Kathy Dumbleton, MSc, MCOptom Kathy is Head of Clinical Logistics at the Centre for Contact Lens Research, University of Waterloo. Her research interests include the ocular response to contact lenses, silicone hydrogel materials, visual performance, compliance and the measurement of ocular discomfort. Lyndon Jones, PhD, FCOptom, DipCLP, DipOrth is a Professor at the School of Optometry and Director of the Centre for Contact Lens Research at the University of Waterloo. He is also a Topical Editor for Optometry & Vision Science and the Chair of the Research Committee of the American Academy of Optometry.
Lyndon Jones, PhD, FCOptom, DipCLP, DipOrth is a Professor at the School of Optometry and Director of the Centre for Contact Lens Research at the University of Waterloo. He is also a Topical Editor for Optometry & Vision Science and the Chair of the Research Committee of the American Academy of Optometry.
If there are “Fifty ways to leave your lover”, according to Paul Simon, then there are certainly at least fifty ways in which patients can be non-compliant with their contact lens wear and care. Our patients are, it appears, “Still crazy after all these years!” Eye care practitioners (ECPs) responding to a poll posted on siliconehydrogels.org reported that their patients are non-compliant in the following areas:
♦ Failure to replace lenses when scheduled (reported by 55% of ECPs)
♦ Failure to wash hands prior to handling lenses (reported by 18%)
♦ Switching care products (reported by 13%)
♦ Inappropriate use of care products (reported by 9%)
But does it really matter if contact lens wearers do not follow the instructions given to them by their eye care practitioners (ECPs)? This editorial reviews the recent literature on compliance and contact lens wear and explores what “serious” risks may be associated with the most common areas of non-compliance.
Compliance with contact lens wear: concerns then and now
A 1986 study of 100 contact lens wearers in Australia found that only 26% of patients were fully compliant with lens care and wear instructions from their practitioner1. Other reports have cited 40-91% non-compliance with instructions2-6.
Unfortunately, non-compliance among contact lens wearers continues to be a problem worldwide, despite improvements in lens materials and simplified care regimens.
♦ A European study found a staggeringly low 0.3% of respondents to be fully compliant with all the recommended procedures for contact lens wear and care7,8.
♦ A Hong Kong study reported that all contact lens wearers were non-compliant to some degree, and 60% were non-compliant with at least 6 of the 15 procedures evaluated9.
Do these patients consider themselves to be non-compliant though? In a recent study conducted in the United States10,
♦ Only 32% of patients were found to be compliant in at least 90% of the lens wear and care associated behaviours evaluated, while
♦ 86% of patients perceived themselves to be compliant with their current lens wear and care practices.
Several factors2,9,11-13 have been reported to affect compliance in contact lens wearers including gender, age, magnitude of refractive error, recommended lens replacement interval and recommended care system.
These factors can be broadly characterized as being either patient-related factors, or lens- and lens care-related factors. ECPs clearly cannot choose to only prescribe lenses to patients meeting a certain demographic for age, sex, intellect or refractive error, but they do have some degree of influence on patient compliance is with respect to which contact lenses and care products they decide to prescribe for their patients. Counselling and education for all contact lens patients is however the most important factor of all.
Contact lenses and handwashing
There are many ways in which a patient can fail to comply with recommendations for lens wear and care. While patients may consider missing a certain step to be relatively unimportant, particularly if they “got away with it” previously, the consequences, although they may rarely transpire, can be devastating. Research indicates that,
♦ 11% to 49% of patients always fail to wash their hands before handling their lenses 6,7,9,14,15, and that
♦ There is an increased risk of 1.5 times for developing microbial keratitis and two times greater risk for developing sterile keratitis16,17 in patients who fail to wash their hands.
Sleeping in contact lenses
Non-compliance with the recommended wearing schedule such that patients sleep in their lenses is often reported.
The majority of patients are advised to wear their lenses during the day and to remove them prior to sleeping, but not all patients follow this advice, though they may acknowledge that “infection” is a potential consequence if they sleep in lenses10.
♦ An increased risk of microbial and sterile keratitis has been reported with both conventional hydrogel and highly oxygen permeable silicone hydrogel materials18-21.
♦ A recent study reported that 6% of wearers wear their lenses overnight despite being advised to wear them for daily wear only22.
♦ In another study, only 11% of silicone hydrogel lens wearers reported that they had been prescribed lenses for extended wear, but 51% reported napping in their lenses and 16% reported sleeping in lenses occasionally, frequently or almost every night23.
♦ Sleeping in lenses is associated with a 10x increased risk of microbial keratitis16,19,24,25.
Contact lenses and care systems
Contact lens wearers are frequently not able to recall the names of their contact lens brands or care systems which can be a problem when re-ordering lenses (particularly if an order is placed via the internet) and purchasing their care system supplies.
♦ A study recently conducted at the Centre for Contact Lens Research (CCLR) found that only half of the study participants were able to recall the brand names of their habitual contact lenses from memory, and the proportion was even lower with respect to correctly recalling the brand name of their lens care system23.
Inadvertently switching to a different contact lens brand and/or care system may result in a compromised contact lens fit or visual performance and other possible incompatibilities, manifesting as solution induced corneal staining, between the lens material and the components of the care system26-29.
Failure to use care systems as recommended
Research also shows that contact lens wearers are not always compliant when it comes to their use of lens care system, failing to “rub” before rinsing and/or topping up their lens case instead of replacing the contents with fresh solution prior to disinfection:
♦ 40 to 75% of contact lens wearers fail to rub and rinse with their multipurpose solutions14,15,23.
♦ 22% of wearers report topping up their lens case occasionally, frequently or almost every night23.
Butcko et al. have reported on the importance of rubbing and rinsing lenses prior to disinfection and its role in reducing the risk of microbial keratitis30. Recently, contact lens wearers who reported that they did not rub and rinse their lenses were found to have a higher rate of self-reported contact lens related problems than those who regularly carried out these procedures23. Topping up solution can lead to incomplete contact lens disinfection which may present a significant risk for infection31. In both the recent outbreaks of Fusarium keratitis and Acanthamoeba keratitis failure to replace contact lens solution each day was associated with greater risk for infection32,33.
The role of water
Contact lenses and cases should not come into direct contact with water, but studies report that lens wearers do not always heed this advice.
♦ Approximately 50% of contact lens wearers questioned have reported swimming while wearing their lenses6,10.
♦ In a recent study, 12% of contact lens wearers admitted to exposing their lenses to tap water10.
♦ Two separate studies have found that more than 50% of patients reported using tap water to clean their contact lens cases15,23.
Microbial contamination of soft lenses has been reported to be significantly greater following swimming while wearing lenses34 and two separate case series reported that 25 to 32% of Acanthamoeba keratitis cases were associated with swimming while wearing lenses35,36. A trend has also been reported for a greater risk of developing Acanthamoeba keratitis in patients who showered while wearing their lenses33, and the direct use of tap water on contact lenses is strongly discouraged. The consequences of using tap water with contact lenses can be devastating as demonstrated by the recent outbreaks of sight threatening Acanthamoeba keratitis associated with tap water use in the Chicago area33,37,38.
Failure to clean and/or replace lens cases regularly
The recommended replacement interval for contact lens cases ranges from monthly to every six months39 but,
♦ Failure to clean lens cases daily has been reported in 61 to 79% of contact lens wearers9,15,23.
♦ Failure to replace lens cases at least every six months is reported by 22 to 63% of wearers9,15,23.
Patients who have experienced a contact lens-related problem have been shown to be 3.4 times more likely to replace their cases regularly after experiencing the problem10. This is most likely in response to either counselling by their ECP or could possibly be a self-directed preventative measure.
As a case ages, a biolfim builds up within it, which may compromise the disinfection process40,41.
Failure to replace lenses on schedule
It is well established that the most commonly reported aspect of non-compliance by contact lens wearers is with respect to lens replacement4,7,13,42,43. But does failure to comply with either the manufacturers’ or the ECPs’ recommendations for replacement result in a greater risk for patients?
Two recent studies have reported that wearing lenses for longer than recommended before replacement does indeed appear to be associated with a greater risk of contact lens related complications23,43. Use of contact lenses past the scheduled replacement date was also found to be associated with a greater risk for developing Fusarium Keratitis in a study in Singapore44. It has also been shown to be associated with inferior performance with respect to comfort and vision while wearing lenses45.
Contact lens wearers are apparently “Still crazy after all these years”. The rate of non-compliance with contact lens wear and care, similar to infection rates, does not appear to have changed significantly in the past 25 years. Non-compliant behaviours can result in serious complications and patients may not always be aware of this. It is therefore extremely important for ECPs to strive to improve compliance among their patients and to help them to modify their contact lens wear and care procedures by regular reinforcement of relevant instructions. Hopefully a combined approach by ECPs and the contact lens industry to improve compliance will help to create a “Bridge over troubled water”!
1. Collins MJ, Carney LG. Patient compliance and its influence on contact lens wearing problems. Am J Optom Physiol Opt 1986;63:952-6.
2. Claydon BE, Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt 1994;14:356-64.
3. de Oliveira PR, Temporini-Nastari ER, Ruiz Alves M, Kara-Jose N. Self-evaluation of contact lens wearing and care by college students and health care workers. Eye & Contact Lens 2003;29:164-7.
4. Donshik PC, Ehlers WH, Anderson LD, Suchecki JK. Strategies to better engage, educate, and empower patient compliance and safe lens wear: compliance: what we know, what we do not know, and what we need to know. Eye & Contact Lens 2007;33:430-3; discussion 4.
5. Efron N. The truth about compliance. Contact Lens & Anterior Eye 1997;20:79-86.
6. Sokol JL, Mier MG, Bloom S, Asbell PA. A study of patient compliance in a contact lens-wearing population. CLAO J 1990;16:209-13.
7. Morgan P. Contact lens compliance and reducing the risk of keratits. Optician 2007;234:20-5.
8. Morgan P. Contact lens compliance and reducing the risk of keratitis. www.siliconehydrogels.org.
9. Yung AM, Boost M, Cho P, Yap M. The effect of a compliance enhancement strategy (self-review) on the level of lens care compliance and contamination of contact lenses and lens care accessories. Clin Exp Optom 2007;90:190-202.
10. Bui TH, Cavanagh HD, Robertson DM. Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens 2010;36:334-9.
11. Chun MW, Weissman BA. Compliance in contact lens care. American Journal of Optometry and Physiological Optics 1987;64:274-6.
12. Radford CF, Woodward EG, Stapleton F. Contact lens hygiene compliance in a university population. J Brit Contact Lens Assoc 1993;16:105-11.
13. Dumbleton K, Woods C, Jones L, Fonn D, Sarwer DB. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye & Contact Lens 2009;35:164-71.
14. 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;34(5):207-215.
15. Wu Y, Carnt N, Stapleton F. Contact lens user profile, attitudes and level of compliance to lens care. Cont Lens Anterior Eye 2010;33:183-8.
16. Dart JK, Radford CF, Minassian D, Verma S, Stapleton F. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology 2008;115:1647-54, 54 e1-3.
17. Radford CF, Minassian D, Dart JK, Stapleton F, Verma S. Risk factors for nonulcerative contact lens complications in an ophthalmic accident and emergency department: a case-control study. Ophthalmology 2009;116:385-92.
18. Chalmers RL. What have pre- and postapproval studies shown about contact lens-related inflammatory events? Eye & Contact Lens 2007;33:388-91; discussion 99-400.
19. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet 1999;354:181-5.
20. Schein OD, Ormerod LD, Barraquer E, et al. Microbiology of contact lens-related keratitis. Cornea 1989;8:281-5.
21. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115:1655-62.
22. Jansen ME, Chalmers R, Mitchell GL, et al. Characterization of patients who report compliant and non-compliant overnight wear of soft contact lenses. Contact Lens & Anterior Eye 2011;34(5):229-35.
23. Dumbleton KA, Woods CA, Jones LW, Fonn D. The relationship between compliance with lens replacement and contact lens-related problems in silicone hydrogel wearers. Cont Lens & Anterior Eye 2011;34(5):216-222.
24. Schein OD, Glynn RJ, Poggio EC, Seddon JM, Kenyon KR. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. A case-control study. Microbial Keratitis Study Group. The New England Journal of Medicine 1989;321:773-8.
25. Schein OD, McNally JJ, Katz J, et al. The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology 2005;112:2172-9.
26. Andrasko G, Ryen K. Corneal staining and comfort observed with traditional and silicone hydrogel lenses and multipurpose solution combinations. Optometry 2008;79:444-54.
27. Garofalo RJ, Dassanayake N, Carey C, Stein J, Stone R, David R. Corneal staining and subjective symptoms with multipurpose solutions as a function of time. Eye & Contact Lens 2005;31:166-74.
28. Jones L, MacDougall N, Sorbara LG. Asymptomatic corneal staining associated with the use of balafilcon silicone-hydrogel contact lenses disinfected with a polyaminopropyl biguanide-preserved care regimen. Optom Vis Sci 2002;79:753-61.
29. Willcox MDP, Phillips B, Ozkan J, et al. Interactions of lens care with silicone hydrogel lenses and effect on comfort. Optom Vis Sci 2010;87:839-46.
30. Butcko V, McMahon TT, Joslin CE, Jones L. Microbial keratitis and the role of rub and rinsing. Eye & Contact Lens 2007;33:421-3; discussion 4-5.
31. Stapleton F, Dart JK, Minassian D. Risk factors with contact lens related suppurative keratitis. The CLAO Journal 1993;19:204-10.
32. Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA 2006;296:953-63.
33. Joslin CE, Tu EY, Shoff ME, et al. The association of contact lens solution use and Acanthamoeba keratitis. Am J Ophthalmol 2007;144:169-80.
34. Choo J, Vuu K, Bergenske P, Burnham K, Smythe J, Caroline P. Bacterial populations on silicone hydrogel and hydrogel contact lenses after swimming in a chlorinated pool. Optom Vis Sci 2005;82:134-7.
35. Radford CF, Minassian DC, Dart JK. Acanthamoeba keratitis in England and Wales: incidence, outcome, and risk factors. Br J Ophthalmol 2002;86:536-42.
36. Thebpatiphat N, Hammersmith KM, Rocha FN, et al. Acanthamoeba keratitis: a parasite on the rise. Cornea 2007;26:701-6.
37. Joslin CE, Tu EY, McMahon TT, Passaro DJ, Stayner LT, Sugar J. Epidemiological characteristics of a Chicago-area Acanthamoeba keratitis outbreak. Am J Ophthalmol 2006;142:212-7.
38. Shoff ME, Joslin CE, Tu EY, Kubatko L, Fuerst PA. Efficacy of contact lens systems against recent clinical and tap water Acanthamoeba isolates. Cornea 2008;27:713-9.
39. Wu Y, Carnt N, Willcox M, Stapleton F. Contact lens and lens storage case cleaning instructions: whose advice should we follow? Eye & Contact Lens 2010;36:68-72.
40. Dart J. The inside story: why contact lens cases become contaminated. Contact Lens & Anterior Eye 1997;20:113-8.
41. McLaughlin-Borlace L, Stapleton F, Matheson M, Dart JK. Bacterial biofilm on contact lenses and lens storage cases in wearers with microbial keratitis. J Applied Microbiology 1998;84:827-38.
42. Dumbleton K, Richter D, Woods C, Jones L, Fonn D. Compliance with contact lens replacement in Canada and the United States. Optom Vis Sci 2010;87:131-9.
43. Yeung KK, Forister JFY, Forister EF, Chung MY, Han S, Weissman BA. Compliance with soft contact lens replacement schedules and associated contact lens-related ocular complications: The UCLA Contact Lens Study. Optometry 2010;81:598-607.
44. Saw SM, Ooi PL, Tan DT, et al. Risk factors for contact lens-related fusarium keratitis: a case-control study in Singapore. Archives of Ophthalmology 2007;125:611-7.
45. Dumbleton K, Woods C, Jones L, Richter D, Fonn D. Comfort and vision with silicone hydrogel lenses: effect of compliance. Optom Vis Sci 2010;87:421-5.