Over the course of every BCLA conference a theme eventually becomes clear. As the credits roll and delegates emerge from another performance, for performance it is, it’s not difficult to see what someone, somewhere has decided it’s all about.
In 2013 there was no doubt: it was all about contact lens comfort. And in 2014 it seemed to be about comfort again. Or was it?
The well-rehearsed arguments that comfort is the key to contact lens success and discomfort the primary reason for failure were played out. Contact lens dropout, said Lyndon Jones in the opening keynote address, was due to one of three causes: the lens, the solution or the patient.
For Jones, dryness and discomfort were the number one reason for dropping out, experienced by over half of wearers. The next most common reason was vision, especially for those in older age groups.
With regard to the lens, no ‘level 1’ studies had shown oxygen transmissibility alone was linked with discomfort but there was recent evidence for an association between friction and comfort. The link with lens deposits was unclear and the ideal replacement frequency for comfort inconclusive. The impact of solutions was also uncertain since changing solution seemed to help some but not all patients.
Looking at patient factors, there were many associated with contact lens discomfort: female gender, young age, poor tear film quality and quantity, seasonal allergies, systemic drugs, diet, hydration, alcohol intake, smoking, compliance and ethnicity.
Practitioners needed to pay attention to lens, solution and patient, keep abreast of developments and adopt a multipronged, systematic approach to avoid dropout. But, for Jones, it was clear that contact lens comfort was key and all the strategies he put forward were aimed at improving it.
Vision not comfort
Graeme Young described a new study that challenged that view. Young had reviewed case records for 534 recently fitted contact lens patients in 29 practices of different types and locations across the UK. One year after they had been fitted, 74 per cent were still wearing lenses and 26 per cent had lapsed.
In this study, unlike almost every other to date, the most common reason for lapsing was poor vision (32 per cent), followed by discomfort (17 per cent) and handling (15 per cent). For nearly one in three dropouts (32 per cent) the reason was unknown.
Crucially, of those who lapsed, one in four (25 per cent) discontinued during the first month and nearly half (47 per cent) within the first two months. For more than two-thirds (71 per cent) no alternative lens or strategy had been tried.
[CaptionComponent="476"]Retention rates depended on age (younger), lens type (sphere vs toric) and sphere power (higher). But there was no significant difference for other factors such as gender, cylinder power, modality (daily disposable vs reusable), material type (hydrogel vs silicone hydrogel) or replacement frequency.
Retention rates varied widely between practices, from 40-100 per cent, although there was no significant difference in rate between independents, multiples and regional groups, or for type of location, such as city centre, town or suburb/village.
Young said that practitioners should determine retention rates for their own practices, follow up new wearers closely to prevent them drifting away, and get them back in and try alternative strategies if necessary. While comfort was still an issue, vision should be optimised, especially for presbyopes. Better multifocals, more choice of lens diameter and more materials with low coefficient of friction (CoF) were also needed.
Identifying suspects
Robin Chalmers cited other recent factors influencing dropout such as the advent of improved contact lenses and solutions, an increase in daily disposable prescribing, the rise of internet purchase/direct supply, and changes to practitioners’ education and scope of practice.
Dropouts were more likely to be male, to have started wearing lenses later in life and to be wearing RGPs. The proportion of males wearing contact lenses fell by a third from eight to 25 years of age, for reasons such as handling problems, having to pay for lenses rather than parents paying, and weak cosmetic motivation. This group might need a different approach to retain them in contact lenses, she said.
But for Chalmers, asking patients about comfort and dryness was still key to predicting dropout. Each patient brought factors that were unique, so strategies had to be tailored accordingly. Wearers over 40 might need an adjunct distance Rx and any surface symptoms addressed. With new wearers, useful strategies were to ensure lens supply, minimise misuse and consider daily disposables.
‘Products have got better but the way patients use their eyes has changed and they’re more distant from the practitioner – very often when things go wrong they never think to go back to the practice again,’ she said.
[CaptionComponent="477"]Avoidance strategies
Danish practitioner Bo Lauenborg’s presentation on the ‘scary numbers’ of patient dropout offered more advice. Of 943 new fits in his Aarhus practice in 2012, only 279 remained on his system. Change of address was a factor in 20 per cent of lost patients and price/internet purchase in 16 per cent. Half never came back after the initial fitting. A time consumption study showed the practice used 1.2 employees to get a net increase of only 52 customers per year.
Patient communication, upgrading to the latest products, keeping up to date via CET and attention to dry eye were all factors in minimising dropout. Lauenborg recommended practitioners talk about ‘care time’ rather than chair time, ‘keep the patient close’ and ‘never let go’. He used a questionnaire to identify patient priorities and to probe comfort and vision. Also, if the patient reported a Net Promoter Score (customer relationship indicator) less than 7 he would change product or intervene.
Regular contact was key – the practice now sent out more than 1,500 emails or pieces of video information in a year. His advice was to leave a maximum of seven days from fitting to first appointment (and make it before the patient left), no more than 14 days until a follow-up call, email or text, and to text a reminder before each appointment. Make sure that bank details, as well as contact information, was collected for every patient.
But one piece of advice was especially pertinent. ‘If you want to grow your business you need to know how many patients are entering the business and how many are leaving,’ he said.
Science or art?
These comments set the scene for the most interesting exchange of the day. It came during a panel discussion that followed a session where researchers involved with the Tear Film and Ocular Surface Society (TFOS) International Workshop on Contact Lens Discomfort presented an update on their findings. The workshop’s conclusions included a detailed flowchart of strategies for managing discomfort.
Robin Chalmers and Edinburgh optometrist Ian Cameron clashed on the use of pre-examination questionnaires to probe symptoms. Chalmers argued for the use of validated questionnaires, such as the CLDEQ-8 which scores frequency plus late-day intensity of dryness, discomfort and blurry vision, frequency of closing eyes to rest them and removing lenses to relieve discomfort. Cameron argued against, saying putting numbers on comfort was ‘purely subjective’ – what mattered was whether they were happy with the comfort they were getting.
Addressing the TFOS workshop authors, Cameron said: ‘As a practitioner reading this [report], you’ve spent a year climbing a mountain to find us at the top. We know we don’t know why contact lenses are uncomfortable.
‘We know that for some patients it might be the lens edge, in some it might be the solution or in some the modality.’ There were different types of comfort even in the same patient, he said. ‘It’s lots of factors. You can’t possibly find a golden bullet for such a large number of problems.’
Chalmers said questionnaires were an easy way to start the conversation in a controlled way, then try a treatment and see if the score changed. Patients often said they had never been asked in detail about their symptoms. And self-assessment in private produced very different results from interviewing patients.
But the practitioners on the panel were not convinced. Cameron went on to say: ‘If you’re more knowledgeable than the average practitioner you will be able to find novel solutions and handle a greater range of patients than some other practitioners.’
It fell to James Wolffsohn to ask him what his own dropout rate was – he didn’t know – and challenge him to present his rate at BCLA 2015.
Excite and motivate
There was little discussion at this meeting about the motivation of the patient to wear contact lenses and the practitioner’s role in maintaining that motivation to avoid dropout. Philip Morgan touched on this in his BCLA Medal Address when he reported the findings of a new study among children and teens that suggest initial excitement about contact lenses wears off after one or two months’ use and satisfaction also tails off.
Tools such as Lenspal from Johnson & Johnson and the new Alcon ETIP (Enhanced Trialist Interaction Protocol), a log book for support staff to record and monitor patients’ experience with their new contact lenses, reflect a growing awareness that the early stages of lens wear are crucial.
But the suspicion remains that ways to rekindle patients’ initial excitement about contact lenses and re-motivate them might be just as important as supporting them through the early days. The psychology of patients, and practitioners, warrants further scrutiny in relation to contact lens dropout.
Talking history
Following a similar theme, the British Universities Committee of Contact Lenses (BUCCLE) ran a session on how to balance time and efficiency when taking history and symptoms.
At the initial fitting, a quick questionnaire on iPad or with the receptionist was a ‘very powerful tool’, said James Wolffsohn. It need not take up practitioner time and provided good feedback for patients too if their scores increased in future. For changes in general health, medication and smoking, a simple questionnaire saved time and embarrassment, and could impress the patient.
Once in the consulting room, questions such as ‘How do you spend your time during the working week?’, ‘How do you spend the rest of your time?’ and ‘How many hours a day do you want to wear your lenses?’ helped determine lifestyle and occupational needs.
At aftercare visits, pre-exam questionnaires could again be useful. For Katherine Oliver they ensured consistency, although answers must be followed up, starting with primary questions, such as ‘How do you clean your lenses?’ then probing more deeply into how their lenses felt, asking when, how, how long for, and at what time during the wearing schedule. ‘It’s your job to ask the patient not the patient’s job to tell you,’ she said.
So what were practitioners actually doing in practice? Robert Conway reported from a BUCCLE survey on history and symptom-taking that most (85 per cent) asked about visual tasks but only 38 per cent about typical working distance. At aftercare almost all queried wearing time (94 per cent) and days per week worn (93 per cent), but fewer asked directly about discomfort/pain (86 per cent). Only about half (49 per cent) rated severity of discomfort/pain on a grading scale.
Kids and contacts
Fitting children and teens with contact lenses was another strong theme again this year. Michael Bowen described a new survey among 748 College of Optometrists’ members to determine practitioner-reported attitudes and behaviour to contact lens use in children and young people.
Most (92 per cent) currently prescribed contact lenses to patients under the age of 18 and frequency of recommendation increased with age. Interference of current vision correction with sports was the reason parents most often gave for requesting contact lenses. The age deemed most appropriate to introduce children to soft lenses was 10-12 years but interest and motivation, maturity and ability to care for contact lenses were seen as more important considerations.
In his keynote address, Bruce Evans reported that the UK was in the bottom third of international prescribing rates for children and teens. Looking at strategies for myopia control, if the child had esophoria at near or high accommodative lag, multifocal soft contact lenses, although off-label, could be recommended.
The aim was to use the minimum add that eliminated esophoria, typically +2.00D but Evans might consider +2.50D for a more powerful treatment effect in some children since multifocals did not appear to compromise vision. He might start myopia control before the child became myopic, such as if both parents were myopic.
It was important to explain to parents what ‘average’ meant with respect to myopia control outcomes, and to balance the quality of life benefits with the risks, in any discussion with parents.
Turning to contact lens marketing for children, Kate Johnson said, ‘You want your patients to buy your opinion. Your most important marketing tool is your words. If you have belief, and the words to talk about contact lenses with your patients, that’s the best starting point to increase contact lens fitting.’
Half of Johnson’s own practice was in paediatric or binocular vision and half contact lenses, and nearly one in three of her patients was aged 6-12 years. Her advice to delegates was to tackle their own concerns about fitting children and prepare explanations for talking to parents. Think beyond the regular uses of contact lenses and remember that the risk of complications was probably less than practitioners might think.
The discussion that followed covered lens designs for myopia control. Johnson agreed there was a need for a silicone hydrogel centre-distance multifocal. From the audience, Tom Aller said it did not seem to matter whether multifocals for myopia control were centre-distance or centre-near, it was the differential in power that mattered, or ‘Any plus, any place’. Johnson added that picking the right candidates was more important than lens design.
[CaptionComponent="478"]Changes ahead
So what else was new at BCLA 2014? The role of the eyelids in contact lens comfort was another focus this year. Heiko Pult’s Irving Fatt Memorial Lecture reviewed his research into clinical signs of dry eye, including lid parallel conjunctival folds (LIPCOF) and lid wiper epitheliopathy (LWE). A pilot study found refitting experienced lens wearers with a LIPCOF grade of 1.0 or greater with a low CoF lens improved LIPCOF, LWE and dryness symptoms.
During the TFOS session on eye/lens interactions, Nathan Efron observed that the eyelids were more likely than the cornea to be associated with contact lens discomfort. And Philip Morgan identified a new clinical sign: changes to the lid margin seen with confocal microscopy attributed to an increase in inflammatory cells during a day of contact lens wear. Early data suggested this sign was related to the friction characteristics of the lens.
Morgan’s closing medal address, ‘Changing the world with contact lenses’ provided a glimpse of the topics that might be on the agenda at future BCLA meetings. Studies at Manchester were looking at a wide range of topics, from modelling the tear film using fluorescent microspheres with and without a contact lens on the eye, to the impact of proteins on bacteria and whether it was possible to enhance and retain the natural defence mechanisms of the tear film on a contact lens. The tear film, he said, remained ‘the big unknown’.
Among other developments in prospect were liquid-crystal based contact lenses for presbyopia that altered refractive index when voltage was applied to alter power, and a storage case sensor that changed colour as bacterial contamination reached a specified threshold.
Look out for more information on these and other novel devices at the 39th BCLA Clinical Conference, to be held in Liverpool from May 29 to June 1 2015.