HIGHLIGHTS FROM A ROUNDTABLE DISCUSSION HELD DURING SECO 2013

Groundbreaking Technology Debuts in Daily Disposable Market

Panelists discuss a unique new lens that has surprising characteristics designed to defeat discomfort.

Dr. Eiden: Today, we’ll share our experiences with what we believe is a revolutionary new contact lens technology. The Alcon Dailies Total1 lens was designed to address some of the key challenges we still face in daily practice in a way that we haven’t been able to do before, relating to all-day comfort, visual performance and breathability. Let’s begin by discussing some of those challenges.

	S. Barry Eiden, OD, FAAO (moderator): Dr. Eiden is president and medical director of North Suburban Vision Consultants Ltd. with offices in Deerfield and Park Ridge, Ill. He reports no financial disclosures.
	Mile Brujic, OD: Dr. Brujic is a partner in Premier Vision Group, a four-location practice in northwest Ohio. He is a consultant/advisor to Alcon, Allergan, Nicox, TelScreen, Transitions, Valeant Pharmaceuticals, Vmax Vision and Valley Contax. He has received research support from Alcon and VMax. He has lectured and/or received honoraria from Alcon, Allergan, Vmax and Valley Contax.
	April Jasper, OD, FAAO: Dr. Jasper practices at Advanced Eyecare Specialists in West Palm Beach, Fla. She is a consultant/advisor to Alcon, Eyefinity and Marco. She has lectured or received honoraria from Konan and Carl Zeiss Meditec.
	Jordan Kassalow, OD: Dr. Kassalow is a partner at Farkas, Kassalow and Resnick in New York City, N.Y. He reports no financial disclosures.
	Kelly Nichols, OD, MPH, PhD, FAAO, Dipl PH: Dr. Nichols is a FERV Professor at the University of Houston College of Optometry. Dr. Nichols has stock options inTearLab. She is a consultant for Alcon, Allergan, Bausch +Lomb and SarCode. She has received research support from Alcon, Allergan, SarCode, TearLab and Vistakon.
	John L. Schachet, OD: Dr. Schachet is president and CEO of Eyecare Consultants Vision Source in Englewood, Colo. He is a consultant/advisor to Alcon and Tear Science. He has received research support from Alcon. He has lectured and/or received honoraria from Alcon and CooperVision.

Number One Complaint

Dr. Eiden: Dr. Brujic, do you always know when patients are dissatisfied with their habitual contact lenses?

Dr. Brujic: I see two types of challenging patients. The first is the non-complaining patient, and the second is the habitually complaining patient. The non-complainers seem to have no problems, but often, I think they’re reluctant to complain, because they’re concerned they’ll have to stop wearing contact lenses.

Dr. Eiden: How do you help these patients open up?

Dr. Brujic: I ask them to rank the quality of their vision and the comfort of their lenses, each on a scale from 0 to 10. Many people who tell me their comfort is “fine” or “great” give their lenses a grade that is less than the 10 I’d expect for comfort that is “fine.” This is a huge opportunity forme to introduce new technologies to these patients, as well as to patients who do verbalize their complaints.

Dr. Eiden: Dr. Jasper, do you find the same thing happening in your practice? Do you see it as an opportunity to make changes for your patients?

Dr. Jasper: Absolutely. The most common complaint I hear is that patients can’t wear their lenses as long as they want to during the day. When a patient tells me this, it’s my job to find out why. Typically, it’s because the lenses are not comfortable, or the patient’s lenses feel dry. Another challenge is the patients who tell us what they think we want to hear just to make us happy.

Dr. Eiden: What do you do when you suspect a patient is just telling you what you want to hear?

Dr. Jasper: I help them get past that by rewording my questions. I may ask, “What’s the longest amount of time you can wear your lenses comfortably during the day?” or “How often do you switch to your eyeglasses before the end of the day?”

Dr. Eiden: Dr. Nichols, what questions do you ask your patients to uncover any comfort issues?

Dr. Nichols: I always ask patients how many hours a day they wear their lenses, how many hours they want to wear them and what things they’ve tried to eliminate some of their discomfort. In my practice, I see patients who are having more significant issues. Many of these patients are former contact lens wearers who really want to wear them again. I think sometimes we’re quick to say, “You’re done with contact lenses,” instead of trying something new. When patients start to drop out in their 30s or 40s, we need to try to figure out if we can do something to keep them comfortable in lenses, because they want to wear them.

Dr. Eiden: Other issues that concern us in terms of contact lens performance include ocular health response and visual response. Dr. Schachet, how important are these aspects in comparison to comfort tissues?

Dr. Schachet: They’re all important and interrelated. Most of my patients who have discomfort have either a dryness problem, which can be accompanied by fluctuating vision, or they’re not using the ideal lens care solution for their lenses. So, whether we’re talking about initial comfort or end-of-day comfort, I look at those two things primarily before looking at anything else. We have to be proactive, and we need to listen. When we listen carefully to what patients say, the problem often becomes apparent even before we go to our instrumentation.

Unmet Needs in Daily Disposables

Dr. Eiden: Dr. Kassalow, you fit a significant number of daily disposable lenses. What impact has this modality had on your practice?

Dr. Kassalow: The four areas I always focus on when discussing contact lenses with patients are comfort, convenience, vision and health. Daily disposable lenses hit each of those areas square on. From my experience, daily disposable lenses are the most comfortable modality, and patients who wear them are my happiest group of patients. When I see a patient who’s wearing daily disposable lenses, I know that 9 out of 10 times, it will be a relatively easy office visit.

Dr. Eiden: How do they rate their vision?

Dr. Kassalow: They’re just as happy with their vision, because every day, they have a fresh lens. The lens is wet and clean, and they like that. They also love the convenience. They don’t have to use care solutions and feel like a chemist every night.

Dr. Eiden: And health?

Dr. Kassalow: My patients and I both love the fact that daily disposable lenses are a healthy option. The modality has been a fantastic practice builder. Overall, my patients are happier than they were before they started wearing daily disposables.

Dr. Eiden: Where do you see opportunity for advances in daily disposable lenses?

Dr. Kassalow: Despite having many daily disposable lenses, we still have a group of patients who aren’t comfortable wearing them, so I’m excited about the Dailies Total1 lens and the advent of this new technology. I think it will fundamentally shift the comfort curve.

Dr. Jasper: I think it all comes back to the one thing we’ve discussed so far. Discomfort is still an issue for some patients. I still have patients who tell me they can wear their lenses for only 6 hours a day. New and Unique Properties

Dr. Eiden: Dailies Total1 technology is truly revolutionary, because it’s totally different from any other material. It’s the first water gradient silicone hydrogel lens. Dr. Brujic, what is meant by water gradient and how is this lens different from any other HEMA or silicone hydrogel lens?

Dr. Brujic: Dailies Total1 lenses are manufactured in a new silicone hydrogel material called delefilcon A, which is designed to enable a gradual transition from 33 percent water at the core of the lens to over 80 percent at its surface. Amazingly, this happens in a 6-micron space.

Dr. Nichols: All contact lenses aim to simulate the ocular surface and conform to the environment of the tears in a way that enhances the tears or at least doesn’t harm anything about the tears — almost as though the lens isn’t there. In short, the Nirvana of contact lens wear is to have no lens awareness. A number of studies have shown that changes to the ocular surface tissues are highly associated with symptomatic contact lens patients.^1,2 This lens has a surface that mimics the natural hydrophilic ocular surface.

If you design your marketing properly and let people know this truly is a revolutionary new contact lens, there’s absolutely nothing like it anywhere in the world, I think you’ll have quite a few people coming in to try it. — John L. Schachet, OD

Dr. Eiden: Dr. Kassalow, how do you explain the concept of lubricity to your patients?

Dr. Kassalow: I always talk about lubricity as a feature of the lens. Different patients have appetites for different amounts of information, so to some patients, I say, “This is the single best, most comfortable lens I’ve worked with in my 25-year career. Let’s try it,” and they say, “Great. Let’s do it.” Others may tell me they’re comfortable with their current lenses and ask for more information. For them, I focus on how lubricity equates to comfort.

Dr. Schachet: What’s nice about this lens is that the lid has no effect on it because it virtually glides over water. That’s another point that makes it easier for patients to understand.

Dr. Eiden: Handling a contact lens can be a challenge for some patients. We always talk about the convenience of daily disposables, but I’ve had patients reject contact lenses simply because they were difficult to handle. Dr. Jasper, tell us about the modulus gradient and how that influences lens handling.

Dr. Jasper: Dailies Total1 lenses have a low-modulus surface, which enhances comfort, and a high modulus core, which facilitates ease of handling. I proactively explain to patients how I want them to apply and remove these lenses. I think the most noteworthy characteristic, especially for patients who have worn lenses all their lives, is that after applying the lens, they hardly know it’s there — except that they can see. Lens removal may be somewhat challenging for some patients. I instruct them to be sure their hands are thoroughly dry before they remove the lenses.

Dr. Eiden: The same attribute that makes the lens so lubricious makes it some what difficult to remove if your fingers are wet, because it just slides right over the lens surface.

Dr. Brujic: I refit a patient who’d been wearing another brand of daily disposable lenses into Dailies Total1 lenses. When he tried to remove them by pinching them off of his cornea, he had some trouble. After I explained how to remove these lenses — the slide-and-pinch technique — and that he was having trouble because of how slick the lens surface is, he suddenly said, “Wow, now I really understand why this is such a comfortable lens.”

Highest Dk/t in a Daily Disposable

Dr. Eiden: With a Dk/t of 156 (@ –3.00D), Dailies Total1 lenses have the highest oxygen transmissibility of any daily disposable lens. Assuming perfect compliance, do you think the cornea needs this much oxygen?

Dr. Schachet: Each patient’s requirement for oxygen is different, but I don’t think there’s anything wrong with aiming for high oxygen transmissibility.

Dr. Jasper: We don’t know every reason why people drop out of contact lenses. People say discomfort and dryness, but it seems to me if you provide them with the most oxygen throughout a lifetime of contact lens wear, they’ll have fewer problems. As Dr. Schachet mentioned, we don’t know what each individual’s unique oxygen need is. It depends on their lens, where they live, what they do, and so on, so going high in my mind is not a bad thing.

Dr. Brujic: It used to be a more relevant argument when deciding between oxygen transmissibility and wettability. With the Dailies Total1 lens technology, we don’t have to give up either.

Dr. Jasper: I tell my patients, “I want to give you a contact lens that is like having nothing on your eye.” In other words, we want a lens that’s the least like a lens, and I would hope that every company that works with contact lenses would strive to do that for our patients.

Dr. Eiden: That is a powerful statement. Why do we put a contact lens on anybody’s eye? To help them see better. So, the more that it’s like nothing, other than vision correction, the better it is for our patients.

Personal Experiences

Dr. Eiden: We’ve discussed many of the attributes that make Dailies Total1 unique and exciting. Most of us have had the opportunity to wear these lenses. I’d like to get your personal feedback on wearing these lenses.

Dr. Nichols: I’m the perfect example of a patient looking for a more comfortable daily disposable lens. I’m probably always going to have some comfort issues, because I work long hours late at night on the computer. I’ve worn Dailies Total1 lenses for about 6 months, and I can wear these lenses longer and more comfortably than any other daily disposable lens that I’ve worn.

Dr. Schachet: Overwhelmingly, this is the most comfortable lens I’ve ever had on my eye, and that is directly attributable to the water gradient. When it’s on the eye, you don’t even know you’re wearing a contact lens. It’s the most incredible lens-wearing experience I’ve had in all the years I’ve been practicing.

Dr. Nichols: Our patients deserve the chance to try these lenses. I don’t think people recognize they’re uncomfortable until they experience comfortable.

Dr. Eiden: More than a year ago, I had my first exposure to this technology in Europe. At the end of my first day wearing the lens — we sat down to dinner at about 11:00 p.m. — I realized I still had the lenses on, but I didn’t feel them. That’s never happened to me before. Usually after 3 or 4 hours, I have to peel the lenses off of my eyes. We’ve recounted our personal experiences. Now, let’s discuss how our patients are reacting to Dailies Total1 lenses.

Patient Experiences

Dr. Brujic: One of the high moments for me as a clinician is putting lenses on eyes at the beginning of lens wear, because that sets a precedent in a patient’s mind of how that lens will perform. The beautiful thing about the Dailies Total1 lens is its excellent initial comfort.

Dr. Eiden: Dr. Jasper, you had an anecdote you wanted to share.

Dr. Jasper: One of my patients, a teenager, was wearing another lens, apparently successfully, but I wanted her to try the Dailies Total1 lenses. As soon as she put them on her eyes, she said, “Oh my goodness. I had no idea my contacts were supposed to feel like this.” She didn’t really understand how to answer my questions about comfort, but once she had experienced the “no-lens” feeling, she understood what it was really supposed to be like.

Dr. Kassalow: When a patient comes in happy and with the attitude “if it ain’t broke, don’t fix it,” it’s easy for us to buy into that, because it makes our day go more smoothly. When contemplating a change for one of these patients, I sometimes ask myself, “Am I setting myself up for headaches? Am I slowing down my day? Am I inconveniencing the patient?” Sometimes, my inclination is to just leave well enough alone. Every person on whom I’ve tried the Dailies Total1 lens has had a positive experience. It doesn’t create that backlash of having to try a different lens and repeat the cycle. That’s an important dynamic in my practice that will prompt me reach for this lens frequently. It’s not creating more work for me. It’s making my day go faster, and I’m putting patients into a premium product.

Dr. Nichols: I like the idea that it streamlines your process, because you’re not trying a lens that might be uncomfortable. You’re confident this lens will be successful.

Dr. Eiden: We have to constantly present new technologies and reinvent ourselves to give patients a reason to come to see us regularly. For that reason, I’ve presented these lenses to happy patients who apparently have no problems. I say, “Yes, I know everything is great, and if you want to continue with your current lenses, you can, but I want you to test drive some new technology.” I’ve found that these patients do see an improvement. It may not be as dramatic as the improvement seen by symptomatic patients, but they still see a bump up.

Dr. Brujic: That’s the true test of good technology: taking an asymptomatic patient, someone who has no problems, and improving his experience. This lens is giving us the ability to do just that.

Dr. Kassalow: I’ve definitely seen that happen. Several hundred of our patients are wearing a competitor’s product that is being discontinued. We mailed them information, letting them know the product would no longer be available, and we invited them to come in and try the Dailies Total1 lens. Four out of five of the people who have tried this lens so far have said, “Wow, thanks, doc. This is better than I knew I could have.”

Dr. Schachet: Another patient whom we haven’t discussed is the new contact lens wearer. Anyone who’s never worn a contact lens has an opinion of how it will feel on their eyes. When new wearers try Dailies Total1 lenses, they’re amazed, because they don’t even know it’s there.

Dr. Nichols: That’s a good point. Why not start with innovative technology rather than “fix” a problem? Many patients are accustomed to new technology in other aspects of their lives.

Dr. Eiden: That’s an interesting perspective. We’re “fixing” so many of our patients because they have contact lens-associated problems. This technology takes us to a whole new level in terms of prevention — having patients start with a great lens so they can stay with it for a long time.

Dr. Schachet: Even though this is the closest to a perfect lens we have, we have to remember that some patients will have dryness issues. If we don’t address that, they won’t be able to wear the lenses all day.

Dr. Kassalow: That’s a great point. Even though we all believe this technology is a quantum leap forward, we still need to assess issues that could lead to contact lens-associated dryness.

Dr. Nichols: I agree. When there’s an underlying condition, a lens can’t make that go away. We need to evaluate the ocular surface and lids at every visit and manage the findings appropriately, even for a patient who says everything is “fine.”

Value Versus Cost

Dr. Eiden: From my perspective, Dailies Total1 lenses are for everybody whose prescription fits the parameters. Do you agree? Will this be a problem-solver lens or a go-to lens in your practice?

Dr. Kassalow: I will clearly position Dailies Total1 contact lenses as a go-to, first-reach lens. It is a premium lens with a premium-lens price, so some people may push back because of the cost and stay with products that are less expensive. In those cases, I’ll use it as a problem-solver when appropriate.

Dr. Eiden: How have patients responded so far to the higher cost of this new technology?

Dr. Schachet: Reactions have been mixed so far. It wouldn’t be fair to say it has been accepted overwhelmingly; however, I recently had an interesting case. Some long-time patients came in with their sons, ages 13 and 15 years. They had been wearing contact lenses, but not very comfortably. When they tried Dailies Total1 lenses, both boys had an overwhelmingly positive experience. This was the first time they’d been able to wear contact lenses all day. I explained the cost to their parents. I guess they went home and thought it over, because 3 days later, they called and ordered Dailies Total1 lenses for both boys.

Dr. Eiden: Practitioners often wonder: Should we or shouldn’t we discuss the cost before the patient experiences the lens? I’ve decided I want my patients to experience the lens first. I do mention the cost is a bit higher, but I tell patients, “I don’t want to talk about the cost now, because I don’t want that to influence how you respond to this lens. I just want you to experience it. If your experience is as positive as I expect it to be, then we’ll have that conversation. You can decide if the value is worth the price.”

Dr. Jasper: I think patients hear “new technology” and “innovative contact lens,” and they know it will cost more. I’m okay with that. I’m not going to prejudge a patient’s ability or willingness to pay for a premium product. Those of us who have optical centers encourage our staff to present the best frames to everybody, so why would we not present the best medical device to everybody. In the end, patients know I did not prejudge them, and I treated them like my best friend and my family.

Groundbreaking Technology

Dr. Eiden: What does the introduction of Dailies Total1 lenses mean to you and your practice?

Dr. Nichols: If everyone’s experience is similar to my own with this lens — being able to wear it comfortably longer than any other daily lens, having minimal lens awareness, yet maintaining good quality vision — then this technology is going to impact the daily market. I think it could revolutionize how we think about the technology behind daily disposable contact lenses, and how we select lens options for patients, including patients with comfort issues.

Dr. Schachet: This is a unique lens that should be in a category all alone. There isn’t anything like it anywhere. When my patients try it, I simply say, “If this lens isn’t the most comfortable lens you’ve ever put on, I’d like to hear why.”

Dr. Kassalow: We’ve learned that almost 50 percent of people who stop contact lens wear do so because of discomfort issues,³ and I can’t assume that my practice is any different. If we can reduce that number in our practices, it will have a ripple effect and help us grow exponentially. I think it’s going to have a huge impact on my practice, because fewer patients will leave contact lens wear.

Dr. Brujic: We’re taking comfort to the next level with this lens, and I think that’s an exciting place to be, because comfort is an unmet need in our patient populations. We now have this new tool to help us keep more patients in contact lenses.

Dr. Jasper: I’m excited about this lens, because, to me, it means I have a slam dunk, a lens that will take care of my patients’ needs. I love being able to tell my patients, “I’m going to give you the best lens in every category. It’s also going to give you the best vision.” This lens makes me look good, and it makes my patients extremely happy.

Dr. Eiden: Dailies Total1 lenses represent groundbreaking technology that will enable us to address our patients’ comfort and vision needs — the whole package. I know I speak for the panel when I say we’re honored to have been part of the initial group of practitioners to have access to this technology and to experience it. Now, it will be equally as exciting for us to share it with our colleagues. ■