Continuous Wear
Is Your Practice Ready for Continuous Wear?
We've seen many breakthroughs in contact lens technology. Now prepare yourself for an innovation as big as the first soft lens.
BY N. REX GHORMLEY, O.D., F.A.A.O., St. Louis, Mo.

In the fall of 2001, the FDA approved two silicone hydrogel contact lenses for up to 30 days of continuous wear. Both lenses have a Dk/t in excess of 100 and a treated lens surface that enhances wettability. So what's the big deal?

ILLUSTRATION BY PHIL HOWE

Our patients want good, continuous vision. And they don't want the daily hassle of inserting, removing, cleaning and disinfecting their lenses. I've fit both of these silicone hydrogels on my patients for continuous wear and they've all been thrilled with the ability to see clearly for several weeks at a time. Adverse events have been minor and I haven't observed any major ocular health complications.

Looking to the future

Silicone hydrogel contact lenses are the biggest breakthrough in contact lens technology since the FDA approved the original soft lens in 1971. I predict that silicone hydrogel lenses will significantly reduce the number of standard hydrogel contact lenses fit within the next few years. Why? Because they're comfortable, they provide excellent visual acuity, solve many daily wear lens complications and allow many patients to wear them continuously for up to 30 days.

If you want your contact lens practice to grow rapidly and you want to enjoy the benefits of this new technology, then I suggest that you evaluate the following two aspects of your practice:

1. practice education

2. contact lens patient care.

Educating the office

We can only fully understand and use new technology in our practices if we're educated. Practice education encompasses the education of you, your staff and your patients. Here's what I mean.

What you need to do. As the leader in your practice, you must become familiar with silicone hydrogel technology and the fitting needs and follow-up care that continuous wear lenses require. Understand the opportunity for practice growth and share your excitement with your staff.

We've been convinced because of the past history with low Dk/t soft lenses that extended wear is bad for our patients. This opinion has been relayed to our staff and our patients. Progressive doctors will change, endorse new technology and become educated about the care of the continuous wear patient.

Here are suggestions to help you increase your knowledge:

• Read articles in professional journals about silicone hydrogel and continuous wear lenses
• Attend continuing education (CE) courses on these topics
• Study the Web site designed by the contact lens research units in Canada and in Australia: www.siliconehydrogels.org
• Read the new text book, Silicone Hydrogels: the Rebirth of Continuous Wear Contact Lenses, written by D.F. Sweeney and published by Butterworth/Heinemann.
• Talk to colleagues who have clinical experience with these new contact lenses.

Give your staff a few pointers. Your staff answers your telephone and makes appointments for your patients. They take case histories and assist you with patient care. Obviously, they should also learn about silicone hydrogel lenses and display a positive attitude toward continuous wear.

Consider the following ideas to help educate your staff:

• Fit staffers with continuous wear contact lenses
• Schedule staff meetings to discuss this new technology
• Share articles about continuous wear lenses with your staff
• Send key members of your staff to CE meetings
• Have company representatives provide you with educational materials to pass out to your staff.

Keep patients in the loop. Patients need to hear from you and your staff about this new development in contact lens technology. We've done the following in my practice to inform our patients about silicone hydrogel contact lenses:

• During the patient consultation, I educate good continuous wear candidates about the lenses
• Staff members "plant the seed" about these new lenses when talking with patients on the telephone or in the office
• We use our newsletter and Web site to spread the word
• Develop "handout" educational material about continuous wear contact lenses
• We enclose continuous wear educational materials in all mailings that leave our office.

Remember, many patients feel that sleeping in their lenses is bad for their eyes. Re-educate them about this new technology and inform them about the opportunities for safe continuous wear.

Contact lens patient care

With this new technology, I suggest that you examine the following aspects of contact lens care: patient selection, the contact lens exam and follow-up care.

Selecting patients. Those who need constant vision correction, such as moderate to high myopes and hyperopes, and patients who live a busy lifestyle and want a hassle-free vision care system are good candidates for continuous wear. Patients who ask you about refractive surgery are also good candidates.

The easiest patient to convert to continuous wear is your existing successful hydrogel daily wear contact lens patient. You'll be successful because you know the patient. Upgrade this patient to continuous wear and he'll become the foundation of your new continuous wear practice.

Successful continuous wear depends on a healthy, wet eye. Patients who have dry eye and a history of severe allergies aren't good candidates for continuous wear. Evaluate a patient's work environment and his hobbies before choosing him as a candidate.

Compliance is an important factor in the success of the continuous wear contact lens patient. Patients need to understand the importance of replacing their lenses every month and agree to follow the recommended wearing schedule.

To minimize complications, see the continuous wear patient every 6 months for a contact lens exam. Include a contact lens exam on every candidate.

What to include in your exam. Perform a thorough contact lens exam on every candidate for continuous wear. Include an evaluation of the patient's refractive error, ocular health, corneal physiology and tear system.

Invert all lids to look for signs of giant papillary conjunctivitis (GPC). A small degree of GPC may become a larger problem with continuous wear. Look for external pathology, such as blepharitis and meibomian gland dysfunction, as these patients may be more susceptible to corneal pathology.

If biomicroscopy shows a microbial keratitis scar, then this patient has a much higher probability of having a reoccurrence of microbial keratitis.

Take a complete medical history to eliminate any systemic condition or medication that will interfere with the integrity and health of the cornea.

Perform a diagnostic lens fitting on all potential continuous wear patients to evaluate the comfort, fit and visual acuity with the new lens. Silicone hydrogel lenses can take 10 to 15 minutes to "settle" before you can accurately evaluate the fit and vision.

Observe lens centration and movement with the slit lamp. Adequate lens movement is important in achieving successful continuous wear.

A well-fit lens should be centered, comfortable and show no edge lift or vessel impingement. A flat lens will show excessive lens movement, edge lift, lens fluting and poor lens comfort. A tight lens may have little or no movement and conjunctiva vessel impingement.

Follow-up care. Because of the high degree of oxygen transmission with silicone hydrogel lenses, you can be more aggressive in recommending a wearing and office visit schedule. I recommend that a new lens patient wear his lenses full time (12 to 14 hours per day) for the first week because it's not necessary for him to gradually build up his wearing time.

At the 1-week office visit, if the patient is adapting well, I then start a continuous wear schedule and schedule office visits at 1 week and 30 days. At the 30-day office visit, I give the patient a 6-month supply of lenses.

I immediately begin current soft lens patients on a continuous wear schedule and have them return for 1-week and 30-day office visits. I see all patients every 6 months to evaluate their vision, lens comfort and ocular health.

We pre-appoint all appointments before the patient leaves the exam room. Professional follow-up care is important in the success of continuous wear.

Prepare yourselves

Silicone hydrogel continuous wear will satisfy the convenience and vision needs of many of your patients. They have the potential to dramatically affect your contact lens practice in a positive way. Change happens! Anticipate change, adapt to it quickly and enjoy it! Prepare your practice now for the many changes that are occurring in the contact lens industry.

Dr. Ghormley has been in private practice for 30 years. He's a past president of the American Academy of Optometry and is the team optometrist for the St. Louis Rams (NFL) and the St. Louis Blues (NHL).