LENS WEAR & CARE

Laying the Groundwork for Successful Lens Wear

Your recommendations throughout the fitting and wearing process can help ensure lens wearers' success.

By Ernest L. Bowling, OD, MS, FAAO, Dipl.

One of the more challenging aspects of caring for our patients who wear contact lenses is patient compliance with the wear and care of their contact lenses—in particular, compliance with lens disinfection regimens. Contact lenses are readily available, relatively inexpensive, and seen as a commodity by many patients, not as the medical devices that they are.

Patients who wear contact lenses often show poor compliance, and the concerns of eyecare practitioners regarding lens care compliance are justified. Yung (2007) evaluated compliance levels of experienced contact lens wearers and reported that all subjects showed some degree of non-compliance in the care of their contact lenses or lens care accessories. In a study of college students and health-care workers, de Oliveira (2003) revealed that 54.2 percent of subjects self-reported that they were “not good contact lens wearers.” The authors also reported that 29.9 percent of subjects reported themselves to be “poorly prepared regarding contact lens cleaning and maintenance.”

Given this trend of patient non-compliance, even with the ease of use that multipurpose solutions (MPSs) provide, practitioners can expect that most patients will not consistently use a care solution nor care for their lenses properly. The Fusarium and Acanthamoeba keratitis outbreaks were due in part to patient noncompliance.

The Correct Lens Option

So what are we to do? Compliance is summarized as the shared responsibility of practitioner and patient in a healthcare partnership (Koffler and Karpecki, 2009). We desire the best outcome for our patients.

In my opinion, daily disposables are probably the best mode of wear from a health perspective. The advantage of single-use daily disposable lenses is not only that contact lens solutions become a nonissue, but also that there are no lens cases that need to be cleaned or that can become contaminated. Yet daily disposable lenses are not in many of our patients' vision care plans, which means we have to not only select a contact lens, but an adequate lens care regimen as well. The two go hand in hand.

Practitioners are fitting silicone hydrogel materials in record numbers—82 percent select silicone hydrogel materials for new spherical contact lens patients (Gromacki, 2008). While the silicone hydrogel materials provide good oxygen transmissibility, they still need to be cleaned and disinfected just like any other daily wear contact lens. Many of the lens care solutions on the market today were approved before the advent of silicone hydrogel lenses.

Noncompliance Issues

Multipurpose disinfection solutions have dominated the marketplace since their introduction in the 1990s. Multipurpose disinfection solutions combine the previously independent steps of cleaning, rinsing, disinfecting, enzyme cleaning, and lubricating into one step, by means of a single product. Since 2000, no-rub products containing protein removers started becoming more popular, such as ReNu MultiPlus with Hydranate (Bausch + Lomb [B+L]), Opti-Free Replenish (Alcon Laboratories, Inc), and Complete MoisturePlus (currently unavailable, Abbott Medical Optics [AMO]), to name a few (Watanabe, 2006). Multipurpose disinfection solutions may achieve an improvement in compliance through ease of use via an all-in-one disinfection regimen. Studies have found that MPS compliance is approximately 55 percent (Donshik, 2007). A study evaluating the compliance of oxidative care systems, where noncompliance poses significant risks to both safety and comfort, showed that 91 percent of patients were noncompliant in one or more steps in the lens care regimen (Turner, 1993; Figure 1).

Figure 1. Peripheral corneal infiltrates associated with contact lens use. Inflammatory cells enter the cornea as a response to bacterial exotoxins, toxins, or other eye irritants.

New research has demonstrated that adding a rub step to both multipurpose and peroxide systems reduces or eliminates deposition problems on silicone hydrogel lenses, even in a deposit-prone population (Forister et al, 2009). Digital rubbing removes 90 percent of the debris, and the alternative (in general, 10 seconds of rinsing prior to placing the lens in care solution) is more expensive and could prove less healthy. Yet 41 percent of those using an MPS reported never or almost never rubbing and rinsing their lenses after removing them and before storing them in the lens care solution (Woods, 2010).

Patient compliance with the manufacturers' recommended disinfection regimen is crucial for proper contact lens care. Patient compliance with contact lens care depends, in large part, on patients following the recommended minimum soak time. Yung (2007) discovered that 12 percent of subjects in his study did not soak their lenses for the minimum indicated disinfection time or longer.

The lens care procedures with the poorest levels of compliance are reported to be related to the care of the contact lens case, with Yung (2007) finding the microbial contamination of lens cases to be as high as 40 percent. It has been suggested that biofilm formation, a community of microorganisms attached to a surface, may play a role in the persistence of microorganisms on contact lens cases (DiMatteo, 2004). Care of the contact lens storage case is an often overlooked area of the contact lens care regimen. In April 2007, The American Optometric Association released instructions on preventing Acanthamoeba keratitis. Its recommendations included mechanically scrubbing the inside and outside of the contact lens case with contact lens disinfecting solution, avoiding the use of tap water to wash or store lens cases, and to air dry the lens case when not in use. It is recommended that patients replace lens cases every one to three months. Still, Woods (2010) found in his study that only 21 percent of those using MPS reported cleaning their contact lens case daily and only 24 percent used a lens care solution to do so. More than 50 percent of patients reported using tap water when cleaning their case, and almost a quarter (24 percent) of patients never cleaned their contact lens case! While 41 percent of patients reported replacing their case at least every three months, a higher proportion of those who were noncompliant with recommended contact lens replacement frequency reported that they replace their case once a year or never.

Preventing Noncompliance

To minimize noncompliance and to ensure healthy lens wear, provide a list of recommendations for handling, care, and proper use (Gromacki, 2008).

• Patients should always wash hands with soap and water before handling contact lenses.
• Emphasize with your patients the importance of wearing and replacing lenses according to the prescribed schedule. It will surprise no one to hear that patients often wear their lenses longer than recommended. Woods and a team at the Centre for Contact Lens Research (2010) found that silicone hydrogel wearers who are noncompliant with the replacement interval recommended by the lens manufacturer were also more likely to have poor compliance with respect to recommended lens and case care. Give patients helpful tips on how to change lenses at the recommended interval. For two-week disposable lenses, advise patients to replace them on the first and fifteenth of the month. If patients get paid every two weeks, have them use that as a reminder. For lenses replaced on a monthly basis, patients can be told to replace them on the first of the month, or link it with a monthly activity such as paying the mortgage. Newer computer applications (such as Vistakon's Acuminder) can provide automatic reminders to contact patients via e-mail and text message, and can also remind patients when they are due for their annual contact lens examination.
• Advise patients to follow your specific lens cleaning and storage guidelines. It is important to communicate your choice of lens care solution to the patient while you both are still in the examination room. Studies have shown that patients will follow the recommendations of their practitioner 80 percent of the time (Data on File, Alcon Laboratories).
A study by Forister (2009) found a higher rate of lens complications in patients who use private-label lens care solutions. Patients are bombarded with many choices when they shop for contact lens care solutions and will often buy whatever lens care solution is cheapest. Generic brands are often older formulations of the name brands and can change slightly in composition from quarter to quarter. In fact, many of the current generic lens care solutions predate the new silicone hydrogel materials. More importantly, few of the current generic lens care solutions contain formulations indicated by the Food and Drug Administration (FDA) for use with silicone hydrogel contact lenses.
• Tell patients to always use fresh lens care solution. They should discard used lens care solution and replace it daily. Patients will try to save money by “topping off” lens care solutions. Twenty-two percent of contact lens wearers using MPS reported topping off the lens care solution in their contact lens case occasionally, frequently, or almost every night (Woods, 2010).
• Contact lens wearers should not swim, shower, or use a hot tub while wearing contact lenses.
• Advise patients to remove their contact lenses and call you immediately if they experience symptoms such as redness, pain, tearing, increased light sensitivity, blurry vision, discharge, or swelling.

Patient Education

Along with the proper use of lens care products, patient education is an important part of promoting compliance in lens care. My hope is that one good outcome of the Fusarium and Acanthamoeba outbreaks has been the shifted responsibility of lens care system selection from ancillary staff member to eyecare practitioner. Hopefully, practitioners carefully prescribe contact lens care solutions based on good clinical decision-making, taking into account the patients' contact lens material, wearing and replacement schedule, and eye health.

Patient education, however, does not in itself solve the problem. Morgan (2007) reports that in an Internet survey of 1,402 contact lens wearers, 58 percent of subjects did not rub or rinse their contact lenses during lens care; however, 77 percent of respondents reported being advised regarding proper lens care. Providing written instructions on contact lens care does not ensure compliance, either. Cardona (2004) reported that there was no difference in contact lens care compliance between patients given oral instruction versus oral and written instruction. Still, providing patients a written copy of your lens care solution recommendation aids in reinforcing your choice in lens care system.

Education does not stop with your patients. Both you and your staff have to be on the same page. Your technicians must know your philosophy on proper contact lens care and follow up so that patients will receive a consistent message from whomever they communicate with in your practice.

Contact Lens Aftercare

Studies show that contact lens noncompliance is frequent in patients who have worn contact lenses for several years. Therefore, each patient encounter is an opportunity to review and reinforce proper wearing and replacement time and contact lens care. At each follow-up visit, it is important to review the importance of proper lens care with your patient. Recommend a specific contact lens care solution—not a generic. Reinforce this by prescribing the lens care solution and advising patients that not all lens care solutions are created equal. Educate patients about the significance of rubbing the lenses, not topping off lens care solutions, and cleaning and replacing the contact lens case.

A typical contact lens patient is potentially exposed to numerous active ingredients and preservatives contained in contact lens care solutions. Exposure to these substances can lead to an allergic or toxic response to a particular product. If the hypersensitivity is a delayed type IV response, then it can take months of exposure to a particular antigen before a patient becomes symptomatic. So a typical contact lens patient who has previously been asymptomatic and develops a hypersensitivity will suddenly manifest a bilateral allergic type response with contact lens wear. The first step to manage this complication is to have patients discontinue lens wear and any current ophthalmic drops or lens care solutions. Instruct patients to use nonpreserved artificial tears until they are symptom-free. If you suspect that a patient's care system is the antigenic source, then changing care regimens, preferably to a hydrogen peroxide system to avoid other hypersensitivities, is recommended when reintroducing them to lens wear. Hydrogen peroxide has the lowest frequency of lens solution-induced corneal staining and corneal infiltrative events with silicone hydrogel lenses (Carnt et al, 2009). Refitting the patient to a daily disposable is another option.

Conclusion

Many factors contribute to successful lens wear. Hygienic practices and proper compliance with prescribed wearing regimens is crucial, as is the use of appropriate lens care solutions. Patient education, both initially and at follow-up, is essential to ensure continued success. It is important for practitioners to understand care system components, prescribe the proper care products for each patient, and to emphasize the importance of proper compliance with the wearing schedule and lens care regimen. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #187.

Dr. Bowling is in solo practice in LaFayette, Ga. He has received lecture or authorship honoraria from Alcon.