Imagine, for a minute, how a conversation would go if we were to give our patients their choice of wear schedule. Perhaps, it’d go something like this, “Mrs. Smith, we have contact lenses available in one-day, one-week, two-week, monthly and quarterly versions. You can sleep in them or take them out at the end of the day. Take your pick!”
Clinical experience suggests that patients would fall into two opposite—but equally convenience-driven—camps if given such a choice: the extended-wear (EW) and daily disposable modalities. Here is what we know about patient preferences from the limited literature on the subject.
In a randomized crossover trial published in 2000, patients were equally successful in both EW and daily disposable lenses, but a significant number preferred extended wear for the sake of convenience.1 A few years later, when Indiana University researchers asked vision-corrected patients about their interest in other forms of correction, contact lens wearers expressed more interest in LASIK (65%) or orthokeratology (71%), than in EW modalities (51% for seven-day and 44% for 30-day).2 The authors concluded that many patients were cautious about the health and safety of EW. In recent years, epidemiological studies have confirmed that overnight wear increases the risk for microbial keratitis as much as ten-fold over daily wear use, leading many clinicians away from prescribing EW even with lenses that are approved for it.3
“In our large contact lens practice, we strongly discourage any overnight wear,” said Deanna Peña Garcia, O.D., of Houston Eye Associates. “Most of the convenience benefits of extended wear can be achieved with daily disposable lenses.”
Indeed, with daily disposable lenses now available at lower cost and in a wide range of parameters and comfortable materials than in the past, they offer a great alternative for convenience-focused patients.
In the largest randomized trial of contact lens wear in children, the Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE), 93% of parents overwhelmingly chose daily disposable lenses over two-week lenses when cost was not a factor.4 When investigators discussed the actual costs with them, more than 60% indicated they would still make the same choice.
Factoring in the Wear Schedule
The reality is that we can’t—or shouldn’t—give patients an open-ended choice of lens modality. Replacement frequency is just one of the many factors that should be considered in selecting a lens. The fit, modulus and wettability of a lens, as well as the patient’s prescription, ocular anatomy and lifestyle are all relevant to lens choice.
1. The patient ratings of overall comfort of two silicone hydrogel lenses over the course of a replacement cycle.
Remember that patients are not capable of making the best choice without context. Patients who “prefer” an extended wear schedule might change their minds if that choice were coupled with discomfort, for example. After all, ocular dryness and discomfort are the primary reasons for contact lens dissatisfaction and dropout.5 What patients really want is a modality that offers them high levels of comfort and vision throughout the day, with cost and convenience a close second in consideration.
Research has long suggested that longer replacement cycles may negatively affect comfort.6 Most recently, a comparison of two new-generation silicone hydrogel lenses found declines in overall and end-of-day comfort throughout the wearing cycle (see figure 1). Overall comfort was rated excellent or very good at the end of the replacement cycle by 56% of the monthly lens wearers vs. 72% of wearers of the two-week lens.7 After four weeks of wear, 38% of monthly lens patients were more likely to rank the end-of-day comfort of the monthly lens as fair to poor than excellent and 35% ranked comfort as fair to poor more than very good. In comparison, 57% of two-week wearers rated the lens as excellent or very good at the end of the two-week replacement cycle.7
In a retrospective chart review comparing a monthly and two-week lens, unscheduled visits for clinical complaints such as irritation, discomfort and blurred vision were significantly higher among the monthly wearers (see figure 2).8 Adverse events were not statistically different.
Compliance with Prescribed Replacement
Some would argue that patients are essentially choosing their own wear schedules anyway. “When you prescribe a 30-day wear schedule, the patient can ultimately turn that into a 21-day schedule by throwing the lens away early, or stretch it out to 60 days or more. We don’t have a lot of control over it once the patient leaves the office,” said Dr. Garcia.
2. The percentage of patients returning for an unscheduled contact lens-related clinic visit.
And, in fact, a number of published studies have shown broad noncompliance with replacement schedule.9,10 They also provide some important insight into why patients choose to ignore the recommended schedule.10 The good news is that 78% of most patients perceive that replacing their contact lenses on schedule is important, even if they don’t meet that goal. Fifty-one percent of respondents said they forget which day to replace their lenses, which is nearly twice the percentage of patients who claim to stretch out their wear schedule to save money.10 Although my own perception is that stretching definitely increases in tougher economic times, this is a good reminder that cost is not the biggest problem—it is forgetfulness.
Fortunately, we have some tools to address this issue. In the above-mentioned study, 53% of patients said that a reminder system would be useful; most selected an electronic reminder system. Twice as many compliant patients (52% vs. 28% of noncompliant patients) reported using a calendar or other system to help them remember when to change lenses.10
The Moderately Noncompliant Patient
“I think we have the responsibility to give patients the best possible chance of being compliant with the wear schedule. One of the best ways to do that is to make sure they have a consistent supply of lenses on hand,” said Andrea M. Janoff, O.D., assistant professor and chief of the Cornea and Contact Lens Service at Nova Southeastern College of Optometry. “We try to make an annual supply the easiest choice for patients by putting everything they need to collect the manufacturer rebates together in a ready-to-mail envelope. We also offer free shipping and an internal discount on top of the manufacturer rebate for annual supplies.”
Dr. Janoff also recommends signing patients up for a reminder program, such as Acuminder (Vistakon, www.acuminder.com). In a recent survey, two out of three Acuminder users said the service had improved their replacement compliance, with reported compliance with two-week lenses increasing from 40% to 76% after using the service.11
“Finding some way to add the replacement schedule to a calendar is one of the best things you can do for that person who is engaging in moderate overwear,” said Dr. Garcia. This can include strategies like electronic calendar reminders or planning to change lenses on paydays or the first and 15th of the month.
Dr. Garcia ramps up the education when she suspects noncompliance. “Patients think that if the lens feels okay, everything must be fine,” she said. “I try to educate them about the dust and pollen from the air, and the lipids and proteins from their tears that are accumulating on the lens. The longer they overwear the lens, the more time they are giving these deposits to cause allergic reactions and a reduction in comfort or vision.” In some cases, she is able to show the patient early changes under the lid that patients don’t necessarily see or feel.
In one case, Dr. Garcia saw a patient referred to her by a local ophthalmologist for a contact lens refit. The physician’s note said that the base curve in the left eye was too loose and causing discomfort. Upon everting the lids, it quickly became apparent that the base curve wasn’t the problem. The patient had Grade 3 giant papillary conjunctivitis (GPC) that required antihistamine and anti-inflammatory therapy and three weeks out of lenses. “She honestly had no idea that wearing her lenses longer than a month could cause problems,” said Dr. Garcia. “I believe we have to help patients think about the replacement cycle more constructively.”
Dealing With Extreme Noncompliance
We have all seen cases of egregious noncompliance with the replacement schedule—take for example the patient who gets a pair of trial lenses and comes in six months later wearing the same pair or the college kid who just ran out of lenses two years after his last exam. When you know a patient is noncompliant, it is very important to document both the noncompliance and your efforts to address it.
Personally, I am more concerned with the degree of stretching rather than a fixed number of days of wear. If a patient is doubling or tripling the wear time, it’s time for a serious talk. My tendency is always to move noncompliant patients to a shorter wear schedule rather than hope that a longer one might make them more compliant.
Unfortunately, sometimes it takes a serious adverse event for a patient to see the light. I once saw a -6.00D patient who presented with bilateral corneal ulcers. He did not have spectacles and, because he could see very little without correction, he was wearing the lenses all the time and falling asleep in them. Both his care regimen and his replacement schedule were haphazard, but he had not previously been bothered by any discomfort. When the first signs of infection and discomfort began, he made the ulcers worse by delaying the discontinuation of lens wear. This patient was highly motivated to get back into contact lenses, which he was able to do following treatment. Afterwards, he was a model compliant patient—having learned the hard way that the inconvenience of changing his lenses on schedule and avoiding falling asleep in his lenses was nothing compared to the hassle and expense of dealing with a serious infection.
This case is another example of the importance of backup spectacles; after that experience, I was especially strict with patients about owning a pair of glasses.
The Doctor-Patient Relationship
As doctors, we should give patients clear and consistent recommendations. It is very confusing when one doctor tells a patient to wear a given lens for a month, only to be contradicted by another doctor who insists that the same brand should be replaced every two weeks. Other times, patients may solely rely on package inserts—which I liken to prescribing a medication without mentioning the dose or how often to take it. Failing to give precise instructions lowers the patient’s confidence in the eye care practitioner as a healthcare provider.
“You also need to make sure your staff is educated about the risks of noncompliance and that they fully support the messages you want to convey to patients,” said Dr. Janoff. “The reality is that, during some encounters, patients may spend more time with the contact lens technician than the doctor. If that staff member, trying to be helpful, softens your message or gives conflicting advice, it will undermine your instructions.”
When properly trained, staff (front desk to technicians) can play a very important role in promoting compliance and teaching healthy contact lens habits. In Dr. Garcia’s practice, for example, the check-in staff flag charts for her when a patient who was seen a year ago only purchased a six-month supply of lenses to alert her of possible extended wear schedule use. In addition to talking about the replacement schedule, Dr. Garcia takes the time at every visit to emphasize that patients should use a new case every three months, throw away used mascara every three months because it can harbor bacteria, use fresh solution every day instead of topping off and never sleep or swim in lenses. For Dr. Garcia, personally going through a detailed, written care guide before handing it to the patient helps stress the importance of the message.
Dr. Janoff agreed and said that spending more time with patients discussing compliance is a good way to develop rapport or a stronger bond with them. One study has shown that compliant patients were more likely to have had an extensive discussion with their eye care provider that included the health and comfort effects of sticking to the wear schedule.10 One of the most interesting findings from this study was that 90% of compliant patients, compared to only 38% of noncompliant patients, said they follow the recommended replacement schedule because of complete confidence in their eye care professional.10
That could mean that patients who trust doctors are more likely to be compliant, but it could also attest to the quality of the doctor-patient interaction. “When you build rapport with the patient, take the time to give them the information they need, and the tools to help them remember their wearing schedule, they are more likely to follow your instructions,” she said.
These are all good pieces of advice to consider as we ponder our initial question of what would happen if patients chose their own wear schedules. Ultimately, the answer is that patients should never be choosing a wear schedule, any more than they should choose whether to be dilated for an eye exam. Our job as eye care professionals is to guide patients to the lens material, replacement schedule and care regimen that best fits their lifestyle and vision needs and helps them achieve their goal of healthy, clear vision and comfortable eyes all day, every day.
Dr. Routhier serves as manager of the Medical Affairs for Vistakon, Division of Johnson & JohnsonVision Care, Inc.
Dr. Janoff is a paid consultant for CIBA Vision.
Dr. Garcia is a paid consultant for Vistakon.
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2. Riley C, Pence N. Forms of vision correction: Demographic factors in patient attitudes and perceptions. Eye Contact Lens. 2004 Jul;30(3):138-43.
3. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmol. 2008 Oct;115(10):1655-62.
4. Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci. 2009 Mar;86:222-32.
5. Richdale K, Sinnott LT, Skahdahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26(2):168-74.
6. Jones L, Jones D, Simpson T. The impact of replacement frequency and care regime onsubjective satisfaction with disposable/frequent replacement lenses. Optom Vis Sci. 1999;76:12(S):172.
7. Hickson-Curran SB, Young G, Spencer S, et al. Patient wearing experience over the recommended life of silicone hydrogel lenses. Poster presented at the American Academy of Optometry meeting, November 17-120, 2010; San Francisco.
8. Hickson-Curran SB, Alford J. Silicone hydrogel replacement frequency: Impact on frequency of scheduled and unscheduled clinic visits. Poster presented at the American Academy of Optometry meeting, November 17-20, 2010; San Francisco.
9. Hickson-Curran S, Chalmers RL, Riley C. Patient attitudes and behavior regarding hygiene and replacement of soft contact lenses and storage cases. Cont Lens Anterior Eye. 2011 Jan. [epub ahead of print]
10. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009 Jul;35(4):164-71.
11. Data on file. Vistakon. Division of Johnson & Johnson Vision Care, Inc.
