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    The cost of contact lens and lens care noncompliance

    Take-Home Message

    Contact lens and lens care compliance depends on patients following the doctor's recommendations, yet not all of what is imparted to patients is being followed. Diligence is the watchword, in both patient education and looking for contact lens complications from noncompliance in contact lens-wearing patients.


    A lot of us have bad habits. Whether it is gambling, smoking, eating or drinking to excess, or something much worse, it seems we all have demons to fight. This is especially true for our contact lens patients. While many, if not most, of our contact lens patients follow recommended wear schedules and disinfection regimens, some patients choose to ignore wear and care recommendations—even when educated that improper use can lead to serious problems, including sight-threatening infections.

    There are a myriad of reasons: some patients do it to save money, others because they don’t keep track of when they change their lenses, many because it just seems to be a waste to throw the lenses away “when they still feel fine and I see well,” and others just don’t care. Whatever the reason, we see noncompliance far too often. It is not a new problem. The first peer-reviewed article addressing contact lens compliance was published in 1986.1

    Our contact lens patients aren’t alone. Noncompliance is rampant in health care. The World Health Organization reports that only about 50% of people typically follow their doctor’s orders when it comes to prescription drugs.2 Studies have shown that noncompliance causes 125,000 deaths annually in the United States,3 is responsible for 10% to 25% of hospital and nursing home admissions, and is becoming an international epidemic.4

    Noncompliance with medications is one of the most costly health conditions afflicting Americans today. In 2011, medication non-adherence cost the U.S. healthcare system $317.4 billion in treating medical complications that could have been avoided if patients had complied with their medical therapy. That amount was higher than the total U.S. medical cost of treating diabetes, congestive heart failure, and cancer combined, according to Express Scripts 2011 drug trend report.5

    Peripherall corneal ulcer.


    Noncompliance, nonadherence

    One might think that noncompliant behavior is a patient education problem or a breakdown in communication between the patient and doctor. Yet, this is not the case. Even clinical trials report average adherence rates of only 43% to 78% among patients receiving medications for chronic conditions.6 One study showed that up to 1 in 8 patients admitted for acute myocardial infarction discontinued all prescribed medications for their condition within 1 month of being discharged from the hospital.7 So, is it any wonder our contact lens patients don’t comply with recommended wear, care, and lens replacement schedules?

    Something else to consider: Your contact lens patients may not be complying but believe they are. A group at the University of Texas questioned 162 established contact lens wearers regarding their lens care practices and knowledge of risk factors associated with lens wear. Some 86% of them believed they were compliant with contact lens wear and care, yet only 34% of those actually exhibited good compliance when questioned. Some 14% readily admitted being noncompliant.8 Another study from the University of Waterloo of 501 silicone hydrogel contact lens wearers revealed that two thirds of those patients did not comply with manufacturer’s recommended replacement frequency and those patients wearing 2-week replacement lenses stretched the replacement interval of their lenses to a greater degree than those patients wearing 1-month replacement lenses. Failing to replace lenses when recommended and failing to rub and rinse lenses were associated with a higher rate of patient reported problems with contact lenses.9

    These studies demonstrate that many patients are unaware that their contact lens wear and care practices are reflective of actual noncompliance.1 To date, there is no single predictor for noncompliance among contact lens wearers,10 and despite the introduction of daily disposables and 1-step multipurpose disinfection systems, compliance with contact lens wear is an ongoing clinical problem.11

    Deposits on a contact lens.


    Why comply?

    The benefits of increasing patient compliance are clear. Although there are no definitive studies linking noncompliant behavior with increased risk of lens-related complications, high levels of lens case contamination leading to heavy biofilm formation, combined with the inappropriate use of contact lens care solutions is suspect.11

    Loretta Szczotka-Flynn and a group from Case Western Reserve University in Cleveland found that “the presence of substantial bacterial bioburden on worn contact lenses was significantly associated with the development of a corneal infiltrative event (CIE).” In fact, other than smoking, they claim that bioburden is the only statistically significant risk factor for CIEs.12

    The association between bacterial bioburden and CIEs is well-known.16 CIEs result from some stimulus that causes direct infiltration of leukocytes into the cornea.13 Contact lens- related CIEs are the end result of the ocular surface’s normal defense mechanism as it encounters foreign substances. Overnight lens use14 (a modifiable non-compliant behavior) and bacterial adhesion to contact lenses15 significantly increase the risk of CIEs. There is a higher rate of CIEs observed during silicone hydrogel lens wear,14 perhaps due to the fact certain silicone hydrogel lenses bind more microorganisms than do low-Dk lenses.17

    Of lenses, cases, and solutions, lens cases represent the most common source of contamination and have been shown to include a host of pathogenic microorganisms, including bacteria, amoeba, and fungi.18 From 24% to 81% of contact lens storage cases are contaminated with microbial biofilms, with the frequency of contamination increasing in wearers suffering from microbial keratitis.19 Biofilm formation provides bacterial populations with resistance to antiseptics and antibiotics,20 and thus increases the threat of bacterial infection. While contamination is required for an infection, it must be accompanied by some form of corneal compromise for an infection to occur. The most common compromising factor for contact lens corneal infections is overnight contact lens wear,21 a modifiable risk factor.

    A recent report from West Virginia University studied biofilms isolated from cases and lenses of patients with contact lens-related corneal disease. Of the 17 patients in the study, 7 were documented as having slept in their lenses or having lens overuse. The unexpected study outcome was that three bacteria, Achromobacter, Stentrophomonas, and Delftia, rather than Pseudomonas were the predominant bacteria associated with patients having contact lens-related corneal disease.22 All three are Gram-negative bacteria like Pseudomonas and have a propensity to form biofilms.23 Researchers claim that “the survival of these bacteria in contact lens specimens can be explained by their ability to form biofilms.”22

    Pseudonomas ulcer.


    Looking back

    Various hygiene related risk factors were evaluated in case-control studies of both the Fusarium and Acanthamoeba outbreaks of 2005. The practice of solution reuse or “topping off” (refilling the contact lens storage case without discarding used solution) has been suggested as a risk factor in both outbreaks in multiple studies24,25 and is currently listed on the FDA Web site as an important contact lens warning to patients.26 These studies also suggest that a number of other compliance-related practices may have had a role, including a lack of rubbing of contact lenses during the cleaning process, showering in contact lenses, and using lenses beyond their replacement date.25,27 While noncompliant actions may have some clinical bearing in those outbreaks, “the magnitude of their contributions are likely substantially less than either the identified contact lens solution associations or yet to be identified environmental associations for these outbreaks.”28

    Exposure to water during contact lens wear or during cleaning has been repeatedly indicated as a significant risk factor for Acanthamoeba infection.25,29 Most patients were aware of the risk of using tap water, yet “in contrast to risk factors that were easily identifiable by patients... such as sleeping in lenses or wearing lenses longer than recommended, almost one third of patients felt that swimming showed no effect on risk of infection and of those that knew ... 50 percent did so anyway.”8 Because certain silicone hydrogel lenses demonstrate increased Acanthamoeba adherence to the contact lens surface,30 eliminating exposure to water is imperative.

    Fungal ulcer.


    The cost of noncompliance

     In the United States it has been estimated there are at least 35 million full-time contact lens wearers31 and that the incidence of the most severe form of contact lens-associated corneal infiltrative event, microbial keratitis, is roughly 11 per 100,000.32 A recent paper by Andrew Smith and Gary Osborn estimated the overall annual direct and indirect cost of treating patients with both severe and nonsevere contact lens-related CIEs in the United States at $58 million. The authors estimated the cost per non-severe contact lens-related CIE (which they defined as needing primary care with a loss of 18 hours of work due to the condition) to be $1,002.90, while the cost of a severe contact lens-related CIE (defined as requiring specialized care and a loss of 34 working hours) to be $1,496.33

    Promoting compliance

    How do we promote compliance in our patients? It is important for eyecare providers to make a concerted effort to individually address each patient's compliance, instead of simply making blanket recommendations. Do not assume your contact lens patients are practicing healthy contact lens wear and care. Spending time discussing contact lens wear and care with your patients at each visit will help you identify those patients who are more likely to be compliant, but even more importantly, those who may be noncompliant. New contact lens wearers are more likely to be compliant because they haven't had time yet to develop bad habits. Similarly, long-term wearers are more likely to lax into poor habits.34

    Contact lens compliance ultimately depends on our patients following the doctor's recommendations. Educate the patient at each and every visit about why it is important to replace contact lenses as recommended, use the recommended contact lens care solution, and replace the contact lens case regularly. I give patients a copy of the Association of Optometric Contact Lens Educators Healthy Soft Contact Lens Habits handout as we discuss contact lens wear and care. It's generic, but it does have areas where you can enter the prescribed care solution and the prescribed lens replacement schedule.

    For the ever-increasing number of patients using smartphones, there are applications to remind them about contact lens replacements and office visits. Online calendars allow users to establish recurring calendar appointments or tasks which can be used to remind your patients when to replace their contact lenses. Acuminder allows patients sign up for free text messages or e-mail reminders to change their lenses or schedule an appointment.

    Even with high rates of reported noncompliance, the incidence of severe complications associated with contact lens wear is relatively low and has remained constant for more than three decades, regardless of changes in lens material and the introduction of daily disposables and no-rub care solutions.35-37 Current strategies to improve patient compliance are limited. Patient education is paramount, yet not all of what is being imparted to our patients is necessarily being followed. Diligence is the watchword, in both patient education and looking for contact lens complications from noncompliance in our contact lens-wearing patients.ODT

    Dr. Bowling is chief optometric editor of Optometry Times.

    Ms. Bailey is editor in chief, content channel director of Optometry Times.


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    2. Fung B. The $28 billion cost of medication noncompliance, and what to do about it. The Atlantic, 9/12/2012. Available at: www.theatlantic.com/archive/2012/09/the-289billion-cost-of-medication-no.... Accessed 2/13/2013.

    3. Smith D. Compliance packaging: A patient education tool. Am Pharm. 1989 Feb;NS29(2):42-5, 49-53..

    4. Zuger A. The “other” drug problem: Forgetting to take them. New York Times, June 2, 1998. Available at: www.nytimes.com/1998/06/02/science/the-other-drug-problem-forgeting-to-t.... Accessed 2/8/2013.

    5. Express Scripts 2011 Drug Trend Report. Available at: www.express-scripts.com/research/research/dtr/archive/2012/dtrfinal.pdf. Accessed 2/8/2013.

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    7. Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med. 2006 Sep 25;166(17):1842-7.

    8. Bui TH, Cavanaugh HD, Robertson DM. Patient compliance during contact lens wear: Perceptions, awareness and behavior. Eye Contact Lens. 2010 Nov;36(6):334-9.

    9. Dumbleton KA, Woods CA, Jones LW, et al. The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Cont Lens Anterior Eye. 2011 Oct;34(5):216-22.

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    11. Robertson DM, Cavanaugh HD. Non-compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011 Dec;88(12):1402-8.

    12. Szczotka-Flynn L, Lass JH, Sethi A, et al. Risk factors for corneal infiltrative events during continuous wear of silicone hydrogel contact lenses. Invest Ophthalmol Vis Sci. 2010 Nov;51(11):5421-30

    13. Josephson JE, Caffery BE. Infiltrative keratitis in hydrogel lens wearers. Int Contact Lens Clinic. 1979; 6: 223-241.

    14. Radford CF, Minassian D, Dart JK, et al. Risk factors for nonulcerative contact lens complications in an ophthalmic accident and emergency department: a case control study. Ophthalmology. 2009 Mar;116(3):385-92.

    15. Sankaridurg PR, Sharma S, Willcox M, et al. Bacterial colonization of disposable soft contact lenses is greater during corneal infiltrative events than during asymptomatic extended lens wear. J Clin Microbiol. 2000 Dec;38(12):4420-4.

    16. Wu PZ, Thakur A, Stapleton F, et al. Staphylococcus aureus causes acute inflammatory episodes in the cornea during contact lens wear. Clin Exp Ophthalmol. 2000 Jun;28(3):194-6.

    17. Kodjikian L, Casoli-Bergeron E, Malet F, et al. Bacterial adhesion to conventional hydrogel and new silicone hydrogel contact lens -materials. Graefe’s Arch Clin Exp Ophthalmo.l 2008 Feb;246(2):267-73.

    18. Hall BJ, Jones L. Contact lens cases: The missing link in contact lens safety? Eye Contact Lens. 2010 Mar;36(2):101-5.

    19. Szczotka-Flynn LB, Pearlman E, Ghannoum M. Microbial contamination of contact lenses, lens care solutions, and their accessories: a literature review. Eye Contact Lens. 2010 Mar;36(2):116-29.

    20. Behlau I, Gilmore MS. Microbial biofilms in ophthalmology and infectious disease. Arch Ophthalmol. 2008 Nov;126(11):1572-81.

    21. Schein OD, Glynn RJ, Poggio EC, et al. The impact of overnight wear on the risk of contact lens-associated ulcerative keratitis. Arch Ophthalmol. 1994 Feb;112(2):186-90.

    22. Wiley L, Bridge DR, Wiley LA, et al. Bacteria biofilm diversity in contact lens-related disease: emerging role of Achromobacter, Stenotrophomonas and Delftia. Invest Ophthalmol Vis Sci. 2012 Jun 22;53(7):3896-905.

    23. Furuhata K, Ishizaki N, Kawakami Y, et al. Bacterial contamination of stock solutions in storage cases for contact lens, and the disinfectant-resistance of isolates. Biocontrol Sci. 2010 Sep;15(3):81-5.

    24. Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA. 2006 Aug 23;296(8):953-63.

    25. Joslin CE, Tu Ey, Shoff ME, et al. The association of contact lens solution use and Acanthamoeba keratitis. Am J Ophthalmo.l 2007 Aug;144(2):169-180.

    26. US Food and Drug Administration. Medical Devices: Contact Lenses. Available at: www.fda.gov/medicaldevices/productsandmedicalprocedures. Accessed 2/15/2013.

    27. Saw SM, Ooi PL, Tan DT, et al. Risk factors for contact lens-related Fusarium keratitis: a case-control study in Singapore. Arch Ophthalmol. 2007 May;125(5):611-7.

    28. Tu EY, Joslin CE. Recent Outbreaks of atypical contact lens-related keratitis: what have we learned? Am J Ophthalmol. 2010 Nov;150(5):602-608

    29. Thebpatiphat N, Hammersmith KM, Rocha FN, et al. Acanthamoeba keratitis: a parasite on the rise. Cornea. 2007 Jul;26(6):701-6.

    30. Beattie TK, Tomlinson A. The effect of surface treatment of silicone hydrogel contact lenses on the attachment of Acanthamoeba castellanii trophozoites. Eye Contact Lens. 2009 Nov;35(6):316-9.

    31. Ramamoorthy P, Sinnott LT, Nichols JJ. Treatment, material, care and patient factors in contact lens-related dry eye. Optom Vis Sci. 2008 Aug;85(8):764-72.

    32. Erie JC, Nevitt MD, Hodge DO, et al. Incidence of ulcerative keratitis in a defined population from 1950 through 1988. Arch Ophthalmol. 1993 Dec;111(12):1665-71.

    33. Smith AF, Osborn G. Estimating the annual economic burden of illness caused by contact lens-associated corneal infiltrative events in the United States. Eye Contact Lens. 2012 May;38(3):164-70.

    34. Wesley G. How to address compliance. Rev Optom. 2011 August 148(8):58-63.

    35. Schein OD, Glynn RJ, Poggio EC, et al. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. A case-control study. N Eng J Med. 1989 Sep 21;321(12):773-8.

    36. Radford CF, Minassian D, Dart JK, et al. Risk factors for non-ulcerative contact lens complications in an ophthalmic accident and emergency department: a case-control study. Ophthalmology. 2009 Mar;116(3):385-92.

    37. Wu Y, Carnt N, Willcox M, et al. Contact lens and lens storage case cleaning instructions: whose advice should we follow? Eye Contact Lens. 2010 Mar;36(2):68-72.

    Ernie Bowling, OD, MS, FAAO
    Dr. Ernie Bowling is Chief Optometric Editor of Optometry Times. He received his Doctor of Optometry and Master of Science in ...


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