Mike Hale: How did the idea to conduct the first survey come about?
Philip Morgan: We have often reminisced about this. I am pretty sure we hatched the idea on an aeroplane journey, flying back to the UK from the Annual Meeting of the American Academy of Optometry, in New Orleans, in December 1995. We were lamenting the lack of independent information about prescribing trends, and thought we could make a contribution in this regard.
Nathan Efron: That’s right. We decided to initiate a survey of prescribing trends in the UK straight away, and the results were published in Optician the following year.
Was the survey always planned to be an ongoing annual occurrence?
Morgan: Probably not initially. However, the first UK survey seemed reasonably straight-forward, so we thought we could start doing this on an annual basis.
Efron: I had a very full workload at the time, since I was head of the optometry department at what was then the University of Manchester Institute of Science and Technology, and wasn’t sure I could manage the survey on an ongoing basis. Fortunately Phil was very enthused and offered to take the ‘front-running’ from then on.
How was the first survey received within the contact lens community?
Morgan: Not long after the results of the first survey were published in Optician, and we began presenting the results at local and international meetings, colleagues in other countries became interested and asked if they could be involved.
Efron: The survey sort of became a ‘charitable franchise operation’. We had established a very efficient way of collecting prescribing data – whereby clinicians are asked to ‘tick boxes’ relating to patients demographics, the types of lenses prescribed and how they are worn – on the next 10 contact lens patients they saw. Very simple. Phil had also developed a great spreadsheet for entering the data, that facilitated rapid and sophisticated analysis. As such, colleagues realised that it would be easier to slot into our well-oiled system rather than setting up their own surveys.
How do you manage the large amount of data generated each year?
Morgan: We have two contact lens research centres entering the data sent in by practitioners – at Eurolens Research here in Manchester, and the Centre for Ocular Research & Education (CORE) in Waterloo, Canada, headed by Professor Lyndon Jones. The Waterloo data entry operation was originally set up by Professor Craig Woods, who still works closely with us on the analysis and reporting of prescribing data.
Efron: Great credit is due to Phil and Craig, and also to our other collaborators, but especially those who have been in it for the long haul, such as Lyndon, Ioannis Tranoudis and Eef van der Worp, who have been involved for at least 20 years. Also, credit must go to the contact lens industry itself, which provides united funding for basic contact lens research to the Manchester and Waterloo centres, some of which is used to fund staff entering data. As well, we have great assistance from regional optometric associations, optical magazines and contact lens industry offices that assist in distributing the survey forms to local practitioners.
Looking back over the past 25 years, what developments in CL use have come as a surprise and which were more predictable?
Morgan: Perhaps the biggest surprise has been the emergence of contact lenses designed to arrest the progression of myopia. Although the concept of myopia control has been around for decades, only very recently has this become a reality.
Efron: In the year 2000 I predicted a substantial decrease in the rate of prescribing of rigid lenses, and the total demise of polymethyl methacrylate (PMMA) lenses by the year 2010, and indeed our prescribing data has shown that I was correct, notwithstanding small episodes of resurgence in rigid lens prescribing from time to time. The demise of low water content hydrogel (HEMA) lenses, such as those made from hydroxyethylethyl methacrylate, was also forseeable; in fact, I recall Lyndon Jones predicting this as far back as the early 1990s.
How has the survey changed over the years?
Morgan: In terms of the way the survey is conducted, very little has changed, and that has been the secret of its longevity. By collecting data in the same way each year, we have a consistent set of data over time which can be used to accurately establish trends in prescribing practices. The only changes we have had to make were to include more check boxes when new products entered the market, such as silicone hydrogel lenses (2000) and myopia control lenses (2011). We have also removed some check boxes when certain lens types have become redundant, such as HEMA lenses.
Efron: In terms of the overall survey operation, the fact that we have now surveyed over 70 countries, with a core of about 15 countries with solid longitudinal data over 15 to 20 years, is really quite an achievement, and constitutes a very powerful data set.
Can you predict how contact lens prescribing trends will change over the next 25 years and what new categories will emerge?
Morgan: For the UK, I would predict that in five to 10 years’ time, the vast majority of lenses –perhaps 80% – will be daily disposables. Soft extended wear lenses and rigid lenses will probably be prescribed at a rate of less than 5% each.
Efron: I agree with Phil on that. In 25 years’ time, we may see a number of smart lenses on the market, with miniature power supplies and in-built features such as augmented reality, real-time information display, health monitoring via electronic sensing of tear film metabolites, and variable automatic lens power control, such as for correcting presbyopia.
Since 2002 Contact Lens Spectrum has put together reports on global trends in contact lens prescribing. How did this come about?
Morgan: I came to an arrangement with Contact Lens Spectrum in 2002 to publish the results of 2001 survey and then all future surveys on an annual basis in the January issue the following year. Spectrum was interested at that stage because the survey was developing an ‘international look’, with data from six countries reported in our 2001 survey – Australia, Canada, Greece, Netherlands, Norway and the UK.
Efron: That’s right and our recent Spectrum papers have had a very large panel of authors. Further to our publications in Optician and Contact Lens Spectrum, data from the survey has formed the basis of over 30 papers in the peer-reviewed literature.
How has the survey helped inform areas of research?
Morgan: Our published surveys are very highly cited because authors of papers of given aspects of contact lens wear are always keen to contextualise their work in terms of the extent to which the lenses they are discussing are being prescribed. They do this by citing our work.
Efron: The survey data also has other uses. It serves as a valuable yardstick for clinicians who can compare their own prescribing habits to those of colleagues in their local region and, indeed, internationally. This may then lead them to contemplate and question why they may be relatively over or under-prescribing various lens types. Also, although the contact lens industry is aware of the volume and types of lenses sold, our prescribing-based survey data offers useful confirmation of, or challenge to, industry-derived sales-based data.
What does your current research focus on?
Morgan: As well as my ongoing programme of work with the contact lens industry, I have ongoing projects such as investigating subclinical inflammatory processes occurring during contact lens wear – to help us better understand the precise physiological relationship between a lens and the ocular surface, to ultimately reduce adverse events and improve wearer comfort. I am also interested in smart contact lens technology, such as dynamic liquid crystal refractive index control to facilitate the correction of presbyopia.
Efron: I have retired from full-time academia, but am still involved in working with Phil in writing up our contact lens prescribing data for publication. I am continuing to publish updated editions of my books, with the most recent being Contact Lens Complications, 4th edition (Elsevier, 2019). I am also currently the editor of the Australian optometry journal Clinical and Experimental Optometry.