With patient noncompliance among contact lens (CL) patients as high as 44%,1 and the consequences of noncompliance being dropout and/or poor hygiene and its associated health risks, it is essential optometrists educate their contact lens-wearing patients on the importance of complying to their prescribed lens care regimen. As studies recommend providing verbal and written instructions at every encounter to help increase patient understanding and compliance,1 below we will provide ideal patient scripts for four key areas of CL noncompliance — handwashing, cleaning cases and lenses, and improper wear.
Handwashing: re-educate regularly
Handwashing is a critical subject to re-educate patients on regularly: While most (53% to 77%) wash their hands before handling their lenses, they may be doing so inadequately.2,3
To reinforce this practice, I recommend this patient script: “Handwashing is the most important step to prevent complications with your lenses. Before handling your lenses, you should be washing with plain bar soap, not ones with moisturizers or perfumes, as it is the most effective way to reduce the presence of bacteria on your hands.4 These bacteria can lead to a number of ocular pathologies, the most serious of which can result in infection.5,6 Hand sanitizer is not an equivalent, because its high alcohol concentration can damage the lens and hurt your eye. You should be washing your hands for about 1 minute from start to finish. Dry your hands with a clean, lint-free towel.”
There are additional instructions, which you can write down for your patient to refer to at home. These instructions include: Open the contact lens case before washing your hands, as touching the case may re-contaminate your hands. Then, create a lather and scrub hands together for 20-30 seconds. This is about the amount of time it takes to sing through the alphabet. Pay particular attention to your palms and fingertips, and wash for another 30 seconds. Rinse your hands with warm water, dry them, and then handle your contacts.
Cleaning cases and lenses
According to studies, 75-77% of patients fail to properly rub and rinse their lenses,7 making it essential for ECPs to provide education on how to appropriately do so.
Below are two scripts, and written take-home instructions, for discussing proper cleaning, based on whether your patient uses a multi-purpose solution (MPS) cleaner, or a hydrogen peroxide (H2O2) cleaner (which can be helpful if a patient is allergic to the preservatives in MPS formulas).
MPS script: “After you wash and dry your hands, you will remove your lenses, one at a time, and clean them by putting them in your hand, placing solution on them, and rubbing them. Then rinse the lens with a steady stream of MPS solution. Place the lenses in a clean case filled with fresh MPS.”
MSP written take-home instructions: After you remove your lenses, place them in the palm of your hand and add 2-3 drops of solution; gently but firmly rub it to remove deposits and proteins. Rubbing and rinsing should take 20-30 seconds for each lens. Be sure to place them in a case filled with fresh MPS — do not add fresh MPS on top of old solution or reuse old solution. Your contact lens case should be routinely cleaned with an MPS. If there is ever a question about cleanliness, the safest approach is to simply replace the case with a new one, since CL case contamination has been associated with ocular complications that can result in sight-threatening infections.8 For this reason, please change your lens case often – every 1 to 3 months is recommended.9
It’s possible some of your patients may say they do not need to rub their lens during the cleaning process, due to “no rub” MPS marketed in the early 2000s. If they bring it up, you should tell them that there are currently no recommended “no rub” solutions available, and they should still rub their lenses.
H2O2 script: Place your lenses in their designated side of the basket and rinse them with a steady stream of the H2O2 solution for a few seconds. Fill the case with fresh H2O2 solution and leave the lenses for at least 6 hours for the solution to fully neutralize.”
H2O2 written take-home instructions: Rinse your lenses for 5 seconds, then fill the bottom of the case to the line with fresh H2O2 solution and securely screw the basket into place. It is important to leave the lenses for at least 6 hours for the solution to fully neutralize. Do not use the H2O2 solution to rinse your lenses before you put them in the basket. Do not put the H2O2 solution directly into your eyes, as it can damage them. Do not reuse old lens cases – when you run out of solution, purchase a new bottle and use the new lens case that comes with it.
You should also advise patients not to wash their cases or lens with water. I use this script for that: “Water is not sterile and can harbor pathogens that are very harmful to the eyes. You should never rinse your lenses or lens case with water.”
Improper wear
Lens overwear is a common practice, and one of its most frequent forms is patients sleeping in their CLs; one study lists 56% of patients as having slept in lenses during an average week.10 You can discuss this with your patients using the following script: “Your lenses are not approved for overnight wear. Sleeping in lenses, even for short periods of time, is not safe. It deprives the eyes of oxygen and significantly increases the risk of infection.11 Make sure you remove your lenses before you go to sleep.”
For patients who have trouble remembering to take out their lenses before sleep, such as those who work multiple-day shifts (like firefighters and police officers), extended-wear (EW) lenses can be helpful. However, EW lenses can also be prone to complications such as increased likelihood of microbial keratitis.12 For patients using EW lenses, I recommend cleaning them with H2O2 solution, following the directions in that section above for their care.
Also of concern is non-compliance with daily disposable lenses. Approximately 60% of disposable wearers report storing them in a case.13 There is no consistent guidance for proper storage of daily disposable CLs because they are not designed to be used this way.
Try this script for talking with patients about daily disposable lenses: “You are wearing a daily disposable lens. These lenses are designed to be thrown away when you remove them. They are not designed for repeated wear and doing so will increase your risk of complications.” If you have a patient using frequent replacement disposable lenses, you can use this script to discuss proper care for them: “You are wearing an x-week disposable lens. This means you will remove them every evening, disinfect them overnight, and put them in fresh and clean in the morning every day for (insert whatever replacement schedule the lens is approved for). After x-weeks, you will throw these lenses out and open a new pair. Wearing lenses longer than approved can increase the risk of things like discomfort, lens intolerance, and infection.”
Another common misuse of lenses is using them while swimming or showering. Only 1 in 3 CL wearers associate swimming, water sports, and tap water rinsing as risk factors for CL-related adverse events, with an even lower number understanding that showering with lenses is also a risk.14 Further, one study found that 64% of patients interviewed “occasionally or always” wear contact lenses while swimming or playing water sports.10
As discussed above, tell patients that water is not sterile and using it with lenses can result in harm to eyes. To discuss this further, I use this script: “You should not wear lenses in the shower or swim in them. Shower before you put lenses in or after you have taken them out. Avoid swimming in lenses as well, unless you use goggles to protect your eyes.”
You can offer these written instructions, as well, to help reinforce this: Do not shower in your contact lenses, as doing so can expose the lenses to pathogens which can harm your eyes. It is possible to swim in lenses if you wear goggles to help prevent water exposure.15 Reusable lenses (monthly and 2-week) should be removed immediately after swimming and go through a full disinfecting cycle before you wear them again. Daily lenses should be removed and discarded after swimming with goggles.15
Proper communication
It is up to ECPs to provide proper education to new wearers, and to regularly reinforce appropriate lens wear and care for established wearers. Knowing how to properly communicate these facts to patients is an essential part of their education. Anecdotally, we have found that with repetitive education compliance overall improves. Without repetition, patients can easily fall into bad habits and, unknowingly, put themselves at risk. OM
Dr. Lievens is the director of research and professor at Southern College of Optometry, in Memphis, Tenn. He serves as a consultant for AbbVie/Allergan, Bausch + Lomb, and Transitions.
Dr. Rayborn is an assistant professor at Southern College of Optometry, in Memphis, Tenn.
References
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2. Gyawali R, Nestha Mohamed F, Bist J, et al. Compliance and hygiene behaviour among soft contact lens wearers in the Maldives. Clin Exp Optom. 2014;97(1):43-47. doi:10.1111/cxo.12069.
3. Stevens S. Reducing the risk of infection: hand washing technique. Community Eye Health. 2008;21(65):17.
4. Burton M, Cobb E, Donachie P, et al. The effect of handwashing with water or soap on bacterial contamination of hands. Int J Environ Res Public Health. 2011;8(1):97-104. doi: 10.3390/ijerph8010097.
5. McMonnies CW. Hand hygiene prior to contact lens handling is problematical. Cont Lens Anterior Eye. 2012;35(2):65-70. doi:10.1016/j.clae.2011.11.003.
6. Stapleton F, Edwards K, Keay L, et al. Risk factors for moderate and severe microbial keratitis in daily wear contact lens users. Ophthalmology. 2012;119(8):1516-1521. doi:10.1016/j.ophtha.2012.01.052.
7. Ramamoorthy P, Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye Contact Lens. 2014;40(1):17-22. doi:10.1097/ICL.0000000000000009.
8. Uno T, Ohashi Y, Imayasu M. Antimicrobial efficacy tests of multipurpose contact lens care solutions simulating poor contact lens hygiene behaviors. Eye Contact Lens. 2012;38(6):388-393. doi:10.1097/ICL.0b013e3182562d9f.
9. Contact Lens Care. American Optometric Association. https://www.aoa.org/healthy-eyes/vision-and-vision-correction/contact-lens-care. Accessed Oct. 19, 2023.
10. Robertson DM, Cavanagh HD. Non-compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011;88(12):1402-1408. doi:10.1097/OPX.0b013e3182333cf9.
11. Szczotka-Flynn LB, Shovlin JP, Schnider CM, et al. American Academy of Optometry Microbial Keratitis Think Tank. Optom Vis Sci. 2021;98(3):182-198.
12. Rhee MK, Jacobs DS, Dhaliwal DK, et al. Contact Lens Safety for the Correction of Refractive Error in Healthy Eyes. Eye Contact Lens. 2022;48(11):449-454.
13. Cope JR, Collier SA, Rao MM, et al. Contact Lens Wearer Demographics and Risk Behaviors for Contact Lens-Related Eye Infections — United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64:865-870.
14. Robertson DM, Cavanagh HD. Non-compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011;88(12):1402-1408. doi:10.1097/OPX.0b013e3182333cf9.
15. Stapleton F, Keay L, Jalbert I, Cole N. The Epidemiology of Contact Lens Related Infiltrates. Optom Vis Sci. 2007;84(4):257-272. doi:10.1097/OPX.0b013e3180485d5f.
