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Wednesday / June 19.
HomemieyecareTime to Comply

Time to Comply

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Daily disposables (DD), as the name suggests, are designed to be worn for a single day and then discarded. This wearing schedule offers a number of prescribing advantages: no need for cleaning procedures, no need for storage cases and greater perceived convenience. Unfortunately, we are witnessing increased patterns of patient non-compliance with dailies. This article will look at various occurrences of misuse including the surprising trend towards storage of dailies in saline and also their overnight wear. Practitioners must be mindful of non-compliant behaviour and take charge to minimise the potential of patient induced negative outcomes.

In Australia, the relative penetrance of DD contact lenses (CLs) has increased significantly from 7.8 per cent in 20021 to 23 per cent in 20083. Efron and Co.2 observed DD prescribing patterns and trends over a 12 year period in the U.K., reporting that usage was gaining acceptance across the spherical, toric, multifocal and monovision categories.

Dailies account for less than 10 per cent of lenses prescribed in markets such as Canada, China and the Netherlands, whereas the U.S. market has doubled from six per cent in 2004 to 13 per cent in 20083. Denmark is still well ahead of the rest of the world with 64 per cent of all wearers in daily disposables3. While there are variations in penetration regionally, the global trend towards dailies is consistently increasing.

Patient education may not only increase compliance to daily disposables, but may also help non-compliant patients to avoid some complications. Ultimately, we should ask ourselves if daily disposable lenses increase the propensity for non-compliance by making these medical devices seem more like a commodity.

In the current uncertain global economic climate, clinicians are now witnessing the signs of perhaps another perfect storm brewing; this time involving the DD lens modality.

Non Compliance

Unlike other medical devices, we see compliance abuse on many levels within contact lens wearers, including daily disposables. A sizeable proportion of contact lens wearers do not adequately adhere to recommended contact lens care and many have an inadequate understanding of lens care guidelines. The ease in which patients can alter wearing schedules demonstrates the need for greater, more effective patient education. These risks are magnified when a daily disposable patient is non-compliant. For example, DD lens wearers may wear their lens overnight, use for more than a single day, store the lens improperly, or handle lenses unhygienically. These examples illustrate the need for more effective patient education.

A New York study showed approximately 24 per cent of patients in a study of 103 participants, state that they never cleaned their lenses prior to disinfection and five per cent used saline solutions as their primary mode of disinfection4.

Philip Morgan’s excellent publication on compliance confirmed what many already suspected: that patients generally do not listen, are non-compliant and many wearers stretch the use of their contact lens products by using lenses for too many days, sleep in lenses when only daily wear has been prescribed, sleep in lenses for too many nights in the case of extended wear and top-up solutions rather than discard5.

Lenses that were specifically prescribed for daily disposal usage where patients either deliberately or inadvertently against the advice of their eye care practitioner slept with their lenses in often ended up suffering keratitis6.

Work based upon a 2004 community study showed DD wearers were less likely to be compliant in rubbing their lenses or completing all steps when cleaning lenses, re-used an old stored lens and had a history of a lens related emergency7.

Clinical Setting

Clinicians in this “post-fusarium outbreak” world now look at contact lens patients with a far more critical eye. Science has shown that the probability of risk of corneal infection could be determined via an algorithm incorporating barrier compromise, wearing time and virulence/numbers of pathogens. The risk of certain lens materials with specific lens care solutions is far better understood. Practitioners have adapted prescribing procedures to minimise patient risk, maximise patient outcomes and follow stringent guidelines to minimise the risk of future perfect storms.

Some practitioners have decided that no solution should be the best solution. Unfortunately, in a world of non-compliant patients, daily disposable lenses which are supposed to be “solution free” have the potential to create their own magnified risk. In the current uncertain global economic climate, clinicians are now witnessing the signs of perhaps another perfect storm brewing; this time involving the DD lens modality. If you agree that some DD wearers reuse their lenses for several days, ask yourself: How many of our daily wearers re-use their daily lenses by storing the lens in the blister pack, reusing the packing solution? How many are using saline to rinse these lenses? And while compliance is the goal, how can we best protect even non-compliant patients?

Without consistent policing of our patients through regular after care visits the relative ease of internet/mail ordering, increased sales of daily disposable lenses and the use of daily disposable lenses on a frequent replacement schedule will increase the risks for both the practitioner and the patient. It is not unusual nowadays for a patient to purchase a six month supply of daily disposables, wear each lens for two or more days and not be seen again for 12 to 24 months. These patients are not trained on proper care of a lens and it is not unusual for these patients to sleep with these lenses overnight or worse, still store them in saline instead of a multi-purpose disinfecting solution.

Studies have also shown that the suctioning effect of many daily disposables leads to unavoidable overnight wear due to stuck lens syndrome 8, a condition which may increase the likelihood of lid parallel conjunctival folds (LIPCOF) 9, a notorious marker for contact lens-induced dry eye, discomfort and patient drop out. It is therefore not surprising to see why microbial keratitis in substantial DD wearing populations figures between two and 4.2 per 10,000 cases10.

So What Advice Can We Offer?

Even though I don’t advocate the re-use of DD lenses, I want to protect even my non-complaint DD patients as best I can. In situations of saline storage let me first state the obvious: saline is attractive to the consumer as it is a much cheaper alternative than multi-purpose disinfecting solutions and not significantly differentiated for the patient on the store shelf. Saline use can be dangerous for reused contact lenses as it does not provide disinfection. Saline solutions also do not have lens wetting systems and are not optimising patient comfort, like multi-purpose disinfecting solutions.

If patients are prescribed daily disposables, we should inform, instruct and educate them not to use saline. Proactively tell them that if they use any solution product, make sure it is a multi-purpose disinfecting solution, especially if they ever use their lenses for longer than the daily prescribed modality. A multi-purpose disinfecting solution, such as Opti-Free Replenish, would be an excellent safety net for such non-compliant situations and is my product of choice for soft contact lens patients.

In the cases of overnight wear an enduring risk assessment of the patient should always be considered in the context of informed choice and risk-benefit. Provided the patients’ prescription falls within parameters, silicone hydrogel daily disposable lenses should be the material of choice, along with the regular use of rewetting drops. Contact lens practitioners can prevent and manage a wide variety of contact lens complications. While there have been monumental advances in lens materials, we still do not have the perfect lens material, not to mention the perfect compliant patient. Daily disposables have not reduced the overall risk of acute non-ulcerative disorders, and in non-compliant patients they may actually increase the risk. Contact lenses must be treated as medical devices. The gravity of proper compliance and lens care, along with the list of potential negative outcomes must be properly communicated to every patient, guaranteeing proper instruction to your anonymous non-compliant individuals.

Allan graduated as an Optometrist from the University of NSW in 1994 and has completed a post graduate certificate in ocular therapeutics. He is a Sports Vision consultant to the NSW Institute of Sport and Ocular Nutrition consultant to Health One which led to the development of his Ultravision macula antioxidant tablets. He has a keen interest in medical optometry and for the past 10 years has presented his weekly talkback eye programme “All About Eyes” on Sydney’s number one radio station, 2GB Wednesday night’s from 9pm AEST.

References
  1. Edwards K, Keay L, Naduvilath T, Stapleton F. A Population survey of the penetrance of contact lens wear in Australia, Ophthalmic Epidemiology Oct 2009;16:5,275-280
  2. Efron N, Morgan PB. Prescribing daily disposable contact lenses in the UK, Contact Lens and Anterior Eye 2008;31:107-108
  3. http://www.clspectrum.com/article.aspx?article=102545 International Contact Lens Prescribing in 2008
  4. Ky W, Scherick K, Stenson S. Clinical survey of lens care in contact lens patients, Journal Contact Lens Association of Ophthalmologists (CLAO) Oct 1998;4:194
  5. http://www.siliconehydrogels.org/editorials/mar_08.asp
  6. Efron N, Morgan PB, Hill EA, Raynor MK, Tullo AB. The size location and clinical severity of corneal infiltrative events associated with contact lens wear. Optom Vis Sci 2005;82:519-27
  7. Edwards K, Keay L, Naduvilath T, Stapleton F. The penetrance and characteristics of contact lens wear in Australia. Under review Invest Ophthalmol Visual Sci
  8. Dart et al. Risk factors for microbial keratitis with contemporary contact lenses. Ophthalmology 2008;115:1647-1654
  9. Miller WL, Narayanan S, Jackson J, Bergmanson J. The association of bulbar conjunctival folds with other clinical findings in normal and moderate dry eye subjects. Optometry. 2003 Sep;74(9):576-82
  10. Stapleton et al. The incidence of contact lens related microbial keratitis in Australia. Ophthalmology 2008;115:1655-1662