Patient perception vs. reality with compliance

Well, here we are, another year behind us, another new start ahead. And what made the cutoff for our list of resolutions? Lose 10 pounds, wake up earlier, save more money, make more family time?

But wait-how can we possibly forget everyone’s list topper: To rub your contact lenses every day and replace the solution, to throw your lenses out on time? Adding this as a resolution sounds preposterous because it just doesn’t hold a place of priority for many patients. Unfortunately, they don’t see an immediate impact from lens care compliance-or the lack thereof. I’ve always believed that if we make it seem substantial to us, it will seem important to the patient.

A comparison of one-step peroxide systems

Bui found that while 86 percent of patients surveyed believed they were compliant with their lens care regimen, only 32 percent were compliant with even 90 percent of the recommended protocol.¹ Another survey showed full compliance to be as low as 0.4 percent, and “good” compliance was confirmed in only two percent of those surveyed.² Because total compliance seems to be an overwhelming goal for patients, let’s look at the impact of simply rubbing and rinsing the lens.

Rub and rinse

It is believed that lipid deposition is more common on silicone hydrogel (SiHy) lenses because the hydrophobic lipids in the tear film have an affinity for the hydrophobic silicone. And with the build up of lipid comes contact lens awareness, or worse yet, dryness, friction, intermittent blur, and inflammation.

Luckily, with the decreased wear cycle compared to years past, the problem is somewhat limited, or is it?

Nash recently compared the amount of lipid deposition on seven different sihy materials (140 lenses) via fluorometric enzymatic assay, each having been worn for two to four weeks. He found that the actual sorption was polymer dependent; enhanced-lotrafilcon B showed the least amount of sorption and enfilcon A showed the most (0.09±0.1microg/lens and 3.96±0.8microg/lens, respectively).³

Recently, Tam conducted research to see how saline and multi-purpose solution (MPS) impact the sorption of radiolabeled dipalmitoylphosphatidylcholine (DPPC) and cholesterol (CH) on five different lens materials. As expected, SiHy absorbed more lipids than hydrogel material. Pre-soaking the SiHy materials in MPS for 16 hours reduced sorption by more than 10 percent compared to the controls; however, the reduction was not statistically significant.⁴

The harsh reality of contact lens care compliance

Tam went on to compare the ability of two branded multi-purpose solutions in reducing lipid sorption in two sihy materials. After pre-soaking the lenses, both PureMoist (Alcon) and Biotrue (Bausch + Lomb) were able to reduce the amount of DPPC and CH sorption in senofilcon A; however, neither was effective with balafilcon A. And while neither solution removed deposition without rubbing, a small but detectable amount of CH was removed from each lens material after a good rub (as compared to controls). Even with rubbing, the sorption of DPPC was not notably affected.⁵

Despite this researcher’s findings that neither the MPS nor rubbing create a monumental reduction in lipid deposition, we need to consider the impact of digital manipulation and compliance on other aspects of the wearing experience.

Compliance is not my problem

In a 2014 study, 200 samples consisting of contact lenses, lens cases, solutions, and bottles were collected and analyzed for contamination. Overall, 52 percent (104/200) of the samples showed contamination via microorganism growth.

However, the patient’s history of compliance was a strong indicator as to the level of contamination. Among those who reported low compliance (habitually completing fewer than three of the six cleaning steps), 100 percent of the samples were contaminated. Subjects reporting medium compliance (three to four of the cleaning steps) incurred contamination in 93.75 percent of the samples, and among those with high compliance (>5 steps), only 43.75 percent of the samples were contaminated.⁶

But how much impact does not rubbing have on the patients’ actual wearing experience? Does the fact that everything in her contact lens world is likely contaminated lead to actual or perceived complications? In Dumbleton’s survey of 501 sihy wearers, 29 percent of those who failed to rub and rinse their lenses daily reported having symptoms suggestive of contact lens complications, while only 17 percent of those who incorporated a daily rub reported symptoms.⁷

That’s almost double!

There is also clear evidence in the literature that when using a MPS, rubbing and rinsing the lenses reduces the risk for microbial keratitis⁸ and may also reduce the incidence of corneal infiltrates.⁷ Yet 40 percent to 75 percent of patients still fail to rub and rinse on a regular basis.^7,9,10

The responsibility of ECPs

This topic of noncompliance has been written about with great frequency for decades. As eyecare providers, we can read the figures and profess to be astonished and offended. But the bottom line remains: until the vast majority of us behave differently in educating the patient, we cannot expect the vast majority of patients to behave differently.

In Bui’s survey previously mentioned, 80 percent of those surveyed were already aware of the risk factors associated with contact lens complications, but this awareness did not cultivate positive behavior.¹ Maybe this is our cue that instead of threatening patients with the travesties of infection and inflammation looming, we should tout the benefits of better compliance. Improved comfort and vision, longer wear time, and whiter eyes: these are enhancements that many patients would like to enjoy.

Dropouts-not in my practice

Looking back, I learned something unexpected from my dental hygienist. Like many kids, I didn’t floss. Year after year I read the gut-wrenching sign that hung over the doorway, “Don’t worry, you don't have to floss all your teeth, just the ones you want to keep!” Disturbing as it was, it didn’t instigate a change in my behavior. But then in high school, my hygienist began to comment that my smile was beautiful. She went on to tell me how flossing regularly would make it even more beautiful. My habits changed that day.

Though some patients will certainly respond to threats of impending doom, we may get an even bigger response if, instead, we offered hope for improved comfort and enhanced appearance? Perhaps improved contact lens compliance won’t land on the resolution list of many patients, but whatever incremental increase in awareness we create will be a step in the right direction toward improving the patient’s experience and outcome.

References

1. Bui TH, Cavanagh HD, Robertson DM. Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens. 2010 Nov;36(6):334-9.

2. Robertson DM, Cavanagh HD. Non-compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011 Dec;88(12):1402-8.

3. Nash WL, Gabriel MM. Ex vivo analysis of cholesterol deposition for commercially available silicone hydrogel contact lenses using a fluorometric enzymatic assay. Eye Contact Lens. 2014 Sep;40(5):277-82.

4. Tam NK, Pitt WG, Perez KX, et al. The role of multi-purpose solutions in prevention and removal of lipid depositions on contact lenses. Cont Lens Anterior Eye. 2014 Dec;37(6):405-14.

5. Tam NK, Pitt WG, Perez KX, et al. Prevention and Removal of Lipid Deposits by Lens Care Solutions and Rubbing. Optom Vis Sci. 2014 Oct 16.

6. Thakur DV, Gaikwad UN. Microbial contamination of soft contact lenses & accessories in asymptomatic contact lens users. Indian J Med Res. 2014 Aug;140(2): 307–9.

7. Dumbleton KA, Woods CA, Jones LW, et al. The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Cont Lens Anterior Eye. 2011 Oct;34(5):216-22.

8. Butcko V, McMahon TT, Joslin CE, et al. Microbial keratitis and the role of rub and rinsing. Eye Contact Lens. 2007 Nov;33(6 Pt 2):421-3; discussion 424-5.

9. Hickson-Curran S, Chalmers RL, Riley C. Patient attitudes and behavior regarding hygiene and replacement of soft contact lenses and storage cases. Cont Lens Anterior Eye. 2011 Oct;34(5):207-215.̢۬

10. Wu Y, Carnt N, Stapleton F. Contact lens user profile, attitudes and level of compliance to lens care. Cont Lens Anterior Eye. 2010 Aug;33:183-8.