Eyecare practitioners have a plethora of options to consider when prescribing contact lenses. How do we choose which lens to prescribe? Is it brand loyalty, preference of material, lens design? Perhaps cost to patients? In our clinics, one factor that is critical to our lens choice is replacement modality. We firmly believe that, when available, daily disposable lenses are the modality of choice. When we discuss soft lens replacement modalities with our colleagues, we are all in general consensus that daily disposable lenses are the healthiest for our patients. Why, then, do most eyecare practitioners’ prescribing habits not mirror these views, and what steps can they take to practice what they preach?

Over the past 10 years, there has been a consistent increase in the percentage of soft lens fits and refits into daily disposable lenses in the United States, from only 11% of soft lens fits in 2008¹ to 35% of soft lens fits in 2018² (Figures 1 and 2). This trend is also occurring internationally, increasing from 18% in 2008³ to an average of 32% this past year.⁴ There are, however, multiple countries that have separated themselves from the rest: Japan, Australia, and Norway all report that daily disposables account for upwards of 50% of their soft lens fits, while Denmark and Finland each report 71%.⁴ We believe that there are two key factors responsible for this trend: 1) a growing acceptance that daily disposable lenses are healthier for patients, and 2) key changes in the industry.

THE HEALTHIER OPTION

The literature shows that daily disposable lenses are healthier for patients compared to frequent replacement lenses. For example, in a study comparing adverse events and corneal infiltrative events (CIEs) in hydrogel and silicone hydrogel daily disposable lenses, the CIE rate for daily disposable lenses was significantly lower compared to those for reusable contact lenses (0.2% per year for daily disposables versus a range of 3.3% to 7.2% for other modalities).⁵ In addition, the risk of contact lens-related microbial keratitis is also the lowest in daily disposable lenses compared to other soft lens modalities.⁶ Anecdotally, as we have transitioned 93% of our contact lens patients into daily disposables, we have observed a great decrease in the incidence of microbial keratitis, contact lens-associated red eye, corneal infiltrates, and giant papillary conjunctivitis. In a 2017 study, Stapleton et al⁶ investigated risk factors associated with microbial keratitis in daily disposable lenses. Their findings suggested that many factors that increased the incidence of microbial keratitis, such as overnight wear, smoking, and poor hand hygiene, were preventable.

Compliance is also significantly better in patients wearing daily disposable lenses compared to other modalities. Practitioners indicated in 2018 that approximately 75% of their daily disposable patients were fully compliant with their replacement schedule; that number was reportedly lower in monthly replacement wearers at 61%, and it was only 39% for one- to two-week replacement wearers. We make it a priority to have a detailed discussion with all of our contact lens patients about hygiene and lens compliance.

With frequent replacement lens wear, an outside factor that is consistently involved is the use of multipurpose lens care solutions, which contain agents to clean, disinfect, and condition the lenses. The ocular surface is a delicate structure, and introducing chemicals to the tear film tends to disrupt it, creating a risk for lens discomfort. The ocular surface also faces additional challenges from reusable lenses as proteins accumulate on the lens surfaces, which in turn can increase cytokines, inflammation, and discomfort. Discomfort is a primary factor in contact lens discontinuation, and a majority of patients discontinue contact lens wear in their mid-40s;⁷ this timing is especially unfortunate, as visual demand increases with the onset of presbyopia. In our clinics, a majority of our patients have expressed that they have experienced improved comfort when switching to daily disposable lenses from other modalities, and they have enjoyed successful lens wear well into their presbyopic years. We feel that because new lenses are used each day and that multipurpose solutions are a non-factor, daily disposable lenses promote a healthier, more stable ocular surface, thereby providing improved contact lens comfort for a longer duration.

PRICING DISCUSSIONS

One common concern when fitting daily disposable lenses is the increased cost of the lenses. When it comes time to discuss cost with patients, we are careful to discuss the potential savings that are available. For example, many daily disposable lenses come with large rebates, often as high as $200 when a year’s supply is ordered.

Because cleaning and storage solutions are unnecessary for daily disposable lenses, that savings is also passed on to patients. After reading the package inserts for many multipurpose cleaning solutions, we have found that if the instructions are followed correctly (a five second rinse per side of each lens, and filling the lens case), upwards of one ounce of fluid should be used per day; this translates to approximately 30 10oz bottles per year, or around $300. We are sure that most patients do not care for their lenses in this way; however, even if only half of the recommended solution is used each day, this still amounts to significant savings for patients who use daily disposables. After accounting for the annual rebate and savings on solutions, the daily disposable lenses are more comparable in price to other modalities.

We have also found success in breaking down the cost (after rebate) in price per day and comparing the daily cost of daily disposable lenses to that for a cup of morning coffee, buying lunch at work, and other common daily activities in which they may participate. Hearing that their lenses may cost just more than $1 per day sounds much friendlier than hearing the total sum for the year.

INNOVATION FROM INDUSTRY

In recent years, our partners in the contact lens industry have introduced outstanding technology that has helped make daily disposable lens wear more comfortable. For example, one manufacturer utilizes a lens that minimizes the amount of silicone to 4.4%, which reduces the lens modulus and helps optimize oxygen permeability. Other manufacturers have introduced wetting agents to create added surface moisture or to mimic the composition of the tear film, and some have created proprietary polymers that help the lenses retain a specific percentage of water to mirror that of the cornea.

Additionally, the parameters available in daily disposable lenses have been continually expanding. The contact lens companies continue to adapt and grow the parameters available to physicians, allowing us to easily fit most of our patients. Daily disposable spherical lenses are available from +8.00D to –12.00D, and toric lenses are available at –1.75D with around-the-clock axes; in addition, –2.25D cylinder correction is available in many axes. There is also a wide range of lenses for presbyopes ranging in power from +6.00 to –9.00D. In our clinics, we also utilize daily disposable center-distance multifocal lenses for some of our myopia management patients (off-label), which are available with sphere powers up to –12.25D.

As the parameters grow, the number of patients for whom we cannot find a suitable daily disposable lens dwindles. In fact, we find that patients who are outside of the available daily disposable parameters are better suited for specialty contact lenses such as custom soft, corneal GP, or scleral lenses.

DO NO HARM

Many of our patients view contact lenses as a common commodity, something that anyone can have. They often are not aware of the vast differences among the myriad lens choices. To them, contact lenses are viewed as a one-size-fits-all product, and we believe that our profession has allowed this commoditization to happen. When patients come into our office asking to try a lens that they saw on TV, that their friend loves, or for which they have a coupon, we are susceptible to letting this—rather than our training and contact lens expertise—drive our decision.

For those of us who are optometrists, before we were christened with the title Doctor of Optometry, we recited the Optometric Oath, during which we pledged that “the health of (our) patients will be (our) first consideration.” When it comes to contact lenses, we feel strongly that prescribing daily disposable lenses helps us stay true to this promise. As we discussed previously, daily disposable lenses have better patient compliance, offer a lower risk of infection or side effects, and limit the potential for disease. If the parameters allow for daily disposable lenses to be an option for a contact lens wearer, then there really is no other option. CLS

REFERENCES

1. Nichols JJ. Contact Lenses 2008. Contact Lens Spectrum. 2009 Jan; 24:26-34.
2. Nichols JJ, Fisher D. Contact Lenses 2018. Contact Lens Spectrum. 2019 Jan;34:18-23, 50.
3. Morgan PB, Woods CA, Tranoudis, IG, et al. International Contact Lens Prescribing in 2008. Contact Lens Spectrum. 2009 Feb;24:28-32.
4. Morgan PB, Woods CA, Tranoudis IG, et al. International Contact Lens Prescribing in 2018. Contact Lens Spectrum. 2019 Feb;34:26-32.
5. Chalmers RL, Hickson-Curran SB, Keay L, Gleason WJ, Albright R. Rates of adverse events with hydrogel and silicone hydrogel daily disposable lenses in a large postmarket surveillance registry: the TEMPO Registry. Invest Ophthalmol Vis Sci. 2015 Jan 8;56:654-663.
6. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115:1655-1662.
7. Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. Int Contact Lens Clin. 1999 Nov;26:157-162.
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