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This was the formula for 'Experts on trial', a special session at the recent BCLA Pioneers' Conference in London, where Dr Michel Guillon, Christopher Kerr, Professor Roger Buckley and Dan Ehrlich were cross-examined by conference hosts, Alan Saks and Nigel Burnett Hodd.
Each expert was asked two questions in their areas of expertise and presented up to five slides in response. The audience of 220 BCLA members cast their votes on each question and took part in an open discussion along with the other panel members.
Divided opinions
So what question provoked the most debate and discussion? Not surprisingly, an issue that has divided practitioners' opinions for 40 years: the acceptability or otherwise of extended wear.
It was a question for former BCLA president Christopher Kerr that prompted one in six of the audience to agree that extended wear has always been risky and should be avoided at all costs (Figure 1). About one in 12 agreed that today's silicone hydrogels (SiHs) were 'perfectly safe' to recommend extended wear if licensed for this modality. But a large majority agreed that, with the correct practice procedures, extended wear was far safer than it had been in the past.
In response, Kerr said he was 'flabbergasted and amazed' by these answers. One in 2,500 patients wearing lenses on a daily wear basis would have microbial keratitis each year, rising to five in 2,500 in extended wear. So the risk of a serious untoward incident increased by a factor of five if the patient slept in contact lenses, he argued.
Kerr described as 'unethical' increasing the risk of this complication by prescribing extended wear lenses because they were more convenient. He voiced concern over moves by manufacturers towards greater promotion of overnight wear and the prescribing of orthokeratology lenses. 'Sleeping in contact lenses is a daft idea and ortho-K is an even dafter idea.'
Using the analogy of air travel to sum up his case, Kerr asked the audience whether they would choose a flight with a convenient departure time but a five times greater safety risk over a safer flight at a slightly less convenient time.
Heated discussion
In the heated discussion that followed, Burnett Hodd said he had many elderly patients who had worn lenses for three months at a time for 10-15 years, and others who wore monthly conventional hydrogels on an extended wear basis. 'Does that make me unethical?' he asked.
For ophthalmologist Professor Buckley, the 80-year old patient who could not handle lenses was a good candidate for extended wear, and there were some therapeutic applications that required it, but otherwise he would not recommend overnight wear.
Alan Saks took issue with Kerr's assertion that extended wear RGP lenses posed a greater risk of infection than extended wear soft lenses. Dr Guillon went further, saying he completely disagreed with Kerr's view, and wore extended wear lenses himself. Daily wear patients could also get infectious keratitis that would not happen if they wore spectacles, so was prescribing daily wear lenses also unethical?
'In the context of patient management, patients have got to have all the choices. Extended wear is a modality of correction for our patients and should be used on those that are suitable, knowing of the risk,' said Dr Guillon.
From the audience, Dr Trusit Dave observed that quoting relative risk was dangerous saying the risk with extended wear was five times greater when the overall risk was low was 'probably not the right way'. For Dr Dave, an advocate of ortho-K, RGP extended wear was perfectly safe, and the risk of one episode of refractive surgery was equivalent to 30 years of contact lens wear.
But Kerr remained unconvinced, concluding: 'We must have our patients' best interests at heart. The smallest convenience of waking up in the morning and seeing is not worth the increased risk.'
The discussion looks set to continue at the BCLA Clinical Conference in Birmingham (May 27-30) when 'If I wore contact lenses would I sleep in them?' will be the topic for Professor Suzi Fleiszig's introduction to 'The Sunday Debate'. Four Professors, Brien Holden, Phil Morgan, Lyndon Jones and Mark Willcox, will debate the motion, 'With modern SiH lenses continuous wear is not a crazy idea.' ?