Article Date: 9/1/2006

UPGRADING TO SILICONE HYDROGELS
Upgrading Patients To Silicone Hydrogels

Concerns for ocular health and comfort are leading these contact lens professionals to reevaluate their hydrogel wearers. See why you should, too.

Dr. Quinn: I'm interested to hear about your experiences with silicone hydrogel materials. Do you keep your current hydrogel wearers in these lenses, or do you transition them into the newer materials?

Dr. Hom

Dr. Hom: I feel very strongly that silicone hydrogels are the wave of the future and a great first choice for contact lenses. I'm refitting about half of my hydrogel-wearing patients with silicone hydrogels.

Dr. Miller: I'm transitioning as many hydrogel patients as possible to silicone hydrogels because of the health benefits. While my patients are cost-sensitive, they also appreciate value. When I explain the health and comfort advantages of newer silicone hydrogel materials, much of their opposition to the higher cost goes away.

Dr. Lapple: I'm not refitting patients as frequently as I was when silicone hydrogels were first introduced — partly because of the cost but also because some of my patients didn't like the lenses very much. Today, with the second-generation materials, I'm switching about 30% of my asymptomatic hydrogel patients to silicone hydrogels because I feel it's the right thing to do. I'm finding that patients like these newer materials better, as well.

Laurie L. Sorrenson, OD: I mention silicone hydrogels to every one of my contact lens patients. About 90% of my hydrogel wearers receive a trial pair of silicone hydrogels when they come in for an examination, and 70% to 90% continue with them. 

Patients have seen these lenses advertised on TV, and if I don't offer them the latest and greatest, they'll think I'm not up-to-date on new treatments and technologies.

Dr. Kaminski: We need to tell patients about the newest and best contact lenses available, so I'm very proactive. In my practice, we've probably switched 75% to 85% of current hydrogel wearers to silicone hydrogels.

When I have frank discussions with my patients, I often find out they're not compliant, and many aren't very happy in their current contact lenses. Silicone hydrogels have been a great problem-solving tool for these patients. Also, we want our aging patient population in a better contact lens for wetting and oxygen delivery.

ARE THERE 'MUST-SWITCH' PATIENTS?

Dr. Kaminski

Dr. Quinn: Our decision to switch a patient to silicone hydrogel contact lenses always will be based on individual assessments, but sometimes the decision is quite simple. Dr. Lapple, what's your experience?

Dr. Lapple: If a patient has a symptom or a sign of hypoxia, the decision is easy. I switch him to silicone hydrogels. I also switch my continuous-wear patients.

Lens power may be a determining factor as well. For example, I'll always switch a hyperopic patient because he needs the extra oxygen through that thick lens.

Comfort is another more subjective reason to switch to silicone hydrogels. We may be able to alleviate some ocular fatigue or redness with these lenses.

Dr. Miller: I would add teenagers to that list. I switch them to silicone hydrogels because, in my experience, they're more likely to be noncompliant. Even their parents don't know whether they're sleeping in their contact lenses or wearing them too long, so I like that extra safety net. And teenagers have many years of contact lens wear ahead of them, so the health benefits and compliance
issues are important.

Laurie L. Sorrenson, OD

Dr. Sorrenson: All my hyperopes automatically get silicone hydrogels. In fact, hyperopes are some of my most enthusiastic silicone hydrogel wearers — the higher the plus power, the more they love them.

Cosmetically, limbal hyperemia is a big issue, particularly for women. If a patient is complaining that her eyes look red and unattractive, which is a significant percentage of patients in my practice, we try silicone hydrogels.

Dr. Szczotka-Flynn: Patients whose lifestyles often put them in "extreme" situations that stress their eyes and their contact lenses — such as frequent fliers — are good candidates for silicone hydrogels. These lenses are an obvious choice for patients who want extended-wear or continuous-wear contact lenses. I also consider silicone hydrogels for anyone who has a corneal condition, such as Fuchs' dystrophy or a corneal transplant.

Dr. Kaminski: Let's not forget that some of the fastest growing age groups of contact lens wearers are people who are between 45 and 65 years old. We need to be on the lookout for signs of aging, such as striae, indicating a need for more oxygen flow to the cornea. Typically, I switch these patients to silicone hydrogels, which provide a better comfort level for both of us.

Dr. Sorrenson: If possible, every contact lens patient in my practice gets silicone hydrogels. Most have at least some limbal hyperemia, so I always try them. They're not a magic cure, but silicone hydrogels definitely help these patients.

NOT FOR EVERYONE

Dr. Szczotka-Flynn

Dr. Quinn: Let's take the opposite point of view. Even Dr. Sorrenson, who's trying silicone hydrogels on 90% of her patients, doesn't try them on everyone. Economic issues aside, which patients do you keep in hydrogel materials?

Dr. Kaminski: In my practice, only the patients whose parameters are not available in silicone hydrogels continue with their hydrogel lenses.

Dr. Lapple: I have patients doing very well in daily disposables. I'm not inclined to switch them.

Dr. Sorrenson: I agree. They're usually in daily disposables for a really good reason. Maybe they are heavy depositors or they had giant papillary conjunctivitis or allergy issues. One-day disposables are problem-solvers for me, so it would be a rare occasion when I would prescribe something else for these patients.

Dr. Lapple: If I have a potential dry eye patient who is asymptomatic in hydrogels — for example, someone who is 40 to 50 years old who wears hydrogels 15 hours a day and loves them — I don't try to switch them. Of course, these patients are rare. 

Dr. Kaminski: We also need to think about patients — particularly women — who try silicone hydrogels for comfort, and then experience lipid deposits. Sometimes, they return to the hydrogel lens material.

By the way, my partner and I seem to be seeing more lipid deposits in female patients. I don't know whether it's cosmetics or cosmetic interaction, but we've seen an anecdotal trend in our practice. Has anyone else observed this?

Dr. Szczotka-Flynn: What you're seeing may not be so much the female tear film as it is external factors like makeup and moisturizer. Silicone hydrogels deposit more lipids and less protein, and it's easy to see how something like moisturizer could contribute to a lipid-based problem.

Dr. Hom: I think of deposits as two different types: symptomatic and asymptomatic. You can almost predict which silicone hydrogel patients are going to have deposits. They're the ones with asymptomatic deposits with hydrogel contact lenses. In my experience, these same patients often show a lot of debris upon specular reflection of the prelens tear layer. It may not create symptomatic deposits on hydrogel contact lenses, but it can coat a silicone hydrogel.

ASYMPTOMATIC RESPONSE FACTOR

Dr. Quinn: Aside from a patient's symptoms or diagnosis, we need to look at issues related to physiological response that may not manifest symptomatically. How do you factor in the health benefits of silicone hydrogels for patients who have no symptoms from their hydrogel contact lenses?

Dr. Hom: We all have patients who are comfortable in hydrogels, and I believe comfort is very important. But comfort can keep us from seeing some problems. Some very comfortable patients can have ocular surface damage, corneal staining or conjunctival staining. So just
because a contact lens is comfortable, that doesn't necessarily mean it's the best contact lens for the patient.

Dr. Szczotka-Flynn: We need to consider why we should be monitoring patients for corneal staining. My colleagues and I presented a poster at the 2006 meeting of the Association for Research in Vision and Ophthalmology (ARVO) describing a study of 30-day continuous wear of silicone hydrogels.1 We found that patients with corneal staining had a significantly greater risk of developing a corneal infiltrate. Another group out of Sydney found an almost identical finding among daily contact lens wearers with solution toxicity staining.2 It doesn't really matter what's causing the staining, but two independent groups found that staining can be associated with future adverse events.

Dr. Miller: Given the possibility for noncompliance — a large percentage of patients will wear their lenses while sleeping, no matter what we tell them — I feel good knowing I'm giving them the best oxygen transmissibility available.

REFERENCES

1. Szczotka-Flynn LB, Debanne S, Cheruvu V, et al. Predictive Factors for Corneal Infiltrates With Lotrafilcon A Silicone Hydrogel Lenses Worn for up to 30 Nights Continuous Wear. Poster presented at ARVO 2006. Ft. Lauderdale, FL.

2. Jalbert I, Carnt N, Naduvilath T, Papas E. The Relationship Between Solution Toxicity, Corneal Inflammation and Ocular Comfort in Soft Contact Lens Daily Wear. Poster presented at ARVO 2006. Ft. Lauderdale, FL.



Optometric Management, Issue: September 2006