Monthly contact lens wearers can thrive, not just survive

Contact lens practitioners have a range of soft contact lens replacement modalities available—from daily disposable to reusable lenses with a two-week or monthly replacement schedule. Personality, lifestyle factors, and ocular health should all be taken into account when deciding which lens and which lens modality to prescribe.

The monthly wearer

Most practices prescribe monthly replacement lenses to one degree or another. But is there really such a thing as a â€Å“monthlyâ€Â personality?

Contact lens wearers with a strong preference for monthly replacement tend to be people who want to wear contact lenses every day as their primary source of vision correction, according to market research from Johnson & Johnson Vision Care Companies. They are busy living life and not particularly engaged in the contact lens experience. These patients want reliable and hassle-free contact lens wear and seek simplicity in their health care and product choices. They are value-conscious and seek to maximize their use of each pair of contact lenses.¹

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From the prescriber point of view, we want to make sure these patients have no significant ocular health concerns before recommending monthly replacement. We also need to be sure that patients have not experienced problems with contact lens comfort or visual performance in the past.

But once that decision has been made, how do we know monthly replacement was the right choice? Are these patients really extracting the value they crave out of their lens-wearing experience?

We think the answer is no, probably not.

To determine whether a contact lens patient̢۪s wear experience is relatively trouble-free, practitioners ideally want to know how the patient̢۪s lenses are performing throughout the replacement interval. With monthly wearers, this can be quite challenging because replacement frequency does not coincide with typical exam frequency.

Next: Office visit timing

Office visit timing

In the typical scenario, the patient comes in for a contact lens exam and fitting, and diagnostic lenses are dispensed at that time. Most doctors see the patient again five to 10 days later for a contact lens check. If everything is satisfactory, the patient orders a supply of the lenses (or walks out with the prescription). There may be no other scheduled appointments until the next annual visit, especially for an experienced wearer.

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At the time of that initial contact lens check, a daily disposable lens wearer has replaced his lenses multiple times, and a two-week wearer is at least halfway through and perhaps nearing the end of the replacement cycle. But the monthly lens wearer is still very early in the replacement cycle. Problems with lens comfort and satisfaction, when they occur, tend to become much more noticeable after the second week.

â€Å“A few years ago, I decided to have my monthly lens patients come in for their follow-up visits at one month so that I could get a better sense of their experience over the full replacement cycle,â€Â said Robert A. Davis, OD, FAAO, in Pembroke Pines, FL.

Although he had suspected that some of his monthly lens patients weren̢۪t fully satisfied, they weren̢۪t actively complaining at annual visits.

â€Å“When I started consistently seeing patients at the one-month mark, it was immediately apparent that they were feeling more dryness at that point than earlier in the replacement cycle,â€Â Dr. Davis said. â€Å“That’s one of the things that convinced me to shift to a much greater emphasis on shorter replacement cycles, including single-use lenses.â€Â

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Two surveys of current monthly contact lens wearers conducted by independent market research firms for Johnson & Johnson Vision Care Companies suggest that what Dr. Davis was seeing is not unusual. In the first survey by Leger (Canada) of 758 wearers from the U.S., UK, and Germany, nearly three-quarters of monthly wearers (73 percent) reported experiencing comfort-related problems (discomfort, lens awareness, feelings of dryness or irritation) during the month.¹

The share of those saying they were very/extremely comfortable dropped by almost 20 percentage points between Week One (68 percent) and Week Four (49 percent), according to a second study. In this study, 237 participants responded to a daily digital survey (Kadence, Boston) over the course of a month of wear of a new pair of their habitual lenses (Figure 1).¹ Blurry vision also become more prevalent as the month went on. As a result, as patients approached the end of the replacement cycle, half of the monthly lens wearers were no longer satisfied with their contact lenses.

Figure 1

Next: Compensating mechanisms

Compensating mechanisms

The return visit schedule typically isn’t set up to capture the full monthly experience. Patients who experience problems after the initial contact lens check would have to proactively contact their doctors to set up a separate follow-up appointment if they wanted to raise concerns about the experience. Most won’t take that step. Instead, they try to â€Å“power throughâ€Â using compensating mechanisms (see â€Å“8 ways patients compensate for contact lens discomfortâ€Â box).

â€Å“What I found is that patients were using drops more frequently and taking their lenses out right after work,â€Â said Dr. Davis. â€Å“By the end of the month, they couldn’t wear the lenses as long as they wanted—but they seemed to think that was normal.â€Â

According to the Leger study, 84 percent of those who experience comfort-related concerns compensate with lens removal, rinsing, cleaning, breaks from lens wear, or rewetting drops at some point during the month.

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Some of these behaviors, especially when relied upon sparingly, are harmless. But directly touching a lens or extra handling of lenses during the day may introduce bacteria or negatively affect the lens surface. One study showed that symptomatic patients actually get little relief from compensating behaviors.²

This is troubling. If patients are removing lenses earlier in the day than desired, replacing them more often than intended due to discomfort, or taking breaks during the day, it’s not hard to imagine that the â€Å“breaksâ€Â may become longer, the wear duration shorter, and patients may eventually shift to part-time wear or drop out altogether.

Suffering in silence

But if the contact lens experience is so uncomfortable for patients, why aren̢۪t these monthly contact lens wearers complaining?

More than 80 percent of the monthly wearers who experienced comfort-related problems said that discomfort made them feel annoyed, inconvenienced, or frustrated.¹ However, the majority of these monthly wearers (73 percent) said they don’t plan to tell their eyecare providers about their comfort problems at their next visit (Figure 2).¹

Figure 2

Why would that be? Some don’t mention it because they are afraid their doctors will recommend they stop wearing contact lenses, but 61 percent of these patients in the Leger study view declining performance over the month as normal and expected—as Dr. Davis said he found. By the time the next annual checkup rolls around, expectations for lens wear have been firmly established and compensating behaviors to deal with fluctuating performance have become so routine they may go unmentioned.

Some patients can keep this up for years, but we should consider them at increased risk of contact lens dropout. Practitioners often don’t even know when dropout happens because that patient—who, one will recall, wasn’t particularly engaged in her vision correction and just wanted something hassle-free in the first place—just stops coming back for annual exams.

8 ways patients compensate for contact lens discomfort
To get through the day or through the replacement cycle, patients may engage in one or more compensating behaviors:
̢ۢ Remove lenses earlier in the day than desired
• Give eyes a â€Å“breakâ€Â from lenses during the day
̢ۢ Remove and immediately replace with same lenses
̢ۢ Remove and replace with a new lens
̢ۢ Remove lenses temporarily to rinse or clean, then re-insert
̢ۢ Move lens in the eye by touching directly with fingers (scleral swish)
̢ۢ Use rewetting drops
̢ۢ Rub eyes due to discomfort

Next: Improving the lens-wearing experience

Improving the lens-wearing experience

We owe patients a better contact lens-wearing experience.

Short of scheduling repeat follow-up visits, there are ways to dig more deeply into the wearing experience during annual exams. Probing questions can help the practitioner better understand whether patients are comfortable and satisfied for the entire month. Are they getting the full 30 days of wear out of their contact lenses so that they feel like they got a good value? Or are they â€Å“making doâ€Â and becoming grumpy about it, as the survey data suggests?

Good questions to get to the bottom of this may include:

̢ۢ Are there times during the month when you need to take a break from your lenses?

̢ۢ How often do you need to use rewetting drops?

̢ۢ At what time of the day do you start noticing your lenses and want to take them out? Does that happen earlier in the day toward the end of your replacement cycle?

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Then, if the patient does seem to be struggling, it may be time to reset expectations. Patients need to hear from their doctors that it is possible to enjoy more consistent contact lens performance—it isn’t normal to be uncomfortable or to have to temporarily remove their lenses every day. Red eyes and frequent eye rubbing or drops don’t have to be the price of admission to the contact lens wear.

For these struggling patients, a shorter replacement schedule may be more appropriate.

A daily disposable lens is the ideal choice for patients who are struggling with lens performance. A fresh lens every day is the most convenient and eliminates problems with solution compatibility as well. But it might be too much of a jump for the patient who really wants to be a monthly lens wearer.

Those patients may simply be demanding a great deal of their lenses. Declines in lens performance have been associated with high levels of digital device use or having to perform in challenging environments. Patients with these types of high demands may do better with a shorter, two-week replacement period.

One study that looked at 112 â€Å“problem patientsâ€ÂÃ¢€”those who were struggling with frequent or constant discomfort or dryness (at least two hours per day of uncomfortable wear, or certain slit-lamp findings)—found that being refit in Acuvue Oasys (senofilcon A, Johnson & Johnson Vision Care) made a big difference.³ Some 88 percent percent of the struggling patients experienced a statistically significant improvement in comfort (p<0.0001), and 76 percent had more hours of comfortable wear (p=0.004).

Although that study was conducted a decade ago, Acuvue Oasys has not been outperformed in comfort by any monthly lens, according to trials reported in the clinical trials database (www.clinicaltrials.gov).⁴

Strategies for success with patients who have a â€Å“monthly personalityâ€Â but need to move to a shorter replacement schedule include emphasizing that getting the best value from their lenses means enjoying worry-free lens wear every day, not just the first week or two of the replacement cycle. Suggesting an annual supply is also an effective way to encourage compliance. Studies have shown that when patients have more lenses on hand, they are less likely to stretch out the replacement cycle and more likely to replace the lenses on time.⁵

There are patients who prefer a monthly replacement schedule and who may be able to tolerate it well. However, it can be challenging to identify those patients without a one-month contact lens check. Many of them are choosing to suffer in silence or resorting to compensating behaviors instead of telling their doctors about the negative aspects of their contact lens wear experience. Think about what you are doing now to prevent these problems before your patients begins the slow spiral to contact lens dropout.

Your patients and your practice deserve a lens that can sustain excellent performance all month long, including Weeks Three and Four. We need to give our patients the opportunity and permission to tell us that their comfort is not acceptable at the end of the replacement cycle, or that they are requiring help to make it through the full month. Be sure to evaluate new monthly contact lens offerings about comfort and performance at Weeks Three and Four…because a month is not just the first two weeks.

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References

1. Canavan KL. Innovation through EYE-INSPIRED. Data presented at: American Optometric Association annual meeting; 2016 July 2; Boston.

2. Navascues-Cornago M, Morgan PB, Maldonado-Codina C. Effect of three interventions on contact lens comfort in symptomatic wearers: A randomized clinical trial. PLoS One. 2015 Aug 12;10(8): e0135323.

3. Riley C, Young G, Chalmers R. Prevalence of ocular surface symptoms, signs, and uncomfortable hours of wear in contact lens wearers: The effect of refitting with daily-wear silicone hydrogel lenses (senofilcon A). Eye Contact Lens. 2006 Dec;32(6):281-6.

4. www.clinicaltrials.gov. The 14 clinical studies evaluated subjective comfort as a primary or secondary endpoint for Acuvue Oasys with Hydraclear Plus Technology. Review conducted 4/16/16.

5. Schnider C, Jedraszczak AM. The â€Å“pantry loadâ€Â effect: Can it help drive happier patients and healthier practices? Paper presented at: American Academy of Optometry annual meeting; 2012 October 24-27; Phoenix.