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Dropout rates remain unchanged and it is said that for every new wearer one gives up. Products have advanced but even those new to contact lenses are reporting discomfort. So why is the current portfolio of lenses failing to meet wearer needs?
Bausch+Lomb convened a group of contact lens practitioners at its Waterford plant in Ireland to discuss this question and to talk about their experiences with the company's new daily disposable lens, Biotrue ONEday.
Patients give up contact lenses for a variety of reasons but discomfort is by far the primary reason among new wearers. For Annette Latham-Jackson, wearers dropping out in the first year might not be building up the right relationship with their eye care practitioner. 'They may be trying one lens, not getting on with it then feeling embarrassed or ashamed to go back and talk to the practitioner.
'If you can build up a relationship with the patient from the first time they visit, you're more likely to get them to come back. The first lens doesn't necessarily work - you need to have several lenses that you can try.
'Sometimes you do want to trial two lenses and let the patient give you feedback,' she said. 'I'm not sure that every practitioner wants to do that - they're not thinking about the lifetime value of that patient to the practice. It's all about the relationship with the patient,' she said.
Product is the key
Ian Cameron had a different take on dropout. 'I think there's an element of that but I'm convinced it's the product that's the key. The reason things haven't progressed markedly in the last 10 years is that few innovations in the last 10 years have really shaken up the market and changed things.'
The introduction of the first daily disposables was the kind of seismic shift needed to really increase market penetration, said Cameron. 'They were hugely exciting compared to other types of lenses.'
Vinod Mistry questioned whether there were other factors involved in dropout such as a growing incidence of dry eye. 'Dry eyes are an issue - it's on the increase and that population is increasing too. We understand dry eye but we're not doing anything about it.'
Peter Ivins observed that dropout rates varied between practitioners and within optical groups although they were probably using a similar product portfolio. 'It's a complex issue but if you could eliminate dropout altogether we'd have twice as many contact lens wearers in the UK in five years as we have right now. It is about products but it's also about the practitioner - it's a bit of both,' said Ivins.
The amount of time practitioners spent with patients was a factor, he added. 'What's happened in the industry has been that you come in, you get fitted, you're given lenses, shown how to put them in and out, then told to go away and come back and tell us in two years if you've got a problem. We don't actively monitor these people and therefore a lot of them just disappear.'
Sandip Doshi pointed to selecting the optimum product for the individual patient as the key to avoiding dropout: 'It's not about the amount of time you spend - it's about addressing the patient's specific need. It's really about choosing the right product to start with.' But are we asking wearers the right questions to match the choice of lens to their needs?
What, how often and when?
For Cheryl Donnelly, there were unarticulated comfort and vision issues with current lenses, as demonstrated in an online survey of the types of symptoms experienced by 568 successful daily disposable lens wearers. The top three symptoms cited were dry eyes (49 per cent), tired eyes (46 per cent) and blurry eyes (28 per cent).
Wearers recorded the frequency of their symptoms in a diary. Dry eye sufferers experienced this symptom 62 per cent of the time, those with tired eyes had the symptom 71 per cent of the time, and those with blurry eyes 65 per cent of the time. There was also a very high correlation between these three symptoms.
When asked how they felt about the symptoms, the most common words chosen were 'annoyed', frustrated', 'tired' and 'uncomfortable'. Most patients said their symptoms had a negative impact on wearing experience and on comfort.
Amar Shah was not surprised that comfort and vision were related. 'There's definitely a correlation and that's something I talk to people about. It's a "chicken and egg" situation - it's trying to pick through it and find out whether it's the vision that's making them uncomfortable or the comfort that's causing the blurry vision.'
Eliciting symptoms depended on the questions asked. 'If you just ask "are you having any problems" then 90 per cent of them are going to say no,' Shah observed.
Asking open questions, probing more carefully using 'comfortable vision' to encompass comfort and vision symptoms, and breaking comfort down into more descriptive terms such as dry, tired or blurry eyes, seemed to be a better approach. Questions about symptoms at different times of day and in different environments or work situations were also helpful in getting patients to articulate issues with their lenses.
Motivating factors
Kjell Nolke found that motivation to wear lenses was often very strong. He used the analogy of wearing high-heeled shoes: 'Some patients come in with what I consider to be huge problems but they want to wear their contact lenses. It's like women wearing high heels - they're uncomfortable but some people will put up with that. Some patients want to stay in lenses, even if their eyes are very dry. They'll tolerate discomfort and poor vision just because they don't want to wear glasses.'
Motivation was influenced by age and personal circumstances, and also by degree of refractive error. 'They may not always be supremely comfortable but you'll wear them 17 hours a day - comfort is acceptable and compared to wearing glasses it's better,' said Cameron. 'It comes back to what you're willing to put up with.'
The question was whether patients should have to tolerate discomfort with the portfolio of lenses at practitioners' disposal today.
Discussion turned to the relationship between dry eye, lens dehydration and blurry vision. The panel recognised this scenario and that it was a real problem in their patients. In addition to lens and patient factors, environmental factors such as computer use and air conditioning were also involved.
With patients who complained of blurry vision it was important to find the source of the problem. Mistry's tip was to check VAs then rehydrate the lenses to see if acuity improved. 'I do that all the time and they may get one or two lines' extra vision. Then you know it's not the refraction.'
'If you don't go into enough detail you could end up changing the prescription when it's just that the lenses are drying out,' added Latham-Jackson. Both agreed with Adrian Bissell's view that blurry vision was mainly caused by lenses dehydrating.
Symptoms vs dehydration
Time of day that symptoms are experienced and the accumulation of symptoms through the day are useful indicators to probe at aftercare visits. Donnelly compared the time of day when patients reported symptoms of dry, blurry or tired eyes with the dehydration profile over time of commonly prescribed daily disposable lenses.
Current market-leading silicone hydrogel (SiH) and hydrogel daily disposables were likely to produce more symptoms at the times of day when dehydration was greatest, she said. If dehydration could be kept constant throughout the day, would patients, in theory, not experience dry, blurry or tired eyes?
Cameron challenged whether lens dehydration was the main factor in comfort, arguing that what counted was the patient's actual experience with the lens. For both Cameron and Shah, the key was to have patients trial lenses and then ask them a simple question: 'would you buy these lenses?' Price was also a factor in lens acceptance, added Shah.
'The phrase "comfortable vision" is an interesting one,' said Ivins. 'I don't think dehydration is correlated to comfort. But if a lens dehydrates then that will affect vision. If vision is one of the things that affect comfort, because it's highly correlated, then maybe dehydration is correlated to comfortable vision.'
Benefits and features
Turning to the material properties of current hydrogels and SiHs, Nichola Menzel posed the question: are practitioners matching the features of lenses and materials to the needs of their patients?
Donnelly said that the introduction of new SiH materials had led to a shift towards prescribing more SiHs but little overall growth in the number of contact lens wearers. 'Whether a lens has got silicon in it or not, is not what the debate should be about. It's about whether it's the right lens material for that patient. Adding silicon doesn't necessarily mean that the lens material is the best available for that individual.'
'I'd agree with that,' said Latham-Jackson. 'We've all got patients who we've put into SiHs and for one reason or another it hasn't worked so we've gone back to a hydrogel. In an ideal world we'd like a lens that offers enough oxygen permeability, doesn't dehydrate and remains comfortable up to 11 o'clock at night.'
Although Cameron routinely fitted SiHs, his own lenses were hydrogels. 'I wear my lenses seven days a week, 18 hours a day and I don't have any problems with hypoxia. There are plenty of people like that - in fact most people are like that. But there are some people for whom hypoxia is an issue and you have to manage them.'
Selecting a daily disposable lens material was a tougher choice. 'In the monthly market, the SiHs are among the most comfortable available but in daily disposables the SiHs are hit or miss in the comfort factor,' said Cameron. 'Why is it that daily disposables generally are not as comfortable as leading monthlies?'
For some of the panel, choosing the best lens for the individual patient involved a comparative trial to demonstrate lens features, and not just in the consulting room. 'I don't just give them one lens to try,' said Shah. 'I give them two sets of different lenses to take away and I do that every time. One lens does not fit all.'
Options and unmet needs
Given that lens factors, patient factors and environmental factors all influenced dehydration blur, how did the current portfolio of daily disposable lenses perform? Donnelly asked whether material developments had failed to keep up with the increasing demands of air conditioned environments, prolonged computer use and longer working hours.
'I think we've got better at using wetting drops - we're using more of these - but contact lenses themselves haven't necessarily got better,' said Latham-Jackson.
Even with the addition of comfort agents into daily disposable blisters, the consensus was that only some of the materials were meeting some of the patients' needs, and only some of the time.
Looking at current daily disposables, Mistry observed that each company's lenses had traits that were good but no company had put all those traits together. 'Each lens has had some kind of deficiency,' he said.
Ivins summed up the general feeling that practitioners would welcome more choice of daily disposable. 'What you've got at the moment is creating too many dropouts therefore your business is not growing. The main lens-related reason for dropout is comfort, and part of the reason for that is dehydration. If there were a lens that didn't dehydrate as much on the eye, I'd say give it a try.'
Shared experiences
Donnelly reviewed the key attributes of Biotrue ONEday (see panel). The lens material was 78 per cent water with a surfactant added during the final curing process rather than the lens being surface coated. The surfactant was integral to the material and there was poloxamine in the blister.
Describing her experience with the lens, Latham-Jackson found that prolonged comfort was the main trend among the patients she had fitted. 'Towards the end of the day they could wear the lenses for longer,' she said.
Ivins agreed. 'I fit a lot of daily disposable lenses and we've not been happy fitting SiH daily disposables. We're seeing lid changes after a year or two. For me what's so good about Biotrue is to have a lens that's comfortable and has the oxygen transmission. It's a really engaging property of this particular product. It ticks my oxygen box, especially for full-time, long-term wear.'
Donnelly said that dehydration could not only decrease oxygen transmission; studies had shown that it could also affect lens parameters and optical properties. Biotrue's material properties allowed it to retain its shape and image stability compared with other daily disposables and maintain optical image quality, she said.
It was also a lens that handled well. 'Patients loved the handling,' commented Shah. 'It doesn't feel so much like a daily - it feels like a more robust lens,' added Cameron. 'Some patients said it feels like a quality lens compared to other daily disposables.'
'I really like the way the lens looks, sits and moves on the eye,' said Ivins, who reported good results for vision in young wearers and for sports use. 'It handles well on insertion and the packaging is brilliant - it looks fresh and modern when you put it against other products.'
Ease of handling was one of the reasons why the lens would appeal to new wearers. 'I'm going to change what I do with my new fits,' said Shah. 'One of the two lenses I give as a trial will be Biotrue.'
All the panel members agreed that the lens would be among their first lenses to consider. Doshi commented: 'I'd definitely use it for new fits and strongly consider it for refits. I was really impressed and the consumer message is a very strong one. I even had one patient come in and ask specifically for Biotrue having read about it on a patients' forum.'
Inspired communication
ONEday is the second product in B+L's Biotrue portfolio, following the launch of Biotrue solution in 2010. Will the concept of bioinspiration appeal to consumers and help practitioners communicate the benefits of the lens on a non-technical level? And are terms such as 'inspired by the biology of your eyes', 'mimics the tear film' or 'works like the eye' useful to get the message across?
Some were sceptical that practitioners would use these terms but for Ivins bioinspiration was a 'very, very engaging consumer proposition'. He told patients that the lens was 'made of a material that behaves similarly to the front of the eye'.
Others had different ways of describing the product; Doshi positioned it as 'more compatible with the eye', Mistry called it 'the biological lens' whereas Bissell simply said 'this lens dehydrates less'. For Cameron, there wasn't just one story: 'You'd talk about a combination of the features we've discussed, depending on the patient.'
Several on the panel preferred to describe Biotrue as 'the latest lens' or just 'new'. Nolke used the analogy of buying a mobile phone: 'When patients come to me I make it quite clear to them that when there's a new product out, I will be telling them about it. I say "you can decide if you're going to buy the new i-Phone 5 or stick with the one you had five years ago". If you don't give them that option, they'll question why they should come to you.'
So is Biotrue ONEday the iPhone 5 of daily disposable contact lenses? 'Biotrue fits the bill nicely,' said Nolke. 'Great product, price, brand, and a new material, as well as being made in my home town!'
Summing up the panel's view he added: 'I think this is a very successful lens. It makes a big difference to my practice to have a new daily out there. The marketplace for daily disposables is competitive and this lens will make customers think twice about going elsewhere.' ?