I stand corrected

Until we started asking patients about wearing schedules, I thought we didn't have a large extended-wear practice. We told our two-week replacement lens patients, "Don't sleep in your contact lenses." We assumed they left our office committed to compliance with our removal and replacement instructions.

What we found from asking our patients about their wearing habits, however, was that about 60% sleep in their lenses on a somewhat routine basis. Nine percent report routinely sleeping at least one or two nights a week in their lenses — whether they are approved for overnight wear or not — and more than 50% report occasionally sleeping in their lenses. We learn this by asking a series of questions, starting with, "Do you sleep in your lenses at all?" If they answer yes, we ask how often. "Do you nap or sleep in them overnight sometimes?" If they answer overnight, we ask how often.

Our technicians in pre-testing and the O.D. during the exam each ask these questions. We've found that when patients admit to staff that they occasionally sleep in their lenses, they are more likely to spill the complete truth to the O.D. We keep a database of our patients' responses. We categorize patients by everything from age to prescription (myopia, astigmatism, presbyopia, type of contact lens worn, etc.). We can perform surveys that help us serve our patients better, as well as improve our practice's performance.

Getting to the root of it

We also found that about 80% of our patients extend the life span of their lenses beyond the stated replacement schedule. So patients disregarded our instructions. How, then, could we impress on patients the need for compliance? We analyzed the problems and perceptions and created steps to counter those.

Problem: Eyelids. Most of the complaints we hear are about contact lens discomfort. In my experience, this discomfort is often times related to eyelid changes caused by an unclean contact lens. We invert the patient's eyelid, take a digital photo and let them compare it to a photo of a healthy eyelid with no papillary changes. We can almost see the light bulbs illuminate over their heads. They understand intuitively that when their eyelid surface is compromised, contact lenses may be uncomfortable. This one image has done more to impress the need for compliance than anything else we've done.

Perception: Cost. For some reason, patients hang onto the perception that contact lenses are expensive and that it's wasteful to dispose of them on the schedule. It's human nature. We've probably all failed to replace our tires when the manufacturer recommended. In some regard, we've brought this problem on ourselves by telling patients that new contact lenses are so much better than the early soft lenses.

But the overall cost of contact lenses on a per-day basis is remarkably low. Find a way to illustrate that point. In our community of 39,000 people (22,000 of whom are college students) we learned that 66% of all meals are eaten out. We tell patients, "You're spending $5 to $10 a day eating out; that's much more expensive than the cost of a daily disposable, monthly replacement or the breathable silicone hydrogel lenses that are approved for either six nights, or up to 30 nights of continuous wear."

Solution: Switch lenses. All of this leads up to our final presentation. We aggressively move patients into a daily disposable lens, or hyper-Dk/t silicone hydrogel lenses approved for extended wear.

For those who report only occasionally sleeping in their lenses, we recommend the only silicone hydrogel two-week replacement lens approved for up to six nights extended wear. For those who prefer or report sleeping in their contact lenses for up to 30 nights, we recommend the monthly replacement silicone hydrogel lens.

Our one-two punch

In our practice, it's simple — if patients want to sleep in their lenses overnight, we want them in the lens with the highest oxygen transmissibility level. If they want to wear contact lenses occasionally or strictly on a daily-wear basis, we encourage daily disposable lenses and use the eyelid photos as an incentive to replace lenses. When a patient tries to get a second day of wear out of a daily disposable lens, and it feels uncomfortable, the image of those bumps on their eyelids may be enough to scare them straight.

In addition to our frank discussions about the benefits of healthy contact lens wear, the second part of our two-pronged approach is to disabuse patients of the notion that contact lenses are costly. Compare it to the price of a soda from a vending machine or a cup of coffee. At the same time, move them into a contact lens that is a healthy option for their eyes.

Over the past year, this new approach has been very effective. Patients return on time, replace lenses more regularly and, with the eyelid photo, have received an entirely new education on eye health and contact lens compliance. Put another way, recommending healthy contact lenses options for our patients has been not only good for our patients, but also good for our practice. It starts with knowing how contact lens patients wear their lenses.  That requires asking them whether they are occasionally, frequently, routinely or never sleeping in their lenses.

Dr. Cockrell is in private practice. You can reach him at Dacockrell@cockrelleyecare.com.

Optometric Management, Issue: July 2005