contact lenses

Stop the Drop-Out

Take action before patients leave contact lens wear. Here's how.

Tara Rosenzweig, Contributing Editor

Do you know how many of your patients drop out of contact lens wear? If your number falls in line with recent studies, it ranges anywhere from 5% to 30%. To fully appreciate the implication of such numbers, consider these percentages in terms of dissatisfied patients and lost practice revenue.

Not surprisingly, patients most often cite discomfort and poor vision as the two main reasons they drop out of contact lens wear.

Despite these statistics, John Rumpakis, O.D., MBA, president and CEO of Practice Resource Management, Inc., says, “It's really rare that we cannot be successful with a contact lens patient. O.D.s must do a proper diagnostic workup and clinical evaluation, make the appropriate recommendations, and the patient has to stay with those recommendations in order to maximize their chances of being successful.”

Who is dropping out?

Contact lens dropouts occur across demographic groups, but some of the O.D.s we talked to see the rate begin to rise as patients enter their 40s.

“Quite a few patients drop out of contact lens wear when they start to hit presbyopia, but we try to divert that by talking [with them] about what to expect [in terms of vision change] and letting them know there are options when that starts,” says Jason Miller, O.D., of Eyecare Professionals Inc. in Powel, Ohio and faculty member at The Ohio State University College of Optometry in Columbus.

“Presbyopes in their 40s are probably a larger demographic dropping out, even with the advancements in multifocal contact lenses and/or monovision options,” agrees Gina Wesley, O.D., of Complete Eye Care of Medina in Medina, Minn.

Dr. Wesley adds that women in their 50s are also more likely than other age groups to drop out of contact lenses due to ocular dryness.

Desmond Fonn, MOptom, F.A.A.O., retired professor at the University of Waterloo's School of Optometry in Ontario, Canada, says practitioners can prevent presbyopic patients from contact lens drop out by educating them that they can continue contact lens wear despite this vision change.

“There are many different forms of correction that will satisfy patients,” he says.

For example, some may continue to wear contact lenses for distance vision and use reading glasses for near vision, he notes.

Young patients may also drop out of their contact lenses due to either discomfort or vision limitations, says Greg DeNaeyer, O.D., of Arena Eye Surgeons in Columbus.

So, how do you keep patients happy and healthy in contact lenses? The doctors we interviewed recommended the following steps.

Identify problems early with a careful history

Whether it's dryness, discomfort or vision problems, patients drop out of their contact lenses when the problems become too frustrating, says Thomas Quinn, O.D., of Drs. Quinn, Quinn and Associates in Athens, Ohio.

“It kind of comes down to when the patient perceives the value of the contact lens to not be worth the hassle or not worth whatever issue they're dealing with,” he says.

So what's the best test to identify potential problems?

“The biggest ‘test’ is actually a careful history assessment at every eye exam,” says Dr. DeNaeyer.

Dr. Rumpakis adds that because there isn't a diagnostic test for predicting contact lens discomfort, a very thorough health exam of the anterior segment must be done to determine potential issues.

“Not only quantitative output of tears but a qualitative assessment of the tear makeup should be done,” he says. “That means also looking at the lids — both the margin of the lids to see that you've got good meibomian gland function, and the underside of the lids to rule out any concurrent conditions, such as ocular allergy or clinical dry eye.”

With regard to the meibomian gland, Dr. Quinn recommends taking a step back, without magnification, to check for meibomian gland dysfunction.

“Sometimes the low-magnification external view allows you to see whether the eyelids are a little thickened or maybe a little red-rimmed. You kind of lose perspective on that if you go straight to the slit lamp,” he says. “You really need to push on the lids and express the contents of the glands to really be able to pick that up.”

He adds that inverting the upper lid on the underside of the upper eyelid can also provide information regarding potential problems.

Dr. Wesley says she agrees with thorough exams, possibly done on a more frequent basis.

“A thorough history and description of the symptoms by the patients, along with a comprehensive exam, including adequate slit lamp evaluation, are key and need to be done at least annually, more often — as much as biannually or quarterly — if the patient is having consistent problems,” she says. “Certain types of corneal staining and conjunctival injection may indicate a problem with contact lens wear, as well as follicular reactions on the palpebral conjunctiva,” she explains.

Ask questions to encourage patient feedback

Another way to keep patients happy and healthy in lens wear is to ask them questions regarding wear, say those interviewed.

“I think the key in eliciting information from patients is asking open-ended questions, such as ‘When do you experience discomfort with your contact lenses?’ vs. ‘Do you experience discomfort with your contact lenses,?’ says Dr. Wesley. “Making it seem like it's a routine part of their experience will help patients feel comfortable in answering freely.”

Dr. Quinn agrees: “Asking patients very open-ended questions like, ‘How are you doing with your contact lenses?’ opens the door for them to go down the path they feel compelled to go down,” he says.

Similarly, Dr. Rumpakis recommends asking patients to describe their possible discomfort using qualitative terms. For example, the O.D. might ask: “ Does the discomfort happen upon insertion or after several hours of wear? Is the discomfort accompanied by blur? Is it more in one eye than the other? Does it feel scratchy or burny?”

Dr. DeNaeyer suggests having the patient rate their experiences on a number scale.

“Have them grade comfort one to 10, have them grade vision one to 10, and ask about specific subjective real world vision difficulties,” he says.

In addition, Dr. DeNaeyer advises having the patient describe their cleaning regimen process and lens replacement schedule. (For a complete discussion of hygiene and replacement schedule compliance, see “Bridging the Compliance Gap,” Optometric Management, November 2011. The article is also available online at www.optometricmanagement.com.)

O.D.s may want to enlist the help of other staff to begin the patient feedback process, adds Dr. Miller.

“I feel the technician should start the discussion and gather as much data as possible before the doctor comes into the room, but the doctor will often need to follow-up on a few things,” he says. “Specifically, with contact lens wear, the doctor needs to follow up on the patient's contact lens wearing schedules and compliance, as the patient may be more honest with their doctor.”

Dr. Miller says he also likes to ask patients questions like, “How many days a week do you sleep overnight in your contact lenses?” and “How many of the XX hours you typically wear your contact lenses in a day would you consider comfortable wearing hours?”

“If the patient is experiencing even an hour or two of uncomfortable wear at the end of a typical day, they may be at risk for contact lens dropout,” he says.

Be on the lookout for patients reluctant to give specific answers to contact lens wear questions, says Dr. Wesley.

“Vague responses or unsure responses would raise a red flag for me,” says Dr. Wesley. Such responses may indicate that the patient is compromising his vision or eye health and, therefore, is a dropout risk.

Help potential dropouts

There are actions your practice can take once it has identified a patient who may drop out of contact lens wear. Those interviewed recommend these steps:

1. Offer plenty of options. When dealing with patients who are at risk of dropping out of their contact lenses, Dr. Wesley says it's important to educate them about all the options they have, such as single vision and multifocal contact lenses, wearing reading glasses with contact lenses, wearing nighttime driving spectacles with monovision contact lenses, etc., so they are aware of all that optometrists can do for them.

“They won't know if we don't tell them, and the impact of keeping someone in contact lenses for even a few more years can be huge for both the patient and practice,” she says.

2. Scale back wearing time. Sometimes, dissatisfaction in contact lens wear arises because patients simply have expectations that exceed what the O.D. (and contact lenses) can provide, says Dr. DeNaeyer.

“Many patients have the mindset that contact lenses are an all-or-nothing proposition (all day every day or they have failed),” he explains. “However, many patients are better part-time wearers and don't need to drop out just because they can't successfully wear lenses 16 hours a day, seven days a week.”

Along these lines, Dr. Fonn says his preference is always to prescribe a silicone hydrogel lens, potentially on a shorter wearing schedule than what the patient is currently following.

“I think we would want to try to ensure that the disposability of that lens is sooner rather than later, so daily disposable lenses are often a very good strategy and should be used more,” he says, adding that statistics show North America lags behind in daily disposable lens use compared to other countries.

2. Recommend the right lens care materials. For patients experiencing discomfort, Dr. Rumpakis stresses the importance of prescribing the right lens care solution.

“Certain care solutions are better suited for silicone hydrogel materials than others,” he says. “You want to make sure you're using the right contact lens solution and the right [contact lens] material.”

Dr. Rumpakis adds that he's an advocate of telling doctors they can no longer think of lenses and solutions as two separate components.

“You have to think of them as acting as a single system,” he says.

Dr. Rumpakis also says O.D.s need to make sure that patients understand the doctor's reasons for recommending a specific solution with the patient's lenses.

“When prescribing, explain why they need a particular type of lens and solution (due to insufficient tears, for example), as both work together as a system to allow them to wear their contact lenses safely and comfortably during all waking hours,” he advises.

The presence of preservatives in solutions may also cause discomfort, which could lead to dropout, says Dr. Fonn.

“The strategy is not uncommon for hydrogen peroxide disinfecting systems to be used by patients who express these sorts of difficulties,” says Dr. Fonn. Therefore, if the patient experiences problems that you feel could be related to a preservative, consider switching the patient to a hydrogen peroxide solution.

An educational aid is worth a thousand words

Because many O.D.s may not have the time to plan all the points they need to discuss with patients, educational aids can be very useful, say those interviewed.

Dr. Miller says he prefers to show patients actual photos of their condition to drive home the importance of compliance or a treatment program to improve their condition. He says he also uses an educational software program to discuss the patient's condition(s) and to discuss “why we need to make a change,” he explains.

“I think the visual imagery often helps the patient understand what is going on with their condition, and they will be more likely to follow through with our treatment program to improve it,” says Dr. Miller.

Dr. Quinn says a good resource to point patients to is www.contactlenssafety.org, created by the American Optometric Association's Contact Lens and Cornea Section in conjunction with the American Academy of Optometry.

“It's geared to the consumer to answer questions we think the consumer would have,” says Dr. Quinn. “There are about 50 questions on the website. That's a new resource we can give patients when they're leaving the office.”

When taking a patient out of their contact lenses temporarily, Dr. Miller stresses the importance of involving the patient and discussing with them why a change must be made.

“They have to understand the treatment program and what steps we need to take to improve their contact lens wearing experience,”he says. “If we just start changing things up and taking them out of their contact lenses for a period of time, they may get frustrated if they don't understand why we are doing it.”

He says a treatment program must address any underlying conditions (such as dry eyes, ocular surface disease, meibomian gland disease, etc.) and to treat those conditions first.

“As long as the patient is patient throughout the process, successful contact lens wear is often resumed without any concerns,” he says. OM