Download AOA Cornea and Contact Lens Section, Research Paper

AOA Contact Lens and Cornea Section, Research Paper
“Care and Compliance in Contact Lens Success”
Support from Advanced Medical Optics
By: Gloria Chiu, O.D.
Resident, Cornea and Contact Lenses
Southern California College of Optometry
Even with a perfect contact lens fit by a highly experienced optometrist, patients must
practice proper care and compliance in order to have contact lens success. While ample
time is often dedicated to helping patients achieve a good fit and acceptable vision,
practitioners do not always spend sufficient time reviewing lens care and compliance. I
have encountered many experienced lens wearers who abuse their contact lenses and
have suffered the uncomfortable consequences of bacterial infections and painful corneal
ulcers. As a soft lens wearer myself and a current cornea and contact lens resident, I
strive to deliver optimal lens fits and appropriate education on contact lens wear, care,
and compliance.
The first step towards contact lens success is to ensure that your patient is a good contact
lens candidate. This can be determined during the annual comprehensive examination,
where the patient’s refraction, ocular health, and goals for wearing contact lenses are
evaluated. If the patient is a good candidate, then the contact lens fitting and evaluation
may proceed. Once the fit has been finalized, the practitioner must instruct the patient on
proper lens care and compliance. In this paper, I will review several topics essential to
care and compliance in contact lens success.
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The topics include:

Lens replacement and wearing schedules

Lens handling and hand washing

Lens cleaning

Ocular lubricants

Multipurpose solutions

Consequences of poor compliance
Lens replacement and wearing schedules
The daily average lens wear time for patients may range from 2 hours to 24 hours. While
some patients may prefer to wear lenses only during particular activities, such as sports or
social events on the weekends, most prefer to wear lenses full time. Lenses are FDA
approved for daily wear, flexible wear, or extended wear, and it is ultimately the
responsibility of the eye care practitioner to determine which wearing schedule is best for
the individual patient. Daily wear is generally preferred to minimize lens complications,
as patients must clean and disinfect their lenses regularly or dispose of them after one
use. Corneal ulcers have even been found to be 4 to 15 times more likely in patients
using the extended wear modality versus daily wear [1]. Daily wear lenses are generally
disposed after 1-day, 2-weeks, 1-month, or even annually. Studies have shown that
compliance with soft lens daily and monthly replacement schedules is often better than
the 2-week schedule [2]. However, technological developments such as the Acuminder
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(Johnson and Johnson) provides computer desktop, email, and cellular telephone text
reminders to enhance replacement schedule compliance [3].
With recent advances in lens designs and improved materials, flexible and extended wear
modalities have become more acceptable. The Silsoft (Bausch & Lomb, Rochester, NY)
silicone lens has been shown to be effective and safe for pediatric aphakes when
prescribed for a 1-week extended wear modality [4]. Silicone hydrogel lenses, such as
PureVision (Bausch & Lomb, Rochester, NY) and Air Optix Night & Day (CIBA Vision,
Duluth, GA), have also been prescribed for extended wear up to 30-days [5]. While not
all practitioners recommend this wearing schedule, some feel that with careful
monitoring, these lenses can be worn successfully [6]. The use of rigid gas permeable
(GP) lenses with the Menicon Z (tisilfocon A, Menicon America, Inc., San Mateo, CA)
material has also been shown to be safe in extended wear up to 30-days and comparable
in safety to 7-day (6-night) wear in soft hydrogel lenses [7]. While the increase in
oxygen permeability with silicone hydrogel and gas permeable lenses has led to a rise in
flexible and extended wear, research shows that hypoxia is only one of several factors
that contribute to contact lens complications [8]. Therefore, practitioners must discuss
and prescribe replacement and wearing schedules with all patients.
Lens handling and hand washing
To health care professionals, it may seem like common sense to wash your hands before
the application, removal, and handling of contact lenses. However, some patients often
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value convenience over sanitation. The Center for Disease Control and Prevention
(CDC) recommends that hand washing should be performed with soap and warm water,
with continued hand rubbing for 20 seconds. Then, hands should be rinsed well under
running water and finally dried with a paper towel [9]. Proper hand washing should be
stressed to all patients during contact lens training and follow-up care.
Because contact lenses are directly applied onto the eye with fingers, hand washing is
essential. Bacteria on a patient’s finger will translate into bacteria on the eye, which may
lead to undesirable and costly infections. Drying one’s fingers before handing the lens is
also important to avoid germs that may be found in tap water. A recent outbreak of
Fusarium keratitis in contact lens wearers has forced eye care practitioners to be even
more vigilant regarding contact lens care and compliance. During this outbreak in the
Northeastern United States, investigators found that many of the affected contact lens
wearers had been using Bausch and Lomb’s ReNu with MoistureLoc Multipurpose
Solution. However, they also found that many of these patients were using tap water to
rinse their contact lens cases [10]. Therefore, practitioners must be careful to warn of the
potential contaminants in tap water. Instead of rinsing cases with tap water, patients
should conduct the final rinse with a recommended saline or multi-purpose solution. The
case should also be left to air dry open in a clean environment when not in use. Drying
hands completely to remove tap water residue is equally important to minimize the risk of
infection. It is also valuable to advise using lint-free towels when drying hands, as lint
pieces under a contact lens can be extremely uncomfortable.
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Lens cleaning
In hopes of making contact lens care and cleaning more “user-friendly” and “hasslefree,” many companies developed their version of the “No-Rub” multi-purpose contact
lens solution. Over the last few years, many contact lens wearers have embraced this
philosophy and eliminated the “rubbing” step in their contact lens care. Along with this
new trend came unexpected outbreaks of contact lens-related keratitis.
Prior to the development of “No-Rub” solutions, patients were instructed to clean their
contact lenses each time upon removal. Cleaning would consist of a thorough rubbing
and rinsing before overnight storage. Although many of the “No-Rub” solutions indicate
that lenses must be rinsed for 5 or more seconds on each side of the lens before overnight
storage, many lens wearers overlook this important step.
The debate remains as to whether contact lens care should include a rubbing step for
effective cleaning. However, studies seem to indicate that the digital rubbing process is
essential to remove loosely bound deposits [11], which cannot be adequately removed by
a longer rinse. Although some manufacturers still promote their “No-Rub” formulation
and process, other companies have changed their recommended care instructions. Abbott
Medical Optics (AMO Abbott, Santa Ana, CA) recently changed the name for their
Complete Multi-Purpose Solution from the “No-Rub” Formula to an “Easy Rub”
Formula [12]. The instructions for the AMO solution now include a 10-second rub on
each side of the lens, followed by a 5-second rinse on each side of the lens with the
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solution before overnight storage. Clearly, eye care product manufacturers are learning
about the importance of proper contact lens cleaning and taking steps to ensure safe
contact lens wear. Practitioners must also stress proper cleaning and lens care techniques
before dispensing lenses to new and experienced wearers. A weekly enzymatic cleaner
may even be prescribed to patients who tend to build up more deposits in the tear film
and on the lens surface.
Ocular lubricants
Contact lens wear is often associated with dry eye. It has been shown that contact lens
wear interferes with the normal ocular tear film and contributes to a higher rate of tear
film evaporation [13], leading to symptomatic dry eyes. To improve comfort during lens
wear, practitioners often recommend the use of artificial tears or rewetting drops. There
are many rewetting drops that have been approved for contact lens use, such as Aquify
Comfort Drops (CIBA Vision, Duluth, GA), Opti-Free Express Rewetting Drops (Alcon,
Fort Worth, TX), Complete Lubricating and Rewetting Drops (AMO Abbott, Santa Ana,
CA), Blink Contacts (AMO Abbott, Santa Ana, CA), ReNu Rewetting Drops (Bausch &
Lomb, Rochester, NY), and Boston Rewetting Drops (Bausch & Lomb, Rochester, NY).
There are even rewetting drops that have the unique ability to prevent protein build up
during lens wear; these are Clerz Plus (Alcon, Fort Worth, TX) and Complete Blink-NClean (AMO Abbott, Santa Ana, CA).
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Eye care practitioners should always prescribe a rewetting drop to be used concurrently
with contact lens wear if dryness becomes an issue or even to prevent ocular dryness. A
specific recommendation is also important so that patients do not become confused with
lubricants that are not compatible with contact lens use. While some ocular lubricants are
used in an off-label manner with contact lenses, some may be non-compatible.
Lubricants such as Refresh Endura (Allergan) and SootheXP Emollient Eye Drops
(Bausch and Lomb) contain oil, which may alter the contact lens surface and cause
blurred vision. Ocular ointments, such as Refresh P.M. (Allergan) or Lacri-Lube
(Allergan) are often prescribed for severe dry eyes and for overnight use. Is it therefore
essential to educate patients that the ointment should not be used over contact lenses, as
this would certainly interfere with normal lens wear and vision.
Rewetting drops may be recommended for use as needed throughout the day or more
often to prevent dry eye in extreme instances. During computer use and movie watching,
lid blinking has been shown to be altered, contributing to increased tear film break-up
and dry eye [14]. The low humidity conditions in airplane cabins during flights may also
exacerbate dry eye [15], especially with contact lens wear. When used appropriately,
rewetting drops can greatly enhance ocular comfort in contact lens wear.
Multipurpose solutions
Given the extensive options in multipurpose solutions for soft and gas permeable lenses,
patients are often confused about which solutions are compatible and appropriate to use
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with their lenses (See Image 1). Therefore, it is important for eye care practitioners to
prescribe contact lens solutions for their patients.
Image 1. Various contact lens solutions.
In recent years, the development of silicone hydrogel lenses has decreased hypoxic
corneal complications. However, it has also contributed to unforeseen reactions with
some multipurpose care systems. The U.S. Food and Drug Administration (FDA)
requires that new care systems be tested for compatibility with hydrogel lenses before
product marketing, but FDA guidelines have not been updated for testing with silicone
hydrogel materials [16, 17].
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Several studies have shown that certain combinations of silicone hydrogel lenses and
multipurpose solutions contribute to more corneal staining than others [17-23]. The
degree of staining also appears to vary with contact lens wear time [17, 18]. However,
there is no consensus on solution-induced corneal staining. Depending on the type of
lens material and solution tested, along with the length of wear and method of staining
assessment, results are mixed. Although seemingly inconclusive, these studies reveal that
practitioners must be aware of the multipurpose solution being used by their patients. If
corneal staining is present following contact lens wear, the practitioner should question
the patient with regards to all aspects in contact lens care and compliance, including the
multipurpose solution type. Corneal staining represents a compromise in the corneal
epithelium, and despite a direct correlation between staining and microbial keratitis,
staining should be avoided as it may contribute to decreased lens comfort and an
increased risk for corneal inflammation [24].
While patients should be consistent with the type of multipurpose solution being used,
they must also be aware of how to use the solution properly. Hydrogen peroxide cleaning
systems, such as Clear Care (CIBA Vision, Duluth, GA), include a bottle with 3%
hydrogen peroxide and a disposable lens case with a neutralizing disc. It is important that
patients soak their lenses overnight in the solution with the special case so that the disc
may completely neutralize the hydrogen peroxide. The red tip on the bottle should be a
sign to the patient that the solution cannot be placed directly on the eye. If this is not
made clear to the patient, active hydrogen peroxide may cause extreme pain and irritation
to the ocular surface.
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Once the hydrogen peroxide solution has been neutralized, patients should be aware that
the solution has become a saline, which no longer disinfects the lenses. Therefore,
practitioners should educate their patients that new solution must be used every time to
clean and disinfect the lenses. “Topping off,” or adding new solution to previously used
solution, would make the disinfecting process ineffective. And regardless of the solution
type, solution must be discarded after each use to avoid contamination of the storage
case, lenses, and the solution itself.
Patients must also be aware that different solutions exist for soft and gas permeable
contact lenses. Rigid gas permeable solutions, such as Boston (Bausch & Lomb,
Rochester, NY), contain a separate daily cleaner and conditioning solution, of which the
cleaner must be thoroughly rinsed from the lens before application on the eye. The
cleaning solution is a milky white color to contrast the clear conditioning solution, which
may be safely applied to the eye. Because the gas permeable solutions are more viscous
than multi-purpose solutions for soft lenses, they cannot be used with soft lenses. The
thicker solution would alter the soft lens surface and may cause permanent damage to the
lens. All gas permeable cleaners and solutions must be avoided in soft contact lens care.
Again, the bottle for the cleaner has a red tip to warn the patient that this solution may not
contact the ocular surface. Practitioners must ensure that their patients understand proper
usage of their contact lens solutions to avoid potential toxic keratitis and other painful
situations.
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Consequences of poor compliance
When eye care practitioners stress the importance of contact lens care and compliance,
they must make sure that their patients understand why it is important. Contact lenses are
medical devices and should be handled with care. If lens handling or wear is abused,
patients are at risk for developing various contact lens associated complications (See
Table 1).
Table 1. Contact Lens Associated Complications
MK
Microbial Keratitis
CLARE
Contact Lens-Induced Acute Red Eye
CLPU
Contact Lens-Induced Peripheral Ulcer
IK
Infiltrative Keratits
VLK
Vascularized Limbal Keratitis
AI
Asymptomatic Infiltrates
AIK
Asymptomatic Infiltrative Keratitis
Microbial keratitis is a serious, sight-threatening complication associated with contact
lens wears. A recent study showed that risk factors for contact lens-related microbial
keratitis include overnight lens wear, poor storage case hygiene, and less than 6 months
of lens wear experience [25]. Given these results, eye care practitioners must be
extremely cautious with new lens wearers and properly educate patients on lens care and
compliance.
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In order to promote contact lens success, practitioners must ensure that their patients
return for necessary follow-up visits and annual comprehensive eye examinations. The
Vision Council is a non-profit organization that works to provide better vision care for all
people, and promotes annual eye exams through their “Check Yearly, See Clearly,”
campaign. It is during these examinations that the optometrist can evaluate any changes
in vision, ocular health, and lens care hygiene. If changes in vision or ocular health are
detected, the optometrist can address these changes to improve eyesight and eye health.
These annual visits also provide eye care practitioners the opportunity to review lens care
and compliance with their patients.
In conclusion, there are many aspects that contribute to contact lens success. Lens care
and compliance are essential to successful wear, and involve proper lens replacement and
wearing schedules, lens handling and hand washing, lens cleaning, ocular lubricants,
multipurpose solutions, and understanding the potential for serious consequences from
poor compliance. Optometrists and eye care practitioners play pivotal roles in contact
lens care and compliance, which must be actively maintained to ensure contact lens
success.
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