Article Date: 4/1/2005

contact lens solutions
Be a Solution Expert

Are you satisfied with your patients' contact lens regimens? Learn how to ensure compliance by prescribing a winning solution.
BY NANCY S. BARR, O.D., F.A.A.O., Atlanta, Ga.

Are your patients compliant with the contact lens care regimen you prescribe? Perhaps, but not always.

Patient compliance is an issue with critical conditions such as hypertension, diabetes and glaucoma. Compliance is an issue with recommended lifestyle changes such as weight loss, exercise, diet, smoking cessation, substance abuse and seat belt use. Patient behavior, or misbehavior, frustrates practitioners because we know how various regimens can impact a patient's outcome, both positively and negatively.

I read with a jaded eye the doctor commentaries in our online press, some doctors maintaining that they carefully interview each patient as to their contact lens care regimen and have the patient review it with them. I know when the dental hygienist asks me to review flossing technique that I can give exactly the performance they want, but I confess to you that I fudge a bit with my actual home care.

Addressing real problems

Frankly, when I compare the possible complications of a patient switching brands of contact lens disinfectant versus noncompliance with a chronic condition such as diabetes, I feel we sometimes make mountains out of mole hills. A great majority of our contact lens patients can use any one of the multi-purpose solutions (MPS) available and experience similar lens comfort and wearing time. However, there is that group that needs firm guidelines as to what solutions to use and what to avoid. Maybe this follows the old "80-20" rule: 80% of the problems are in 20% of the patients?

These are the patients we see in our office and hear about in the national statistics as the contact lens "dropouts" who discontinue lens use because of some degree of discomfort. I have empathy with that group of challenged patients: I have a 12-year history of dry eyes myself -- ever since the birth of my first child. I also live in the official allergy capital, Atlanta. No kidding, our springtime pollen counts can be 10 times the "extremely high" level. Each spring, I write a dozen or so prescriptions each day for mast cell stabilizers.

Learning from myself

One of my eyes is plano and the other is about ­1.00 (lucky me!). I have toyed with wearing contact lenses over the past 20 years, but the boost to my vision was never worth the tradeoff in comfort. As presbyopia marched relentlessly nearer, I fervently hoped the industry would rescue me from eyeglasses by developing a lens I could tolerate eight to 10 hours each day. The industry did come through, with the development of silicone hydrogels.

The first day I wore a +.50 in my myopic eye, I was incredulous; I wore it for at least 10 hours with no discomfort. On my way out the office that evening, I grabbed whichever MPS was closest to me and used it that night. After several days, I felt the lens wasn't as comfortable as it had been initially. It was springtime though, and maybe the pollen was causing me some irritation.

I added a mast cell stabilizer to my regimen, which helped. I also switched to a different MPS, and felt there was some minor improvement in comfort of my contact lens. After a couple of weeks, I switched to a hydrogen peroxide system and felt I was back to the comfort of the first day in the lens.

So, do I now prescribe peroxide for all my soft lens patients? No. Here's my explanation.

Prescribing preferences

I base my contact lens care recommendations on the following several factors:

Safety and efficacy. I rely on the manufacturers and the FDA to get this right. If the solution passed muster through Research & Development and then clinical trials to make it to the store shelves, then I trust that it will do its job when my patients use it correctly.

Compatibility with ocular tissues. At follow up, I want to see a fairly white eye, clear cornea and nothing new under the lid. I also want to hear reports from the patient that he experiences no stinging or burning on insertion and can maintain a full-day wearing schedule. If issues do exist, then I'll recommend that the patient switch to a non-PHMB preserved solution (Opti-Free) or to a peroxide system such as Clear Care.

Patient preference. Some practitioners disregard this point, but unless I see a problem with continuing with what a patient has been using, I give him my blessing. Patients are brand-loyal for a reason -- be it financial, habit or because other family members use that brand.

Availability in local stores. If a solution I prescribe isn't readily available, then patients will switch to something that is.

Cost. Likewise, if a patient perceives a solution to cost too much, they'll switch unless they see a value (increased comfort) in staying with my recommendation. I've had some patients mention the ongoing cost of peroxide. A bottle costs about 15% more at a local discounter, and the method requires more solution as well. My most recent patient who mentioned this then said, "But it's worth it!"

Lifestyle. I also take a patient's lifestyle into account. While I'm a big fan of peroxide, I hesitate to prescribe it for children and pre-teens. If these patients inadvertently misuse peroxide, then a chemical keratitis, uncomfortable patient and unhappy parent will result. If the patient needs a quick turnaround time on his disinfection, then I'll tend to prescribe an MPS as well.

A factor I didn't list but that is of practical importance is the availability of starter kits. If I see that I don't have any kits of my favorite brand, I don't send the patient out the door empty handed. Instead, I'll substitute my second favorite, and so on.

Then and now

In my early years of practice, most of my soft lens patients wore a Group I lens (crofilcon A/CSI) and used a peroxide system (AOSept). In general they were a happy group, but the lenses were somewhat costly and the AOSept system required a patient to purchase solution, cup and disc separately. In the late 1980s, we switched most patients to disposable contact lenses with MPSs for cost effectiveness, ease of use and a healthier replacement schedule.

Today, most of my patients are going into a Group I lens (lotrafilcon or galyfilcon) and many are using peroxide for maximum comfort. They have the comfort benefits of the low water non-ionic lens material, and the effectiveness and comfort of peroxide -- both at price points lower than their counterparts of 20 years ago.

A solution is on the way

As new materials evolve, the solution manufacturers will continue to tailor their products to meet the requirements of the materials as well as the expectations of doctors and patients. The technological advances in both material design and manufacturing techniques that allow us to prescribe these products for our patients today will go a long way toward addressing our contact lens dropout situation.

Dr. Barr is a graduate of the Ohio State University College of Optometry and is a past president of the Georgia Optometric Association. She's currently in private practice.


Optometric Management, Issue: April 2005