Features

The importance of continuous contact lens aftercare

Why continuous aftercare matters for CL wearers, and long-term benefits involved

Contact lens (CL) aftercare is about more than just an annual follow up appointment; it is a continuous process for all CL wearers and should be of relevance and benefit to both the CL neophyte and the established wearer, in addition to their eye care professional (ECP).

Before the introduction of disposable CLs, rigid gas permeable (RGP) and conventional soft lenses were the go-to options for ECPs. Fitting these lenses could be complex, requiring significant skill and time to optimise fit and manage complications.1-3

Since the introduction of disposable soft CLs, the CL industry has significantly invested in research and development to deliver a continuous pipeline of innovation. Technological advancements have improved soft CLs with a wider range of materials, modalities and designs to suit more refractive errors (for example toric designs and multifocals) and deliver an enhanced experience for wearers. This has helped to both retain current wearers in CLs, as well as allowing ECPs to offer CLs to a wide range of patients.4 ECPs are now able to offer the option of CLs to suit and match the individual needs of patients, whether young children or mature people enjoying retirement.

CL wearers are high net worth patients for optometric practices. Research from 2006 found that the lifetime value of a CL patient makes them, on average, 60% more profitable than spectacle wearers.5 The value of CL wearers was acutely demonstrated during Covid-19 lockdowns, where the regular revenue from CL sales was the primary source of income for many practices.6

In his 1978 article on aftercare problems in soft lens fitting, Andrew Gasson wrote:7

‘Setting aside fitting and related refractive problems, aftercare difficulties may be classified into five main groups: acute problems, reduced comfort and tolerance, problems with no subjective symptoms, visual problems and problems related lens condition and ageing’.

The advent of disposable soft CLs now means many previously seen CL complications are much less frequent. In particular, regular replacement of lenses (monthly, weekly, two-weekly or daily) has virtually eliminated issues relating to lens condition and ageing.8

Modern day aftercare continues to show similarity to 20th century aftercare in the maintenance of good vision, optimising comfort, ensuring satisfactory lens fitting performance and the preservation of ocular health.8 Modernising the approach to aftercare could help rejuvenate the process and therefore lead to improved chair time and patient satisfaction, and more importantly, patient outcomes (such as vision, comfort and health).8 Delighting patients also helps drive loyalty, with 46% of spectacle and CL wearers choosing to return to an eye care practice based on a previously good experience with them.9


Where does aftercare start?

Ensuring that CL wearers remain confident and happy with their vision correction option should be a priority for ECPs. This is why continuous aftercare is so important. The CL aftercare journey begins when the patient first leaves the store with their new trial CLs. The ECP will have performed an up-to-date refraction and selected the most appropriate lenses for the new wearer’s lifestyle and visual needs. Practices should pay particular attention to new wearers during their early period of wear and develop strategies to support and manage patients through the initial stages of lens wear. Contacting patients with phone calls in the first few days to check on their progress is among one of the potential strategies.10

CL dropout means disappointment for patients and lost chair time for ECPs. To minimise dropout of new and existing wearers, it is important patients know that support is available from you and your practice. While vision and comfort are key areas for ongoing success as might be expected, handling problems tend to be the most likely reason for dropout after the initial one to three months, whereas cost tends to be more likely a reason three months or more after fitting.11 A retrospective chart review of the status of CL neophytes fitted in the UK showed that while a large proportion of neophyte CL wearers are successful after fitting, a number drop-out very shortly after fitting. During the first year of CL wear, the overall retention rate for neophyte CL wearers was 74% (spherical 79%, torics 73% and multifocals 57%). Nearly half of CL wearers who discontinued did so within two months of starting CL wear.


Figure 1: Revenue loss over five years with 26% CL dropout (model to represent potential opportunity based on Indie Grewal’s in-practice experience), 26% dropout = €84.150 loss over five years


Lost revenue from dropout is demonstrated in figure 1, where losing one patient per month would result in a potential loss of approximately €84K in revenue over a five-year period. Many ECPs may not be aware that patients have discontinued CL wear and so plotting exact figures of dropout can be difficult.

Communication is the key to ensuring continued success after CL fitting. ECPs should be providing all CL wearers an easy and clear channel to communicate with our practices (figure 2). This is especially the case in the early days of CL wear. During the initial few months of CL wear regular touch points like aftercare appointments, phone calls and texts may help with motivation and solving issues that could lead to dropout.10,12

New CL wearers may benefit from a phone call or virtual appointment a few days after collecting CLs to monitor progress and to gauge if an early face-to-face appointment is required to ensure ongoing success in CLs. This initial contact can be made by a trained member of the practice support team10,12 or ECP.


Figure 2: Technology now allows us to communicate with patients in so many different ways


Retaining patients in CLs may help long-term loyalty to practices and provides an opportunity to grow a sustainable business. This is an important area for ECPs to monitor, review and modify their approach on a regular basis. It has been shown that patients purchasing from their ECP show greater levels of CL compliance than those obtaining CLs from internet suppliers.13 Patients purchasing CLs online are also those most likely to overlook CL aftercare.14

Many ECPs consider patients who purchase lenses online a threat to their business and that price is the main driver. However, many patients continue to purchase directly from their ECP and 67% of consumers who have not purchased vision correction products online prefer to use a trusted high-street retailer.15

While price may be a driver for purchasing online, many patients may choose to purchase online for other reasons including avoiding a trip to the practice to collect CLs (41%), quicker delivery (38%) and the option to easily reorder a supply of CLs (30%).16

Convenience is one of the backbones of e-commerce and a huge reason that online shopping has boomed over the past few years. Shopping online offers the convenience of purchasing items when and where it suits consumers, via a choice of payment and delivery methods.16 Convenience when it comes to offering CLs and aftercare is increasingly an area where practices need to consider a variety of options.

Many practice software packages offer the facility for online booking for eye examinations and CL aftercare. Reminders for aftercare can be sent in many different formats and a moment spent with a patient to enquire about their preferred method of communication may improve reminder uptake. A European consumer survey has shown that only 49% of CL wearers attend for regular aftercare. Of those who do not attend regular CL aftercare, 51% say they have not been offered a CL aftercare appointment.18

To make it easier for patients to purchase CLs, their preferred method of communication could also be used to remind them to re-order lenses at timely intervals.


How can you lock retention into your practice?

Many ECPs are familiar with subscription models for domestic utilities, medical fees, cars and mobile phones. However, many of these subscription models can be tailor-made for each individual, ie mobile phones may be tailored for calls and data usage and include the cost of the phone in a monthly subscription. Car retailers tailor packages that may include maintenance, insurance and even consumables such as replacement tyres.

Patients do value clinical expertise above cost, and 63% of consumers who have not purchased vision correction products online agree that their ECP’s knowledge is more important to them than shopping online.19 Offering an in-house subscription model gives patients the flexibility of having a tailored scheme that covers both CLs and aftercare appointments. The loyalty of this business model has been demonstrated recently with 43% of consumers buying CLs on subscription not changing their purchasing habits during the Covid-19 pandemic, compared to 33% who were buying ad hoc.20

It has also been demonstrated that patients on a monthly subscription model attend for more frequent and regular CL aftercare and have a higher frequency of CL purchases.18 The greater proportion of professional fees generated mean monthly subscriptions are an attractive business model and practice builder.21

In the authors’ experience, patients on a subscription model are also more willing to upgrade to a new CL more easily and with greater frequency than those who do not pay by subscription.20


What is the ideal aftercare schedule?

The necessity and planning of regular aftercare is not specific to CL practice and can be compared to the on-going care requirement in dentistry. A Cochrane review in 2013 sought to find evidence in the literature to support recall intervals of any duration for dental patients.22 No evidence was found to support or refute the traditional practice of encouraging attendance for dental check-ups at six-monthly intervals. A more recent study also found no evidence of difference in oral health for participants on a 24-month, six-month or risk-based recall interval.23

As is the case in respect of dentistry, there is no evidence underpinning an appropriate or recommended aftercare frequency for CL wearers. CL aftercare schedule should be personalised for each patient, although many businesses treat all patients in a similar way and slot them into the same aftercare schedule.

A greater move towards daily disposable CLs means a reduction in the potential for serious infection in compliant patients. Daily disposable lenses are associated with a 12.5 times lower risk of corneal infiltrative events compared with reusable lenses.24 A review of aftercare for modern day CLs indicates aftercare could be matched with a routine eye examination to aid convenience and uptake of CL aftercare (figure 3).8


Figure 3: Proposal of an ideal aftercare based on soft CL replacement and refractive change for daily wear, adapted from Efron 20178


For daily wear, initial review should be soon after CL fitting, with regular review every six months for those likely to have structural changes or frequent changes in prescriptions, such as myopia management patients. Annual review may be considered good practice for multifocal CL wearers and 24 months for patients using single vision, daily disposable CLs.8 Patients fitted with RGPs, extended wear or orthokeratology lenses would likely require some additional appointments at specific stages.

ECPs have an opportunity to use the aftercare appointment as a chance to review how patients are getting on with their current CLs, as well as advising patients of the availability of new and improved materials, lens designs and replacement frequencies, which may help optimise vision, comfort and health.


Conclusion

A comprehensive and timely CL aftercare strategy, which effectively provides value and information to patients as well as addressing issues relating to vision and comfort will help ECPs to grow their CL business rather than maintain it. Technology within the industry is constantly evolving. The advent of new materials and designs means a timely CL aftercare is the perfect opportunity for ECPs to share with and recommend the latest innovations with patients. Upgrading technology, such as phones and digital technology, is commonplace once the benefits of upgrading are known. Regular discussions around new product availability, along with the features and benefits of new CLs gives ECPs an easy route to upgrade patients and improve their wearing experience.

  • Indie Grewal is an optometrist, immediate past-president of the BCLA, Contact Lens Practitioner and Director of a Leightons Opticians & Hearing-care franchise in St Albans, Hertfordshire. He is a paid consultant of CooperVision.
  • Fabio Carta is an optometrist, Fellow of the BCLA and professional services manager, EMEA, at CooperVision.


References

  1. Gill FR, Murphy PH, Purslow C. A survey of UK practitioner attitudes to the fitting of rigid gas permeable lenses. Ophthalmic and Physiological Optics. 2010:30(6);731-739
  2. Nilsson SEG. Ten years of disposable contact lenses – a review of benefits and risks. Contact Lens and Anterior Eye. 1997:20(40);119-128
  3. Efron N. Obituary – Rigid contact lenses. Contact Lens and Anterior Eye. 2010:33:245-252
  4. CVI data on file 2018. ECP perception of the benefits of 1 day silicone hydrogels – Cello Health Insight. Survey carried out online in US, UK and Japan. Total sample size n=300 (100 ECPs in each country)
  5. Ritson M. Which patients are more profitable? Contact Lens Spectrum March 1, 2006.
  6. CVI data on file 2020, Covid-19 contact lens practitioner survey, Flame Health, May 2020. Base (all respondents): Total n=385, UK (n=215), Spain (n=170), multi-answer
  7. Gasson A. Aftercare in soft lens fitting. Journal of the BCLA Volume 1, Issue 2, May 1978, Pages 3-9
  8. Efron N, Morgan PB. Rethinking Aftercare. Clinical & Experimental Optom 2017; 100: 411–431
  9. CVI data on file, 2019. YouGov European customer satisfaction survey. UK (N=451), France (N=461), Germany (N=392), Italy (N=395), Spain (N=394)
  10. Cooney E, Morgan P. The impact on retention figures of the introduction of a comfort call during a contact lens trial. Poster presentation at BCLA conference 2017.
  11. Sulley A, Young G, Hunt C. Factors in the success of new contact lens wearers. Contact Lens and Anterior Eye 2017;40:15–24
  12. Patel K, Ley-Smith R, Drury L, Phelan F. The impact on new contact lens wearer retention after introduction of a patient support tool. BCLA conference paper presentation June 2021
  13. Dumbleton K, Richter D, Bergenske P et al. Compliance with lens replacement and the interval between eye examinations. Optometry & Vision Science, 2013;90:351–8
  14. Wu. Y, Carnt N, Stapleton F. Contact lens use profile, attitudes and level of compliance to lens care. Contact Lens and Anterior Eye. 2010;33:183–8.
  15. CVI data on file 2019. Optician Customer Service Report EMEA, YouGov, n=1424. June 2019. Those who have not purchased eyewear products online. France (294), Germany (200), Italy (286), Spain (328), Sweden (275), and the UK (369). % varies by market Italy 76%, France 63%, Germany 74%, Spain 66%, Sweden 65%, UK 60%.
  16. CVI data on file 2019. Optician Customer Service Report EMEA, YouGov, n=511. June 2019. Those who have purchased eyewear products online. France (57), Germany (115), Italy (89), Spain (74), Sweden (126), and the UK (50). Other reasons included 66% good value for money and 40% easy to shop around for the best price.
  17. CVI data on file 2020: EU merged with UK results PL study, YouGov September 2020, 4683 consumers. UK (493), 2019 data, Germany (734), Italy (1481), Spain (1275) and France (700). % varies by market Italy 69%, France 44%, Germany 42%, Spain 25%, UK 66%.
  18. CVI data on file 2020: EU merged with UK results PL study, YouGov, September 2020, 2153 consumers. UK (133), 2019 data, Germany (383), Italy (407), Spain (860) and France (372). % varies by market Italy 51%, France 55%, Germany 44%, Spain 56%, UK 25%.
  19. CVI data on file 2019. Optician Customer Service Report EMEA, YouGov, n=1424. June 2019. Those who have not purchased eyewear products online. France (294), Germany (200), Italy (286), Spain (328), Sweden (275), and the UK (369). % varies by market Italy 50%, France 55%, Germany 65%, Spain 65%, Sweden 67%, UK 78%.
  20. CVI data on file 2020. Covid-19 contact lens users survey, Verve, April 2020. Base (all respondents): Total n=1180 (subscription n=857, ad hoc n=323), UK, Italy, France, Sweden, Germany & France (significant p<0.05)
  21. Patel NI, Naroo SA, Eperjesi F et al. Customer loyalty among daily disposable contact lens wearers. Contact Lens and Anterior Eye, 2015 ;38(1):15-20.
  22. Riley P, Worthington HV, Clarkson JE et al. Recall intervals for oral health in primary care patients. Cochrane Database, Systemic Review, 2013:CD004346.
  23. Clarkson JE, Pitts NB, Goulao B et al. Risk-based, 6-monthly and 24-monthly dental check-ups for adults: the INTERVAL three-arm RCT. Health Technology Assessment. 2020;24(60):1-138
  24. Chalmers RL, Keay L, McNally J, Kern J. Multicenter case-control study of the role of lens materials and care products on the development of corneal infiltrates. Optometry & Vision Science, 2012; 89: 316–325