We would all like our practices to be busy with happy, loyal patients. If our appointment book is full and our contact lens wearers assure us that everything’s fine, it’s easy to think that we’re doing our best.
But are we really continuously maintaining ocular health and optimising lens performance for everyone, even if there is ‘no change’? Or are we assuming that everything’s fine, and that what works for our patients today will still be working a few years, or even a few months, in the future?
The previous article in this series talked about the conversations we can have in practice that help identify the changing needs of long-term contact lens wearers, such as developing presbyopia and uncorrected astigmatism. However, we should be making sure that every wearer’s contact lenses are as comfortable as possible, with minimal impact on ocular physiology, no matter what their visual correction or history of wear.
In this article, we look at conversations that will help you balance the needs of a busy clinic with the needs of your patients, who will then leave your practice better informed, delighted that they have received the best attention and reassured that they are wearing the best lenses for them. They may then be more likely to recommend you to their friends and family.
Contact lens satisfaction and the need to update
The relationship between the contact lens wearer and the eye care practitioner can be a maze of assumptions and unspoken thoughts. It’s easy for us to assume, especially if our next patient is already waiting outside our consulting room, that if our patient doesn’t express any dissatisfaction with his or her lenses then everything is fine.
It’s also easy for the patient to assume that if we don’t ask then it can’t be important. Patients may feel silly mentioning that their lenses actually feel uncomfortable by the time they get home from work. They may think we’re too busy and simply don’t have time for a conversation, or that all contact lenses are the same and they’re supposed to feel like that. It may be easier just to say ‘fine’, especially as the patient may feel that expressing dissatisfaction could lead to no longer wearing lenses.
Patients may assume that we will tell them about any new development in contact lenses and offer them something better if it is appropriate; if we don’t suggest they change, they may think it must not be relevant to them. We may assume that our patients will be aware of and ask about the latest options, whereas this is rarely the case.
As eye care practitioners, we seem better able to manage visible changes due to lens wear that directly affect ocular health – if we can see something tangible we know what to do, like changing the lens parameters, managing an inflammatory reaction or improving oxygen transmissibility. We may find discussing – and actively eliciting – overall satisfaction and symptoms of discomfort more difficult.
But we also know that discomfort during lens wear is the main cause of dropping out of contact lenses.1,2 In fact there is a series of behaviours that come into play before someone gives up on lenses, which starts with ‘struggling’ with physical awareness or visual disturbance, and comfort (or lack of it) is the driving force (Figure 1).3 Indeed, many contact lens wearers start and stop lens wear repeatedly over several years.1 A seemingly satisfied patient can be just a few steps away from giving up on contact lenses due to discomfort.
So, why is long-term comfortable contact lens wear unattainable for some patients? The scientific basis for comfortable contact lens wear has been studied since the 1960s,4 but despite huge advances in all areas of contact lens science since then, it remains our greatest challenge.
A recent comprehensive review from the Tear Film and Ocular Surface (TFOS) Society confirmed there is still much to be done to develop an evidence-based approach to managing contact lens discomfort.3 Perhaps this is what makes us slightly reticent in our conversations at times – do we tend to hold back from really finding out how comfortable our patients are with their lenses because solving the issues raised feels a bit like trial and error?
The other factor that comes into play is limited expectations, of both the patient and the eye care practitioner. Do some just accept that the last few hours of the day in contact lenses are less than wonderful? Patients may not seek out a solution at appointments, and never really feel that their complaint is significant or abnormal. It’s our job to encourage patients to voice their concerns and explain to them that there are many options available to maintain healthy and comfortable contact lens wear.
Opportunities and patient benefits
We should constantly be aware that our patients may not be as pleased with their lenses as we think they are, and that even a happy lens wearer would always like to be even happier. For example, a seemingly satisfied part-time wearer may be delighted with a new type of lens which ‘lets more oxygen through to keep your eyes whiter’ or contains ‘an extra element to help keep them comfortable throughout the day’.
[CaptionComponent="748"]From the patients’ perspective, long-term contact lens success will come if they understand from the initial fitting that the type of lens they wear may change over time, and that one of the purposes of regular reviews is to make sure they have the best lenses for their needs at all times. This will make them more likely to seek out your opinion when they suspect an issue or hear of new contact lens developments.
From the practitioner’s perspective, long-term success – both for your patients and your business – comes from keeping up to date with technology and understanding the benefits of new developments. For your credibility as a competent contact lens practitioner, it’s essential that your contact lens patient hears about lens developments from you – if they have to ask you before you inform them, you have already lost the advantage.
What to look and listen for
Look out for non-verbal cues to dissatisfaction in long-term wearers and enlist the help of your team. Strugglers may come along to make an appointment, collect lenses or arrive for their contact lens review wearing spectacles. They may show a change in purchasing patterns due to decreased wearing frequency. Or they may simply look unhappy or reluctant to be visiting you when they’re sitting in the waiting area.
Once in your consulting room, what’s the best way to truly find out how successful their experience of contact lenses is? Just asking ‘How are your lenses?’ during your history-taking is a question loaded with suspicion for some patients – if they answer in a certain way they may fear they will be told to stop wearing contact lenses, have to reduce their wearing time or pay more for their lenses.
The same applies when you ask patients how many hours they wear their lenses each day: somehow they seem to know the magic answer is 12! But when you actually ask what time they apply and remove their lenses, a different picture often emerges. Satisfaction with the lenses is also likely to vary during wear; for example, their comfort five minutes after applying the lenses compared to that at the end of the day, at the end of the replacement cycle or in different environmental conditions might be different, and this information will be very helpful to our management.
[CaptionComponent="749"]Eliciting concerns means using open questions and empathy. With those you’ve been seeing for many years and with whom you’ve established a good rapport, ‘How are your lenses generally?’ might be a good opening gambit. You might also want to ask patients to give their lenses an overall score (out of 10) when they first apply them and also when they are about to take them out. If you don’t ask about comfort specifically in your initial question, this will also pick up on issues with vision or redness, etc.
You’ll then need to follow up with specific questions on comfort and satisfaction. Table 1 outlines some of the ways you can modify your key questions to elicit the most honest information that reflects the true habits and opinions of the contact lens wearer. Again, asking them to mark their lenses out of 10 can help to overcome any reluctance to report symptoms.
Depending on the responses, you can then move on to probe in more detail, such as ‘You take them out at 6pm every evening – is that because you want to or because you have to?’ or ‘You said you were happy taking them out when you get home from work – would you like to be able to wear them longer?’
If the patient shows limbal redness in the absence of any symptoms, probe their awareness and concern with ‘Do your eyes ever look red when you look in the mirror?’ and follow up with ‘Would you like me to try and improve that for you?’
Checking compliance is also important. Again, asking questions in a way that gains an honest answer is imperative. A closed question like ‘Do you wash your hands before handling your lenses?’ is likely to produce only one type of response.
However, if you ask whether they understand the importance of washing their hands, this provides the opportunity to reinforce the need for hand hygiene as well as being a reminder. You can also ask patients to demonstrate their lens care routine to reveal non-compliance with solutions, tap water, etc. When you ask them to remove their lenses, do they look around for a sink or just take them out?
Discuss the importance of following your lens wear and care recommendations in terms of maintaining comfort and vision. Advise them of the benefits of complying with your instructions fully if they want to continue to wear contact lenses successfully.
Watch the patient’s lens handling technique and reinforce instructions at each visit
What to say and do
Educate yourself and your team
The starting point for engaging with the long-term wearer is to reflect critically on your own skills. Are you sure that, wherever possible, you are taking an evidence-based approach to the management of your contact lens patients? Sharing knowledge with colleagues in your practice is essential so that the patient receives the same messages and reinforcement.
For example, the guidelines for looking after contact lens cases have changed relatively recently – the current recommendation is that patients rub their cases with the care solution and then wipe the case with a clean tissue, and air-dry face down on a clean tissue.5 Rub and rinse steps are now recommended with multipurpose solutions yet rubbing has been the most frequently omitted step in the care regimen.6 Mention these to patients and discuss the latest research, or your attendance at a recent conference, to show patients you’re abreast of current thinking.
[CaptionComponent="750"]When it comes to educating the whole team, it’s easy to assume they know something just because you do. Your staff doesn’t learn facts by osmosis – try to have regular staff training sessions to keep everyone up to date and remember to fit them with the latest contact lenses, which will inspire confidence when they’re talking to patients.
If organising a whole education session seems daunting try the ‘little but often’ approach. Sometimes a regular 15-minute discussion about a particular topic, for example the benefits of daily disposability, can work much better than two hours packed with facts that your staff may just find confusing. Use your contact lens account managers to assist you with developing a staff training programme.
Explain new developments
Armed with a thorough understanding of the latest products, you will be well placed to discuss them with patients. When there’s no change in prescription but the patient would benefit from an update, reassure them that the current lenses are still fine but that you can offer them something even better.
Talk about the benefits of the lens and offer a trial, such as: ‘I know you’re happy with your lenses but how would you like to try something you might find is even more comfortable?’ Or describe the features as well as the benefits, for example: ‘There’s now a lens available which has a smoother feeling surface and is more wettable than the ones you have at the moment so you should be able to wear them comfortably all day.’
Wording on physiological performance may be patient dependent. ‘Would you like to try a lens that lets even more oxygen through?’ would be appropriate for some patients, although a majority of modern soft contact lenses meet most patients’ oxygen needs for daily wear. For others you might make the advice more detailed and personal: ‘There are new types of lenses called silicone hydrogels which let more oxygen through, in case you have to wear your lenses for very long hours’, or ‘with your particular prescription where your lenses are quite thick.’
Pictures or images can be useful to demonstrate the benefits of an update to a new material, such as to show differences in limbal redness or lid changes. Empathise with patients and show that you’ve listened to them, for instance: ‘You mentioned you almost felt guilty wearing your lenses for so long during the day. Modern lenses allow virtually as much oxygen to your eye as if you weren’t even wearing any lenses at all.’ Or ‘If you’re tempted to wear your lenses on a long flight, you could try taking some daily disposables for the journey.’
Remember that silicone hydrogels and hydrogels both have their place and it’s important to find the right lens for the individual patient. For upgrading to hydrogels with enhanced performance, try: ‘These lenses provide extra care, even if your eyes are sensitive.’
Table 2 outlines other clinical scenarios and how you might respond to them.
Reinforce compliance
Good compliance is essential for maintaining comfortable and healthy lens wear. You and your team should take every opportunity to reinforce this message. Be alert to any compliance issues with lenses or care products, such as by checking that the patient is still using the lens type and solutions you prescribed.
If you suspect your patient may be sleeping with their daily wear lenses on, don’t be afraid to take a direct approach. For example, instead of asking ‘Do you take your lenses out each night before you go to sleep?’, the answer to which will generally be ‘yes’, try ‘How often do you take your lenses out before you go to sleep?’ or even ‘How often do you leave your lenses in overnight?’ The question will surprise the wearer who won’t have a chance to think of the ‘correct’ answer and the response might surprise you too!
The same line of questioning can be used if you think the patient is extending lens wear beyond the recommended replacement frequency, such as ‘How often do you keep your lenses for longer than two weeks before throwing them away?’ LensPal is a useful tool for reminders to change lenses, and includes personalised tips and video tutorials, or patients can set their smartphone to remind them.
Prepare your explanations for these clinical scenarios. A visual demonstration of the effects of non-compliance, such as images of heavily deposited lenses, can also be effective in reinforcing the need to follow instructions and explaining the consequences for comfort, vision and satisfaction of not following your recommendations. Having to stop or reduce lens wear may be more of an incentive to compliance than the rare chance of infection.
Memorable analogies also work well. A useful analogy to reinforce rub and rinse is to ask patients whether washing dishes in the sink works better if the dishes are agitated or just left to soak. Try ‘You don’t wash your hands just by plunging them into water’, ‘When you’ve finished your dinner you don’t put the dirty dishes back on the shelf’ or simply ‘Soaking lenses is to make them safe but rubbing is to make them clean.’
Encourage regular reviews
At each visit, remember to stress not only the importance of regular follow-up but the opportunity this presents to update. Think about the wording you use, such as ‘I like to see my contact lens wearers regularly. Even if everything’s fine, it’s always good to make sure that it stays that way. Also, contact lenses keep getting better and your regular follow-ups are a great way to make sure that you’re always wearing the best lenses for you.’
Alternatively try, ‘Your needs change over time so there may be lenses that are even better for you than the ones you have.’ Explain that various updates may be appropriate to them, such as to fit, material or modality, as well as to prescription.
Don’t forget that what may seem ‘old hat’ to you might be a new development for your patient. They may never have heard of two-weekly replacement lenses or considered daily disposability. If their monthly lenses start to get uncomfortable in weeks three and four then two-weekly replacement or daily disposable lenses are the obvious way forward.
Discuss costs
When discussing the cost implications of upgrading lenses, the patient is quite likely to look at what they’re paying at the moment (perhaps for a more ‘entry level’ monthly replacement lens) and compare it to what they might be paying in the future, eg for daily disposable lenses. That could make them seem expensive, although daily disposables might be the cost-effective option if used on a part-time or occasional basis. The initial approach should be to explain the patient’s needs, why you’re suggesting a change and the benefits of the recommended lenses, before moving on to discussion of costs.
Contact lenses are a lifestyle decision and, as such, should be related to other lifestyle outgoings. For example, the monthly cost of daily disposable contact lenses is likely to compare favourably with any gym membership and they are probably going to be used more. The proliferation of coffee shops in every high street has made it much easier to talk about the cost per day of lens wear. We might think nothing of spending £2-£5 a day on a coffee and pastry to take away. Put into this context, daily disposable and multifocal lenses offer great value for money.
Supplementing reusable lenses with daily disposables just for holiday or sports use is a simple way of demonstrating the convenience vs cost benefits.
Don’t prejudge the patient’s ability to pay. Think about things we use every day in our lives – would you really want to use an entry-level mobile phone, car or TV? Then why assume that our patients would want to do that when it comes to eye care? That said, patients may have their reasons for not wanting to update to a more costly lens type. There may be times when they need to change to a less expensive option, even though they are happy with their current lenses, and we should be sensitive to this.
What to say when an update declined
You have a duty of care to offer a chance to update if you feel that the patient would benefit. But however well we think we have phrased the suggestion, there will be a small number of patients who are sceptical and may even express this verbally. This is always a testing time for even the most experienced practitioner as it is hard not to feel offended professionally. Your first reaction is most important as the relationship with your patient going forward is at risk.
Where the purpose of discussing an update is to make sure the patient knows about all the options available to maximise comfort, vision, ocular health and overall performance, reassure them that it can be reviewed at any time in the future and that regular checks are important – offer some written information about the products and prices discussed to take away.
[CaptionComponent="751"]If, on the other hand, this is about a necessary update for eye health, then the patient may not be able to wear their current lenses as much (if at all) if they choose to ignore your advice. This situation is more difficult as you must be sure that any lenses you prescribe for a patient are fit for purpose. You must therefore be prepared to refuse to prescribe/supply if you no longer think they are suitable and make a note on the record.
Whether your advice is declined before or after a trial, make it clear that this is not a one-time opportunity. Leave them with ‘We’ve talked about the new types of lenses. If you’d like to try them another time let me know, I’ll make a note and we will review things when we next meet.’
Top tips
- Advise your patients from the initial fit that they should expect your recommendations for successful lens wear to alter with time – lens type, parameters, modality, and care may need to be changed
- Ask your patients to come in wearing their lenses then remove them during the review appointment, and make sure you observe their method
- Use an analogy for updating contact lenses: modern cars have all the safety and comfort features we could wish for, and we all tend to buy the best we can afford – contact lenses are moving at a similar pace in terms of technology
- Be gracious when a patient seemingly questions your motives for recommending a more expensive product – they may have had a bad experience in the past that you are unaware of. Stick to the science and the benefits
Conclusions
Eye care practitioners need to be proactive about offering the most appropriate contact lens products to existing wearers even when there is seemingly ‘no change’. This approach maintains patient confidence in our abilities and skills, and can help preserve future contact lens success. There is an old adage that ‘If it ain’t broke, don’t fix it’ but it really shouldn’t be applied to contact lenses. Update long-term wearers to the latest products and there should be nothing to fix!
Acknowledgement
Images courtesy of The Vision Care Institute.
References
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2 Richdale K, Sinnott LT, Skadahl E et al. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea, 2007;26:2 168-174.
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8 Hayes VY, Schnider CM and Veys J. An evaluation of 1-day disposable contact lens wear in a population of allergy sufferers. Cont Lens Anterior Eye, 2003;26:2 85-93.
9 Dart JK, Radford CF, Minassian D et al. F Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmol, 2008;115:10 1647-54.
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Professor Christine Purslow is head of medical affairs at Thea Pharmaceuticals UK & Ireland, honorary professor at Plymouth University and senior research fellow at Cardiff University. Simon Donne owns an independent optometric practice in Bedfordshire. He is also a clinical investigator and professional affairs consultant for Johnson & Johnson Vision Care. Both are members of faculty at The Vision Care Institute