strategic skill builders
A Free Continuing Education Series

Stanley J. Yamane O.D., F.A.A.O. Vice President, Professional Affairs	Howard B. Purcell O.D., F.A.A.O. Director, Professional Affairs

Dear Colleague,

Vistakon, Johnson & Johnson Vision Care, Inc., the world's largest manufacturer of contact lenses, is proud to sponsor the 2004 Strategic Skill Builders Continuing Education (CE) Series. Support of eye care education is a high priority at Vistakon. We sincerely hope you find these CE modules to be useful educational tools in your optometric practice.

Optometric CE certification is provided by the Irving Bennett Business and Practice Management Center at the Pennsylvania College of Optometry. Because CE requirements and correspondence credit rules vary from state to state, we advise you to check with your state board to determine if these modules have been approved.

Today's healthcare environment is exciting and dynamic. New developments are occurring almost every day, challenging us to stay abreast of new clinical and practice management information. To meet the challenge, we must continue the learning process throughout our lives because doing so keeps us on the cutting edge, paying big dividends in terms of benefits to our patients and practices.

We want to acknowledge the hard work and dedication invested in this project by the authors of these modules and the outstanding Optometric Management staff.

We hope you take advantage of this educational opportunity. It's just one of the ways Vistakon wants to help you provide the best possible care to your patients. Certainly, that's a goal we can all share.

With warmest regards,

Stanley J. Yamane and Howard B. Purcell

This Strategic Skill Builders Continuing Education article is made possible by a grant from Vistakon. The content is independently produced by Optometric Management.

strategic skill builders
Avoiding Contact Lens Dropouts
Customizing lens care and educating contact lens patients is important.
BY HEIDI WAGNER, O.D., FT. LAUDERDALE, FLA.

When patients use them appropriately, contact lens solutions promote healthy and comfortable contact lens wear. However, when used inappropriately, these solutions may lead to symptoms of discomfort, inconvenience and dryness -- all of which are leading causes of patient drop out in contact lens wear.

SOME THINGS ARE ALWAYS IMPORTANT

Fortunately, contact lens care has evolved from a multi-step process that emphasized the lens care system to, in many cases, a one-bottle solution. Despite these advances in technology, you and your patients shouldn't adopt the belief that all solutions are alike. You'll find it beneficial to understand the nuances between different care systems so you can customize lens care regimens to meet the needs of individual patients. Educating patients to use lens care systems properly also remains important.

In their inception, lens care systems contained numerous components including:

A daily cleaner. Removes loosely adhered debris.

Rinse. Rinses away the cleaner from the lens.

Disinfectant and storage solution. Eliminates potentially pathogenic organisms.

Periodic enzymatic cleaner. Removes protein from the lens.

Lubricant. Keeps the lens lubricated and moist.

These key steps are still critical to lens care. However, in most instances, manufacturers have combined some or all of these steps in their products. The pursuit of simplified systems that offer patient convenience and promote compliance with the lens care regimen has driven the highly competitive market.

DISINFECTING CHEMICALLY

The challenge with chemical disinfection systems is to find a solution that isn't toxic to the eye but is efficacious in cleaning and disinfecting the lens. Although the preservatives used in today's lens care systems are less prone to cause adverse effects to the eye than are older preservatives, a number of patients continue to experience discomfort that's possibly associated with preservatives.

Symptoms may not be immediate and may be vague -- a syndrome characterized by complaints of dryness, discomfort and decreased wearing time that may or may not be accompanied by corneal staining. Patients who are experiencing these symptoms may benefit from changing their lens care system, particularly to one that's preservative-free. Consider the preservative formulation of all components of the lens care system, including the rewetting drops.

CARING FOR HYDROGELS

Multipurpose lens care systems continue to evolve with well-known brands reformulated since their inception. These updates include the addition of protein removal to the one-bottle systems that initially combined surfactant cleaning, rinsing, disinfection and storage. The advent of liquid protein removers has supplemented the use of the weekly enzyme tablet regimen, particularly for planned replacement lenses. A more recent addition is FDA approval to market such solutions as "no rub" regimens. However, many of these systems require additional rinsing to exhibit efficacy without digital cleaning.

"Hydrogel Multipurpose Chemical Disinfection Systems" summarizes a representative sample of chemical hydrogel lens care disinfection systems that patients in the United States use. These systems combine cleaning, rinsing, disinfection, storage and protein removal. All have demonstrated some degree of efficacy without digital cleaning.

► Opti-Free Express Lasting Comfort No Rub Formula (Alcon) contains the preservatives polyquaternium-1 (Polyquad) and myristamidopropyl dimethylamine (Aldox), while citrate enhances protein removal. For patients who replace their lenses infrequently or who are prone to lens deposits, consider dispensing Opti-Free Daily Cleaner. SupraClens Daily Protein Remover is a liquid form of pancreatin enzyme that patients may add daily to the storage solution to further enhance protein removal.

► COMPLETE MoisturePLUS (Advanced Medical Optics [AMO]) uses the preservative polyhexamethylene biguanide HCl, which contains hydroxypropyl methylcellulose to enhance viscosity and lubrication.

► ReNu MultiPlus Multi-Purpose Solution No Rub Formula (Bausch and Lomb) contains polyaminopropyl biguanide (Dymed) as a preservative, poloxamine to remove dirt and debris and hydranate (hydroxyalkyl-phosphonate) to enhance protein removal.

► SOLO-care PLUS (CIBA Vision) is approved for use with both hydrogel and GP lenses. Polyhexanide (PHMB) acts as a disinfectant, Pluronic F127 enhances cleaning and Aqualube (Cremaphor RH40) promotes lens moisture retention.

"Hydrogel Peroxide-Based Disinfection Systems" summarizes a representative sample of oxidative hydrogel lens care disinfection systems used in the United States. Oxidative lens care systems use 3% hydrogen peroxide and have maintained a steady presence in the lens care market because of their known antimicrobial efficacy and preservative-free nature.

AOSEPT (CIBA Vision) and UltraCare Disinfecting Solution/Neutralizer (AMO) are traditional lens care systems with multi-step components. AOSept uses MiraFlow (CIBA Vision) extra-strength cleaner, an alcohol-based daily cleaner that has antimicrobial activity and effectiveness with lipid removal, while UltraCare uses the preservative-free LENS PLUS Daily Cleaner. AOSEPT Disinfectant uses a platinum disc catalyst to neutralize the hydrogen peroxide while UltraCare uses a catalase-based neutralizing tablet that is encapsulated in hydroxypropyl methylcellulose (HPMC). AOSEPT is marketed with SoftWear SALINE (CIBA Vision), a buffered saline that is preservative free. UltraCare is marketed with LENS PLUS Sterile Saline Solution, packaged in an aerosol container, and is also preservative free. Both products are compatible with AMO's ULTRAZYME Enzymatic Cleaner, which is specially formulated with use with hydrogen peroxide. CIBA Vision markets two additional products (Pure Eyes and AOSEPT Clear Care) that combine components.

With all the peroxide-based systems available, you and your patients should recognize that once neutralized, the solution doesn't exhibit disinfectant properties.

Quick Care (CIBA Vision) differs from other products in the marketplace in that the first step (the Starting Solution) is an alcohol-based cleaner that also disinfects the lenses. The Finishing Solution is SoftWear saline that functions as a rinse and storage solution. Potential benefits of this system are its preservative-free nature, its short disinfectant cycle (30 seconds) and its resulting practicality as an in-office disinfection system.

CARING FOR GP LENSES

GP contact lens care solutions are also following the trend of multipurpose lens care products, although at a slower pace. The traditional components of GP lens care systems also incorporate a cleaner, rinse, storage and disinfection solution. With GP lenses, the soaking component is particularly important in enhancing lens surface wettability and promoting patient comfort. The GP contact lens care system has traditionally been comprised of a daily cleaner and a separate disinfection/storage solution.

Unlike hydrogel lenses, patients frequently use a rinsing solution (e.g., tap water, saline or hydrogel multipurpose solution) that's not a part of the prescribed GP lens care system. You may also prescribe a separate protein removal step based on the patient's needs. As with hydrogel lenses, tablet-based enzymes have been partially displaced with liquid protein removers.

"GP Lens Care Systems" (pg. 66) summarizes a representative sample of GP lens care systems used in the United States. Use abrasive cleaners with caution in conjunction with high-Dk lens materials. With the exception of SOLO-care PLUS, the GP lens care systems are not compatible with hydrogel lenses and you therefore shouldn't use them with hybrid or piggyback lens care systems.

Unique pH (Alcon) is a multipurpose lens care system that includes cleaning, rinsing, disinfection and storage and contains Polyquad as the preservative. Patients may use Opti-Free Daily Cleaner to enhance cleaning.

Boston Original Formula System and Boston Advance Comfort Formula System (Bausch & Lomb) incorporate a separate cleaner. Because the storage and disinfection solution is viscous, a separate rinsing solution is required. The preservative in Boston Original lens care system is chlorhexidine while the preservatives in Boston Advance lens care system are biguanide and chlorhexidine.

Boston Simplus is the second generation of Bausch & Lomb's multipurpose lens care system, although its predecessor, Boston Simplicity, remains on the market. You may use it for cleaning, rinsing, storage and disinfection. Patients may add Boston One Step Liquid Enzymatic Cleaner, a subtilisin derivative, to the storage solution of any of the Boston products on a weekly basis to enhance protein removal.

Patients may use Optimum (Lobob) with or without the extra strength cleaner. Both solutions contain alcohol, so patients must rinse them before applying them. Claris (Menicon) also contains alcohol and combines the cleaning, disinfection and storage and, like Optimum, requires a separate solution for rinsing before application.

CURRENT CARE ISSUES

Despite the many advances in contact lens care products, concerns still exist regarding many of them.

Silicone hydrogel materials. Experts have expressed concern about potential interactions between hydrogel lens care systems and silicone-based lens materials. Anecdotal reports of diffuse punctate epitheliopathy secondary to the interaction, particularly with lens care systems preserved with biguanide derivatives, exist. Experts don't yet fully understand this interaction.

Generic care systems. Generally, generic solutions contain older lens care formulations that may not be as efficacious or may be more likely to elicit sensitivity reactions than their brand-name counterparts. The contents are largely unknown, although the package labeling may provide some indication of the contents. Additionally, the formulation may change over time, with the label vacated to the more competitive bidder. Problems may occur from this new, differently formulated solution, but the patient will report not having changed solutions.

GP lenses and tap water. Researchers associate the use tap water to rinse GP lenses with Acanthamoeba infection. Although the risk of such infection may be small, the consequences are severe. And manufacturers' instructions for GP lenses often include mention of tap water, making it difficult to reinforce the message.

Contact lens care is synonymous with health care. Industry experts have reported that less regulated markets have a much higher incidence of drop outs when eyecare practitioners don't closely follow their patients. This finding underscores the importance of our role in monitoring the health of our patients, in ensuring that we've prescribed the most appropriate lens material for their vision needs and in educating patients about proper contact lens care.

Contact lens complications are particularly associated with patients ignorant of hygiene and health care issues peripheral to contact lens wear. Such issues include hand washing before lens handling, lens case care, respect for solution expiration dates, avoidance of "topping off" storage solution and the importance of routine eye care.

EDUCATE TO SUCCEED

With a thorough understanding of current lens care products you can tailor a lens care system to fit the needs of any patient. Comprehensive patient education with periodic reinforcement promotes healthy and comfortable contact lens wear, potentially curtailing contact lens dropouts.

Dr. Wagner is an associate professor at Nova Southeastern University College of Optometry where she teaches contact lenses and serves as the chair of the Department of Clinical Education. She is a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry.

1. Which of the following lens care systems is preservative free?

a. SOLO-care PLUS

b. UltraCare

c. ReNu MultiPlus

d. COMPLETE MoisturePLUS

2. Which of the following solutions contains alcohol?

a. LENS PLUS Daily Cleaner

b. MiraFlow Extra Strength Cleaner

c. Boston Original Daily Cleaner

d. Boston Advance Comfort Formula

3. AOSEPT Clear Care is a(n) ________ disinfection system.

a. heat

b. chemical

c. oxidative

4. What preservative does Alcon use in its Unique pH and Opti-Free Express Lasting Comfort Formula?

a. Polyquad

b. Biguanide

c. Chlorhexidine

d. Thimerosol

5. Which of the following GP soaking and disinfection systems requires a rinse before applying the lenses?

a. Unique pH

b. Boston Advance

c. Optimum

6. Which of the following enzymatic cleaners is specifically formulated for use with hydrogen peroxide?

a. SupraClens

b. Boston One Step Liquid Enzymatic Cleaner

c. Ultrazyme

d. all of the above

7. What's the minimum disinfection time for UltraCare?

a. four hours

b. six hours

c. 10 minutes

8. Which lens care system is FDA approved for use with both hydrogel and GP lenses?

a. SOLO-care Plus

b. ReNu Multiplus

c. Simplus

d. Optimum

9. Alcohol is recognized for all of the following EXCEPT:

a. Antimicrobial activity

b. Moisture-enhancing properties

c. Lipid removal

10. Use caution with abrasive GP daily cleaners for:

a. High-Dk GP lens materials

b. PMMA lenses

c. Low-Dk GP lens materials

11. Which of the following saline solutions is NOT preservative free?

a. Lens Plus Sterile Saline Solution

b. SoftWear Saline

c. Sensitive Eyes Saline

12. What is the regimen for SupraClens?

a. Daily

b. Weekly

c. Monthly

d. Bi-monthly

13. Patients and practitioners easily recognize the formulation of generic lens care systems.

a. True

b. False

14. Silicone-based lens materials may not be completely compatible with all hydrogel lens care systems.

a. True

b. False

15. Researchers have associated Acanthamoeba with:

a. Heat disinfection

b. Preservative-free saline

c. Tap water rinse

d. Preservative-free daily cleaner

16. The shortest soft contact lens disinfection time with any system is for Quick Care.

a. True

b. False

17. AOSEPT Clear Care is a one-step system that patients can use to rinse lenses as well as disinfect them.

a. True

b. False

18. Generic multipurpose hydrogel solutions are required to prominently change their labeling (name and/or colors) when they switch the solution in the bottle.

a. True

b. False

19. Patients on a preservative-free lens care regimen can still be exposed to preservative if they use certain rewetting drops.

a. True

b. False

20. "Topping off" of storage solution lessens the disinfecting efficacy.

a. True

b. False