extended wear
What You Need To Know About Extended Wear
Understand all the benefits and risks of these popular contact lenses.
MICHAEL J. LIPSON, O.D., F.A.A.O., Livonia, Mich.

Extended wear (EW) contact lenses are here to stay! The newest of the EW lenses are highly oxygen-permeable and much safer than their predecessors, but it still pays to proceed with caution.

Currently, there are a number of lenses with FDA approval for between six and 30 days of extended or continuous wear. They are generally categorized as soft-hydrogel, silicone-hydrogel and gas-permeable. With a large range of parameters available, and more becoming available every month, extended wear is a viable option for you and your patients.

Why fit extended wear?

First, patients like it! They enjoy the convenience of spending less time on care and handling, along with the pleasure of waking-up to a clearer world. Patients who experience chronic redness from solution reactions or lens deposits may experience fewer red-eye reactions. Others, who frequently damage their lenses during handling, may gain better comfort and longer-lasting lenses. It can also reduce the risk in situations when it may be difficult to handle lenses, like while camping or using public restrooms.

Second, doctors like it! Many of those who are fitting extended wear find they have fewer CL dropouts, less complications and increased patient loyalty. When patients have fewer problems, they continue to wear these lenses and return to the doctor who prescribed them. They also talk to others about these contact lenses that give them clear, comfortable vision.

Not everyone is a candidate for this modality, however. Patients who will likely do well with extended wear are those have a history of compliance and healthy corneas. Patients with chronic allergies, significant dry eye, corneal dystrophy, any corneal pathology (like keratoconus) and some diabetics (due to increased healing time) are generally not good candidates for this wearing schedule.

Patients who upgrade from other lenses to extended wear may show slight Rx changes after the first few weeks of wear. Advise them of this possibility beforehand and schedule follow-up visits sooner than you would for new wearers to monitor for these refractive changes. Having patients discontinue their current lenses for a few days prior to commencing extended wear can also be helpful.

Proceed with caution

Even though some high-Dk lenses are approved for up to 30 days of continuous wear, you, as the prescribing doctor, must determine each patient's wearing schedule individually. Prescribe with safety as your top priority, convenience second. Even with plenty of oxygen transmission, careful follow-up is necessary to assess proper lens fit and movement, the presence of any debris/deposits on or under the lens, keratitis (mechanical or microbial) and possible eyelid reactions. Any patient wearing a lens while sleeping has the potential to get debris trapped between the eye and the lens. Based on observations of the lens and the cornea during initial follow-up visits, establish a safe wear schedule for each patient. According to one study, the incidence of microbial keratitis with extended wear of soft hydrogel lenses was estimated to be one in 500 (a 2004 study estimates about one in 200). Similar studies have projected the incidence of microbial keratitis with silicone/hydrogel extended wear at one in 5000, and with extended wear GP, one in 10,000.

Conduct fitting evaluations at three to four days after the initial fit and again two to three weeks later. Strongly advise patients to report any discomfort, blurred vision or redness immediately for evaluation. Regular follow-up care is just as essential as the wearing/replacement schedule. In our office, we schedule annual exams with a contact lens evaluation every six months after the initial fitting visits. I also advise having a strategy for in-office and specialty referral management of potentially serious complications.

Managing EW

Many patients will wear lenses for the prescribed time period and dispose of the lenses upon removal. Obviously, these patients will not require solutions or a care system for disinfection. For those who do re-use lenses, proper disinfection is crucial. In these cases, stress the importance of hand washing, lid hygiene and exact following of disinfection procedures. Multi-purpose and hydrogen peroxide systems have been found very effective. Re-using a contaminated lens significantly increases the risk of infection with overnight wear. However, gas permeable lenses may periodically need special cleaning or polishing and require regular replacement.

One activity that poses a risk for extended wearers is swimming. A recent study at Pacific University showed water-born bacteria binds to the surface of all soft lenses. The researchers concluded that if patients wear lenses while swimming, they should remove lenses after swimming for a thorough cleaning and disinfection prior to overnight wear. They also advised that patients wear tight-fitting goggles while swimming.

Extended wear gained FDA-approval because it satisfied requirements for oxygen transmission and safety. You are obligated to ensure that each patient is monitored for continuing eye health and as such, must establish a safe wearing schedule for each patient. Once that schedule has been determined, it is imperative that the patient follow it. Hand the patient (or parents if the patient is a minor) a written wearing/disposal schedule and keep a copy in the patient's record. I also include the date and time of their next follow-up appointment written on this sheet. When dispensing lenses, it is important to stress that the next complete vision and contact lens evaluation will be necessary when the prescription for theses lenses expires.

Another tool to help with compliance is an "informed consent form." This is an in-office document explaining what the lenses do, the benefits and risks associated with extended wear, alternative modes of vision correction and the importance of following your recommended wearing, replacement and follow-up schedule. This form should also include emergency contact information of the doctor and office so patients can contact the ECP any time a problem may arise. Have each patient or guardian read and sign the form and include it in their file. Also give a copy to the patient to keep in their records.

The professional expertise involved and the additional time requirements demand that you establish higher professional fitting fees for management of EW. Explain this to patients going into extended wear. Those who want the convenience will appreciate that you are providing a service that they may not have experienced before.

Prescribing extended wear lets your patients know you are working with the latest contact lens technology. It also allows you to market yourself to a new group of potential patients. This creates excitement for patients, while generating referrals and revenue for the practice. As a final reminder, prescribe a safe wearing schedule and monitor with careful follow-up to assure compliance.