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Noncompliance With Daily Disposables: The Perfect Storm?

BY ALLAN G. ARED, BOPTOM (UNSW) HONS. GRADCERT (OCULAR THERAPEUTICS)

In Australia, the relative penetrance of daily disposable contact lenses has increased significantly from 7.8 percent in 2002 (Edwards et al, 2009) to 23 percent in 2008 (Morgan et al, 2009). Efron et al (2008) observed daily disposable prescribing patterns and trends over a 12-year period in the United Kingdom and reported that usage was gaining acceptance across the spherical, toric, multifocal, and monovision categories. Daily disposable wearers account for less than 10 percent of lenses prescribed in markets such as Canada, China, and the Netherlands, whereas the U.S. market has doubled from 6 percent in 2004 to 13 percent in 2008. Denmark is still well ahead of the rest of the world with 64 percent of all wearers in daily disposables (Morgan et al, 2009).

While there are variations in penetration regionally, the global trend towards daily disposables is consistently increasing.

Noncompliance With Daily Disposables

We see compliance abuse on many levels with contact lens wearers, including those wearing daily disposables. A sizable proportion of contact lens wearers do not adequately adhere to recommended contact lens care and many have an inadequate understanding of lens care guidelines. The ease with which patients can alter wearing schedules demonstrates the need for greater, more effective patient education.

These risks are magnified when a daily disposable patient is noncompliant. For example, daily disposable lens wearers may wear their lenses overnight, use them for more than a single day, store the lenses improperly, or use poor hygiene when handling the lenses. These examples illustrate the need for greater, more effective patient education.

Here are a few examples in the literature of contact lens noncompliance:

• In a New York contact lens compliance study, approximately 24 percent of patients out of 103 participants stated that they never rubbed or cleaned their lenses prior to disinfecting them. Furthermore, 5 percent of the participants went on to say that they only used saline as their primary mode of disinfection (Ky et al, 1998).
• Dr. Philip Morgan's publication on compliance (2008) confirmed what many of us already suspected: patients generally do not listen, are noncompliant, and many wearers improperly use their contact lens products by using lenses for too many days, sleeping in lenses when daily wear use only has been prescribed, sleeping in lenses for too many nights in the case of extended wear, and topping-off rather than discarding used solution.
• Either deliberately or inadvertently against the advice of their eyecare practitioners, patients slept in lenses that were specifically prescribed for daily disposable use and developed keratitis (Efron et al, 2005).
• Work by Edwards et al based on a 2004 community study showed that disposable lens wearers were less likely to be compliant in rubbing their lenses or in completing all steps when cleaning lenses and that they reuse old stored lenses and have a history of lens-related emergencies.

Clinical Setting

Clinicians in this "post-Fusarium outbreak" world now look at contact lens patients with a far more critical eye. Science has shown that the probability of corneal infection risk could be determined via an algorithm incorporating barrier compromise, contact lens wearing time, and virulence/numbers of pathogens. The science of lens material/lens care solution interaction is far better understood. Practitioners have adapted prescribing procedures to minimize patient risk and maximize patient outcomes, and they follow stringent guidelines to minimize the risk of future perfect storms.

Some practitioners have decided that no solution should be the best solution. Unfortunately, daily disposable lenses, which are supposed to be "solution-free," have the potential to create their own magnified risk in a world of noncompliant patients. In the current uncertain global economic climate, clinicians are now witnessing the signs of perhaps another perfect storm brewing, this time involving the daily disposable lens modality. If you agree that some daily disposable wearers reuse their lenses for several days, ask yourself: How many of our daily disposable lens wearers reuse their daily disposable lenses and the packing solution by storing the lenses in the blister pack? How many are using saline to rinse these lenses? And while compliance is the goal, how can we best protect even noncompliant patients?

The relative ease of internet/mail ordering, the increased sales of daily disposable lenses, and the use of daily disposable lenses on a frequent replacement schedule create increased risk for practitioners and patients. It is not unusual nowadays for a patient to purchase a six-month supply of daily disposable lenses, wear each lens for two or more days, and not be seen again for aftercare for 12 to 24 months. These patients are not trained on how to properly care for their lenses, and it is not unusual for these patients to sleep with the lenses overnight and, worse still, to store the lenses in saline instead of in a multipurpose disinfecting solution (MPS).

Studies have also shown that the suctioning effect of many disposable contact lenses leads to unavoidable overnight wear due to stuck lens syndrome (Dart et al, 2008), a condition which may increase the likelihood of lid parallel conjunctival folds (LIPCOF) (Miller et al, 2003), a notorious marker for contact lens-induced dry eye, discomfort, and patient dropout. It is therefore not surprising to see microbial keratitis in daily disposable contact lens wearing populations is between 2 and 4.2 per 10,000 cases (Stapleton et al, 2008).

What Advice Can We Offer?

Even though I don't advocate reuse of daily disposables, I want to protect even my non-complaint daily disposable patients as best as I can. In situations of saline storage, let me first state the obvious. Saline is attractive to consumers because it is a much cheaper alternative to MPSs and not significantly differentiated on the store shelf. Saline use can be dangerous for reused contact lenses as it does not provide disinfection. Saline solutions also do not have lens wetting systems and are not designed to optimize patient comfort as MPSs are. If patients are prescribed daily disposables, we should inform, instruct, and educate them not to use saline. Proactively tell them that if they use any solution product, make sure it is a multipurpose disinfecting solution, especially if they ever use their lenses for longer than the daily prescribed modality. An MPS that is highly biocompatible would be an excellent safety net for such noncompliant situations. A Polyquad/Aldox-based MPS product is my preferred choice for soft contact lens patients.

In the cases of overnight wear, an enduring risk assessment of the patient should always be considered in the context of informed choice and risk-benefit. Provided that the patient's prescription falls within parameters, silicone hydrogel daily disposable lenses should be the material of choice for these patients, along with the regular use of rewetting drops.

Contact lens practitioners can prevent and manage a wide variety of contact lens complications. While monumental advances have occurred in lens materials, we still do not have the perfect lens material, not to mention the perfectly compliant patient. Daily disposable lenses have not reduced the overall risk of acute non-ulcerative disorders, and in some cases (noncompliant patients) they may increase risk. Contact lenses must be treated as medical devices. The gravity of proper compliance and lens care, along with the list of potential negative outcomes, must be properly communicated to every patient, guaranteeing proper instruction to your anonymous noncompliant individuals. CLS

To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #174.

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Dr. Ared is currently senior sports vision consultant to the NSW Institute of Sport's 700 athletes based at the Olympic stadium in Sydney, Australia. He is a therapeutically trained optometrist with clinical interests in medical optometry.