contact lens solutions
Prescribing Contact Lens Care Solutions
As in everything else, quality counts. Here's how to get the message across to patients.
BY WALTER D. WEST, O.D., F.A.A.O., Brentwood, Tenn.

Years ago, when I asked soft lens patients what solutions they used, they almost always knew the names of the daily cleaner, disinfectant, saline, enzyme tablet and rewetting drops. As lens care has progressively become easier, less expensive and more effective, patients have become progressively less aware of what they are using.

When asking patients which solution they use, they respond with, "I don't know, but it's in a green bottle." Or they'll try to describe the manner in which they use the solution. Oftentimes, the forthright patient will answer with, "Whatever is on sale" or "Generic" or "Whatever it is my mom/dad/spouse buys." Your patients are probably similar.

When I ask my colleagues how much importance they place on lens care solutions in their practices, many shrug and say they leave that to the contact lens technician. Some optometrists find the topic fairly boring and ignore it for the most part. After all, gone are the days when jelly bumps and 4+ GPC consistently brought us interesting refits.

As lens care has progressively become easier, cheaper and more effective, practitioners have become less aware of what lens care products their patients are using. Both doctors and patients are taking details of soft contact lens care for granted.

Confronting human nature

It's important for us as practitioners not to allow these complacent attitudes toward lens care to exist with our patients or our staff. Admittedly, some patients will use any multipurpose solution that they find on sale and think that they're doing fine. Their perception is that there's no real difference between brands and they find no appreciable difference to their comfort or wearing time. Other patients will experience discomfort and reduced wearing time and not realize that the price-buster solution is the reason.

It's interesting that the bulk of patients seeking primary care for contact lens-related keratitis and keratoconjunctivitis in my practice are the very ones who have no idea which solution they use or how to properly use it. These same patients may feel that all solutions are the same. I believe that it's part of our job to educate patients as to the importance not only of lens hygiene but of product consistency.

Every little bit counts

The more we learn about dry eye, ocular surface disease, meibomian dysfunction and contact lens intolerance, the more we realize the importance of each contributing factor on a case-by-case basis.

For some patients who are contact lens intolerant, changing the particular contact lens material may solve a patient's problems. Others come back telling us that they didn't find the new material any more comfortable. Perhaps you had already tried nonpreserved artificial tears, lid hygiene, punctual plugs and mast cell stabilizers with little improvement. Imagine your chagrin if you had failed to investigate whether the patient had switched solutions from your original recommendation!

Get a "signature solution"

The key, then, is to have a practice protocol for lens care solutions. Select your number-one brand and have your staff refer to the brand as the solution that you prescribe. If a new patient tells my technician that they've used Brand X for years with no complaints, then my technician responds with, "Dr. West generally prescribes (my number-one brand), but he may permit you to continue with what you've been accustomed to using. I'll make a note in your chart and he can discuss that with you."

This signifies to the patient that the brand of solution is significant. I then will discuss with the patient which solution I am prescribing for them, why and the risks involved in switching solution brands.

I have my reasons

I have stayed with my preferred brand since it came to the market. I prefer it for several reasons. Patients may find the array of multipurpose solutions confusing, particularly if a family member does the shopping instead of the patient. My preferred brand has unique packaging, which helps distinguish it on the shelf.

We can all think of products we purchase in a supermarket where we can't name the brand off the top of our heads, but we recognize the box or container. Think of the number of your patients who've told you that they can't remember the name of solution they use but, "It's in a green bottle." I like a solution that has a high degree of recognition among patients because it helps ensure compliance at the point of purchase.

In most practices, a staff member typically dispenses a starter kit. Look at the starter kits in your office -- open them and really look at what's inside. A package insert printed in both English and Spanish, for example, may seem trivial at first. Yet it's of increasing importance in our country and demonstrates the manufacturer's commitment to patient education.

Several brands' starter kits have package inserts (in English only), as mandated by the FDA, but they are printed inside the box -- literally, the patient has to use a pair of scissors to cut the box apart to read the information. This sends a signal to me, and probably to our patients, that the information is really not that important. After all, you don't even have to rub the things, just stick 'em in the juice and that's all there is to it. At least, that's the impression patients are likely to have.

Dealing with the generic

When patients tell me that they are using a generic or store brand, I know there's a strong likelihood that it's nearly identical to a leading name brand, so I can't tell them in good conscience that it's a poor product. I can, however, tell them that I'm not aware of the ingredients (unless they have the bottle with them) and that I have the most confidence in the brand I prescribe, which is only sold under that name. In fact, the labeling on the package reads, "This patented formula is not sold under any other name." This eliminates confusion for both the practitioner and for the patient.

Consider the facts

I'm confident in the brand I've chosen, both for its chemistry and for its physiological compatibility. It contains Polyquad, which has demonstrated to be the least toxic preservative for soft contact lens wearers. Experts have published numerous studies on ocular compatibility with lens care products. They examine the papillary reaction of the tarsal plate, bulbar injection or the degree and location of punctate epithelial staining.

Some of these studies offer conflicting evidence, or highlight the fact that while many patients show signs of epithelial insult, they are largely asymptomatic, rendering this a subclinical issue. I would disagree with that premise. The continual presence of diffuse superficial punctate keratitis doesn't bode well for most soft lens patients. Wearing time will decrease, dry eye complaints will ensue, and the patient may well give up lens wear altogether. I recommend a brand that has consistently resulted in significantly less epithelial staining than other leading solutions.

Complimenting lenses

I have prescribed silicone-hydrogel lenses for a large number of patients. While many of them wear their lenses continuously, effectively removing the role of solution, a large majority still remove them at least several nights each week. So the brand I prescribe shows no evidence of corneal irritation and has also been shown to be compatible with silicone-hydrogel lenses.

I'm also confident in my prescribed solution when it comes to my conventional soft lens wearers -- primarily custom bifocals, torics and specialized cosmetic lenses. I find these patients more likely to be solution compliant, as their lenses are more expensive to replace if not properly cared for. In cases where a conventional lens is made from a polymer that's less deposit resistant than some of the new polymers, I prescribe the solution along with a daily protein remover. This keeps the system streamlined for these patients, as well as providing effective disinfection and cleaning to improve the life and comfort of the lens.

Get the message out

I encourage you to educate your staff as to your choice of lens care solutions for all of the soft lens products that you prescribe. Make sure that your techs include solution information in the case history of all contact lens patients. Discuss the patient's level of compliance with them, including any changes they may need to make. Use the most technically advanced solution with the lowest toxicity, and you're sure to effectively close the loop and improve lens care compliance and patient satisfaction in your practice.