Contact Lenses
CONTACT LENS UPDATE
A look at overall trends affecting many lens modalities. Plus, a round-up of options for dry eye treatments for your contact lens wearing patients.
Optometric Management Staff and Steven Bennett, O.D.

Convenience, comfort and safety are the mantra of contact lens makers when striving to develop the next new contact lens. This is evident when you look at the trends toward longer wearing schedules and increased disposability in many modalities.

The need for lenses that are more convenient and comfortable is as urgent as ever with laser-assisted in situ keratomileusis (LASIK) nipping at the contact lens market's heels.

Presently, only 3% to 4% of all eligible LASIK patients have undergone the procedure, and, according to new data from Health Products Research, the use of laser surgery to correct refractive errors has increased an average of 75% per year since 1997. Obviously, LASIK is just one more thing that opens the door to increased competition in the contact lens market.

With that said though, it's not as if the contact lens market is standing still. There's a lot happening. We asked contact lens expert and Editor of our sister publication, Contact Lens Spectrum, Joe Barr, O.D., M.S., F.A.A.O., to give us insight into the growing trends in the contact lens market.

Continuous wear. One of the major trends Dr. Barr notes is the move toward continuous wear lenses made of silicone hydrogel materials.

"The manufacturers will tell you that in this decade you'll have 30% of patients in this material," says Dr. Barr. "Within a few years, we'll see torics and multifocals made of silicone hydrogel materials," he adds. "If people want the convenience of extended wear, they'll want it in every modality."

But before this modality takes off as expected, Dr. Barr explains that resistance from practitioners will need to ease.

It was the same way when disposables first came out, he says. At that time, most practitioners didn't want to use them. Doctors thought that if their patients wore this modality that they wouldn't see them for years, that patients wouldn't comply with their lens wear regimens and that the lenses would cost too much. "But then a few practitioners started using them," says Dr. Barr, "and many others followed.

"I think we'll see the same thing happen with continuous wear," he predicts. "Consumer advertising will be huge with this modality because the companies have put so much into the continuous wear effort. Once that happens, patients will want it. Then, you only need a few doctors to say it's safe and many more will follow."

If industry data accurately reflect practitioner sentiment, continuous wear is already poised for success. A recent survey of nearly 500 optometrists conducted by CIBA Vision explored the prescribing tendencies regarding the new silicone hydrogel materials. The survey found:

• 46% of O.D.s said they'd try these lenses on selected patients, but they wouldn't recommend them to most patients
• 12% of doctors indicated they'd aggressively refit patients who now wore disposable lenses because of the new lenses' increased oxygen transmissibility
• 27% said they'd recommend these lenses to any patients who were interested.
• 15% wanted to wait to use the lenses until more clinical data were available.

"It's hard for doctors to believe that this lens material is really better," says Dr. Barr, "until they get to use it."

Daily disposables. It's estimated that 1 million people in the United States wear daily disposable lenses. Also, various industry sources logged 20% growth in this modality in 2000. However, this number "isn't nearly as high as some other countries -- such as England and some of the other European countries" explains Dr. Barr.

"Probably the major reason for this is that doctors think it's too expensive -- even though many patients don't," he says. "What ends up happening is that many doctors make an economic decision for their patients. But if you look at the fact that you can wear daily disposables for $1 a day, that's not much.

"This is the healthiest lens modality," he adds. "And I do think it will get bigger because the manufacturers have to make it bigger. If price comes down a bit and manufacturers keep communicating the message, I think more patients will ask for it and more doctors will embrace it."

Multifocals. Between the fourth quarter of 2000 and the first quarter of 2001, the entire multifocal category increased by 17%, says Dr. Barr. "Historically speaking, that's huge growth. If you'd predicted that 10 years ago, people would've said you were crazy."

In addition, the growth of disposable multifocals is astounding. At present, CIBA Vision is only manufacturer with a daily disposable multifocal (the Focus Progressive) and about a dozen other companies have a 2-week disposable multifocal. No doubt that we'll continue to see a trend toward disposability in multifocals, as well as in other modalities, explains Dr. Barr.

Disposable and planned replacement torics. We're also seeing a clear trend toward toric disposables, says Dr. Barr. We also have about a dozen new options in the 2-week category.

According to Dr. Barr, the category of disposable and planned replacement torics increased from about 11% to almost 14% of new fits for the four quarters that ended in June 2001.

"That's substantial growth," he comments. "I think we're seeing this jump because we have more options. The lenses are better, and there's been significant promotion from the manufacturers. That's also true at the professional level.

"In truth, patients expect every type of lens to be disposable," he continues. "So, if you combine that thinking with the increasing trend of doctors believing that soft toric contact lenses are quite predictable compared to a decade ago, it's evident why we're seeing an increase with this modality."

Not only do practitioners have a greater comfort level with these lenses, explains Dr. Barr, "but there's no denying that this is a value-added product -- the profitability is greater to the practitioner, as well."

Opaque and color-enhanced lenses. Some growth is expected in this area over the next year, especially because Vistakon is expected to launch a colored lens. Dr. Barr estimates they'll introduce this lens in early 2002.

"They really know how to market to consumers," says Dr. Barr, "so I anticipate we'll see increased consumer awareness and interest in this lens modality because of this."

Rigid gas permeable lenses. This modality will experience a little growth, says Dr. Barr.

"I'm confident that we'll see overnight orthokeratology approved in 2002. However, I think you'll see a small cadre of doctors who are comfortable with ortho-K."

In addition, he adds that we'll see the introduction of a 30-day continuous wear RGP lens in 2002.

Continuous Wear
How Will O.D.s Embrace this Modality?
BY KAREN RODEMICH, Senior Associate Editor

For the most part, extended wear contact lenses have been classified as optical medical devices that are worn for 7 days or less. All of the major companies manufacture 7-day extended wear contact lenses: Bausch & Lomb's PureVision silicone-hydrogel lens, CIBA Vision's Focus Night & Day lens and Vistakon's Acuvue, to name a few.

B&L's PureVision lens is going before the FDA for approval to market the lens for 30 days of continuous wear, and advisors to the FDA recently recommended CIBA Vision's Focus Night & Day for 30-day continuous wear because these lenses allow much higher oxygen levels to reach the cornea than standard soft lenses.

The FDA isn't legally bound to accept the panels' recommendations, but it generally does. A final decision is expected soon.

Expert opinion

Contact lens specialist Lee E. Rigel, O.D., F.A.A.O., shares his thoughts on the present and future of continuous wear contact lenses. To start out, Dr. Rigel pointed out that continuous wear lenses won't just be available in soft lens materials -- there's a rigid gas permeable (RGP) in the works for continuous wear up to 30 days from Menicon. "Having some experience with RGP and soft continuous wear, RGPs seem to have advantages," says Dr. Rigel, "both from a physiological standpoint and patients can wear them comfortably for extended periods of time."

Impact on optometrists

When asked what this emerging technology will mean to optometrists, Dr. Rigel responds, "I think it will have a tremendous impact on contact lens practices. It will be a viable alternative to refractive surgery, and it boasts patient convenience. That's what patients want -- better sight without having to fool around with contact lenses or glasses."

So will refractive surgery become less desirable? "If patients have an alternative that lets them eliminate glasses and the hassle of inserting and removing contact lenses, I think it will," says Dr. Rigel. He also says that continuous wear will offer an opportunity for O.D.s to grow their contact lens practices by offering an alternative that patients want.

Continuous wear contact lenses may sound good, but how will you react to this technology once it becomes widely available?

Dr. Rigel believes that some O.D.s will readily embrace it but that others will hesitate because they remember the problems in the past with extended wear. These O.D.s will most likely wait on the sidelines to see how the first patients fare with continuous wear contact lenses.

Getting patients interested

Finally, Dr. Rigel offers a tip to help you better embrace this new technology. He suggests that you survey patients as they come into your office, and evaluate the responses. For example, if you're in the exam room with a myopic patient, tell him that his options are glasses, contact lenses, refractive surgery or contact lenses that he can wear for up to 30 days at a time.

"If you offer continuous wear contact lenses as an alternative, many people will get excited about them," he says.

Dr. Rigel won't conduct a survey in his own practice but will introduce the new modality through an e-mail newsletter his office is developing. "We'll also mention 30-day lenses to all contact lens patients who come in to make sure they hear about it from us and not an outside source," he says.

Dr. Rigel says that it's well-documented that there's enough interest in patients wearing lenses for up to 30 days.

Cost questions

You may be wondering how to approach the subjects of corneal health and cost with patients. Dr. Rigel says, "We'll inform patients that this lens modality is an improvement over older modalities because it enhances oxygen permeability, and that other problems can occur that we'll have to check for more often."

He admits that 30-day wear lens prices will be more expensive. It's all a part of new and improved products. Dr. Rigel clarifies, "I may mention that there's a slight cost increase to patients, but when you're talking about a few dollars, that's not significant to them. Do, however, emphasize that there's more professional involvement, which translates into an increase in cost."

Continuous wear lenses are gaining in popularity and, more than likely, they're here to stay. Take these tips into consideration when introducing your patients to this new modality.

An Option They're Itching to Wear
Daily disposable contact lenses for patients who have allergies.
BY STEVE BENNETT, O.D., F.A.A.O., Ann Arbor, Mich.

If you're like many O.D.s, you're always looking for a new and better way to help allergic patients cope with the challenge of finding comfortable eyewear.

One contact lens technology that I've been particularly impressed with is the daily disposable lens. I've increased my contact lens practice and my patient base by adding this option to my contact lens arsenal; here's why you could, too.

Why try?

The foremost reasons for fitting daily contact lenses are quite obvious:

• They're easy to fit.
• They don't require solutions.
• They're convenient for patients.
• They're a healthy option as well.

I find that these lenses are especially healthy for patients with allergies, as you'll see below. Seasonal allergy sufferers dread the redness and itching that plagues them each year.

Those patients who don't wear daily disposable lenses may notice that their lenses become coated much earlier in the day because of the increase in mucus production, which the various allergic reactions of the eyes can produce.

What you're up against

Nearly 30% of the American population have allergic eye diseases, and seasonal allergic conjunctivitis (SAC) accounts for about 50% of allergic eye disease. Patients with SAC who wear contact lenses experience discomfort, mostly caused by allergens sticking to the lens surface or by pollen spread to the eyes by hand contact.

Other types of allergic responses are also common:

Giant papillary conjunctivitis. Protein deposits on lenses can lead to giant papillary conjunctivitis. Initial symptoms include ocular itching during lens wear and after removal and decreased lens tolerance. Patients experience vision problems from increased lens deposits and displacement from superior lid papillary hypertrophy.

Phlyctenulosis. A more unusual but still common problem is the development of an allergy to bacteria that are present on the edge of the eyelid.

These bacteria produce toxins, which become trapped in the tears, especially beneath a contact lens. This can lead to phlyctenulosis, a blepharitis-related complication of the cornea and conjunctiva with symptoms of itching, redness and tearing. A white, sterile lesion occurs at the edge of the cornea, causing a foreign-body sensation whenever the patient blinks.

Solution allergies. Problems also occur with contact lens solution allergies and sensitivities. Although preservatives like thimerosal are history, we still have sensitivities to the benzalkonium chloride and EDTA commonly found in contact lens solutions. Patients who develop allergies or sensitivities to these chemicals can experience redness, itching and discharge, especially when the lens is first inserted.

Solutions made for "sensitive eyes" generally contain the same amount of preservatives as other solutions. Patients are miserable, they don't want to wear their glasses and they insist that we do something.

With daily disposable lenses, these problems are minimized. Patients don't need to use solutions. Regularly replacing lenses avoids the problems of protein, allergen and toxin buildup.

To the rescue

Several daily disposable lenses are available to you today.

1-Day Acuvue. I started using 1-Day Acuvue lenses early and had good success. They have a handling tint and two base curves. However, there are some handling issues due to the thinness of the lens. Spectacle wearers occasionally have trouble with insertion and removal. It's also difficult to tell the inside from the outside. They're best for experienced contact lens wearers.

Focus Dailies. In 1998 CIBA Vision introduced Focus Dailies. I tried this lens on any patient with allergy symptoms as well as other contact lens and solution problems. It worked very well. The pricing was good and my patients had few, if any, handling problems. The lens is clear, which presents a minor inconvenience for some patients.

One important point to mention about this lens is that on April 25, 2000, the U.S. Food and Drug Administration (FDA) recognized Focus Dailies as the only contact lens that's shown to reduce the occurrence of seasonal allergic conjunctivitis.

SofLens One Day. Bausch & Lomb's SofLens One Day disposable lens is the newest on the market. It has also worked well, but is best on flatter corneas.

I always recommend that my patients irrigate their eyes in the morning before inserting daily disposable lenses and in the evening upon removing them. I still may prescribe allergy medications for them, if necessary.

Some patients use prescribed drops while wearing their lenses. These drops can discolor the lenses and cause eye irritation over time. If they wear daily disposables, however, any effect of the drop is long gone by the time they discard the lenses.

The long and short of it

In short . . . daily disposables are a great option, they're easy to fit, their pricing and/or rebate offer the patient reduced expenses, and you can help your patients with new technology. Not bad for a day's work.

Dr. Bennett is CEO of Dr. H.W. Bennett and Associates in Ann Arbor, Mich. His areas of interest include low vision and contact lenses. Dr. Bennett is a certified low vision specialist and is past chairman of the Michigan Optometric Low Vision Committee.

They've Come a Long Way
Great stability and large fitting sets make disposable toric lenses great for your practice.
BY TERRI B. GOSHKO, Senior Associate Editor

The past 10 years have seen great strides in the manufacturing of disposable toric contact lenses, especially since the first 2-week disposable, FreshLook Toric, was released less than 4 years ago. Not only have prices kept dropping as production capabilities increase, but the newer lenses on the market are also dependable, and the large fitting sets can mean great benefits for your practice and patients, as you'll see here.

The lenses

The following are the newer disposable toric lenses. The difference in cost usually reflects 2-week vs. monthly replacement cycles.

Biomedics Toric by Ocular Sciences, Inc. This lens has just been released. It has UV blocking and is stable on the eye. Available in a power range of plano to -6.00D, with 3 cylinder powers in 10 degree steps, it costs $20.00 per six-pack.

According to Rick Franz, Vice President of Professional Relations at OSI, the largest trial fitting set for Biomedics Torics is 294 lenses. However, he adds, many O.D.s find the lenses are so stable that they prefer to fit them empirically rather than take up office space with fitting sets, so the company is considering other options for such practices.

P. Douglas Becherer, O.D., F.A.A.O., chairman of the American Optometric Association (AAO) Contact Lens and Cornea Section, says that large fitting sets offer these advantages to your practice:

• Often, you can easily evaluate a lens that's reasonably close to the actual prescription.
• You can refine the prescription on the patient's first visit and so increase his confidence in the lens and in you.
• You can reduce the number of refits.
• You can achieve success or recognize failure and the need for a different lens sooner.

FreshLook Color Blend Torics by CIBA Vision. Released several months ago, this is the colored version of the first-approved 2-week disposable soft toric introduced in 1998. The power range is more limited than in the FreshLook Toric, -4.00D, in three cylinders and +/- 20 degrees from 180 and 90 degrees. The colors are blue, green, honey and gray. The cost is $45 per six-pack. There is no fitting set; use the clear toric fitting set for fitting and the Color Blend set to determine color.

Acuvue Toric by Vistakon. This disposable toric introduced last year has a UV blocker and a 600-lens fitting set. Dr. Becherer explains, "it's easy to tell whether you'll be successful with it at the initial visit." It's also the only lens of its type to come in 12-packs, at $40.00.

Frequency 55 Toric by CooperVision. With two base curves at 8.4 and 8.7 and four cylinders, this lens permits you to accurately fit a wide range of corneas and costs $34.00 per six-pack. The large fitting set of 300 lenses raised the industry bar.

SofLens 66 Toric by Bausch & Lomb. A slightly older, stable lens, the SofLens 66 has a marking system of 5, 6 and 7 o'clock. This lens costs $21.60 per six-pack. The fitting set is mid-sized, at 165 lenses.

Notes of caution

Though improved stability and fitting may impress your patients, Dr. Becherer cautions against letting them take your skill and these lenses for granted.

"Some patients think that disposable means a simple fit, but these lenses are complicated and sophisticated optical systems," he explains. "Though manufacturing has improved drastically, a difficult case is still a difficult case. It takes your expertise to achieve maximum success with toric lenses, both physically and physiologically."

Help patients understand the value of your professional services. Dr. Becherer says, "Explain that small refinements can make the difference between marginal and maximum success. Make sure that your patient understands that this may take considerable amounts of his and your time and that different lenses may need to be evaluated. And remember, with so many toric lenses in the large fitting sets available to us today, most astigmatic patients can readily achieve safe, crisp vision."

No Fair Share
Promoting eye health with your novelty and colored contact lens patients.
BY TERRI B. GOSHKO, Senior Associate Editor

As you know, colored contact lenses and novelty lenses are popular options today, especially among teenagers. Crazy Lenses -- including NFL Crazy Lenses -- by CooperVision and Wild Eyes by CIBA Vision appeal to young patients around Halloween or during the football season. Some patients wear daily tinted enhancer or opaque lenses (such as CooperVision's Expressions; CIBA Vision's Softcolors, Illusions and Durasoft line; Bausch & Lomb's Optima 38 Natural Tint lines and Metro Optics' Metrotint M series and Metrotint like accessories) for special occasions.

But young patients especially can be tempted to swap or share lenses with friends, giving rise to eye health concerns. What can you do to minimize the likelihood of this problem among your patients?

Golden rules

Wayne Wood, O.D., of Drs. Wood, Lanier, Bowman and Rogers in Jacksonville, Fla., feels that these lenses can be an exciting addition to a contact lens practice in light of their unique appearances as well as the extensive marketing manufacturers to do promote them. However, he thinks extra precautions are necessary.

Dr. Wood hasn't seen any infection or other eye health problem from shared lenses in his large practice that specializes in fitting all types of contact lenses. He thinks the reason is these rules he follows in his practice, which may help you in yours:

• Don't fit patients who you think will ignore your instructions against trading or lending lenses. It's okay to refuse to fit if you believe your advice won't be followed.
• If the patient is a teen, get her parents' permission for her to wear the lenses. Emphasize proper lens hygiene to patient and parents.
• Create a form on your letterhead saying the patient promises not to share or exchange lenses, and have the patient sign it. This goes beyond informed consent; it's like a contract and emphasizes the seriousness with which you take this issue.
• Charge appropriately. Your chair time and professional expertise matter -- make sure you're paid for them. Not only do you deserve this, but the higher cost will also discourage impulsive, irresponsible patients.
• Don't avoid fitting novelty or colored contact lenses, but fit them judiciously only for those patients whom you believe appreciate the health concerns.

Soothing Your Contact Lens Patients' Dry Eyes
Here's a look at a range of available options.

In our September 2000 issue, Deepak Gupta, O.D., provided tables of artificial tears and ointments. He's updated these lists to reflect new options for treating dry eye.