IMPROVING COMPLIANCE

Compliance and Contact Lenses

A look at why contact lens patients are noncompliant and what you can do to improve their lens-wear safety.

By Douglas P. Benoit, OD, FAAO

Compliance is defined in Webster's Dictionary as the act of conforming; accordance; cooperation or obedience. That means that people who are noncompliant are nonconformists, uncooperative, or disobedient. Basically, they do not follow instructions. What does this have to do with contact lenses? Why do we need another article on noncompliance issues? In a nutshell, noncompliant contact lens patients are at risk. Usually the risk is for no good reason. This article will explore the reasons for noncompliant behavior and attempt to put in place tools to ensure increased compliance.

Noncompliance is Part of Life

If we look at noncompliance in general, we see that this behavior occurs in all facets of life. For instance, people do not always service their vehicles on the proper schedule. They usually are trying to avoid the service charge. In the long run, this translates into larger bills to solve a bigger problem that could have been detected or prevented with routine maintenance.

A large percentage of the population does not obey traffic laws such as speed limits and stop signs. This behavior can be expensive (tickets) and dangerous (accidents). One study (National Highway Traffic Safety Board, 1988) showed that 66 percent of people approaching a four-way stop intersection do not stop. When asked why they did not stop, most replied that they figured the other driver would stop.

Many people fail to comply with doctors' orders in a variety of areas (DiMatteo 2004). We all have diabetic patients who cannot tell us their last HgA1C number; they do not know their blood glucose figure because they do not check it. They fail to exercise or watch their diets, and some even stop taking their medication because they feel fine. While this approach seems harmless to the patients, in the long run they could develop diabetic retinopathy, peripheral neuropathy, loss of extremities, and even suffer an early death.

Then there are the patients who change their dosing or frequency of taking medications in an attempt to save money. This kind of behavior also runs the risk of dire consequences with regard to their health, but if it means that they can afford to eat...

There are many more examples of general non-compliance out there; however, let's move on to the area that we all care about.

Noncompliance With Contact Lenses

Noncompliance issues related to contact lenses have been around for as long as contact lenses have been available (Bowden et al, 1989). There are three primary areas of concern: contact lens wear schedule, lens care, and contact lens replacement schedule. First let's look at the contact lens wear schedule.

Contact Lens Wear Schedule There are two basic wear modalities: daily wear and extended or continuous wear. Not all lenses can be worn safely overnight and not all people can wear lenses overnight and remain problem-free. However, many patients wear daily wear, low-oxygen-permeability lenses while they sleep. These patients are at risk for developing complications including sight-threatening infections (Schein et al, 1989).

Why does this occur? Some of it is laziness. The patients do not want to take the time to clean their lenses each night. Others have one or more friends who sleep in their lenses on a regular basis and never have difficulties. Most of this behavior can be traced back to poor training and lack of explanation as to why nightly cleaning and removal are necessary.

When you first introduce patients to contact lens wear, discuss how they intend to wear their lenses. Will it be part-time or full-time? Choose the lens modality based on the response to this question. A part-time wearer would be a better candidate for a daily disposable lens. Then there is no question of lens freshness even if the lenses are worn only once a week or once a month.

If lenses will be worn on a regular, daily basis, then a lens that is used for two to four weeks before discarding could be more appropriate. That type of lens needs to be cleaned well and disinfected after each wear, stored properly, and discarded as scheduled. Even with the latest silicone hydrogel materials, some patients still cannot wear lenses overnight safely (Schein, et al 2005). These factors and the health risks and advantages of each need to be reviewed with patients. If patients are engaged up front, some of the risky behavior can be eliminated.

Contact Lens Care When it comes to contact lens care systems, the same principles apply. The care regimen should match the lens material and be biased toward safety. When soft contact lenses were first introduced, the cleaning solution was often baking soda paste. Rinsing was performed with saline made from salt tablets dissolved in distilled water. Disinfection was accomplished by using heat, either by putting the lens case in a pot of boiling water on the stove, or later with specially designed lens cases.

Problems arose with these care systems almost immediately. Patients did not want to take the time to dissolve a salt tablet in distilled water every night, and therefore, it was not uncommon for them to dump a 125-count bottle of salt tablets into a gallon of distilled water and let it sit around for weeks until it was used up. This of course was folly because the moment the distilled water was opened it became a breeding ground for organisms that were present in the air. The salt tablets even provided nourishment for the contaminating organisms. Luckily, the heat disinfection units reached a sufficient temperature to kill these organisms in most cases. But what if patients did not use the heat disinfection unit? What if they just put the lenses in a case in their bathroom overnight?

Commercial solutions to clean and disinfect were developed over time, and while they helped simplify the process, they did not eliminate problems. Some patients were allergic to components of these products, particularly to the preservatives. Over the years the solutions were modified to eliminate those problems, and hydrogen peroxide-based systems and multipurpose solutions were developed to do all three parts of the process.

With the multipurpose solution revolution, patients could spend less time and still clean their lenses appropriately. Rubbing was still needed (FDA Matrix Guideline, 1982; Shovlin, 1989), but only one solution was required. Rubbing is necessary to remove the debris that accumulates daily while the lenses are being worn. Not removing this buildup leaves the lens surface rough, which could irritate the conjunctiva and cornea and lead to inflammation and/or infection as well as to allergic tissue reactions.

Of course, people being people, shortcuts were soon being taken. Why rub the lenses if they were going to soak in the disinfecting solution overnight anyway? Why replace the solution every day? It disinfects so it shouldn't be necessary to discard it when you could just add to it (aka topping off). And that would also save money!

Topping-off behavior puts patients at risk for contamination in a number of ways. Outbreaks of Fusarium keratitis in 2006 (Ley) and Acanthamoeba keratitis in 2007 (Joslin) are confirmation of the risk with noncompliant behavior. Let's not forget about the lens cases themselves. Many studies (Szczotka-Flynn et al, 2010) have shown that cases become contaminated very easily, and much of the problem is not visible to the naked eye. Even clean-looking cases can be compromised, so do not be fooled just because the case is not covered in caked on debris. Cases need to be replaced on a regular basis, and thankfully many lens solution manufacturers provide a new lens case with solutions that they sell.

Contact Lens Replacement Schedule The last area to explore is the contact lens replacement cycle. It would seem obvious that a fresh lens every day is the safest and easiest approach to lens wear. The new silicone hydrogel lenses also should add a layer of protection for contact lens wearers because they provide much more oxygen to the cornea. To some extent that is true, but again noncompliant behavior exists (Jones et al, 2002).

Dumbleton and colleagues (2009) were the latest to find that compliance with replacement schedules was poor. In their study, daily disposable contact lens wearers were the most compliant patients (88 percent). Patients on a monthly replacement schedule were the next most compliant group (72 percent), and those on a two-week discard cycle came in last (48 percent). The major reason for not replacing their lenses on time was that they forgot (59 percent). Twenty-six percent did not replace lenses on schedule to save money, 11 percent cited a lack of time, 9 percent felt it was not harmful to extend the wearing time, and 3 percent said that their eyecare practitioner said that it was okay.

These figures may seem startling, but it is not all the patients' fault. The same study asked eyecare practitioners to report their recommended replacement frequency for the three lens-wearing groups. Practitioners reported recommending that daily disposable lenses be discarded between one week and one month 4 percent of the time. For the two-week group, 18 percent said three weeks to three months was okay. In the case of the one-month replacement lens type, less than one percent of practitioners recommended a longer discard cycle. These statistics are the real shockers.

Any one of these noncompliant behaviors by contact lens patients could be problematic (Collins and Carney, 1986). If there is a compounding effect due to poor cleaning habits coupled with overwear of lenses and a failure to discard lenses as recommended, the consequences could be severe (Yeung et al, 2010). Giant papillary conjunctivitis, conjunctival redness, keratitis, and discomfort are minor compared to corneal ulceration. Microbial keratitis can be devastating to vision and may even lead to penetrating keratoplasty.

How to Get Through to Patients

So what is the solution? How can we make patients more compliant? Can we modify their behavior in this area at all? The answer to the last question is yes. Practitioners have the means to enhance compliance in their contact lens wearers (Donsik et al, 2007). It comes down to proper education from the start of the lens-wearing experience. As stated earlier, patients (and parents of minors) need to have complete information on the type of lens being chosen, the intended wear time per day, and the replacement schedule. This approach will reinforce the concept that a contact lens is a prescription medical device, not just an inconsequential commodity.

A frank discussion of why contact lenses need to be cleaned and how it should be done is necessary. Demonstrating the proper technique for the lens care regimen is also required. Providing patients with written instructions will reinforce the message.

The reasons for using one particular lens care regimen over another must also be explained. Not all care systems are compatible with all contact lens polymers. The wrong solution can make the contact lens uncomfortable and lead to conjunctival hyperemia and/or keratitis.

It goes without saying that the proper technique for application and removal of any contact lens is required. Patients need to be proficient in this task before they are allowed to take contact lenses home.

Practitioners have the opportunity (and a duty) to reinforce all of these concepts when patients return for follow-up care. Of course questions and comments about comfort and vision need to be discussed. But, we need to go further. Ask patients how they are cleaning their lenses and have them demonstrate their technique. Be sure to ask what they are using to do the job. Discuss how many hours per day they are wearing the lenses. Also find out how often they are discarding their lenses and opening a fresh pair. All of these steps will reinforce the message that contact lens wear and care are serious issues. It also presents an opportune moment to correct aberrant behaviors early on. With this approach, it is possible to keep patients safe and happy with contact lens wear. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #186.

Dr. Benoit practices in a multi-subspecialty ophthalmology group in Concord, NH. He is a Diplomate and currently Chair of the American Academy of Optometry Section on Cornea, Contact Lenses and Refractive Technologies.