Article Date: 11/1/2011

Bridging the Compliance Gap

Bridging the Compliance Gap

The following five steps enabled me to achieve patient compliance to the prescribed contact lens regimen.

Michael Mayers, O.D., F.A.A.O.,
Powell, Ohio *

* At the time this article was submitted, Dr. Mayers was in private practice in Mount Vernon, Ohio. In early October, he accepted a position as senior research optometrist for Vistakon Division of Johnson & Johnson Vision Care, Inc.

The news on patient compliance with contact lens regimens is discouraging. Research has identified a significant number of patients who wear their contact lenses past their recommended replacement schedules, yet the problem of compliance with contact lens regimens runs deeper than the practice of stretching schedules.1-3

“There is likely a cost in comfort and quality of vision from this practice,” says Robin Chalmers, O.D., F.A.A.O., a co-author of one of the compliance studies and a clinical trial consultant with Alcon Research, Ltd, Bausch & Lomb, CIBA Vision, Johnson & Johnson Vision Care and Inspire Pharmaceuticals. “But what is far more concerning to me is that other practices, such as exposing contact lenses to tap water, which increase the risk of microbial keratitis, are so common.”

More than half the respondents to one of the surveys in Dr. Chalmers' study said they rinse their case with tap water or don't clean it at all.3 In fact, patients have reported non-compliance with a host of issues that involve lens replacement, lens cleaning, hygiene and case cleaning and replacement.

In light of all the issues that impact safe and healthy contact lens wear, what can we, as doctors, do to increase patient compliance? (See “The Cost of Noncompliance,” below.)

In my practice, the following steps have enabled me to increase patient compliance to the prescribed contact lens regimen.

1 I stopped making assumptions.

I no longer assume that established wearers are practicing healthy contact lens wear. I came to this conclusion when I recently began personally advising patients not to swim when wearing their lenses. (I decided to do this after I read a journal article that revealed several contact lens-wearing patients were swimming in their lenses, and it was the start of summer.) Several of my established wearers reacted in disbelief to this advice. As a result, I now explain to all patients, regardless of contact lens-wearing history, that 96% of lenses worn during swimming are contaminated with bacteria, and that while this bacteria is usually harmless to one's skin, it can be dangerous when trapped under a contact lens.

I further explain that while goggles reduce the number of bacterial colonies on the lenses, they do not entirely keep out water-borne bacteria.4,5 The fact that I get a surprised reaction nearly every time I bring up this subject reminds me that quarterly or annual newsletters about healthy contact lens wear, perhaps citing the latest research, are a great resource to keep long-term wearers up to date on best practices.

A recent study proves my point: Specifically, although 85% of patients in the study perceived themselves as compliant with their lens wear and care practices, essentially all of them practiced behavioral non-compliance with a resulting increased risk for significant complications.6 The purpose of the study: to compare the effects of existing patient awareness of lens-related complications and underlying risk factors on actual patient behavior during contact lens wear and care practices.

2 I say: “Correct care plays a major role in good vision.”

I've found that both educating and reminding patients that the correct care of their lenses helps maintain their quality of vision has enabled me to increase patient adherence to the prescribed contact lens regimen.

A recent survey indicates this step works as well. Specifically, the survey showed that vision was the most important consideration for patients when choosing eyecare products.7

In addition, comfort (or lack thereof) is also a major factor in satisfaction with contact lenses. So, reminding patients that compliance helps maintain the quality of vision and the comfortable wear they want is a positive reinforcement approach.

3 I provide a compliance guide.

I've discovered that handing my contact lens patients a full-page tear-off sheet from the Association of Optometric Contact Lens Educators (AOCLE) called Healthy Soft Contact Lens Habits has also helped increased patient compliance to the prescribed contact lens regimen. The Guide, which can be downloaded at, provides 13 healthy contact lens habits, with accompanying images. Examples of the habits: hand-washing prior to handling lenses, rubbing the lenses and cleaning and regularly replacing one's contact lens case.

The Guide is completely generic, but it includes areas where you can write the prescribed care solution and check a box for the prescribed replacement schedule (daily, two weeks or monthly). It also includes all the references that back up the clinical evidence behind the specific 13 habits. This way, the patient knows there is indeed science behind these healthy habits.

In regard to the creation of the Guide, Etty Bitton, BSc, O.D., MSc, F.A.A.O., former chair of the AOCLE, who's a consultant for Alcon, CIBA Vision and Johnson & Johnson Vision Care and has received speaking honoraria from Abbott Medical Optics, says, “With such a high percentage of patients engaging in poor contact lens habits, I think we, as clinicians, have to acknowledge that we aren't delivering the message as well as we could.”

4 I use the Efron Grading Scale Card.

When it comes to convincing patients of the importance of compliance to a prescribed contact lens regimen, I've found that seeing is indeed, believing. And, I'm fairly certain that believing has also led to an increase in such compliance at my practice.

Personally, I've accomplished this by showing patients the Efron Grading Scale card. Specifically, the card shows images of a normal eye (Grade 0) and eyes with trace (Grade 1), mild (Grade 2), moderate (Grade 3) and severe (Grade 4) contact lens-related complications. The card is available to practitioners from several contact lens-related organizations. (For a free copy, you can e-mail

I'm not the only practitioner who's achieved patient compliance success with this card. Fellow optometrist Deanna Pe$nTa Garcia, who practices in Houston, Texas, told me that if she sees any signs of papillary conjunctivitis or epithelial erosion during an exam on a contact lens wearer, she uses the scale to show the patient exactly what his eye looks like, and then explains that he can get his eye back to Grade 0 if he complies with the prescribed contact lens regimen. She adds that she's also been able to reinforce good compliance by verbally congratulating patients when they achieve a Grade 0.

5 I discuss helpful technology

Another way I've been able to increase patient compliance to the prescribed contact lens regimen is by educating patients about the current technology available to help them accomplish this. This way, they can acquire this technology.

To start, I tell patients that if they use an electronic calendar via phone or e-mail, they can employ the calendar's task reminder feature to help them achieve compliance to the prescribed contact lens regimen.

In addition, I educate patients that smart phone application stores now offer versions of contact lens reminder services for either a nominal charge or for free. (Keep in mind that more than 500 million consumers will soon to be using their mobile phones for health-care applications.8)

Further, I tell them that a free online service ( and a device ( are available to help them achieve compliance regardless of their lens brand.

Final thoughts

Although it can seem as if we're fighting a losing battle in instilling patient compliance to the prescribed contact lens regimen, I've found that taking the time to employ the aforementioned five tips can indeed increase patient compliance, which in turn, improves and maintains ocular health, leading to patient satisfaction, and, therefore, fewer contact lens dropouts. OM

The Cost of Noncompliance
Beyond the obvious patient benefits of compliance to the prescribed contact lens regimen, teaching your patients to follow established guidelines for healthy contact lens wear is also a good business strategy. Keep in mind that:
When patients stretch out their wear schedule, this translates into far fewer lenses purchased and, even more importantly, fewer scheduled office visits.
A noncompliant patient is at great risk of dropping out of contact lenses due to associated vision problems and discomfort. (In fact, discomfort and dryness symptoms are the leading reason for contact lens dropout.9) Calculate the revenue of just one contact lens patient through one year. Can you really afford to lose one or more of these patients to the discomfort, deposits and fluctuating vision that's associated with non-compliant behavior? And, for arguments sake, if you can, do you really want to?
Emphasizing ocular health builds patient confidence in our role as the medical eyecare provider. When patients perceive contact lenses as true medical devices and their optometrist as a full-scope provider, they are more likely to come to us for other eyecare issues, such as ocular disease. Providing additional services equals acquiring additional fees.

1. Dumbleton K, Richter D, Woods CA, et al. Relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Optom Vis Sci 2010, E-Abstract.
2. Yeung KK, Forister JFY, Forister EF, et al. Compliance with soft contact lens replacement schedules and associated contact lens-related ocular complications: the UCLA Contact Lens Study. Optometry 2010;81:598-607.
3. Hickson-Curran S, Chalmers RL, Riley C. Patient attitudes and behavior regarding hygiene and replacement of soft contact lenses and storage cases. Cont Lens Anterior Eye 2011, epub ahead of print.
4. Choo J, Vuu K, Bergenske P, et al. Bacterial populations on silicone hydrogel and hydrogel contact lenses after swimming in a chlorinated pool. Optom Vis Sci 2005; 82(2):134-7.
5. Wu YT, Tran J, Truong M, et al. Do swimming goggles limit microbial contamination of contact lenses? Optom Vis Sci 2011 Apr;88(4):456-60.
6. Robertson DM, Cavanaugh HD. Non-compliance with contact lens wear and care practices. A comparative analysis. Optom Vis Sci. 2011 Sep 22.
7. B+L 2011 Archive. Global Study Reveals Patients' Vision Care Priorities: Vision is the Most Compelling Feature When Choosing Eye-Related Products. (Accessed Sept 5, 2011.)
8. Research2guidance: the mobile research specialists. 500m people will be using healthcare mobile applications in 2015. (Accessed Sept 5, 2011.)
9. Richdale K, Sinnott LT, Skahdahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea Feb; 26(2):168-74.

Dr. Mayers is senior research optometrist for Vistakon Division of Johnson & Johnson Vision Care, Inc. E-mail him at MMayers@ITS.JNJ. com., or send comments to

Optometric Management, Issue: November 2011