Percy Lazon de la Jara is Head of Clinical Research at the Brien Holden Vision Institute and Visiting Fellow at the School of Optometry and Vision Science, University of New South Wales, Australia.
From the earliest days of contact lens solutions, when patients would prepare their own saline solutions, to the latest generations of double disinfectant multipurpose solutions, contact lens care systems have evolved to provide convenience and comfort without sacrificing antimicrobial efficacy.
Care and maintenance is one of the most important aspects of contact lens wear. However, patient compliance and prescribing the appropriate lens care system both play crucial roles in successful contact lens wear.
Early care systems
A few decades ago, typical care systems required use of a daily cleaner, rinsing solution, disinfecting solution, weekly protein cleaners, lubricating or rewetting drops and a lens storage case. Thermal and hydrogen peroxide disinfection were (and are still) alternative lens care systems. A significant disadvantage of these early care systems, apart from the ample opportunity for non-compliance, was the occurrence of hypersensitivity reactions and lid changes such as contact lens-induced papillary conjunctivitis, and (in the worst cases) giant papillary conjunctivitis, both of which were associated with some of these disinfecting agents.
Manufacturers formulated their own lens care systems independently and in most cases compatibility between brands was not a consideration. For the contact lens wearer, it was a challenge to remember how to use these products and their ability to achieve compliance was compromised. Many patients did not follow the instructions and modified the care regimen according to their needs, with the unfortunate outcome of a series of undesirable contact lens complications.
The advent of multipurpose solutions
The first multipurpose solutions (MPS) were launched in the early 90s. These modern lens care systems offered the convenience of a single solution to perform the functions of the previous multi-component regimen of cleaning, rinsing and disinfecting. Moreover, the use of high molecular weight preservatives to avoid disinfectant-related hypersensitivity was a novelty. Soft contact lenses were starting to be replaced more frequently, adding to the reduction in contact lens associated adverse events. The advent of these new approaches marked a clear benefit to the ocular health of the contact lens wearing population.
Although early studies suggested that a digital rub step was necessary to remove lens deposits, which are a potential anchor point for bacteria1 and induce discomfort and inflammatory reactions,2 it was predicted that these simplified care regimens would result in increased compliance and a reduction of ocular adverse events due to increased antimicrobial efficacy and reduced ocular surface toxicity. In an attempt to offer increased convenience to the user, “no rub” MPS were launched, with claims of superior cleaning efficacy.3 Peer-reviewed studies detailing a comparison of disinfection efficacy of “rub and rinse” versus “no rub” are scarce.4,5 However, these extant reports support only the complete rub and rinse regimen as providing an appropriate level of cleaning to ensure disinfection against all microorganisms.4,5 The outbreaks of Acanthamoeba and Fusarium Solani 6-14 were a wake-up call for the contact lens industry to re-think approaches to contact lens care and maintenance and, more importantly, to improve safety.
Prescribing the right combination of lens and lens care system
Recently, new multi-purpose solutions with dual disinfectants and comfort enhancers have been launched, offering good antimicrobial efficacy. Nowadays, practitioners and contact lens wearers have a variety of options in terms of lens care systems and contact lenses. However, given the increasing evidence that ocular adverse events can arise due to interactions of contact lens materials and the ingredients of lens care systems,15 prescribing the right contact lens-solution combination is important in achieving a successful contact lens wearing experiencing. Getting the balance right between antimicrobial effectiveness and low levels of adverse events on the ocular surface is not a trivial exercise and might be beyond current technologies.
To, “Is the solution the real solution?”. I think partly, yes. Current lens care products meet FDA standards, but only based on laboratory and in-vitro experiments—not taking into account “real world conditions”. Improving compliance might be more important than we thought. We, as practitioners, play a key role in prescribing appropriate products and educating patients about the importance of following recommended regimens to minimise any risk of ocular complications during contact lens wear.
Patient compliance plays a key role in minimising ocular adverse events.16 Avoidance of rubbing lenses and rinsing lenses and lens cases, inadequate contact lens disinfection, “topping up” solutions, wearing lenses beyond their recommended replacement schedule, and not replacing lens cases frequently enough (monthly) are factors that are more likely to lead to complications during contact lens wear. The good news is that these are modifiable factors that can reduce this risk.
So, Is the solution the real solution? Partnership between industry, regulatory bodies, practitioners and patients is the solution to minimise undesirable events during contact lens wear.
1. Shih KL, Hu J, Sibley M J. The microbiological benefit of cleaning and rinsing contact lenses. Intl Contact Lens Clin 1985;12(8).
2. Luensmann D, Jones L. Albumin adsorption to contact lens materials: a review. Cont Lens Anterior Eye 2008; 31(4): 179-187.
3. Larsen S, Smith C, Mathis J, Smith PB, Bronner C, Maynard R, et al.. Comfort differences between multi-purpose solutions. Contact Lens Spectrum 2002;17(12):4.
4. Kilvington S, Lonnen J. A comparison of regimen methods for the removal and inactivation of bacteria, fungi and Acanthamoeba from two types of silicone hydrogel lenses. Cont Lens Anterior Eye 2009;32(2):73-77.
5. Zhu H, Bandara MB, Vijay AK, Masoudi S, Wu D, Willcox MD. Importance of rub and rinse in use of multipurpose contact lens solution. Optom Vis Sci 2011;88(8):967-972.
6. Bernal MD, Acharya NR, Lietman TM, Strauss EC, McLeod SD, Hwang DG. Outbreak of Fusarium keratitis in soft contact lens wearers in San Francisco. Arch Ophthalmol 2006;124(7):1051-1053.
7. Bullock JD. An outbreak of Fusarium keratitis associated with contact lens use in the Northeastern United States. Cornea 2008;27(8):973-974.
8. Chang DC, Grant GB, O’Donnell K, Wannemuehler KA, Noble-Wang J, Rao CY, et al.. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA-Journal of the American Medical Association 2006;296(8):953-963.
9. Gaujoux T, Chatel MA, Chaumeil C, Laroche L, Borderie VM. Outbreak of contact lens-related Fusarium keratitis in France. Cornea 2008;27(9):1018-1021.
10. Gorscak JJ, Ayres BD, Bhagat N, Hammersmith KM, Rapuano CJ, Cohen EJ, et al.. An outbreak of Fusarium keratitis associated with contact lens use in the northeastern United States. Cornea 2007;26(10):1187-1194.
11. Gorseak J, Ayres BD, Chu DS. An outbreak of Fusarium keratitis associated with contact lens use in the Northeastern United States – Reply. Cornea 2008;27(8):974-974.
12. 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(2):212-217.
13. Khor WB, Aung T, Saw SM, Wong TY, Tambyah PA, Tan AL, et al.. An outbreak of Fusarium keratitis associated with contact lens wear in Singapore. JAMA-Journal of the American Medical Association 2006;295(24):2867-2873.
14. Verani JR, Lorick SA, Yoder JS, Beach MJ, Braden CR, Roberts JM, et al.. National outbreak of Acanthamoeba keratitis associated with use of a contact lens solution, United States. Emerg Infect Dis 2009;15(8):1236-1242.
15. Carnt NA, Evans VE, Naduvilath TJ, Willcox MDP, Papas EB, Frick KD, et al.. (2009). Contact lens-related adverse events and the silicone hydrogel lenses and daily wear care system used. Arch Ophthalmol 2009;127(12):1616-1623.
16. Bui TH, Cavanagh HD, Robertson DM. Patient compliance during contact lens wear: Perceptions, awareness, and behavior. Eye & Contact Lens-Science and Clinical Practice 2010;36(6):334-339.