A few months ago, a patient came into my office for a comprehensive eye exam. She was an average patient who came in for a glasses exam. During our conversation, she told me that she had previously worn contact lenses but discontinued lens wear because they initially got uncomfortable towards the end of day. The patient then reported that the lenses were never quite comfortable in her eyes to begin with.
After her refraction and looking at her ocular surface, I told her that we could—and would—get her in contact lenses if she was still motivated to do so. Her demeanor instantly changed from one of dejection to that of excitement and hope. We set forth a plan, and she is now wearing her contact lenses all day without compromise. She is ecstatic about her eyecare and has referred a few patients into our office already!
This seems like quite the story, right? But it never had to be like this.
Why contact lens dropout happens
Contact lens dropout happens silently and without much fanfare in our offices every day. As I have noticed, it generally takes a few years going from full-time to occasional wear to not getting a new contact lens evaluation in about 3 years. According to recent studies, the contact lens dropout rate remains around 20% each year. There are even more patients out there who are on the brink if we do nothing. Despite expanded parameters, innovative designs, and novel treatments, patients are still opting for spectacle lens correction in lieu of contact lens wear.
Everyone wants the luxury of choice. To be the one deciding what course of action is preferred. Helping our patients be the advocates for their eyecare is one of the best ways to be their expert.
On patient surveys, the top reasons patients drop out of contact lens wear are comfort (50%) and vision (25%). If we think about all the various aspects of contact lens wear, we need a healthy ocular surface, optimized lens technology, and lens care systems. The balance of these three is paramount to the patient experience with contact lenses.
The ocular surface upon which the contact lens rests is the most important factor. If you have a sprained ankle, a new pair of shoes may work well in the short term, but won’t fix the ultimate problem. The same is true for our contact lens wearers with a compromised ocular surface. Altered meibomian glands, decreased tear break up time, ocular surface inflammation, and/or tear irregularity all play a role in contact lens dropout. Any time we fit a patient in a contact lens, we are examining closely for any of these signs that can compromise excellent comfort and vision.
The importance of case history
Prevention of ocular surface disease in contact lens wearers leads to longer lifetime wear and longer daily wear. Using surveys is helpful to get subjective information from patients. There are several different options that can be used to determine if there are any possible underlying issues. The SPEED (Standardized Patient Evaluation of Eye Dryness) is one such survey. Relatively short and accurate for patients with ocular surface disease. Another survey is the CLDEQ-8 (Contact Lens Dry Eye Questionnaire-8). Both have been studied to show utility in determining dry eye in contact lens wearers.
Asking targeted patient history questions is also valuable in determining potential for dropout. In patient surveys, it has been reported that over 90% of patients have some compensating behavior in order for their lenses to make it through the day. Whether that’s using lubricating drops, rubbing their eyes, taking out their lenses and re-inserting, patients are having to do something for their lenses to be comfortable or clear. See the below list of questions to help address patient concerns.
Patient assessment questions
To determine the best plan, ask the patient the following questions about their contact lens wear:
- On a scale from 1 – 10, how happy are you with your contact lenses?
- What time do you put in the lenses, what time do you take them out, and what time would you like to take them out?
- When do you start to notice your lenses?
- Does your vision fluctuate in the lenses or do you have to blink in order to make your vision clearer?
- Are you using any lubricating drops or solutions to get through your day?
- Do you have to do anything to make your contact lenses last the whole day (rubbing, taking them in and out, etc.)?
- Is there anything we can do to improve your contact lens wear?
Treating the ocular surface
Once we’ve identified a problem, it’s time to start recommending therapies and solutions for their problems. Starting from outside and going in, usually there is a meibomian gland dysfunction. According to one study, patients who wear contact lenses have decreased function and change in morphology in their glands. Treatment for MGD include supplementation like Science Based Health HydroEye or PRN DE3 Dry Eye and therapeutic procedures (LipiFlow, Intense Pulse Light, Photobiomodulation, TearCare, iLux). Using both types of treatment help break the cycle and maintain regulatory function of the glands.
Looking at the ocular surface, if there is any inflammation, staining, or tear film irregularity, prescribing a drop helps stabilize the tear quality. Using current therapies like cyclosporine (Restasis, Cequa, Klarity-C), lifitegrast (Xiidra), nasal spray (Tyrvaya), or biologics (Regener-Eyes) reduce surface issues while increasing contact lens comfort and visual stability. Sometimes a short course of steroids is necessary using loteprednol (Eysuvis, Lotemax) or FML (Flarex), but typically these patients need more chronic therapy.
Recommending the latest technology
After the surface has been optimized for contact lens wear, now it is time to recommend the latest innovations designed to account for the higher demand on the lens. Each manufacturer has developed cutting-edge technology to provide longer wear hours, greater comfort, easier handling, and better vision. Most of the time, the patient ends up in a daily disposable to create the best combination of surface and lens treatments. However, sometimes by treating the surface alone, the patient can remain in their reusable lenses for years with increased comfort.
Utilizing new technologies like Alcon’s water surface technologies (Dailies Total1, Precision1, and now Total30), Bausch + Lomb Infuse (based on TFOS DEWS II recommendations), CooperVision MyDay family (Smart silicone for increased water content in the lens), and Johnson & Johnson Oasys 1-day with Hydraluxe create a better experience for the patient.
Educating your patients
Educating the patient is key because let’s be honest, they are the ones actively managing this disease. Patients get the treatments from their optometrists, and with the exception of in-office procedures, that’s the extent of the OD’s role. Getting buy-in and motivation beyond the first improvement of symptoms defines the successful adoption by the patient. Explaining the chronicity of the disease and how the outcome of this is to make contact lens wear better for the patient helps drive this point home.
“Contact lens wearers are motivated to stay in lenses, so continue educating throughout the process and congratulate patients on being diligent in their efforts.”
Patients come to see optometrists as their eye experts. They usually don’t know what they don’t know, and that couldn’t be more true when it comes to the latest contact lens technology. Use the examination to recommend and discuss new trends in eyecare and contact lenses, especially with patients that are having issues with their current lenses.
You’ll be surprised how many people didn’t know how good it could feel to treat the dryness or change into a newer lens. Without looking more closely at the ocular surface and asking more targeted questions, you don’t know what you don’t know about the patient as well. Don’t let unnecessary contact lens dropout negatively impact your patients or your practice. Be sure to educate and update your contact lens patients each time you meet with them.