PREVENTING DROPOUT

What Contact Lens Dropout Costs and How to Prevent It

These 10 steps will help you reduce the economic and patient costs of contact lens dropout.

By John Rumpakis, OD, MBA, & Mile Brujic, OD, FAAO

Being in eyecare practice today is a challenging endeavor. I (Dr. Rumpakis) hear about numerous challenges from my clients, but the loudest one pertains to decreasing cash flows and patient loyalty. Practitioners point their fingers at everyone else whose fault it is: staff, insurance carriers, the health care system, the Internet competition, and even patients. Yet, we ignore many opportunities on a day-to-day basis that could banish this complaint if only we were to take advantage of what is right in front of us.

Which brings us to the point of this article. Dr. Brujic and I want to expose opportunities that practitioners can control (and benefit from) to prevent contact lens dropouts. Many practitioners are critical of this issue, not completely understanding either the economic impact or the clinical tips that can increase patients’ satisfaction with their contact lenses. Let’s address the economics first, then provide some clinical wisdom to help prevent contact lens dropouts.

The Economics of Dropout

Using optometry as an example, the American Optometric Association’s (AOA) recently published report titled “The State of The Optometric Profession: 2013” indicates that optometrists performed the same number of examinations per hour in 1997 as they did in 2012 (AOA, 2014). So optometrists, by and large, haven’t created additional opportunities for increasing either patient volume, productivity, or profitability over this time frame. To see this statistic remain completely unchanged makes me wonder what has been going on with patient flow over the years. According to the same report, optometrists are not performing up to their potential in other areas as well (Table 1). We hope that these statistics serve as an economic call-to-action and stimulate some thought about how you can be capturing your economic potential.

You might be thinking that these statistics don’t apply to your practice and that contact lens dropout is not a concern for you. Perhaps you aren’t even measuring dropout or patient satisfaction with contact lenses. But numbers don’t lie, and we should be thinking about how much money inaction in our practices is costing us.

Material sales have been declining over the years. With an increasing number of purchase channels available to consumers—including social media—new sources of competition have steadily eroded this once consistent source of profitability. We can no longer depend on material sales to compensate for low productivity on professional services.

Contact lens usage has remained flat over the last decade (Table 2). Eyecare practitioners have not been able to grow the market despite the tremendous technological advances in this segment. Worse yet, many consumers aren’t aware of the new technology that exists because, all too often, they don’t ask about what’s new, and we don’t tell them if they don’t ask.

So, not only are 20% of our contact lens prescriptions walking out the door, but the “returning contact lens patient” marketplace is also shrinking. In January 2010, I wrote an article on contact lens dropout rates around the world (Rumpakis, 2010). This data showed that the average practice has a nearly 16% dropout rate, low by some measures as published in subsequent studies. Nonetheless, a 16% dropout rate represents a significant opportunity to not only provide our patients with better care, but to increase our income as well.

A dropout rate of 16% means that one out of every six of your contact lens patients discontinues lens wear, which is a large number of patients over the life of your practice and a large amount of revenue. For those of you who think that this doesn’t affect you, remember just how costly denial and inaction can be. Consider that the average contact lens patient generates $275 per year. While $275 may not seem significant by itself, Table 3 shows that this can have a $2 million impact economically during 45 years in practice (Rumpakis, 2013). In addition, losing a contact lens patient doesn’t merely cost you that revenue stream; it also forces you to incur the “replacement cost” of bringing in a new patient.

10 Steps to Minimizing Contact Lens Dropout

So stop denying that contact lens dropouts are occurring in your practice. There’s been much innovation in the contact lens industry to address this problem. Dr. Brujic will now provide you with 10 easy steps to help you reduce dropout in your practice and retain your contact lens patients for life.

1) Pay particularly close attention to the lid margin. For the ocular surface to adequately support a contact lens, it must produce sufficient tears and also be healthy enough to support comfortable lens wear (Truong et al, 2014). As such, a comprehensive examination of the ocular surface is critical to identify underlying deficiencies in the structures that support comfortable lens wear (Efron et al, 2013). Additionally, it is critical to examine the lid margins for any signs of blepharitis as a risk factor for contact lens complications (Weissman and Mondino, 2002).

Even a small amount of debris at the base of the lashes can be deleterious to lens wear because of excessive bacterial populations along the eyelid margin. Excessive bacterial exotoxins, including lipases and esterases, could then adversely affect meibomian gland secretions (meibum) and the cleanliness and comfort of contact lenses (Knop et al, 2011).

So in cases of anterior blepharitis, make sure to prescribe regular eyelid hygiene. Fortunately, a number of options are currently available for this. Life Wipes LLC produces Visi-Cleanse, which are individually packaged wipes that contain herbal ingredients. NovaBay Pharmaceuticals, Inc. produces i-Lid Cleanser, which contains hypochlorous acid cleansing solution that is applied to a cotton swab and then used to clean the lash margin. Ocusoft produces Ocusoft Lid Scrub Original and Ocusoft Lid Scrub Plus, which are individually packaged wipes. Alcon produces Systane Lid Wipes, which are also individually packaged wipes. For some patients, it may be appropriate to briefly discontinue lens wear and prescribe an antibiotic or antibiotic-steroid combination in addition to long-term lid hygiene.

Additionally, assess for meibomian gland dysfunction (MGD) by evaluating the meibomian gland secretions and the lid margin for any inflammation around the meibomian gland orifices, and treat any MGD appropriately. There are two forms of MGD: obvious and non-obvious. Obvious MGD is relatively easy to diagnose because the lid margins are visibly inflamed and there is usually a visible capping of the gland orifices. Non-obvious MGD, as its name implies, is not apparent through initial evaluation of the lid margin. But upon attempted gland expression, the quality of the expressed meibum is significantly reduced, which is believed to be a precursor to obvious MGD (Blackie et al, 2010). In either of these conditions, the function of the meibomian glands will have to be improved to optimize the lipid layer and the supporting tear film for contact lens wear to succeed.

2) Think systemically for best ocular surface results. We have traditionally considered dry eye signs and symptoms to be local manifestations of the condition. We often associate a decline in contact lens comfort in a very similar manner. Our initial strategy is usually to change contact lens material, design, and, if required, contact lens care systems in an attempt to make patients more comfortable. Many practitioners even treat local tear film insufficiencies in an attempt to increase comfortable contact lens wear.

But we may be thinking too locally when it comes to the symptoms of uncomfortable lens wear that some patients experience. When contact lens discomfort persists after we have tried these initial changes, then the discomfort may have other causes. Understanding systemic conditions can help explain this. We need to be cognizant of the potential ocular manifestations of a variety of autoimmune conditions (Lee et al, 2012).

Eyecare practitioners are now poised to help with diagnosing at least one category of such conditions using the point-of-care blood test Sjö (Nicox). A lancet is used to pierce the skin on the finger, and five to 10 drops of blood are placed on a Whatman card (Figure 1) and sent directly to a laboratory. The card is then analyzed to determine whether a patient is positive for markers associated with Sjögren’s syndrome, which could help patients get appropriate treatment and ultimately could explain a sharp decline in contact lens comfort (Shen et al, 2012).

Figure 1. A Whatman card with nine blood droplets for a patient being tested for Sjögren’s syndrome.

Additionally, diet is playing a greater role in our understanding of ocular surface health and thus support for healthy, comfortable lens wear (Roncone et al, 2010; Rosenberg and Asbell, 2010). Although a number of nutrients are critically important to a healthy ocular surface and tear film, the essential fatty acids have been studied most extensively, in particular looking at improvement in patients’ dry eye signs and symptoms (Pinazo-Durán et al, 2013; Brignole-Baudouin et al, 2011; Kangari et al, 2013; Kawakita et al, 2013). Ongoing studies are investigating whether a direct relationship exists between ocular nutrition and optimizing contact lens comfort.

3) Be sure to uncover the silent sufferers. Many of our patients are currently having a difficult time wearing their contact lenses. Would it surprise you that between 35% to 50% of your patients who wear contact lenses describe uncomfortable lens wear? This is, in fact, the reality with our current contact lens wearers (Doughty et al, 1997; Uchino et al, 2008; Uchino et al, 2011). This is concerning because these patients are at risk for discontinuing contact lens wear.

So, are we doing enough to identify these patients? We may ask our patients how they are doing with their contact lenses, and they will often respond with “fine” or “good.” Unfortunately, these subjective terms often do not uncover the true reality of their lens-wearing experience.

We can learn a number of lessons from the research in the dry eye field in terms of objectifying a patient’s responses. The Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) questionnaires are two examples of giving a “number” to subjective symptoms that a patient may be experiencing. If standardized questionnaires are not something that you are planning to implement in your practice, consider asking questions during your patient encounters that will result in a number to represent their subjective symptoms.

As an example, you could ask patients to grade the comfort of their lenses on a scale of zero to 10, in which 10 represents the most comfortable and zero is the least comfortable that they believe a lens should be. You could further ask them to use the same scale to rank their lens comfort at the beginning and at the conclusion of the day. You would be surprised by how many patients experience a precipitous drop in comfort toward the end of the day. By uncovering contact lens comfort issues, you are better armed to provide patients with the strategies necessary to wear contact lenses more comfortably.

4) Make patients responsible for their level of noncompliance. Compliance is a challenge with contact lens wearers. Recent research demonstrates that patients who do not follow manufacturers’ recommendations and who wear their lenses longer than they are supposed to are more likely to experience decreased lens comfort (Dumbleton et al, 2010). Additionally, patients tend to poorly comply with proper cleaning and disinfecting habits with their contact lenses (Dumbleton et al, 2013). There is not a clear consensus on the effects of optimizing lens care compliance on contact lens-related dryness (Ramamoorthy and Nichols, 2014). But truly understanding a patient’s care regimen is critical to making proper lens care recommendations.

So, is there an opportunity to help improve lens wear? Certainly. Consider having patients bring in their contact lens case, care solutions, and any other products that they use to care for their lenses. This will make it easy to take stock in how they are truly caring for their lenses. It also creates a platform for discussion regarding daily disposable lenses and the simplicity that they offer in terms of contact lens care. Consider this strategy to help you understand your lens wearers’ compliance and to provide your patients with proper direction.

5) Optimize the utilization of new technologies. New lens designs and materials are revolutionizing the way we think about contact lens comfort. Dailies Total1 (Alcon) is a water gradient contact lens introduced in 2013 that has a 33% water silicone hydrogel core (100% at the surface) (Thekveli et al, 2012; Rudy et al, 2012).

Daily disposable lenses in silicone hydrogel materials are becoming increasingly utilized in the marketplace. Johnson & Johnson Vision Care, Inc. was the first to introduce a daily disposable silicone hydrogel lens with its 1-Day Acuvue TruEye, which is manufactured in narafilcon A. More recently, Sauflon introduced its Clariti 1day spherical, toric, and multifocal daily disposable silicone hydrogel family.

Bausch + Lomb’s (B+L) Ultra is a recently introduced monthly replacement silicone hydrogel lens created using samfilcon A and MoistureSeal Technology. It provides additional opportunities for patients who are well-suited for monthly replacement contact lens wear.

Understanding new technologies and incorporating them into clinical practice can be critical to helping patients wear their lenses more comfortably when they can’t achieve this with traditional technologies.

6) Think outside of the box for astigmatic patients. At this point, it is rare that an astigmatic patient can’t wear contact lenses if he wants to. A number of soft toric options for astigmatic patients are readily available in a variety of diagnostic sets. Additionally, a number of specialty lens companies can incorporate high levels of astigmatic correction in their lenses. Some specialty soft lens companies can now even produce toric lens options in Contamac’s Definitive lathable silicone hydrogel lens material.

But even with all of these options available, some patients will still experience problems with visual stability. In such cases, consider these three options that can improve visual outcomes and stability for astigmatic patients:

Corneal GP Lenses It is well known that a GP contact lens provides optimal optics for high levels of astigmatism. Many custom and proprietary designs are available for our patients (too many to mention here). Both back-surface toric and bitoric lens designs provide improved optics and help prevent lens flexure on toric corneas.

One of the greatest concerns with transitioning a patient into GP lenses is initial lens comfort. Consider increasing the diameter of the GP designs that you use to 10mm or larger (Figure 2). This will minimize lens movement as compared to smaller-diameter GP lenses and can also improve initial lens comfort.

Figure 2. The left eye of a patient who has 3.00D of astigmatism and was transitioned into a GP lens. The lens diameter is 10.0mm.

Hybrid Lenses With a GP center and a soft silicone hydrogel skirt, the latest hybrid lenses truly combine the benefits of GP optics with the comfort advantages of soft lenses (Figure 3). Additionally, some of these lenses can now be fit empirically utilizing keratometry readings and refraction results, which further streamlines the process.

Figure 3. A patient wearing a hybrid lens. Note the junction in the superior portion of the figure showing where the GP portion is connected with the silicone hydrogel skirt.

Scleral Lenses Traditionally used for highly irregular corneas, scleral lenses can also be utilized for regular corneas. They provide stable vision and a comfortable wearing experience when fit successfully (Figure 4). Again, as with corneal GP lenses, there are many custom and proprietary designs available, too many to mention here.

Figure 4. A scleral lens appropriately vaulting the central cornea in a patient who has high corneal astigmatism.

7) Orthokeratology is a great option for a number of patients. Much of the more recent discussion about orthokeratology has focused on its role in myopia control (Koffler and Sears, 2013). But don’t forget that this option represents a phenomenal opportunity to help patients who may have comfort issues with traditional contact lenses while offering the additional benefit of not requiring lens wear during the day (Lipson, 2014). By gently remolding the surface of the cornea overnight as a patient wears the lenses, ortho-k provides excellent vision throughout the day after the lenses have been removed (Swarbrick, 2006; Hiraoka et al, 2009). Consider this as an option for patients who have unresolved contact lens comfort issues (Figure 5).

Figure 5. A –2.50D myope OD and OS who is presbyopic. She now wears a reverse geometry lens in the evening to correct distance vision in her dominant eye, and has no lens in her nondominant eye to correct for near.

8) Stop neglecting presbyopes. It is remarkable that when presbyopes are questioned, very few of them know that there are contact lens options available to help them with their visual needs. These patients are usually looking for increased functionality without the need for reading glasses. Additionally, cosmetic consideration is something that is becoming increasingly important among presbyopic patients. It is incumbent upon us to be the conduit of appropriate options and information to help our patients. With an ever increasing number of options available, we are now better equipped than ever to help our presbyopic patients wear contact lenses. But remember, the first step is communicating to potential wearers that they are candidates for lens wear.

9) Embrace new lens options for presbyopes. New multifocal contact lens options continue to be introduced to the market. Proclear 1 day multifocal (CooperVision), Dailies AquaComfort Plus Multifocal (Alcon), Biotrue Oneday for Presbyopia (B+L), and Clariti 1day Multifocal (Sauflon) are four options that provide multifocal corrections with the convenience of a daily disposable modality. Additionally, SynergEyes recently redesigned its hybrid multifocal lens as the Duette Progressive to optimize its fitting characteristics and lens design. It features a simultaneous multifocal design in three add powers.

A multitude of specialty contact lens options are also available in both soft and GP materials. With the number of available options, most of those patients interested in multifocal contact lenses can oftentimes be fit successfully. This will ultimately provide more presbyopes with the opportunity to wear contact lenses successfully.

10) Offer the best. The perception that patients develop of our practices and our services is based on a combination of things: the initial impression, the examination process, their experience in the optical and/or contact lens department, and ultimately their experience with the products that we have prescribed to them.

Today, more then ever, it is critical to offer patients what you feel is in their best interest. In the contact lens portion of our practices, this means continually embracing the newest technologies that have the potential to improve patient outcomes. Ultimately, this is the best way to provide our patients with an optimal wearing experience and to prevent dropouts.

Give Patients the Best Chance for Success

Keep these 10 steps in mind to give your contact lens wearers the best chance for successful lens wear and to ultimately exceed their expectations. Doing so will be a win for patients because of the optimized wearing experience and a win for the practice because you will retain more of your lens wearers. CLS

For references, please visit www.clspectrum.com/references and click on document #226.

Dr. Rumpakis is currently president & CEO of Practice Resource Management, Inc., a firm that specializes in providing a full array of consulting, appraisal, and management services for healthcare professionals and industry partners. He is a consultant for or has received speaking honoraria from Alcon, Vistakon, CooperVision, Oasis Medical, Odyssey Medical, Bausch + Lomb, and Essilor.

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, Allergan, B+L, Optovue, Nicox, Paragon, SpecialEyes, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision, VSP, and ZeaVision.