cl dropouts
Give Those Dropouts Another Chance
A practical guide to returning lapsed wearers to contact lenses and refitting them successfully.
BY JANE VEYS, MSc, MCOptom & ANNA SULLEY, BSc, MCOptom, Bracknell, Berkshire, United Kingdom

Drop outs. In the contact lens field, we know all too well that this term refers to those patients who, for whatever reason, have given up contact lens wear. But when you think about it, "lapsed wearers" is a more appropriate term for these patients because many of them will have resumed lens wear at some stage or intend to wear contact lenses again in the future.

Some practitioners have neglected lapsed contact lens wearers, tending to view them as problem patients who require complex lenses and excessive chair time. However, recent studies challenge these misconceptions and highlight the opportunity to successfully and easily refit lapsed wearers with available contact lenses.

Because lapsed wearers represent a sizeable proportion of those needing vision correction, this article will provide a practical guide to refitting them with reference to the results of a major study in the United Kingdom (see sidebar on pg. 56).

How big is the problem?

Keeping track of patients who discontinue contact lens wear is often difficult in practice. Many patients don't return for follow-up appointments, leaving the practitioner to wonder if they've ceased contact lens wear. In fact, many practitioners may not even perceive that they have a drop-out problem in their practices.

Recent market data from Health Products Research (HPR) suggest that the total number of dropouts may be as high as 16.3 million -- or 10% of the vision-corrected population. According to this data, over the previous four years, on average, 5% of contact lens wearers discontinued lens use each year.

In 1990, when the average lapsed wearer was last fitted with contact lenses, the first soft disposable lenses had only recently been introduced, and it wasn't until 1995 that the world's first one-day disposable lenses were made available in the United States and in Europe. A majority of lapsed wearers would have been conventional lens wearers and few would have worn one-day disposables. The seven years that have elapsed since the average lapsed wearer last wore contact lenses have also seen the introduction of new toric soft disposable lenses and soft bifocal lenses to the market.

Practitioners today, therefore, have a greater variety of lens types from which to choose when refitting a lapsed contact lens wearer. Since these patients last wore contact lenses, the eyecare industry has introduced advanced lens designs and improved care systems that offer greater simplicity and convenience.

Lapsed wearers rarely perceive a reaction to care products as the reason for problems with their contact lenses, but practitioners cite this as the main reason for discontinuation in more than one in 10 lapsed wearers. Previous failure with contact lenses is likely to be either product or practitioner related rather than patient related, although a patient's inability to adapt to contact lenses is also an issue. But before you can correct these problems, you have to draw the attention of lapsed wearers.

Luring them into your office

Practitioners recruited half of the subjects in the U.K. study through ads in local newspapers. They also used other, more cost-effective recruitment methods such as word of mouth and in-office notices. For patients who discontinued lens wear some time ago, the most effective promotional message is for you and/or your staff to tell them that contact lenses are much more comfortable and, with improvements in lens designs, they may experience better vision than in the past (this will appeal to the principal reasons why wearers gave up).

Once you've attracted lapsed wearers to your office, proceed with care. Here's how we manage lapsed contact lens wearers.

Managing lapsed wearers

With lapsed wearers, the initial consultation is even more important than with new wearers. You must take a detailed case history, including the reasons for previous discontinuation, the product or products previously worn, and the time that has elapsed since first trying contact lenses and last dropping out. It's essential to make sure that patients have realistic expectations.

As with all lens wearers, effective communication is a key factor in fitting success (see "Key Factors to Consider When Communicating with Lapsed Wearers" on pg. 55). Lapsed wearers are likely to be more informed about contact lenses than new wearers. They'll already have some knowledge of lens care and handling procedures, and should recognize the importance of follow-up appointments.

Lapsed wearers are also likely to be highly motivated. Having been unsuccessful with lenses in the past, yet trying them again, they've shown their commitment to contact lens wear. They may also be happy to pay whatever cost is involved if the new lenses meet their expectations. Many will have stopped wearing contact lenses on their previous clinician's advice, so it's important to manage them carefully with regard to any misinformation they may have received. Try to reassure those who have stopped wearing contact lenses for product-related reasons that lenses and care products have advanced in recent years and are now more comfortable and convenient to use. Take every opportunity to improve patient retention by continually obtaining feedback and anticipating any potential problems. Recommend new products as they become available and suggest alternative means of lens delivery (such as direct shipment) that you offer.

Don't neglect appearance and lifestyle factors. When practitioners asked lapsed wearers entering the U.K. clinical why they were returning to contact lenses, the most common reason given was, "My appearance is better than with eyeglasses."

The proportion of soft bifocals fitted to the lapsed wearers in the U.K. study was higher than for new fits overall (8% vs. 4%), and greater than the proportion of multifocal soft lens dispenses in the United States (4%). This is consistent with HPR data that show that six in 10 patients stop wearing their lenses after the age of 40. Lapsed wearers were also more likely to be fitted with torics than were new wearers (35% vs. 16%). Therefore you'll refit most lapsed wearers with soft lenses and are more likely to need toric or bifocal soft lenses than those new to contact lenses. So how successful will your efforts be?

Gauging success

Lapsed wearers recruited by notices in office windows have the highest success rate, followed by those recruited by office staff. To target lapsed wearers who are already your patients, approaching them in the office or using direct mail and in-office posters is the best strategy. The most important finding of the recent U.K. study was that a high proportion of lapsed wearers can be successfully refitted with current products. As many as 77% will successfully complete a one-month trial and 92% of these will go on to purchase lenses.

Factors predictive of success on refitting are listed in the sidebar on page 58. Younger lapsed wearers are more likely to be successful than older patients, and success rates are similar for myopes (77%) and hyperopes (75%). Those less astigmatic and less presbyopic are also more likely to succeed.

With respect to slit lamp findings, lower grades of palpebral redness and roughness were predictors of success. Dry eye assessments weren't particularly useful in predicting the outcome of refitting, although lapsed wearers with less tear film thinning near the lids were more likely to be successful and those who had higher McMonnies scores had marginally higher success rates.

Patients unsuccessful on refitting tended to have first worn lenses longer ago and to have last worn them for a longer period. But those who had given up lens wear twice or more were just as likely to be successful as those who had discontinued only once. The reasons for dropping out or for returning to contact lenses did not appear to influence refitting success, which was also unaffected by previous lens type.

Once refitted with lenses, lapsed wearers tended to cite vision problems rather than discomfort as the most common reason for giving up. This suggests that developments in lens material and design have, to some extent, reduced the problem of lens related discomfort.

You can succeed

Lapsed contact lens wearers are a significant problem for the contact lens practitioner and industry. They represent a large, untapped opportunity for the practitioner because large numbers of them are interested in returning to contact lenses. The high success rates achieved on refitting lapsed wearers may seem surprising, given that the reason for previous failure is, in many cases, lens related. But recent advances in contact lenses -- such as the wider use of frequent replacement, daily disposable and toric lenses, improved designs and materials, and more convenient care products -- have improved the prospects for patient success.

Although discomfort is the principal reason for discontinuing contact lens wear, a history of discomfort with contact lenses is not a contraindication to refitting. You can successfully refit a high proportion of lapsed wearers with current contact lenses and see six months later that almost all of them are either still wearing lenses or planning to continue lens wear. The highest refitting success rates are for one-day disposable, two-week and monthly replacement soft spherical contact lenses.

Give them another chance

Recent advances in contact lenses have improved prospects for continuing contact lens wear and solving the problem of contact lens dropouts. We need to attract lapsed wearers back in to our offices, communicate the benefits of modern lenses, and give them another chance to succeed.

Dr.Veys is director of clinical affairs, Europe, Middle East and Africa, and Dr. Sulley is professional affairs manager, UK and Ireland, at Johnson & Johnson Vision Care.