contact lenses

Contact Lens Wear Dropout: The Top Reasons

Here are the most popular reasons for discontinuation and how you can successfully address them.

S. Barry Eiden, O.D., F.A.A.O., Deerfield, Ill. and Robert Davis, O.D., F.A.A.O., OakLawn Ill.

There are just some of those days. We all have them. Those days when every other patient presents complaining about their contact lens wear for one reason or another, and some flat-out tell you: “I don't want to wear contact lenses anymore.”

To make these days less challenging and dissuade patients from contact lens dropout, we've looked into our own patient records and also polled a panel of fellow contact lens specialty practitioners to present the top reasons for contact lens dropout and how you can successfully address them.

Dryness

Contact lens-related dryness and its associated discomfort may very well be the number one reason for contact lens dropout.

To dissuade these patients from kicking their lenses to the curb, perform dry eye testing to determine the dry eye type (e.g. aqueous tear-deficient dry eye and/or evaporative), so you can tailor your management approach accordingly.

If the patient has blepharitis, for instance, prescribe lid hygiene, such as warm compresses b.i.d. generally for one month concomitantly with a macrolide antibiotic applied to the lid margins before bedtime. Then, reevaluate and either continue, reduce to qd or discontinue. If significant inflammation of the lids exists, prescribe a combination antibiotic/steroid preparation (either ointment or drops) b.i.d. for two weeks. In addition, prescribe topical cyclosporine b.i.d., which can serve as a longterm anti-inflammatory agent off-label.

A new over-the-counter (OTC) drop is now available to manage meibomian gland dysfunction. Specifically, it has been shown to stabilize the tear film and inhibit evaporation. Another non-preserved OTC drop incorporates both glycerine and hyaluronate to keep the tear film intact. We have found b.i.d. application of these drops for contact lens patients (once before insertion and second during lens wear later in the day) has been very effective in extending our patients' comfortable wearing time.

For reusable lenses, the care systems must also be considered to minimize dry eye symptoms. A clean lens is often a comfortable lens. In this regard, peroxide care systems have been suggested for both their ability to clean lens surfaces and their lack of irritating and drying preservatives. On the other hand, a number of new multipurpose lens care systems are now available that address lens dehydration.

Inconvenience

Other patients say they want to cease wear and undergo refractive surgery either because they're “tired of having to take care of their contact lenses,” or they find lens insertion and removal bothersome. The latter patients tend to sleep with their lenses despite the fact they were not prescribed for overnight wear. Concerns about overnight wear, especially if done with low oxygen, non-extended wear-approved lenses, include increased risk of infection, inflammation and hypoxic sequelae, such as corneal edema, vascularization and limbal stem cell deficiency.

To dissuade the patients from contact lens dropout who find lens care a hassle, educate them about daily disposable lenses. Specifically, tell these patients that in addition to no lens care regimen, these lenses offer ocular health benefits by virtue of their wear schedule. (Remember: Many choices of materials, designs and parameters [e.g. torics multifocals, etc.] are available in this modality.)

To address perceived cost issues, educate these patients that they'll no longer have the cost of cleaning and disinfecting solutions, which can add up to hundreds of dollars annually, and that almost every manufacturer offers significant rebate programs. We've found that by illustrating both the benefits and savings of these lenses, patients are typically willing to spend more on them within reason.

To dissuade the patients from ceasing wear who find lens insertion and removal tiresome (and are likely sleeping in their non-extended wear-approved lenses as a result), consider switching them to continuous wear contact lenses fabricated from high oxygen permeable silicone hydrogel materials. Keep in mind, however, that patients who have chronic ocular surface disease (especially if associated with epithelial staining), smokers and those who haven't worn contact lenses previously aren't viable candidates for this modality. The reason: Research indicates these factors increase the risk for microbial keratitis.^1,2 If extended wear isn't a possibility, due to the aforementioned reasons, contact lens wear is likely not an option, and it may be time to evaluate the patient's candidacy for refractive surgery.

Cost

Due to the current state of the economy, many of us are hearing this reason for dropout lately.

To dissuade these patients from discontinuing lens wear, find ways to reduce patient cost. Aside from using manufacturer rebate programs, consider offering a discount on the purchase of an annual supply of contact lenses that is competitive with discount retailers. Some O.D.s sweeten this discount by also providing annual supplies of lens care solutions at a lower cost than that of discount retailers. Another idea: Set up a monthly or quarterly no-interest payment plan with automatic charge to a patient's credit card.

Whatever method(s) you choose, clearly show patients the savings they can achieve. Doing so on a fee-explanation sheet is highly effective. Show the usual costs vs. patient savings with annual lens and/or solution supplies, manufacturer rebates and insurance discounts or allowances if applicable. We've found that when patients can actually see the savings, they're likely to maintain wear.

On the other hand, if the cost issue is related to frequent lens damage and additional purchases as a result, be sure to have clear policies that provide free replacement of lost, torn or otherwise damaged disposable lenses. Make sure your replacement policies for rigid and custom soft lenses, in particular, are very liberal. The reason: You want to keep the perceived value high and concerns regarding lost/damaged lenses low. For example, provide no cost replacement of damaged GP or custom soft lenses within a 90-day period from dispensing plus a 20% discount if lost or damaged up to six months from the initial dispensing. Also, make sure your lens labs match the replacement policy you offer your patients. Remember: Your patients are your customers, and you are your lab's customer. You must keep your patients happy, and the labs must keep you happy.

To prevent tears, among other damages to contact lenses, instruct patients about appropriate handling at the outset. For instance, educate them how to digitally rub their lenses and to apply lubricating eye drops roughly 30 to 60 seconds prior to lens removal. The latter makes the lenses less brittle from dehydration, and, therefore, less likely to fracture.

Finally, consider GP lenses as an option for these patients. Typically, GP lenses have a life expectancy of one-to-two years and are far less likely to fracture vs. soft lenses. A highly motivated patient will get over the adaptation period and most often wear them with great success. We have achieved high GP lens adaptation rates via topical anesthetics at the diagnostic fitting and dispensing visits and through non-steroidal anti-inflammatory drops 15, 10, and 5 minutes prior to lens insertion for the first three-to-five days of lens wear.

Lack of motivation

Some patients have been wearing contact lenses for so long, they either forget or take for granted the benefits of wear vs. the limitations. These patients present saying they want to cease wear, but can't point to any one single issue when asked “why.”

To get these patients re-motivated to wear contact lenses, outline for them the implications of ceasing lens wear. Do this by discussing how spectacle wear would impact the enjoyment of their specific activities (e.g. golfing, biking, etc.) and the freedom that contact lens wear provides.

If, however, patients express a specific complaint about wear, such as dryness or blurry vision, inform these patients that there's likely a solution to their problem. Specifically, explain that the contact lens market has evolved to offer an array of materials, designs, lens care solutions and products to address the problems often associated with wear, and that you'd like to work with the patients to find the best solution.

All too often, practitioners simply acquiesce to stopping contact lens wear for good. Don't take the easy road. Instead, make the effort, and your patients and practice revenue will benefit.

Solution sensitivity

These patients often present with chronic redness of the bulbar and palpebral conjunctiva, diffuse superficial punctate staining, possible small multiple subepithelial corneal infiltrates and a follicular conjunctival response. Subjective symptoms of irritation and reduced contact lens tolerance prompt many of them to say, “I don't want to wear contact lenses anymore.”

To dissuade these patients from contact lens dropout, discontinue the patient's current solution system, and consider temporarily discontinuing lens wear to give the eyes time to normalize. Next, prescribe a “soft” topical steroid q.i.d. to be used five-to-seven days. Once these patients are able to restart lens wear, prescribe a peroxide-based system, non-preserved saline for lens rinsing and non-preserved artificial tears for their fresh pair of lenses on an “as needed” basis. Almost all these patients are happy to use a non-preserved care system if it provides a significantly improved response.

Of note: Some of these patients experience solution sensitivity due to non-compliance to our recommended lens care solution. To get patients to adhere to your recommended solution from the start, educate them that not all solutions are the same and that chemical differences in ingredients — especially preservatives — can result in sensitivity responses and ocular complications. (For further tips on patient compliance to your prescribed solution, see “Lens Solution Compliance: Lessons from a Best Seller,” www.optometric.com/article.aspx?article=104832.)

Contact lens-induced papillary conjunctivitis

Contact lens-induced papillary conjunctivitis (CLPC), or giant papillary conjunctivitis (GPC), has been largely relegated to a small percentage of patients since the advent of disposable/frequent replacement contact lenses. That said, patients wearing either conventional specialty soft lenses or patients prone to lens depositing — even with frequent replacement lenses — can present with this problem. And, it can be bothersome enough for them to express a desire to cease lens wear. Symptoms include a gradual reduction in maximum comfortable wearing time, intermittent blurring, increased lens movement upon blink, ocular itching following lens removal and a desire to heavily rub the eyes after lens removal. The clinical appearance of this condition includes increased papillae of the superior tarsal surface associated with limbal injection and inflammation along with active mucous production.

To dissuade these patients from dropping out of contact lens wear, first inform them that the condition isn't vision threatening and resolves with treatment. This treatment: Switch the patient to a daily disposable lens produced from polymers more resistant to protein deposition than other lenses and have smooth edge profiles. Inappropriate lens-to-cornea fitting relationships can cause this condition.

For cases in which this switch isn't possible or desired (due, perhaps, to parameter limitations, cost, etc.), prescribe a soft lens produced from a polymer that will minimize protein deposition and offers a frequent replacement schedule. Also, prescribe a peroxide-based and non-preserved care system along with enzymatic lens treatments. Simultaneous peroxide disinfection with subtilisin enzyme treatment is still a relatively convenient method for lens care.

Something else to keep in mind: GP lenses are a good option for CLPC/GPC cases, as they are typically more resistant to depositing vs. soft lenses.

To medically manage CLPC/GPC, prescribe topical steroids. If the patient is able to maintain wear during the condition, have him apply a drop prior to lens insertion and then immediately after removal, followed by a third application at bedtime. Although treatment duration is relative to each patient, we typically find that steroids are useful in CLPC/GPC for two-to-four weeks with subsequent tapering.

Should lens wear be temporarily discontinued, however, prescribe the steroid drop q.i.d. for two-to-four weeks with subsequent tapering. We also have utilized multi-mechanism anti-inflammatory and anti-allergy agents in conjunction with topical steroids to quell symptoms and reduce inflammation. They are typically used qd to b.i.d. and can be continued for many months, if necessary, to control the problem. We often continue these agents for a prolonged period following a short-term course of the topical steroid.

By modifying lens replacement, using different lens polymers, care systems and applying medical therapy, these patients have been able to continue wear (all be it perhaps with a more limited wearing schedule).

Inappropriate sagittal depth

We, as clinicians, are beginning to understand that despite unremarkable corneal topography or fairly average keratometry readings, patients may still experience fitting and lens instability issues due their corneas' sagittal depth. Typically, this is the patient who has been in and out of your practice for months now complaining that regardless of the lens you fit, it always moves, sometimes falls out, and their vision isn't great.

To prevent this issue, estimate all your contact lens patients' corneal sagittal depth from the get-go. The best way to estimate corneal sagittal depth: Measure the overall corneal diameter (most typically taken along the horizontal meridian of the cornea), and combine that with information about corneal curvature (per keratometry or corneal topography).

Additionally, corneal eccentricity influences overall corneal sagittal depth. Large sagittal depth is found with large corneal diameters, steep corneal curvatures and corneas that have low positive eccentricity values (low eccentricity prolate corneas vs. high eccentricity prolate corneas). To measure corneal diameter, you could: Use a measurement reticle in the eyepiece of a biomicroscope; a measurement gauge on a pupillary distance ruler; use your topographer (e.g. the “white to white” measure); or use advanced anterior segment ocular coherence tomography. To apply these measurements to regular disposable soft contact lenses that have multiple base curves, start with the steep base curve for patients who have large corneas, especially if their corneas are associated with relatively steep corneal curvatures and low eccentricity values. The opposite is true for small, flat and high eccentricity corneas.

If you apply your findings to custom soft lenses, GP lenses and scleral lenses, use quantified values to design these lenses. For example, some custom soft lens labs have developed fitting nomograms based on keratometry readings and corneal diameter to determine lens base curve and overall diameter. Sometimes, patients fall outside of the +/− 2 standard deviation range.

Presbyopia

Some practitioners and patients still mistakenly believe multifocal lenses don't provide adequate vision for distance and near. As a result, these patients decide to drop out of lens wear to avoid wearing readers over their contact lenses, or they opt for monovision — what they believe or have been told is the only alternative to wearing readers over their contact lenses. The outcome of monovision for some of these patients is blurred vision and dizziness, prompting them to cease lens wear altogether.

Educate these patients that the advantages of today's multifocal designs vs. monovision are many and include improved binocularity, enhanced intermediate vision and overall subjective preference by the majority of patients who experience both modalities. (Keep in mind that multifocal options are available in soft disposable, soft toric, soft custom designs, GPs and hybrid designs.)

We've found that the more you fit the various designs, the more you understand the optics of each design. This facilitates your ability to select the most appropriate multifocal lens for each patient.

Astigmatism

Although disposable toric soft lenses function marvelously, in terms of their stability of fit, comfort and physiological response for a large percentage of patients, they do not work optimally for all astigmatic patients.

To dissuade these patients from contact lens dropout, make customized contact lens designs available in your practice. Labs throughout the world pride themselves on their ability to produce lenses that have extensive parameter ranges in regard to size, curvature, thickness profiles, powers and axis options (down to the 0.12D and 1.0° range). Utilizing technologies and methods, such as corneal topographic analysis, corneal saggital height measurements and sphero-cylinder over-refraction techniques, among others, goes a long way in addressing in a precise way the problems experienced by astigmatic contact lens wearers.

When dealing with astigmatism, don't compromise; be precise. Your patients will be grateful, and your practice revenue will increase. (Keep in mind that profitability is higher with custom lenses vs. disposable lenses on materials, and these “needy” patients are typically willing to pay higher professional fees, due to their past unsuccessful wear. Regarding chair time: We have very high success rates and great predictability of outcomes with custom toric soft lenses.)

Although, you won't be able to prevent all your contact lens patients from dropping out of wear, awareness of this list and the ways in which you can successfully address each issue will enable you to prevent many of these patients from ceasing wear. Also, keep in mind that many of these issues can be prevented from the start by simply providing patient education and staying up to date on the latest research and product offerings. OM

Special thanks to Drs. Jeffrey Cooper, Christine Sindt, Glenda Secor, Jeffrey Walline, Edward Williams, David Seibel, Michael McClay, LaMar Zigler, Randal Fuerst, Tom Quinn, Paul Klein, Bruce Hankin, Shana Brafman, and Darin Strako for contributing to this article.

1. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62.
2. Dart JK, Radford CF, Minassian D, et al. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology. 2008 Oct;115(10):1647-54,1654.e1-3.

Dr. Eiden is president and medical director of North Suburban Vision Consultants, a multi-specialty eyecare practice in Deerfield and Park Ridge, Ill. He is co-founder of EyeVis Eye and Vision Technologies and Research Institute and immediate past chair of the AOA's Contact Lens and Cornea Section. E-mail him at sbeiden@nsvc.com. Or, send comments to optometricmanagement@gmail.com.

Dr. Davis is co-founder of EyeVis Eye and Vision Research Institute. Dr. Davis is Diplomate in the American Academy of Optometry and an inductee in National Academy Practice in Optometry. He has published and lectured extensively on topics related to contact lenses and the management of eye disorders. He is an adjunct faculty member of Illinois College of Optometry, University of Alabama and Salus University College of Optometry. E-mail him at EyeManage@aol.com.