We would also like to think that our beloved patients are taking that instruction to heart: washing their hands, rubbing and rinsing their lenses, cleaning and replacing their cases, and never, ever topping off. But the harsh reality is that overall compliance is relatively poor. Research has uncovered the astonishing apathetic behaviors of patients time and time again, but we have yet to use that information to change future behavior. A recent study may help shed some light on how to elicit better habits from our contact lens wearers.
Hopefully, we have at least one person in our office investing the time to educate each and every contact lens wearer on how to properly care for his lenses, and furthermore, ensuring that every established wearer is carrying out those instructions appropriately. We would also like to think that our beloved patients are taking that instruction to heart: washing their hands, rubbing and rinsing their lenses, cleaning and replacing their cases, and never, ever topping off.
But the harsh reality is that overall compliance is relatively poor. Research has uncovered the astonishing apathetic behaviors of patients time and time again, but we have yet to use that information to change future behavior. A recent study may help shed some light on how to elicit better habits from our contact lens wearers.
By the numbers
Recently, Dumbleton1 looked at the most common shortfalls of contact lens compliance by administering an online questionnaire to 100 contact lens wearers. Inaccurate use of lens care, failure to clean or discard the lens case, introduction of tap water, and inadequate hand washing were among the most common discretions. In this study, 27 percent admitted to topping off their solution, while only 39 percent reported rubbing and rinsing their lenses every night.
Twenty-two percent said they never clean their case, and 67 percent of those who do rinse it with tap water. An astonishing 76 percent routinely (and inappropriately) recap their case. Regrettably, the percentage of patients claiming to wash their hands every time before removing their lenses was a mere 45 percent, and not all of them use soap! For many, hand washing was stimulated only by the urge to remove an obvious residue, such as makeup or food.
Next: How do we rank?
How do we rank?
We pride ourselves in our cleanliness; however, a glowing 89 percent of the contact lens wearers surveyed in Saudi Arabia “appropriately” washed their hands before handling their lenses. How can they be better at this, considering 80 percent of the beauty shops in the study admitted to selling contact lenses without an Rx, and 61.4 percent dispensed them with no instructions at all? Yet in the U.S., our patients buy their lenses from authorized distributors and receive their training from us, but only 45 percent wash their hands every time before removing their lenses.2
In the Maldives, a whopping 61 percent of those surveyed were deemed to exhibit poor hand hygiene, and 36 percent reported exposing their lenses to water. Interestingly, approximately 90 percent of those surveyed saw themselves as average or better contact lens wearers. This is yet another sign that patients don’t see deviations in lens care and hygiene as being consequential.3
Among 500 healthcare workers in Pakistan, only 33 percent changed their solution daily, while 42 percent used the same solution for more than two weeks. (Only 24 percent claimed to know proper cleaning techniques). Even among these low standards, 82 percent claim to have adequate hand hygiene prior to handling lenses.4
We think of hand washing as it applies to microorganisms, but there is another factor to consider. Dermal lipids can be transferred to the surface of the lens. One study analyzed the amount of lipids transferred to the lens after a novel hand wash and a thorough hand wash, compared to no hand wash. Fluorescein spectroscopy revealed, on average, 14 fluorescence units (FU), 6 FU, and 28 FU, respectively. This indicates a four-fold increase in lipid deposition for those who didn't wash up.5
The why behind the behavior
Dumbleton1 didn't just look at compliance rates, she took it one step further and explored the reasons behind the behavior. Participants who were ranked as “generally compliant” or “generally noncompliant” were asked to participate in separate focus groups. This was done in an attempt to understand the motivating factors that influenced their level of compliance. She deemed the two biggest influencers of both groups as education, or lack thereof, and consequence of behavior.
Firstly, those who were generally compliant had clearly been given precise instructions to follow, while many of the noncompliant patients had no knowledge of proper behavior. Tilia6 compared the overall compliance of contact lens wearers receiving verbal direction vs. those receiving both written and verbal instructions.
We shouldn't need a study to tell us that the latter method is more effective, but he found that patients receiving only verbal instructions were about twice as likely to inappropriately rinse their cases with tap water (a habit that causes a substantial rise in the presence of gram-negative bacteria in the case).
Secondly, actual consequences and perceived consequences may be two different things. On the lens, noncompliance may cause deposition and dehydration. In the eye, it can lead to corneal staining, conjunctival injection, papillae, and even corneal ulcers, both infectious and sterile.
Some patients may internalize an increased risk for infection on some level, but it seems their behavior was more significantly affected by their perception of other, more immediate, consequences: blur, visible deposits, and discomfort. Patients are more likely to change their lenses or amp up their cleaning regimen when they experience more dryness or a drop in their end-of-day comfort.1
However, research shows the majority of noncompliant tendencies are not associated with contact lens-related dry eye. Inappropriate replacement schedules, inadequate rub and rinse, topping off, and even the omission of hand washing did not seem to negatively affect their dry eye score or their clinical presentation of dryness.7
How do we change behavior?
How can we use this research to our advantage in a clinical setting? Clearly, education is a principal factor, and the burden to deliver that education lies, primarily, on our shoulders, as eyecare providers. However, the required investment of staff and time is far outweighed by the benefit of preparing our patients for a lifetime of successful lens wear. This week, raise awareness among your staff and delegate who in the office will have this crucial conversation with the patient.
None of Dumbleton’s focus groups seemed to have an understanding of the imminent risk imposed by improperly caring for their lenses. Even the compliant patients were more motivated by the perception of their immediate comfort and vision.1 This is key information, indicating that we may be more effective in motivating patients by touting the added benefits of compliance verses the imposed risks of noncompliance.ODT
1. Dumbleton KA, Spafford MM, Sivak A, Jones LW. Exploring compliance: a mixed-methods study of contact lens wearer perspectives. Optom Vis Sci. 2013 Aug;90(8):898-908.
2. Abahussin M, Alanazi M, Ogbuehi KC, Osuagwu UL. Prevalence, use and sale of contact lenses in Saudi Arabia: Survey on university women and non-ophthalmic stores. Cont Lens Ant Eye. 2014 Jun;37(3):185-90.
3. Gyawali R, Nestha Mohamed F, Bist J, Kandel H, et al. Compliance and hygiene behaviour among soft contact lens wearers in the Maldives. Clin Exp Optom. 2014 Jan;97(1):43-7.
4. Khan MH, Mubeen SM, Chaudhry TA, Khan SA. Contact lens use and its compliance for care among healthcare workers in Pakistan. Indian J Ophthalmol. 2013 Jul;61(7):334-7.
5. Campbell D, Mann A, Hunt O, Santos LJ. The significance of hand wash compliance on the transfer of dermal lipids in contact lens wear. Cont Lens Ant Eye. 2012 Apr;35(2):71-7.
6. Tilia D, Lazon de la Jara P, Zhu H, Naduvilath TJ, et al. The effect of compliance on contact lens case contamination. Optom Vis Sci. 2014 Mar;91(3):262-71.
7. Ramamoorthy P, Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye Contact Lens. 2014 Jan;40(1):17-22.