Can eyecare practitioners do more to find the ‘sweet spot’ for contact lens wearers that would reduce the rate of dropout? Insight asks those in the field how they keep their patients in contact lenses and how doing so can help grow the market.
Contact lens dropout is a perennial topic and for good reason – it is touted as likely a major factor contributing to the near stagnant growth in the contact lens market.
That’s the thinking shared by two professors who co-authored ‘A Review of Contact Lens Dropout’ published in Clinical Optometry online in June 2020. The purpose of their review was to summarise the current state of knowledge related to the frequency of contact lens dropout and the factors associated with it, helping to provide useful insight for practitioners across the world, including Australia.
Assistant Professor Andrew Pucker, from the School of Optometry at the University of Alabama at Birmingham, and Dr Anna Tichenor, from the School of Optometry at Indiana University, found contact lens dropout was frequent across developed countries, ranging between 12% and 27.4%.
They found the top cited reason for dropout in established contact lens wearers was discomfort, while vision was the top reason in neophyte (new) wearers.
Pucker and Tichenor wrote that, if given the chance, contact lens dropouts can often successfully resume wear up to 74% of the time. While the literature is mixed with regard to factors promoting contact lens dropout, meibomian gland dysfunction appears to promote it.
Their review concluded that dropout may be curtailed by early detection, patient education, alternative contact lens options, or early treatment of underlying ocular surface diseases.
Australian optometrist and Fellow of the Cornea and Contact Lens Society of Australia (CCLSA), Mr David Stephensen, says Pucker and Tichenor’s review provides a good summary but perhaps doesn’t acknowledge the failures of practitioners in providing continuity of care.
“Studies like ‘A Review of Contact Lens Dropout’ don’t apportion enough accountability or responsibility to the practitioner,” he says.
Stephensen is interested in contact lens research and new product development and has more than 25 years’ experience in the field. He established his namesake practice in the Brisbane suburb of Moorooka in 2007 and has since opened a satellite practice at ophthalmology clinic The Eye Health Centre in Aspley.
He says contact lenses are historically seen as second-line vision correction (after spectacles) and require ongoing intervention to address concerns such as discomfort and any vision-related changes, like onset of presbyopia.
“Contact lens prescribing requires the practitioner to be in regular contact with patients. That can be challenging. It can be hard to track people down. In theory, it should be automated, but often, it’s not. Contact lens patients are also on varied schedules for follow-up care and re-supply, which can make it harder to keep track,” Stephensen says.
While he has had limited experience with the impact of lockdowns on account of his practice location, Stephensen says he has found that his patients working from home has disrupted their contact lens wear.
“My patients seem more inclined to put their glasses on when working from home; that appears to be the reason in the reduction in drive to wear contact lenses. As an extension of working from home and different needs, some have shifted from a re-usable to a daily disposable platform.”
Stephensen says his years spent building a rapport with patients – and encouraging them to “whinge about their contact lenses” – helps to have a conversation about continuing contact lens wear.
“I think there’s an inherent self-permissiveness in working from home, there seems to be more time in the day, and you don’t have to ‘get ready’, so contact lens wear becomes neglected.
“It’s about having that conversation with patients, altering their wearing schedule if needed, and reiterating there are still reasons to wear contact lenses, unconnected to working from home.”
While discomfort has been cited as one of the top reasons patients drop out, Stephensen says it points to a disconnect between patients and the products available.
Fitting a higher-than-average portion of customised contact lenses, Stephensen sees his role – aside from deploying his obvious clinical skills – as being the “contact point” for patients to pass on their negative experiences with contact lenses.
“Ask your patients, ‘Why aren’t you wearing contact lenses?’. Ask, ‘What can I do?’. There needs to be a change in mindset in our role in healthcare because patients not disclosing their negative feedback becomes a bigger problem. We need to listen for information to make headway.
“I tell my paediatric patients, ‘You’ve got one job: to complain. You have to complain’. I want to create an environment where they feel the right thing to do is to fess up to any issue concerning their contact lenses. It works.”
Additionally, there is nearly always new contact lens technology that the patient doesn’t know about, Stephensen says.
“It is the responsibility of the practitioner to ensure patients are always told about new developments. Make use of trial lenses and let patients make an informed decision.
“Two main products that have impressed me in terms of providing extended comfort are the Ultra family of products from Bausch + Lomb and the Total family of products from Alcon. These show a drive for materials innovation that is focussed on genuine patient issues. The challenge is to ensure that at a practitioner level the patients are made aware of these products,” he says.
Advances in technology has removed barriers
Therapeutic optometrist Dr Lisa Ho, a former state president of CCLSA’s South Australia chapter, is well-versed in advanced contact lens fitting and dropout. A contact lens wearer herself, Ho says contact lenses should be one of the options optometrists offer to every patient.
“I talk to everyone about it,” she says.
Ho and practice manager Mr Justyn Ho started independent. practice, Wellness Eyecare, from the ground up in the inner Adelaide suburb of Prospect three years ago. Prior to establishing Wellness Eyecare, the UNSW graduate spent eight years at an independent, specialty contact lens practice in Adelaide.
“It’s interesting to read that early research papers found comfort was the number one reason for dropout; now vision is considered one of the primary reasons for dropout,” Ho says.
Her contact lens wearing presbyopia patients, in particular, fit this description.
“Vision is very subjective, and sometimes patients aren’t willing to compromise on the sharpness of their distance or near vision, even if they are seeing 6/4.8 and N5 with the contacts. As an optometrist we think that’s excellent, but for some people, the quality of the vision is still not enough,” she says.
This inability to compromise is the primary reason her presbyopia patients reject contact lenses, Ho says.
Another reason for dropout, in her experience, is due to patients being prescribed outdated products.
“Technology has really advanced in contact lenses and makes vision more natural and comfortable, but there are still products with obsolete technology available. Some patients are still being prescribed obsolete technology, which can lead to dropout,” Ho says.
“Often people will tell me they stopped wearing their contacts 15-20 years ago because they were so uncomfortable after a few hours that they had to rip them out. When I explain to them that contact lens technology is so much better now, they are generally really surprised at how much technology has changed. When they try the new materials and realise they can wear them so comfortably, it’s really exciting for them.
“In the last 10 years, the technology has improved considerably. About five years ago, Johnson & Johnson Vision made a commitment globally to bring two new contact lens products to market annually through 2020. That’s how fast contact lens R&D is progressing.”
When Ho’s patients dropout, her first step is to have a conversation with them.
“I try to gauge what the reason is. Can it be fixable or avoidable? I once had a patient who was experiencing stinging from peroxide solutions because she had borrowed her husband’s multipurpose case instead of using the peroxide neutralising case. The reason for dropout can be resolved by identifying things like that, or handling issues. Watch patients insert and remove their lenses. Re-asses their vision, re-assess their lenses. For example, if it’s a toric, check if the lens has rotated, causing their vision to be worse,” Ho says.
“Listen to what they’re saying. That conversation comes into play w0hen assessing contact lens suitability to start with. You need to explain that they might lose vision sharpness when wearing multifocal contact lenses. Give them notice, set realistic expectations, and encourage patients to give it some time.”
After a moment’s pause, Ho adds a further thought.
“I think that potentially a reason dropout isn’t talked about a lot comes back to the practitioner,” she says.
“Whenever you fit a patient with contact lenses, there are so many variables at play – ocular surface, lens modality, insertion and removal – even patient psychology. It takes a lot of time, from a practitioner’s perspective, to do it well.
“Personally, I feel contact lens technology is at the level where almost anyone can wear contact lenses – unless they have significant ocular surface disease. I’m confident there aren’t many barriers anymore. It’s up to us, the practitioners, to know what’s available, do a proper work up, and address any issues that arise.”
Focus on existing wearers to grow the market
Scientia Professor Fiona Stapleton, president of the International Society for Contact Lens Research, says current research shows 20% of contact lens wearers will dropout, with discomfort or vision complications the main culprits.
“We did discuss dropout as a consequence of discomfort in the CLEAR report more from a perspective of strategies to reduce discomfort,” she says, referring to the Contact Lens Evidence-Based Academic Reports (CLEAR).
CLEAR represents the work of nearly 100 multidisciplinary experts in the field, Stapleton included, who set out to critically review, synthesise and summarise the research evidence on contact lenses to date.
“My personal view on that is – if you want to grow the contact lens market – if you could halve the rate or number of dropouts, it would make an enormous difference,” she says.
If the choice is between increasing the new fit rate or hanging on to existing wearers, the latter is more likely to grow the market.
“Contact lens material is not the whole issue behind discomfort and dropout. Patient-related factors are also at play. Early diagnosis of comfort or vision related issues is important. David [Stephensen] is on to something by asking patients the right questions,” Stapleton says.
Those ‘right questions’ might entail asking patients if they’ve had to reduce comfortable wear time or their comfortable period of wear, she says, as well as being on the lookout for conditions such as contact lens-induced dry eye or meibomian gland dysfunction (MGD).
“Once those questions have been asked – and answered – the practitioner can respond by changing material lens fitting modalities, changing to an unpreserved care system, such as a peroxide-based care system, or changing the fitting relationship and edge profile, which does help a proportion of patients,” Stapleton says.
However, Stapleton acknowledges, there are times in people’s lives where contact lenses are not a suitable vision correction solution.
“Dropout can and does happen for other reasons. The profession can get a proportion of these back into lens wear by addressing the issues and modifying expectations. For example, a patient ‘dropping in’ to contact lens wear for a few hours to play football is successful, even if its part-time wear. As practitioners, we need to work out what the issues are, and find a solution to each particular problem,” she says.
But hard lockdowns and various restrictions on businesses have made that task harder this year.
“Patients have cancelled their non-urgent follow-up appointments, including contact lens wearers, so there is less opportunity to ask how they are getting on. We also know they are reducing their contact lens wear,” she says, a situation not helped by conditions such as mask-associated dry eye (MADE).
Stapleton returns to her earlier point on reducing dropouts.
“The CLEAR report is the most recent review on discomfort, and it illustrates the dropout rate is not changing – we’re not getting better at retaining wearers. We’re seeing stagnant growth. If you could halve the rate of dropout, you’d do amazing things for contact lens penetration in Australia. It’s harder to get a new wearer than retaining an existing contact lens wearer; you’ve already got them over the line. Where would practitioner’s efforts be best placed?” Stapleton says.
Manufacturing’s supporting role
Mr Angelo Doumbos, managing director of Menicon Australia, says the industry can help reduce the contact lens dropout rate.
Headquartered in Japan, the company says it is the only manufacturer in the world dedicated to all areas of contact lenses-related business including material development. It established an Australian base in Adelaide in 2011.
Although supply hasn’t featured among the reasons for contact lens wearers dropping out, Menicon has taken steps to prevent any supply-related issues.
“In line with our vision and mission to be a trusted partner of the industry, we have switched couriers to National Optical Distribution, which has been positively greeted by our customers. Apart from that, we have not encountered any issues with inventory holdings,” Doumbos says.
He believes most patient-related factors behind contact lens dropout can be solved by education.
“Interesting studies have found what contact lens wearers recall being told and advised does not always match what the eyecare practitioner reports advising. We can support by consistently reinforcing key messages, utilising a variety of resources; written, verbal and digital,” Doumbos says.
While not a practitioner, Doumbos’ experience in the optical industry for more than 15 years has helped him understand the importance of open communication with patients.
“For early dropout, arranging a courtesy call within the first week is good to understand how they are finding the lenses, to identify any red flags and to provide guidance where appropriate, to maximise their success,” he says.
“If compliance, for example, is not optimal, then a new management plan can be agreed, such as using Menicon’s daily disposables with Smart Touch, with a commitment to follow best practice hygiene principles.”
Doumbos says asking open questions, using questionnaires or rating scores can help identify any risk factors for contact lens discomfort or suboptimal performance.
“Determining whether their actual wearing schedules are in line with their ideal wearing expectations will give further clues. Reminding wearers regarding their motivation for contact lenses and activities they enjoy wearing contact lenses for will help motivate and reduce the chance of dropout.”
Doumbos says Menicon has focused not only on contact lens performance but the importance of the packaging too, making the handling process as simple and efficient as possible.
“The literature cites around one quarter of contact lens dropouts occur within the first year due to handling reasons. Menicon has invested significantly in developing consumer driven innovations to help make handling easier, simpler and more convenient.”
In an online survey Menicon conducted in 2011 involving 1,031 respondents, 31% said it was difficult to tell the right side of Menicon’s daily disposable soft contact lenses, and 23% said the lens easily stuck to their fingers.
The company responded by launching Smart Touch technology in 2013.
“Smart Touch technology has been applied across Menicon’s families of daily disposables. The wearer is reassured the lens is always the correct way up. Our online survey in 2011 showed 80% of wearers admitted in a survey they would like easier handling and 91% agree having a lens the right way up (Smart Touch lenses) see this as an advantage,” Doumbos says.