contact lenses

Boost Contact Lens Compliance

Follow these six tips to prevent non-compliance-related infections and subsequent contact lens dropout.

LINNEA ROBBINS-WINTERS, O.D., South Bend, Ind.

Because non-compliance to contact lens care and wear has the potential to contribute to symptomatology (e.g. dryness, giant papillary conjunctivitis [GPC] and corneal infection) that can lead to contact lens intolerance and drop out, it's essential we spend more time and effort on preventing patients from deviating from or ignoring our instructions.

Although no practitioner will ever achieve a 100% compliance rate with their patients, the following six tips will enable you to increase patient adherence to your care and wear instructions, thereby enabling them to maintain their ocular health and you the financial health of your practice.

1 Emphasize the big three

The range of noncompliance is broad. Specifically, research has shown that 60% of lens wearers fail to comply with at least six out of 15 recommended behaviors.¹ To increase the margin of contact lens care and wear safety in your patients, stress to them the most important areas for compliance — hand washing, proper lens storage and case care — rather than overwhelm them with too many instructions, says Graeme Young, Ph.D., FCOptom, director of Visioncare Research Ltd., a United Kingdom-based company that specializes in eyecare clinical research.

"Nobody rinses their lenses for a full minute [for instance]," he says. "Patients realize that, as in all areas of life, they have to weigh the risks of perfect compliance against what is doable. They assume, perhaps optimistically, that there is a margin of safety built into the care system and reconfigure their procedures based on this assumption."

As a result of this contact lens patient thought process, explain to these patients that proper hand washing (including drying hands before touching lenses), storing lenses in a fresh solution (not topping off the solution) and cleaning and replacing the lens case regularly gives them an excellent chance at reducing the potential for infection, Dr. Young says.

(The American Optometric Association, for instance, recommends patients replace their lenses three months or sooner.)

Optometrist Larry Wan, of San Jose, Calif., agrees with Dr. Young.

"I tell patients to rinse the case with solution every morning after they put their lenses in [their eyes], and allow the case to air dry so that they don't introduce pathogens from a cloth or allow existing ones to multiply in the residual moisture," he says. "The greatest dangers in contact lens wear come from the introduction of new or dangerous pathogens into the eye, so if patients are washing their hands, cleaning and storing the lenses properly and keeping their cases clean, I'm a lot less worried about other aspects of compliance."

2 Instruct patients to rub their lenses

In my practice, I now tell my contact lens patients to clean their lenses mechanically even if the solution bottle says "No rub." This is because studies have shown that rubbing lenses is more effective than rinsing or soaking them alone in removing deposits from contact lenses.² In fact, I've found this is especially true for those patients who may have more oils or lipids in their tears than other contact lens-wearing patients.

Consider this: A total of 10 days after I fit a female presbyopic patient in silicone hydrogel multifocal lenses, she presented complaining about a decrease in her quality of vision. On examination, I was able to determine that the patient's reduction in visual acuity was due to several lipid deposits on the lens. If left untreated, this could have eventually lead to ocular tissue changes such as GPC, conjunctivitis or infiltrative keratitis. Although, I had instructed the patient to clean the lenses mechanically with the solution at her prior visit, she told me at this visit that she skipped the process because the solution bottle read "No rub." After educating the patient about the importance of digitally rubbing her lenses, however, the patient adhered to my directions and at her next appointment, she reported regaining the clear vision she needed for successful multifocal wear.

3 Tailor the replacement schedule

Several studies have evolved through the past decade regarding the best replacement schedule for patients in terms of fostering compliance. For instance, one study suggests patients who wear daily disposable lenses are the most compliant with replacement schedules and least compliant when wearing two-week lenses.³ Another study reveals that long wear times lead to long periods of over wear. Specifically, 23% of monthly wearers stretched the wear time of their lenses to eight weeks of wear or more, while just 4% of twoweek wearers stretched their lenses.⁴

I take issue with these studies, as they haven't taken into account that the "ideal" replacement schedule — in terms of encouraging compliance — is relative to each patient.

The bottom line: It's essential you inquire about the patient's lifestyle and ability to stick to a replacement schedule prior to selecting both the lens and replacement schedule that will provide the highest chance for compliance, and, therefore, successful wear.

For instance, if the patient tells me she's a high-level executive who keeps a cot in her office, I can discern from that information that she doesn't make much time for anything outside of work. So, I'd likely prescribe a daily disposable lens to prevent the onset of non-compliance-related infection and subsequent dropout from the outset.

4 Promote an annual supply

Another effective way of getting patients to comply with their care and wear schedules is to have patients buy an annual supply of lenses, says Dr. Wan.

"Having the lenses on hand encourages patients to replace them on schedule rather than stretching out the [wear time of the] lenses while they wait for a new order," he explains. "And based on how many they say they have left at their next annual exam, we [practitioners] can keep track of whether patients are replacing lenses on schedule."

Something else to keep in mind: Some clinicians say they've found success in bundling solutions and/or cases with lenses to ensure their patients are changing their cases frequently and using the correct solution and enough of it to prevent the onset of infection.

5 Show patients the effect of non-compliance

I don't like to use "scare tactics" with my patients, but I do think showing them the results of the diagnostic tools we use to assess compliance can be a very effective means of getting patients to adhere to their contact lens care and wear schedules.

For instance, I often show my contact lens wearers a GPC grading scale, so they can see how their lids should look vs. what their lids look like while the patient is in my exam chair. Then, we talk about what steps we can take together to prevent the patient from moving from Grade 2 to Grade 3 of the GPC scale. These steps may include switching him into a different lens material or modality, more effective cleaning than before or enhanced adherence to the replacement schedule.

Dr. Wan agrees with this approach.

"It definitely helps to tie the patient�s tangible experience to what you see clinically," he says. "For example, if the patient is experiencing end-of-day discomfort, I might relate that to how frequently she replaces her lenses. I explain to the patient that if she can remember to change her lenses on schedule, she'll be able to wear the lenses comfortably for long periods of time. That is a compelling sequence for the patient to hear," he says.

6 Ask patients about lens care and wear

As clinicians, we should never assume our contact lens patients are following our lens care and wear instructions just because their eyes appear healthy at the time of their visit. So, each and every time a contact lens wearer presents, ask him how the process of taking care of his lenses and sticking with the replacement schedule is going.

"We ask patients open-ended questions such as, 'Tell me how you are cleaning your lenses,'" Dr. Wan says.

In addition, he says he's trained his staff to ask questions about case care and what solution brands the patient is using if the patient doesn't offer that information.

"We don't make any assumptions," he says. "Just because someone has been wearing lenses for 10 years does not mean they know how to clean them properly."

The bottom line: A nonjudgmental approach goes a long way toward eliciting the truth. Many patients think they're following doctors' orders when they aren't.^5,6 Also, several patients have every intention of following our directions, yet forget to do so. In fact, forgetfulness is the most frequent reason patients are noncompliant to their lens care and wear schedules.^3,6

To solve the issue of forgetfulness, consider choosing an easy-to-remember date for replacement (e.g. the first of every month for monthly replacement wearers, etc.) and recommending patients write these dates on an easy-to-access calendar or a calendar on an automated reminder.

Currently, two automated reminders exist: Acuminder (Vistakon) and LensAlert (WatchDog Group). Acuminder is a free online service (www.acuminder.com) open to all contact lens wearers regardless of what brand they wear that sends patients a reminder on the day they are supposed to open a new pair of lenses according to their replacement schedule. Further, it reminds them when they are due to purchase new lenses and schedule their next eye exam. Patients can sign up to receive these reminders via e-mail, cell phone text message, Web page widgets and/or most recently through their Facebook newsfeed at www.acuminder.com/facebook.

LensAlert is a timer (in days) that alerts the patient when to replace both his lenses and his lens case. It contains a plate to set one of three differently colored cases included with the device. In addition, patients can purchase a sixor seven-pack of contact lens cases separately to fit on the device's plate. (Visit www.lensalert.com for more information.)

Incidentally, one recent study on lens replacement in the United States revealed that contact lens wearers thought cell phone reminders and sticking to the same days for replacement were the most helpful ways to remember lens replacement (29% and 26%, respectively).⁵ Also, patients said they considered case counters and e-mail reminders helpful as well (22% and 21%, respectively.)

Despite our best efforts, we're not going to get every one of our patients to adhere to our contact lens care and wear instructions. But, we can significantly decrease the amount of non-compliant patients by instilling good behaviors from the initiation of contact lens wear, educating patients about why they should follow our advice and reinforcing that advice at every visit. OM

1. Yung AM, Boost MV, Cho P, Yap M. The effect of a compliance enhancement strategy (self-review) on the level of lens care compliance and contamination of contact lenses and lens care accessories. Clin Exp Optom. 2007 May; 90(3):190-202.
2. Cho P, Cheng SY, Chan WY, Yip WK. Soft contact lens cleaning: rub or no-rub? Ophthalmic Physiol Opt Jan; 29(1):49-57.
3. Dumbleton K, Woods C, Jones L, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009 Jul; 35(4):164-71.
4. Hickson Curran S, Chou P, Gardere J. Longer prescribed replacement intervals leads to more stretching of frequent replacement lenses. Data on file, Vistakon.
5. Donshik PC, Ehlers WH, Anderson LD, Suchecki JK. Strategies to better engage, educate, and empower patient compliance and safe lens wear: Compliance: What we know, what we do not know, and what we need to know. Eye Contact Lens 2007 Nov;33(6 Pt 2):430-3; discussion 434.
6. Claydon BE, Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt. 1994 Oct;14(4):356-64.

Dr. Robbins-Winters is a partner in Eye Care Associates of Michiana, LLC, in South Bend, Ind. She is president-elect of the Indiana Optometric Association and a past appointee to the Indiana Board of Optometry. Also, she's a former Vistakon Advisory Panel member and occasionally receives ad hoc consulting fees but is not an active consultant for any company. E-mail her at linnearobbins@embarqmail.com.