If you wish to comment on this column or are interested in subscribing to In Contact? Email your details to info@nzoptics.co.nz
The way I see it contact lens patients, practitioners and the industry are in for some nasty shocks over the coming years; never in my three decades of CL practise have I seen such evidence of bad attitudes and poor compliance. On some days I see almost 100% non-compliance among wearers. This is evident among my own patients as well as those from all manner and modes of practice.
One may ask why?
There are, of course, a number of factors. Firstly compliance has always been an issue. Practically all research shows that it’s a fact that most patients are non-compliant some of the time. This applies not only to CL wearers. Those who take medication for a variety of serious (and not so serious conditions) are also non-compliant around 50-75% of the time. We see this with glaucoma drops too. I reckon that compliance was better a few years ago than it is now. (When people had greater respect for the professions?)
The main reason I suspect we are seeing worsening levels of compliance – despite it having ever more attention in the literature and clinical meetings – is that in general ‘contacts’ have been dumbed down. This is partly as a result of the internet supply of contact lenses. Some research shows increased risk of MK in patients who purchase lenses off the Net. Some suggest that this is because people who shop online are ‘early adopters’ of technology and that this personality type may be greater risk takers. There’s also evidence that those who buy lenses online also have less frequent aftercare.
The Real World
In one day last week I saw a keratoconic who had not only switched lens brands – from my most recent Rx to another lens brand but had also ordered a different axis and changed solutions. It resulted in months of grief, seeing another practitioner (for convenience), losing out on her DHB subsidy and ending up with half a box of ‘useless’ lenses.
So much for cost savings.
She eventually returned to the fold and I sorted her out in a matter of days. Every other patient that day (and a good many on other days) had also ‘self-prescribed’. Some had decided to buy MPS ‘on special’ (and ‘conveniently’) at the mall (or online) instead of the prescribed peroxide system that had solved their previous solution intolerance and lens greasing issues. It astounds me that they make such silly decisions, as what is more convenient than a phone call or email that says ‘please courier me a value pack’ (at considerable saving) of the correct solution?
Another Px self-medicated with the ‘wrong’ eye drops with a resultant MK. He left it to stew over the Xmas period only to end up as a hospital admission over New Year and beyond. It was not one of my own patients but one with a previous history of infection, loss of vision and an EW bandage lens for a bullous keratopathy. We tell our patients that if something goes wrong they must be seen immediately by us, an ophthalmologist, local eye hospital or A&E. It was the worst case I’ve ever seen with a teaspoon of gooey, yellow mucous covering the eye and lids and a massive corneal ulcer.
Why wait six days before seeking help?
I’ve also been referred a few extended wear patients who have their lenses inserted and changed monthly, for no other reason than they never learnt (or were never properly taught) to do it themselves. My view is that if you want contact lenses the first step is to be able to insert and remove them. I told my wife that and she’s been a star with CLs but I refused to fit her unless she could do it herself. I’ve also recently seen some sensitive young ladies who cried or almost fainted on the first attempts but they have succeeded. Another needed around eight, one-hour instruction sessions but she too got it right. Her Mom had made her paranoid about touching her eyes (and of mice) around fifty years prior. She is still petrified of mice but can handle CLs…
Practice makes perfect.
I can only think of one patient we never got right – a young male who was so unmotivated he gave it a try for twenty minutes then flagged it and still happily wears glasses.
Basically it takes time and commitment, something that a twenty or thirty minute ‘eye test’ - including free CL ‘fitting’ - does not allow for. I’ve seen a few such patients for problem solving, ‘fitted’ both here and abroad. The ‘trial’ involved insertion of a pair of lenses and they were handed a booklet on insertion and removal. Job done!
My patients may not leave the practice with lenses until they demonstrate successful insertion and removal. I also don’t issue a CL Rx until they have completed the fitting and aftercare process.
Basic CL fitting is easy; what’s key to success is proper management and ongoing aftercare.
Many patients are just plain non-compliant and that includes medical practitioners and lawyers, who should know better. Lenses are stored dry or in tap water. Some are never cleaned or spat on when ‘necessary’.
The fact that all patients don’t develop CLARE or MK is testament to the eye’s amazing defence systems.
Some seem to want to prove how clever they are or how they are not letting you rip them off with ‘expensive’ solutions. Most don’t even know the name of the solutions they use. Of course they know the name of their ‘salon only’ $50 hair shampoo! Generally RGP lens wearers are more compliant. Even when they are not, MK is very rare. RGP lens wearers have the safest profile of CL wear and ‘near zero’ incidence of MK. If they do break the rules the whole ‘system’ is seemingly more forgiving.
Dumbo & Mumbo Jumbo
I believe that the trivialisation of contact lenses as a commodity by optical chains and the Internet are the two major reasons for the dumbing down of contact lenses the world over. Of course it doesn’t help that certain idiots dumbed down the supply of lenses in NZ to a consumer level following the farcically ridiculous 1996 Select Committee hearings. That resulted in the current situation whereby anyone can supply CLs in a ‘state ready for use’ and in practical terms without an Rx; only optometrists and ophthalmologists can prescribe CLs but in practical terms they can be sold without an Rx. Prescription expiry dates are apparently also not enforceable in NZ. Additionally CLs in NZ are not registered as ‘medical devices’, as they are in most civilised parts of the world. Hence why Internet sites do so well in NZ and why few, if ever, seek Rx verification as they supposedly must do in other first world countries.
What a crock!
Store Keepers?
Some CL suppliers, manufacturers and elements in the industry are not supporting the levels of professionalism required to enhance safe contact lens wear. For example I and a few other specialist practitioners recently participated in an hour-long discussion with a certain major CL supplier. The discussion centred on how we could drive more business into our ‘stores’ and how the ‘store’ would benefit from this, that and the next thing.
Store this store that, ad nauseam.
We were quick to point out that some of us take pride in our profession and practise optometry in a practice, not a store.
My point is; if we want to take contact lenses seriously and want our patients to as well – and derive clear, consistent vision and safe, comfortable lens wear – we need to ensure certain standards of professional practice.
A store is associated with retail sales of consumer products while professional practice is more conducive to emphasising the medical nature of safe contact lens wear.
One Day
One-day lenses allow us the safety benefits that a growing base of evidence is proving correct. A recent Global Contact Lens Care Summit in Seattle, that I was honoured to be part of dealt with – among other things – such matters as safety and compliance. The results will be published in the first quarter of 2012 in a respected journal and I will share this with you as and when I am able to.
The relative ease of fitting and management of single use disposables allows us more time to discuss and stress to patients the importance of hygiene, safe lens wear, preventing greasy lens deposits, correct cosmetics, application procedures and so on.
We must also implement systems to make lens supply convenient and competitive, so as to retain control of supply and aftercare.
The next hurdle is ‘touch free’ contact lens insertion methods so as to eliminate, as far as possible, the transfer of pathogens from fingers and so on. I am currently working on such concepts and believe that we could have such breakthrough solutions on the market in a few years.
That would certainly be a game changer.
2012
I’d like to wish all readers a great 2012. Despite the weather’s best attempts to thwart my efforts, I managed to eat my first ripe tomatoes early in December and have since been harvesting dozens a day. Unfortunately the damp and resultant mouldy blight are now trashing one or two of my spray-free organic plants.
Of course no one wants or needs to talk weather, so enough for now.
It’s a crazy world.