Soft contact lens designs and materials are constantly developing and it is important for eye care practitioners to ensure their patients are always wearing the best lens for their needs. With this in mind Alcon recently gathered a group of experts in this field to explore the issues and come up with some practical advice.
The session was chaired by Optician clinical editor Bill Harvey.
Setting the scene
Bill Harvey: The subject today is soft contact lens materials, how you decide which ones are best and why patients should know about them. I started working at Optician in 2000 when the silicone hydrogel revolution was kicking in.
Now there are papers coming back in support of conventional hydrogels. So over the last 15 years, there’s been a variation in views and appropriate recommendations. I’m interested to pin down your views on where we’re at and what might be appropriate in terms of clinical care for patients in the future.
But first briefly introduce yourself with some detail of your background in soft contact lens materials and your reasons for being here.
Declan Hovenden [DH]: I’m the clinic manager and head clinical optometrist at the National Optometry Centre in Dublin, which is the clinical training facility for the undergraduate BSc in optometry students at the Dublin Institute of Technology. My role principally is one of management, but I still have some clinical work and a little bit of teaching as well.
Dr Katharine Evans [KE]: I am a lecturer at Cardiff University. I’m the module leader of the second and third year contact lens modules and director of clinics. I supervise undergraduates in our third year contact lens clinics and I practice in Hereford as well. I am a self-proclaimed contact lens material geek - compliance and materials is a real interest.
Keith Tempany [KT]: I’ve recently merged my independent practice with a Leightons store in Poole, so am now store director of Leightons and Tempany. Before the merger my store was a contact lens only practice. That is no longer the case but my time is still spent 80/20 in favour of contact lenses over spectacles.
Dr Inma Perez [IP]: I’m the head of professional affairs for Alcon, but my evolution has come via a few places. I initially got established in academia and I did my PhD at Manchester University while working at the Royal Eye Hospital at the time.
[CaptionComponent="2446"]Ian Cameron [IC]: I have a large contact lens specialist practice in Edinburgh. We have held the contact lens fitting contract for Edinburgh and Lothians in our practice for about 25 years. Like Katharine, I am a bit of a contact lens material geek and used to work for Eurolens as a researcher.
Material selection
KE: We don’t limit the students at Cardiff to one manufacturer or one material. We encourage them to think about the patient as an individual and consider all of their needs. That dictates what material we go for. But we don’t fit every one routinely with silicone hydrogels. We encourage them to think about patient comfort and their health and the Dk/t relative to what the patient actually wants.
DH: But there definitely is a trend in the student’s brain to think, okay, silicone hydrogel is where it’s at. I think that is a mistake.
IC: From 2000, we spent 10 years saying silicone, silicone, silicone.
KT: Every individual is individual, so you’ve got to look at everything to do with background, what they want the lenses for and keep in mind that the solution is not necessarily just one set of lenses. We talk to our patients a lot about ‘visual wardrobes’. So it may be a reusable lens is their main lens, but it may be daily disposables for other recreational uses or holidays and things like that.
IC: We can broadly agree there are two categories. There are silicone- based materials where permeability and modulus are the key parameters of the lens affected by silicone content. Then you have hydrogels which vary broadly by water content and then you’ve got added parameters. Is that a fair way of categorising the two main camps?
DH: I think one possible unfortunate consequence of the recent thinking is that our selection of hydrogels is actually shrinking, because some of them are now being discontinued. This is causing problems, particularly for existing wearers of those materials.
I had a case of this just two weeks ago where I had a patient who used the same lens for roughly a dozen years – mid water content, hydrogel lens – wearing it very successfully. But the lens has become discontinued, so he was seen in the student clinics.
[CaptionComponent="2447"]Oxygen
DH: The advent of silicone hydrogel has largely solved the problem of oxygen transmissibility. Of course, it depends whether you’re talking about daily wear versus continuous or extended wear. Obviously the oxygen needs are different in the latter. But I think by and large, we can assume that pretty much any lens we fit nowadays is not going to cause a problem related to oxygen transmission.
IC: 15 years ago we’d have said you can wear this lens more than x hours a day. Why do we now think that the same lens has better oxygen performance? If we say that maybe 70 or 80% of people could wear a hydrogel and be totally fine in terms of oxygen demand and the 20% that we used to get really excited about 15, 20 years ago, now we’ve got the option to solve that.
KT: I think we’re certainly in a far better place than we were 10 years ago. I remember when silicone hydrogels first came out, the feeling was ‘no more problems with contact lenses because it’s silicone hydrogel’. We’re always on the lookout for the perfect lens – the most comfortable, most oxygen efficient, most easily handleable. But I don’t think we’ve got everything. I wouldn’t sit back and think ‘job done’.
Back to conventional hydrogels?
IC: 50% of people fail in contact lenses worldwide so there’s clearly a lot of work still to do.
BH: What’s the current thinking in terms of failure? Is it veering to comfort or is it veering to vision?
IC: In studies it has always been consistently comfort.
BH: If comfort was something that you were absolutely focused upon, is that why conventional hydrogels should be in your armoury?
KE: We’ve got good comfort enhancing hydrogel dailies now. Things like the AquaComfort Plus and Acuvue Moist, I think those are performing better than our older daily lenses, so they are keeping people more comfortable. Then for people who are symptomatic, we’ve got options. We can change them and try them with something like a water gradient lens that may offer more benefit as well.
IC: So we’re saying that hydrogels are a problem solver.
DH: Yes.
[CaptionComponent="2448"]Upgrading patients
DH: Silicone hydrogel lenses tend to be more expensive than hydrogel lenses because of the nature of the process involved and manufacturing them. So that is an important consideration when you’re talking to a patient. They may have a limited budget, so that has to be taken into account as well.
BH: But are we in a position that we should be recommending a new material as a predictor of future potential concern?
IC: Absolutely. Nobody wants last year’s iPhone. Nobody needs next year’s iPhone, but when it comes out, everybody wants next year’s iPhone.
BH: We’ve got a perfectly valid proposal that it’s good for you and your practice perception to be seen as being ahead of the game and implementing a planned annual programme keeps the patient aware that you’re ahead of the game.
KE: I think we have a duty of care to our patients to tell them what’s new on the market, what’s available. Otherwise there’s a likelihood that their friend may be changing to something and they will go to a different practice because they perceive it as being more up to date. I think it’s about involving a patient in the decision. They need to understand what are the pros and the cons. The option of giving them a trial of a different material is really useful, because unless they’ve tried it, they don’t know whether they’re going to benefit from it. If it’s a more expensive product, they want to get something from it. They want it to have better comfort or longer wearing times.
KT: We talk to our patients a lot and they expect to hear about new products that may benefit them. A patient the other day came in for a check-up and sat down in the chair and, unprompted, asked ‘what are you going to try me out with today?’ They like to see you as a practitioner ahead of the game.
DH: If there is no good clinical reason for changing, should you change?
IC: You can make the recommendation. I mean, the point is you’re making the recommendation.
KE: I think practitioners often struggle to talk about a more expensive product. I think they’re wary of being seen as trying to upsell, especially when a patient’s jumping from a monthly to a daily.
IC: If dailies are £20 more expensive, they’ve got to be significantly better. Patients understand the convenience and so they might say on balance ‘I don’t need solutions and the convenience is worth 20 quid’. I’m okay with putting the option in front of them but you can’t make that decision for them.
[CaptionComponent="2449"]BH: So we have a consensus that it’s your responsibility to keep the patients informed of developments and provide expert advice but keep the patient involved in that decision making.
KE: If there are new developments, then I will definitely talk to patients about them, but I think in a multiple practice perhaps we’ve got patients that are less inclined to try new products. I think our patients have quite different expectations in an independent than a multiple.
KT: With my practice, it’s purely done at the aftercare. That’s where we do most of our recommendations as part of aftercare every six months. I would like to explore contacting the people in between if there is a really good dynamic product launched. But I think there’s a line that you can cross by over-contacting people.
IC: Text is a particularly intrusive one, because you don’t have control over it in the same way you do with email or Facebook. If contacting someone with text you’d probably want to make it about something specific and make it personalised.
Compliance
IP: I think one of the things that is very important is that contact lens materials have developed for a given indication. I’m particularly interested in the area of the compliance and how you see the different materials for the different modalities and how that plays in the equation.
KE: There’s so much more uptake of dailies now and I think people are willing to spend more now for convenience. It has improved compliance, but we still need to bear in mind that we’ve still got issues with people dropping out of contact lenses. So I don’t think dailies solve everything by any means.
KT: It’s a team effort; mine are more prepped at the frontline because I don’t always see the patient that drops out in time. But my staff may pick it up when they see them in the street or when they pop in with a friend. There is always that possibility. I think training staff is vital.
IC: So we quite often will have our reception team and support staff recommending new products to patients and offering trials.
[CaptionComponent="2450"]KT: I think you get two types of members of staff – some of them that won’t switch on to that side of things but others that are really hungry for it.
IC: If you said to anyone who wears contact lenses, do your eyes ever, ever feel slightly dry or less than perfectly comfortable in your contact lenses, everyone is going to say yes. So there’s clearly room for everybody to improve if you go down that line of questioning.
KE: We know the practitioners are really important when talking about compliance with their patients. We know that’s important for reducing the risk of infection. But if a patient’s never had that problem it is harder to talk to them about what they should be doing. So we get our students to talk to them about comfort – try and be more compliant in order to promote comfort. I think we undervalue the importance of regular appointments, not just because we’re talking about lenses but because we’re trying to change behaviour as well.
DH: I find it really useful when the patient is in the room, as well as talking about comfort, just having those grading scales up on the wall, because some of them actually look quite gruesome to patients. You can point to those and say these are the sort of things that can go wrong if you’re not maintaining your lenses properly. I think it’s often a good way to reinforce the compliance message.
DH: While younger people are naturally earlier adopters of things like technology, they tend not to have or want to spend as much money on things like contact lenses. Whereas the older patients may be later adopters, but they’re the ones who maybe can afford the upgrade.
IC: Then it becomes important how you phrase your discussion. So with an older patient, you’re going to maybe talk more about health, because that’s a primary concern for older people. Younger people are concerned with technology, so you stress the technology on them. It’s the same benefit wrapped up in different features.
Price effect
BH: How big an influence do you think price is? You mentioned it before in terms of patient material or design change. Is that totally geographical and socioeconomically driven or do you think there are other elements as well?
DH: It does depend where your practice is located on what your patient profile is. Absolutely, yeah.
IC: You can alter by demographic how big your upgrade jumps are by getting your pricing right, so this is something just to consider in practice. If you struggle to upgrade people, you need to make the upgrade route gentler. If you’ve got a less prosperous area, then you need to make some more jumps.
KT: What I wanted to mention on the price angle, at the risk of sounding like the cliché machine here, is don’t judge the book by the cover. Sometimes you’ll find a patient will consider their contact lens wear as one of the most important things in their life and therefore anything that you can do to preserve that contact lens wearing ability by upgrading, they will make sure they can afford it.
[CaptionComponent="2451"]Future forecasts
BH: Do you see the presbyopic market still growing in the future?
IP: Yes.
KT: A perfect presbyopic lens would be lovely.
IC: Toric multifocals is the massive gap at the moment. There really are not many great options there.
KE: I would like to see extended families of lenses more, with successful materials coming out in different options. So the AquaComfort Plus, they’ve got the toric and the multifocal. I hope at some point the Dailies Total 1 will expand into a family as well, because then it just gives you greater options.
DH: When you do develop a material that works really well - and we have those materials now – then you really do need to look quite quickly at expanding the range.
IC: Looking ahead the problem is we don’t know why lenses are comfortable or uncomfortable. That’s the major problem. For some people, it’s the edge. For some people, it’s the modulus. For some people, it’s the lubricity. For some people, it’s oxygen permeability. For some people, it’s lid interaction. For some people, it’s tear film. It’s not the same for all people. I suppose in future there will be more bespoke options, perhaps through 3D printing.
DH: Yeah, and I think we’re going to see more of the ability to build more and more technology into lenses to open up lens wear to people who don’t need them for vision correction. There are potential uses for contact lenses with sensors for IOP and blood glucose. I think if the material issues can be sorted out, then that’s what will open up that market, because we can very quickly then fit the rest of the population with comfortable contact lenses, perhaps even ones that have projected virtual reality images.
KT: In terms of materials, I would love to see a contact lens that dissolves on eye. So you pick it out the packet, put it on. The patient can’t over-wear it. It just dissolves.
KE: A lot of people have talked about drug-eluting contact lenses as well, but there was a lot of interest and nothing really seems to be coming to fruition just yet.
Top tips for soft CLs materials in practice
• Ensure patients are kept aware of new developments
• Offer regular upgrade options
• Involve the patient in decision making
• Never assume a patient might not want to spend more if there is an advantage
• Phrase questions about comfort carefully to get the true picture