Contact lenses: So much more than simple correction of refractive error
Closing Date: 05/03/2021
The majority of people who require vision correction are spectacle-only wearers. Best estimates suggest that in the US, just over one-quarter of these are dual wearers (27%), choosing to correct their vision with both spectacles and contact lenses (CLs).1 This proportion varies by country; estimates for the UK suggest a lower number, just 17.8% of vision corrected consumers also wear CLs.2 Whatever the actual figure by market, globally there is no doubt that use of spectacles as the only form of vision correction far exceeds CL wear and is usually the default option, and often the only option, offered by eye care professionals (ECPs).
Historically, this fitting behaviour may have been driven by a combination of CL availability and clinical performance. ECPs are aware though that modern frequent replacement soft CLs are available in prescription ranges that fit most patients, with comfort levels which should enable many more people to become CL wearers. So, if not a lack of choice and technology, what else drives apparent underuse of CLs?
A gap in communication exists between patients and ECPs, with the former expecting their professional to recommend CLs as an option if they were suitable, and the latter often reacting only to a patient who thinks to ask about contacts. It has been shown across a number of studies that either the proactive recommendation of CLs to all patients,3-5 or the offer of a CL experience while choosing new spectacles,6,7 results in increased CL fits. Although this information has been available for many years, there is clearly still more opportunity for the profession to engage with proactive CL prescribing. One way to support that is to better understand the benefits patients gain from CL wear, which, in turn should enable ECPs and their support staff to hold more compelling conversations about the advantages of CLs with those who have never tried them.
The experience of CL wearers has been gathered from several markets around the world, including via two separate surveys, conducted within the UK. This article reports on the insights gained from this work and shares how that information can be applied in practice to help many more patients experience the benefits of CL wear. Events of 2020 have also added a new vision-related challenge for many: the issue of spectacle fogging when wearing a face mask. New data are shared from global and European consumer surveys illustrating how common the issue is and the steps, including increasing CL wear, that people have taken to alleviate it.
Impact of refractive error and choice of vision correction
It has been stated that ECPs focus more on the measurable outcomes of vision correction – achieving 6/6 or better – than the deeper impact of living with refractive error that the patient may truly be experiencing.8 When questioned, the feedback from those living with refractive error highlights a number of themes that impact quality of life, including concerns about cosmetic appearance, ocular health and difficulty performing day-to-day activities.9
The positive benefits of CL wear have been explored in young myopes. When compared to spectacles, those fitted with soft CLs over a three-year period reported improved physical appearance, athletic competence and social acceptance.10 Significant differences in vision-related quality of life were also reported, especially for activities, appearance and satisfaction with correction.11 Fitting teenagers with daily disposable CLs resulted in improved quality of life scores after just one month, with significant improvements compared to a spectacle wearing group in appearance, activities, peer perception and overall score.12
Quality of life with vision correction, UK study
While good evidence exists for the younger ametropic cohort, less is known about how adults feel about themselves when they wear CLs. Recent surveys have been conducted to expand knowledge in this area. Prompted by recognition that the proportion of CL wearers is not rising in the vision corrected population, one study explored the behaviours, motivations and perceived beneﬁts of CLs among 104 spectacle wearers and 175 CL wearers in the UK.2 The online survey, conducted in May 2018 asked subjects about what was important in their lives, how those experiences were altered by their vision correction, the impact of wearing spectacles initially, and their opinions on the advice their ECP had given regarding CL suitability.
When wearing their correction for the first time, significant differences existed between the spectacle only and CL wearing groups. At least 2.5 times more CL wearers reported positive feelings such as experiencing freedom, feeling confident and happy compared to spectacle only wearers (table 1).2 Beyond those initial impressions, significant differences also existed for feeling a sense of ‘freedom without restrictions’, improved experiences when ‘meeting friends’ and increased self-confidence. Signiﬁcantly more CL wearers stated they loved their correction (78.9% vs 27.9%) and that it had transformed their life (79.4% vs 45.2%). Of the 132 subjects that were considered ‘dual wearers’ of spectacles and CLs, more than eight out of 10 (81.1%) felt having the option of both forms of vision correction gave them the best of both worlds. This feedback should perhaps be viewed not only in the light of CL wear making patients feel good, but perhaps, conversely, recognising the opposite: that for some, wearing spectacles does not instil such positive emotions. Awareness of this can help ECPs counsel patients both on how best to adjust to spectacles, while serving as a good reminder to also mention the option of CLs.
Table 1: Results of UK-based survey of CL and spectacle wearers2
Differences also existed between the two groups in relation to their ECP. CL wearers were more likely to think highly of their ECP who told them they were suitable for CLs as well as spectacles (72.6% vs 44.2%) and more likely to recommend that ECP compared to the spectacle only wearing group (63.4% vs 30.8%). Most consumers, irrespective of vision correction, expected their ECP to advise about their CL suitability (80.0% CL group and 63.5% spectacle group) however, ECPs only suggested CLs to less than one-third of wearers (31.4%). This result echoes the problem highlighted in the opening of this article of the gap that exists between what consumers expect their ECP to do in relation to vision correction recommendations and what actually happens in practice.13
Deeper benefits of contact lenses; an international survey
A survey conducted by YouGov (Nov to Dec, 2019) sought to understand the deeper benefits of CL wear in a large sample of consumers in five different countries. Approximately 1,000 CL wearers responded in each of Germany, Great Britain, Japan, Spain and the United States, over one-third wore daily disposable lenses, over half wore lenses for more than eight hours a day and nearly two-thirds were classed as frequent wearers (table 2).14 CL respondents were asked their level of agreement to a series of statements, with the results reporting the proportion of those agreeing to statements (strongly agree/ somewhat agree). Minimal differences existed between countries for the majority of statements.
Table 2: Demographics of the multi-country survey of CL wearers14
The results reflect those of the UK study from 2018, with 89% agreeing that CLs have ‘improved their quality of life’ and ‘allow them to live their life on their own terms’.14 The highest level of agreement was to the statement ‘I think I look natural’ (91%), with a number of other deeper emotional benefits experienced by around eight out of 10 wearers (figure 1). These included feeling attractive when wearing CLs and feeling confident.
Figure 1: CL wearer agreement to benefit statements14
Visual benefits of contact lenses
CL wearers have high expectations of their ECP when it comes to vision. Regardless of cost, 86% agreed they expect their ECP to make a recommendation for the soft CLs that provide the best possible vision correction for their eyes.14 This result echoes previous work relating to the health performance of CLs where nearly seven out of 10 agreed that they expect their ECP to recommend the lenses that provide 100% of the oxygen that their eyes need, again, regardless of cost.13 These simple wishes from consumers should give confidence to ECPs that they can recommend the most clinically appropriate CLs to patients, and allow patients themselves to make an informed choice.
The visual benefits of CLs produced an interesting result in the survey. Nearly eight out of 10 CL wearers agreed with the statement ‘I see better in CLs’. Such high levels of patient satisfaction with their vision may be surprising to some ECPs. For example, recently generated data from US ECPs found on average just 50% felt correction with soft toric lenses provides the same visual acuity as a patient’s up to date spectacle prescription.15 It is also noteworthy that the high level of agreement for ‘seeing better in CLs’ held true for the presbyopic group aged 55 and over.14 This age group requires multifocal CLs, monovision or additional near vision spectacles to correct their vision fully.
Younger people, however, are more likely to purchase contact lenses, with 17% of 16 to 24-year-olds, and 14% of 25 to 34-year-old compared to just 5% of 45 to 54-year-olds saying they had done so within the past two years.16 The relatively low penetration of CL use for the presbyopic age group perhaps suggests that ECPs are more concerned CL success is harder to achieve with these patients, with poor vision being one of the reasons for that. In that context, the positive visual benefits reported by presbyopes in the survey are encouraging to help ECPs feel confident to recommend CLs more routinely to this group of patients. Overall, it should be recognised that the visual benefits experienced by lens wearers likely go beyond high contrast Snellen acuity, instead encompassing a more general sense of visual freedom through no loss of peripheral vision related to the spectacle frame and, for presbyopes potentially, gaze-independent viewing.
Consistent benefits across groups
It is interesting to note that the high levels of agreement to statements reported by CL wearers were fairly consistent between different patient groups.
- There was no more than a 3% difference in agreement between men and women for the emotional benefits of CL wear. This included feeling confident, attractive and experiencing an improved quality of life.14 This knowledge is useful in practice: keeping front of mind that men report feeling the same self-confidence related benefits as women provides additional reasons to introduce them to the idea of CLs.
- CL benefits were reported across the age range, with nearly three-quarters of wearers age 55 or over agreeing they feel attractive when wearing lenses.14 Adding this insight to the visual benefits for presbyopes results in a compelling argument to ensure presbyopes are routinely recommended CLs as one of the options to correct their vision.
How can the insights generated by surveying thousands of CL wearers help inform routine clinical practice? Primarily, they serve as an important reminder for ECPs and practice staff of the life-enhancing benefits CLs can confer on the individual. Much more than simply ‘not having to wear spectacles’ or ‘being more convenient for sport’, CLs fundamentally make the wearer feel something different. Those positive changes should be recognised, internalised and used to help motivate all practice staff to extoll the virtues of CL wear. This may result in the conversation about CLs changing from one of practical benefits to one that uses deliberately chosen emotional language. Recognising this may drive a new and initially unfamiliar conversation, table 3 shares some of the deeper emotions and experiences reported across the surveys.
Table 3: Emotional and deeper benefits that may resonate with CL wearers
Naturally, not all patients will respond to such an emotional angle on CLs, and for some it may remain more appropriate to make the recommendation based on a specific situation such as sport or social use.
Rather than simply asking ‘Would you like to try CLs?’, ask patients instead; ‘When are the times you would prefer not to have to wear your spectacles?’
This will help enable ECPs to elicit opportunities to better meet patient needs with CLs. This will cover emotional, functional and lifestyle factors without probing too much into how they feel.
A new reason to try contact lenses
In response to the coronavirus pandemic, the wearing of face masks has become common place in 2020 and looks set to continue in 2021. Multi-national surveys of more than 8,000 consumers found more than eight out of 10 spectacle wearers have experienced their spectacle lenses fogging up when wearing a mask (figure 2).17,18 Nearly one in three (30%) have removed their spectacles and risked not seeing clearly to help cope with the issue, and 21% have worn their mask incorrectly, for example not covering their nose.18 Very few people had sought advice from their ECP (2%),18 yet in a European-based survey, 86% of people agreed they would be interested in finding out more about solutions to the issue.17
Figure 2: Fogging of spectacles while wearing a face mask. Can be reduced with a well-fitting mask and anti-fogging lens products but may also prompt consumers to consider wearing CLs. (Images courtesy of Chau-Minh Phan, CORE, University of Waterloo)
There is much the ECP can do to be proactive in this situation. First providing information on minimising spectacle fogging, at both routine appointments and in patient email and website communications. Improving the fit of the mask and using anti-fogging lens wipes and sprays can help to some degree. However, for many people the more convenient solution is to consider CL wear, a suggestion the ECP can make with confidence knowing that 63% of consumers across Europe would consider CLs when wearing a mask.17 This may be particularly relevant for those required to wear face masks for long periods in the day. This not only includes healthcare workers using personal protective equipment (PPE), but also people working indoors in service industries and office buildings where mask wearing may be mandated. In the current climate – and given the reticence of patients to speak up and ask their practitioner about it – ECPs have an important role to check that their patients are able to see clearly and comfortably when wearing face masks. An action that is expected by the majority of patients, with three-quarters expecting their ECP to tell them about all available eye care options that could avoid their spectacles fogging up when wearing a mask.17
Related to this, and relevant for both spectacle and CL wearers is the need to proactively ask about ocular comfort when the mask is worn. In the same way loose fitting masks result in exhaled air fogging up spectacle lenses, the upward movement of air can also cause increased tear film evaporation and lead to ocular dryness.19,20 Remember here too that the patient may not think to volunteer their issue, making it important to proactively ask about how their eyes feel when they wear their mask. ECPs can provide simple advice about improving the mask seal along its top edge, taking breaks from drying tasks such as digital device use and the use of lubricating drops; advice which has been summarised in an infographic available in over 30 languages from the Centre for Ocular Research & Education (CORE) (figure 3).
Figure 3: For use with patients to explain why MADE occurs and how to alleviate it. Used with permission from the Centre for Ocular Research & Education (CORE) and available at COVIDEyefacts.org
In existing CL wearers, these discussions also provide a good reason to reassess lens comfort from other angles too. ECPs can re-evaluate the suitability of the lens material and modality being worn, and the condition of the ocular surface, lid margins and tear film. Some patients may benefit from a material change, a modality change to the flexibility of daily disposable lenses, an alternative lens care product, or therapy for ocular conditions such as blepharitis or meibomian gland dysfunction.
It is important to remember that the conversation around vision correction should not be framed as ‘either spectacles or CLs’. All CL wearers should have back up spectacles, but more than that, the majority of lens wearers actually identify as being dual wearers of both.2 This is a positive outcome for both the patient and ECP. The patient benefits from choice and flexibility of vision correction type depending on the task and situation; the ECP gains the opportunity to increase sales through spectacles, CLs and ideally sunglasses too. An important point for ECPs is the repeat income CL sales can generate, a fact illustrated by their resilience of sales during the acute phase of lockdown in 2020, where 50%+ of all optical sales in 35% of practices were for CLs.21
The well-known ‘Enhancing the Approach to Selecting Eyewear (EASE)’ UK-based study illustrates the dual benefits of CLs and spectacles perfectly.6 In the study, CLs were offered to patients to help them see themselves more clearly when selecting new spectacle frames. This approach removed the pressure of making the patient decide ahead of trying them whether they wanted to be a CL wearer. There was no initial choice to be made. Instead, they happened to experience CL wear while busy completing another task. The results showed positive impact all round. Spectacle dispensing value increased by 32%, more than three times the number of patients purchased CLs compared to the control (17 vs five), and patients reported a superior spectacle dispensing experience.6 A similar approach conducted in the US also recorded positive results. Patients wearing CLs spent significantly more on their spectacles, were more than 2.5 times more likely to have received or scheduled a CL fit, and 93% reported that they were highly satisfied with the experience.7
A final, important point
The initial UK-based survey discussed in this article was prompted by realisation that little growth exists in the number of CL wearers. In part, this can be addressed by following the advice outlined above: to commit to proactive recommendation with relevant language, and to offer more lens-on-eye experiences. However, it is worth mentioning one other aspect of CL growth and that is the subject of drop out. While a detailed examination of drop out is beyond the scope of the article, a few key points are worth highlighting to ensure new wearers have the best chance of continued success. Firstly, the trial experience needs to be considered; a UK study (2019) with over 500 consumers who had recently experienced a CL trial concluded that 44% did not go on the purchase lenses.22 Just 20% were satisfied with their trial experience, compared to 83% of those who did become lens wearers (‘convertors’). The good news, however, is that the negative experiences of the ‘non-converters’ were driven by actions that could be relatively easily addressed by practice teams. Only 56% were satisfied with their application and removal training (versus 87% for converters) and 47% with the level of follow up from their ECP during the trial (versus 83% for converters). In addition, neophytes who had a more positive attitude to the future prospect of wearing CLs were more likely to convert to purchase. A total of 26% of convertors wanted to try a different look to wearing their spectacles (compared to 19% for non-converters) and 12% said they wanted to trial because spectacles restrict them playing sport/exercising (versus 4% for non-converters). Converters had more notable engagement from the offset with 25% being curious to see what it would be like to trial contact lenses (compared to 17% for converters).
In a prospective study of new CL fits, by 12 months the retention rate was 77.6% (194/250) with the most common reason for discontinuation given as problems with vision (41%), followed by discomfort (36%) and handling problems (25%).23 Similar results were reported in a retrospective chart review of over 500 new lens wearers in the UK, where one-quarter of the 136 drop outs occurred in the first month, and nearly one-half (47%) within the first two months.24 Reasons given were poor vision, discomfort and handling issues.
These studies provide insight for ECPs to use in practice to help enhance the success of new wearers. The possibility of early drop out in the first two months can be mitigated by putting steps in place in practice regarding patient follow up to ensure they are coping well with their lenses. This could be a couple of planned follow up phone calls from practice staff, checking in on patient satisfaction with vision, comfort and handling. Early handling should be supported by giving the patient resources to refer to at home to help remind them of the correct techniques. The results also serve as an important reminder to ensure vision is fully corrected, where necessary with toric or multifocal lenses to help optimise the wearing experience for the patient; a recent study has shown that ocular discomfort symptoms may be more intense if there is also perceived visual compromise with toric lenses.25
Supporting resources like ‘My Lens Life’ from CooperVision are specifically designed to help improve new wearer retention during the first year CL wear (https://coopervision.co.uk/practitioner/my-lens-life) and serve to improve communication between the practice and patient.
While it is easy to appreciate the practical benefits of wearing CLs, such as providing an alternative look, and removing restrictions on peripheral field of view, it is a little more challenging to truly appreciate how CLs affect the way people feel. The insights gained from thousands of CL wearers highlight deep and wide-ranging emotional benefits, including improved self-confidence and improved quality of life. It is important for everyone involved in eye care to recognise these positive effects. Much more than a form of vision correction, CLs make the wearer feel different. ECPs are the gatekeeper for access to CLs, with the majority of patients looking for their practitioner to make a recommendation based on their suitability. What a great position for the ECP to hold: to be able to open those gates a little wider, tailoring the potential benefit to each patient, and proactively recommending CLs, alongside dual use of spectacles, to give many more patients the chance to see how they make them feel.
Krupa Patel BScOptom(hons), MCOptom, FBCLA is Head of Professional Services at CooperVision UK & Ireland where Mark Draper BOptom is Director of Marketing & National Accounts and Zoe Bull is Head of Category Development for CooperVision across EMEA. Karen Walsh BSc, PGDip, MCOptom, FAAO is Professional Education Team Leader and Clinical Scientist at Centre for Ocular Research & Education (CORE), University of Waterloo, Waterloo, Ontario, Canada.
- CVI data on file 2019. Industry and Market data, US consumer CL market in 2018.
- Draper M, Patel K, Russell N. Mixed-methods study of behaviours and attitudes to vision correction of spectacle and contact lens wearers. Contact Lens and Anterior Eye 2019;42:e23.
- Jones L, Jones D, Langley C, et al. Reactive or proactive contact lens fitting - does it make a difference? J Brit Contact Lens Assoc 1996;19:41-3.
- Meyler J. STAR performers. Optician 1996;212:18-9.
- Morgan S, Efron N. The benefits of a proactive approach to contact lens fitting. J BCLA 1996;19:97-101.
- Atkins NP, Morgan SL, Morgan PB. Enhancing the approach to selecting eyewear (EASE): a multi-centre, practice-based study into the effect of applying contact lenses prior to spectacle dispensing. Contact lens & anterior eye 2009;32:103-7.
- Mayers M, Jansen Bishop M, Walerius D, et al. Improving your spectacle patients’ in-practice experience with contact lenses during frame selection. Contact lens & anterior eye 2019;42:406-10.
- Lohr KN, Zebrack BJ. Using patient-reported outcomes in clinical practice: challenges and opportunities. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2009;18:99-107.
- Kandel H, Khadka J, Goggin M, et al. Impact of refractive error on quality of life: a qualitative study. Clinical & experimental ophthalmology 2017;45:677-88.
- Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optometry and vision science 2009;86:222-32.
- Rah MJ, Walline JJ, Jones-Jordan LA, et al. Vision specific quality of life of pediatric contact lens wearers. Optometry and vision science 2010;87:560-6.
- Plowright AJ, Maldonado-Codina C, Howarth GF, et al. Daily disposable contact lenses versus spectacles in teenagers. Optometry and vision science 2015;92:44-52.
- CVI data on file 2018. YouGov online survey on silicone hydrogel lenses. N=1520 adult CL wearers (US 519, UK 501, Japan 500). .
- CVI data on file 2020. YouGov online consumer survey Nov/Dec 2019 in Germany, UK, Spain, Japan, USA. N=5,117 contact lens wearers (‘consumers’), screened from total N=35.397 adults. Data weighted and representative of adults in each market (aged 18+).
- CVI data on file 2020. Kubic online survey; n=404 US ODs who prescribe toric soft CLs.
- Mintel report: optical goods retailing UK. Feb 2020; 2020.
- CVI data on file 2020. COVID-19 spectacle wearers online survey, Verve, October 2020 Total n=1050, UK, Italy, Spain, Sweden, Germany, France, Poland.
- CVI data on file 2020. YouGov online survey. 8,203 adults aged 18+ in US, Japan, Great Britain, Italy, Sweden, Canada, The Netherlands and Australia who wear glasses only (n=4,139) or both glasses and CLs (n=4,064). Fieldwork October 2020.
- Moshirfar M, West WB, Marx DP. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmology and Therapy 2020;9:397-400.
- Jones L. Why face masks can make eyes feel dry, and what you can do about it. The Conversation; 2020 [updated 2020. Available at: https://theconversation.com/why-face-masks-can-make-eyes-feel-dry-and-what-you-can-do-about-it-143261. Accessed: 21 Oct 2020];
- CVI data on file 2020. Covid-19 contact lens practitioner survey, Flame Health & Verve, May 2020. Base (all respondents): Total n=202 UK.
- CVI data on file 2019. Vere online consumer survey May 2019 in the UK. N=522, where respondents had experienced a contact lens trial within the past 3 years.
- Sulley A, Young G, Hunt C, et al. Retention Rates in New Contact Lens Wearers. Eye & contact lens 2018;44 Suppl 1:S273-S82.
- Sulley A, Young G, Hunt C. Factors in the success of new contact lens wearers. Contact lens & anterior eye 2017;40:15-24.
- Maldonado-Codina C, Navascues Cornago M, Read M et al. The association of comfort and vision in soft toric contact lens wear. Contact Lens and Anterior Eye, 2020; In press