I’m sure we’ve all experienced this. It’s a busy Saturday. You are at the end of your consultation. You’ve completed an excellent refraction, a thorough eye health examination and gained commitment for some new glasses. Just as you are about to walk your patient out of your consulting room then take the next patient through, they ask, “Can I try contact lenses?”

new wearers need good communication and support to set them up for success

Table 1. Adapted from Sulley et al

You cheerily respond, “Of course! Let’s book you in next week”.

However the patient continues, “Can I try them now? I have a wedding this afternoon.”

You look around, all your staff are busy with customers, your appointment book is full, but you don’t want to disappoint your patient. It’s down to you.

So you do the fit and teach, but you end up rushing it and a few days later your patient cancels her aftercare appointment. What was the reason? Was it vision, comfort, or did other factors come in to play?

The good news is a recent prospective study1 found 78% of evaluable neophyte contact lens (CL) wearers continued to wear CLs 12 months after being fitted.

But what about the other 22%? Why did they discontinue wear?

COMFORT AND CLEAR VISION

Table 1. Adapted from Sulley et al

For any contact lens wearer, we know comfortable lenses and clear vision are incredibly important, and for those new wearers who stopped wearing lenses, these were the main reasons for discontinuation (Table 1). But interestingly, problems with handling were also a significant factor which impacted on new wearers continuing to wear lenses.¹

This shows the importance of ensuring optimal visual performance and comfort of a lens, but also poses the question, how can we support new wearers so that handling difficulties have less impact on their success?

Firstly, let’s look at vision. Sydney optometrist and contact lens specialist Mark Koszek believes vision is closely linked not only to the optics of the lens, but also to the wettability of the material.

Figure 2. Silicone hydrogel daily disposable after 15 seconds

“CL wettability is a big factor. Wetting angle and tear evaporation on the lens surface are critical factors affecting visual quality,” he says.

Figure 1 (over page) is a still image from video topography of a standard daily disposable SiHy at zero seconds and 15 seconds, between blinks. You can see the mires become blurred and unstable, indicating a dry surface and disrupted tear film. This can lead to both poor vision and discomfort, which for a new wearer is certainly not ideal. However with Dailies Total 1, you can see there is almost no change between zero and 15 seconds, which may assist in keeping vision and comfort stable.

Figure 3. Dailies Total 1

Montes-Mico2 investigated the on eye optical quality of daily disposable CLs for different wearing times. Dailies Total 1 showed the lowest aberrations and smallest point spread function for all time points. More spread out point spread functions indicate a worse retinal image quality and may be correlated with a patient’s poor visual performance. The best optical quality and most stable results over time were obtained with Dailies Total 1 and the author suggests the water gradient material was a decisive factor in its performance. This also demonstrates that the quality of the retinal image for Dailies Total 1 is consistent throughout the day.

Figure 4. Dailies Total 1 after 15 seconds

To avoid the patient experiencing intermittent blur with blinking due to poor tear film quality, Mark Koszek believes in “the importance of paying attention to any underlying dry eye issues”. In a January 2019 optometric management article,³ Wroten also discussed the importance of “identifying and managing some subtle (and some not so subtle) conditions, which can complicate or prevent successful contact lens wear”. Ocular surface disease was at the top of the list.

Eye dryness can be assessed relatively simply using a patient symptom questionnaire to evaluate the severity of the symptoms, followed by assessment of tear breakup time. Staining can also be used to assess coexistence of meibomian gland dysfunction.³

Depending on the type of ocular surface disease, the eye can then be stabilised prior to commencement of contact lens wear with topical lubricants such as Systane Complete which acts on all layers of the tear film, meibomian gland expression and in more severe cases, prescription antiinflammatory drops. Not only should the patient feel more comfortable, but their visual outcome may be improved.³

Factors affecting vision, such as wettability, can also play a role in CL comfort. For a new wearer, if the first experience of CLs is not a comfortable experience, they are less likely to continue. Therefore it is important to fit new wearers with the most comfortable lens for the individual patient, so their initial experience is positive and they go on to become long term wearers. For example, fitting patients in Dailies Total 1 may improve your chances of long term CL success as we know in a survey of 280 patients, nine out of ten sometimes forgot they had them on – the lens feels like nothing.⁴

HANDLING

But what about handling? What strategies can we implement to improve the chances of success for new wearers? Mark Koszek says there are three important factors in the support of patients in the initial stages of wear. He says “firstly new wearers need good communication and support to set them up for success. Secondly they need regular reviews and thirdly, reinforcement of the medical nature of CLs to build compliance”.

Figure 5

Unlike the case of our Saturday morning patient above, Mark brings up the option of CLs at the beginning of the consultation to avoid being rushed at the end. This enables him to explain the effect a CL can have on the eye, and also allows time for the eye to adjust. It’s important to reassure new wearers it can take some practice to get used to insertion and removal. Continued communication is important to resolve any difficulties early in the trial period.

In the Sulley study,¹ 57% of patients who had lapsed by the 12 month stage reported their practitioner was unaware of their discontinuation. This suggests there may be inadequate follow up with new lens wearers. Providing better communication and support represents a significant opportunity to help those who are struggling with vision, comfort or handling.

“The review period should be relatively short, within a week and ideally around three to four days. Otherwise the patient can get frustrated and give up. Many problems can be easily triaged via a phone call,” said Mark.

One of the concerns that busy practices have is the lack of time available for patient follow up. While it takes commitment and teamwork to provide quality follow up, the rewards in building patient confidence and success are there. Providing tips and reassurance to new wearers via phone calls or texts is certainly an area worthy of development in a practice.

Encouragingly, even if a patient discontinues lens wear initially, Sulley’s study found that a high proportion of lapsed wearers (75%) express an interest in retrying CLs.1 When asked what would persuade them to try CLs again, nearly half responded better vision, 43% responded better comfort, 41% responded easier handling, and 39% reduced cost.¹

Knowing that handling, in addition to the well known primary factors of vision and comfort may improve retention in CL patients, manufacturers like Alcon continue to innovate. The aim being to provide more solutions to support practitioners and increase the range of options available for their patients. With this in mind, watch out for Alcon launch events in 2019.

References 

1. Sulley A, Retention rates in new contact lens wearers. Eye & Contact Lens 2018. Volume 44. Number 5. 273-282 
2. Montes-Mico R, On-eye optical quality of DD CL for different wearing times. Ophthalmic Physiol Opt. 2013;33(5):581-591 
3. Wroten, C, Addressing ocular surface disease. Optometric Management 2019, Volume: 54, Issue: January 2019, page(s): 16-18, 48 
4. Perez-Gomez I, Giles T. Clin Optom 2014;6:17–23. 

Helen Gleave BScOpt(Hons) MCOptom holds the position of Professional Training Manager for Alcon, Australia responsible for training and education programs in contact lenses, contact lens care and dry eye. Prior to this she qualified as an optometrist from City University in London and owned a practice focused on contact lenses for fifteen years. She has been a clinical investigator for different contact lens manufacturers and a member of their advisory panels. 

Contact: Alcon Laboratories (Australia) Pty Ltd, (AUS) 1800 224 153. New Zealand, c\o PharmaCo, (NZ) 0800 101 106. NP4# A21902960391