or maintenance
• Less chance of infection
• No worry about losing or damaging lenses

Comments that were less than favorable regarding dailies included:

• Presumably more expensive than PRP lenses
• Wasteful — bad for the environment
• Need to buy a lot of lenses all at once
• Fresh contact lenses don't feel as comfortable as lenses that have been "broken in"

And when surveyed about the benefits of using daily disposables for part-time use, i.e. "certain occasions like sports or dating," the results encompassing the "great idea" and "good idea" responses were as follows (n = 585):

• Pre-teens (72 percent)
• Young teens (69 percent)
• Older teens (62 percent)

An interesting question regarding costs of lens wear included the following: "Assuming that the overall cost was about the same as what you're already wearing, do you think your parents would consider these new daily disposable lenses to be a great, good, fair, or poor idea for you?" (n = 585, percent indicating "great idea" and "good idea"):

• Pre-teen (68 percent)
• Young teen (65 percent)
• Older teen (67 percent)
• Use eyeglasses only (60 percent)
• Use contact lenses only (58 percent)
• Use both glasses and contact lenses (80 percent)

In summary, both tweens and teens are quite aware of daily disposable lenses and feel that they would be advantageous for general use; for part-time wear; and particularly for special occasions, sports, and social activities. They also rightfully express concerns regarding costs for their parents and, as we would expect of this generation, a concern for the environment.

The Parents' Perspectives

Of the subjects surveyed (n = 590), parents' responses indicate that 43 percent of 10-to-18 year olds were currently wearing contact lenses (57 percent not doing so). Of those tweens/teens wearing contact lenses, 31 percent requested them themselves, 14 percent got them as a result of a practitioner's recommendation, and 9 percent received them after parental recommendation.

When surveyed about what they saw as the benefits of their pre-teen or teenager wearing contact lenses instead of glasses, the following themes emerged:

• Increased self-esteem and confidence; socially more acceptable; and feel less "nerdy"
• Improved appearance
• Enables greater activity, including sports, dance, etc.
• Less likely to scratch, break, or lose than eyeglasses
• Better comfort than glasses

When asked about their perceptions regarding the drawbacks of their pre-teens or teenagers wearing contact lenses, comments were noted as follows:

• Need for maintenance and care
• Potential eye irritation or infection
• Upkeep and hassle factor
• Lack of responsibility; maturity issues; and easy to misplace
• Cost/expense

When the parents were asked about their own off-spring's habits with the question, "Would handling and hygiene associated with contact lens wear be a major or minor concern?":

• 37 percent expressed a major concern
• 43 percent expressed a minor concern
• 20 percent expressed no concern at all

So, for every 10 responding parents (n = 586), four would be majorly concerned, four would be minorly concerned, and two would be unconcerned about contact lens-related handling and hygiene issues, implying that solving this problem could interest eight out of 10 parents — half of them compellingly.

In the survey sample, 56 percent of parents felt that PRP contact lenses sounded like a "great" or "good" idea for their children. Parents expressed more concern for pre-teens and boys, and less for older teens and girls. Positive attitudes were related to greater economy of wear and to the idea of teaching responsibility with a contact lens that is not that difficult to care for. Negative attitudes toward PRP lenses revolved around concerns that PRP lenses require too much responsibility for nightly maintenance and that proper cleaning and handling was too much of a hassle.

When asked about their perceptions of daily disposables, 58 percent of parents felt it was a "great" or "good" idea (n = 586) across the board for all ages. Positive attitudes included:

• Ease and simplicity of use without cleaning
• Good for occasions when cleaning of typical contact lenses would be a hassle or too much of a responsibility
• Less risk of infection
• Little worry about costly contact lenses getting lost or damaged

Less than fully positive concerns about daily disposables included:

• Does not teach responsibility
• Perceived higher cost
• Encourages attitude that "disposable is good"
• Environmental concerns

When asked about the benefits of having a supply of one-day disposable lenses for selected occasions such as sports or dating, parental attitudes were 52 percent in favor, thinking it was a "great" or "good" idea (n = 586) for tweens and teens. But when presented with the same question for their own personal use, 43 percent were in favor, showing that tweens/teens represented a target user group 9 percent riper than their parents.

Parents were surveyed about their attitudes toward allowing their tweens/teens to use daily disposables if they were manufactured by a reputable company and recommended as an appropriate choice by their eyecare practitioner. Nearly two out of three respondents described themselves as likely to permit their child to get daily disposables. Trust in their eyecare practitioner's endorsement was a key factor among parents. Yet, the positive attributes of daily disposables as a better choice (including advantages of cleanliness, ease of use, convenience, and less risk of infection) were tempered by concerns that the price differential between daily disposable lenses and PRP lenses needed to be minimal.

Practitioners' Perspectives on Daily Disposables

Having explored the perspectives about daily disposable lenses of both tweens/teens and their parents, the final step in the analysis was to examine eyecare practitioners' perspectives regarding this lens modality for 10-to-18 year olds. This was underscored by the finding that for both tweens/teens and their parents, the recommendation and endorsement of their eyecare practitioner would be an important part of their decision-making. The decision-making process in favor of daily disposable lenses being chosen over PRP lenses as a better match depends on:

• Motivation by tweens/teens to initiate the request
• The parental gate-keeping function, granting permission
• The eyecare professionals' gate-keeping function

The optometrist panel included 382 practitioners who were surveyed online by the Rochester Research Group, with 60 percent of participating optometrists having prescribed daily disposables at a fairly low level: 29 percent reported fitting one-to-nine young patients per year and 31 percent reported fitting from 10-to-49 young patients per year. Even in this higher prescribing group, this would represent less than one patient per week. At the ends of the distribution curve, 12 percent were not prescribing daily disposables to young patients at all, but 18 percent were doing so very aggressively (Figure 2).

Figure 2. Frequency of prescribing daily disposable lenses (n = 382).

When asked about what percentage of all contact lenses prescribed for 10-to-18 year olds were daily disposables, 49 percent of the panel were currently fitting fewer than 10 percent of their young patients with these lenses. On the other hand, 14 percent were already using daily disposables as the predominant choice for their young patients. Such an extreme variation in response shows the opportunity available for a large percentage of practitioners to expand this segment of their contact lens practices.

More than two-thirds of respondents felt that the trend for daily disposable use among tweens/teens is increasing. The reasons given included:

• Easy to use and no hassle of cleaning
• Safety; less risk of infection; and optimal health benefits
• Eliminates need for contact lens solutions

Reasons given from those who feel that daily disposable growth will likely remain the same included:

• Cost issues
• Preference by some patients for PRP lenses over daily disposables
• Daily disposables not yet available in silicone hydrogel materials
• Concern that daily disposable lenses would be overworn and not replaced each day

The optometrist panel was surveyed regarding in which scenarios in the life of 10-to-18 year olds would daily disposables be "most appropriate." Typical responses included:

• Part-time wearers and occasional contact lens users
• Active sports
• Special occasions
• Travel
• Patients who have allergies and frequent lens deposition
• Patients who have hygiene issues (who may not be capable of performing daily cleaning required by other modalities)

In fact, 71 percent of optometrist respondents considered daily disposable lenses to be a "great choice" as a young patient's part-time lens, and 94 percent considered that they are at least a "good choice" in that context.

Given that 32 percent of responding tweens/teens indicated that their vision correction needs were part-time, it seems clear that daily disposables prescribed for this purpose can be a significant advantage in a prescribing practitioner's practice.

Optometrists were surveyed about their perspectives regarding marketing approaches for daily disposables for 10-to-18 year olds. Figure 3 shows the varied marketing techniques that received either a "great idea" or a "good idea" response. The most frequent responses from the 382 practitioners favored a significant initial rebate for new wearers purchasing a one-year supply, as well as consumer-directed advertising that targets parents as well as the tweens and teens themselves.

Figure 3. Hierarchy of optometrist-endorsed marketing approaches (percent great + good idea).

Conclusion

We have learned much from the results of this nationwide survey of tweens/teens and their parents, and of optometrists regarding daily disposables for 10-to-18 year olds. First, tweens and teens have issues of self-esteem, confidence, cosmetics, and the need for social acceptance by their peers. Despite today's fashion emphasis on eyeglasses, most pre-teens and teens want to look "normal" and certainly not "nerdy." Contact lenses can satisfy most of these needs, but many young people who need refractive corrections are wearing (and sometimes refusing to wear) prescription eyeglasses. One-third of these young people need only part-time correction. Onehalf of glasses-only users want contact lenses for when they go out socially with friends. Many want part-time contact lens wear for activities such as sports, dance, and other physical activities. Daily disposables certainly "fit the bill" and can positively meet the needs of this group.

Parents have concerns about safety and compliance with their kids' usage of PRP lenses. They are stressed by the costs of lost and damaged glasses. In some cases, when glasses are lost or broken, the child goes without correction until the next regular eye exam. In other cases, when glasses are purchased, many young people do not or will not wear them because of cosmetic issues and/or peer-ridicule. You can educate parents about the merits of daily disposables provided you can show that their costs are not significantly higher than the cost of traditional PRP lenses and their associated solutions. Parents trust the recommendations of their eyecare practitioner on a wide array of ocular and health issues and would likely choose daily disposables if the modality were recommended for their children or teenagers.

Finally, doctors appreciate the increased safety profile of daily disposable lenses and the inherent improvements in compliance that they afford. There has been historic reticence to recommend daily disposables to the adult population because of perceived cost issues, and this has extended to younger patients. However, there are clear benefits and needs for these lenses, and a great opportunity for practices to increase utilization of daily disposables with the tweens/teens sector. Industry also needs to partner with eyecare practitioners in providing consumer educational materials, direct advertising, and incentives such as rebates to help parents afford the initial purchase and to keep prices for this "value-added" benefit affordable thereafter.

Practitioners need to proactively recommend daily disposable lenses to both parents and tweens/teens instead of falling back on the philosophy of "if it ain't broke…" And practitioners who currently are not recommending daily disposables need to consider altering their habits as others have successfully done within their profession. CLS

Dr. Silbert received an honorarium from CooperVision for this article.

For references, please visit www.clspectrum.com/references.asp and click on document #161.