Heidi Wagner is a Professor of Clinical Optometry at the Ohio State University and co-chair of the Contact Lens Assessment in Youth Study Group. Gina Sorbara is an Associate Professor at the University of Waterloo's School of Optometry and Vision Science and Head of its Contact Lens Clinic.
Previous work suggests that young adult soft contact lens (SCL) wearers are at higher risk for corneal infiltrative events (CIEs) and other contact lens-related complications than their younger1-3 or older1-8 peers. Observational studies and clinical trials examining the frequency of CIEs in adult wearers showed that the frequency of events was highest in wearers younger than 25 years.5-8 Age was also a risk factor in a prospective study of microbial keratitis in decorative SCL wearers.9 Studies that included minors reported that the risk of events peaked in older teen and young adult wearers.1-3,8
Understanding how young adults wear contact lenses provides insight into modifiable risk factors. The associations between patient age and factors that may contribute to CIEs in young SCL wearers were assessed in a survey of SCL wearers aged 12-33 years.10 Young adult wearers reported greater frequency of napping with SCLs as well as greater frequency of sleeping in SCLs after alcohol use, when traveling, and when away from home. In the same study, these young adult wearers were more likely to wear SCLs when showering and were less likely to wash their hands before applying their lenses. Younger wearers (less than 21 years) were more likely to replace lenses when they perceived a problem rather than to adhere to the prescribed replacement regimen. Wearers aged 18-21 years reported more recent nights with fewer than six hours of sleep, more colds/flu, and higher stress levels. These wellness factors were consistent with survey findings whereby both Canadian11 and American12 university students reported that anxiety, stress, sleep difficulties and cold/flu/sore throat were the top items impacting their academic success.
What makes the young adult lens wearer unique?
Young adults face many unique exposures and demands.13 While napping in SCLs is a predictable aftermath of erratic schedules, late night studying or socializing, it can be thought of as a smaller physiological dose of overnight wear and should therefore be discouraged.
Showering in SCLs, a likely consequence of time pressures, lack of hygienic spaces for lens removal in high-density living environments, or heightened self-consciousness about spectacle wear when away from the family home, is of concern because of the association between water exposure and Acanthamoeba keratitis.14,15 Contact lenses should be never come into contact with water.
Less frequent hand washing and poor hygiene has been reported by college students wearing contact lenses.16 In this study, over half of the participants identified themselves as poor lens wearers based upon self-described inadequate lens cleaning and non-compliance with medical advice. Low hand hygiene compliance among students living in high-density living environments has been attributed to outbreaks of upper respiratory illness,17 conjunctivitis18 and Norwalk-like viruses.19 Proper hand hygiene can reduce lens case contamination20 and promote healthy SCL wear.
Reactive replacement may be a consequence of limited access to lens supplies or eye care provider (ECP), lack of funds, reliance on parents to order and pay for contact lenses, inadequate patient education, impulsive lifestyle and/or failure to plan ahead. Reinforcement of the prescribed replacement regimen is merited.
ECPs can utilize this information to deliver targeted patient education for young adult wearers. Age-related contact lens management could include refitting a young adult into a more streamlined care regimen as well as guidance on more proactive planning. Daily disposables have been associated with fewer adverse events3,21 and, if worn as prescribed, could potentially eliminate the risks associated with overnight wear.22,23 Previous investigators have described a “pantry effect” whereby patients who were in possession of an abundant supply of SCLs were likely to adhere to their replacement schedule.24 Therefore, more proactive planning could include maintaining an adequate supply of lenses and lens care products as well as identifying a hygienic space for lens care and storage and ensuring that materials (lenses, lens care, spectacles) are accessible when away from home. Furthermore, ECPs should reinforce avoidance of water exposure, proper wearing and replacement schedules as well as what to do if the patient experiences an eye problem when away from home. Furthermore, education that decorative SCLs require the same vigilance as other SCLs is merited, given reports of abuse.9
Parents and ECPs should take a proactive role in guiding older adolescents and young adults to “health care independence”. Previous studies suggest that parents underestimate the frequency of their young adult children’s risk behaviors25 and their need for guidance.26 ECPs could help educate young adult wearers together with their parents to encourage additional direction during this transition period.
As students prepare for university, they need to learn how to self-manage their health, given that the percentage of young adults furthering their education while living outside the family home approximates 70% in Canada11 and 90% in the US.12 Self-management includes prevention and behaviors that promote wellness. Daily behaviors such as SCL wearing schedules and proper lens care have important implications for ocular health. Similarly, young adults need to learn how to interact with health care providers for both preventive and acute care; the shift in responsibility from parents to adolescents may cause confusion or anxiety, particularly for individuals who have previously relied on parental direction. Additionally, previous studies have reported that situational factors and emotional responses may be barriers to health compliance.27 Situational factors for young adult SCL wearers potentially include time management, stress, inadequate finances and lack of social support. The academic demands and social pressures of college life may undermine timely procurement of contact lenses and lens care products and periodic eye examinations. In turn, the competing priorities in young adults’ lives may compromise the immune system and thus contribute the frequency of SCL-related adverse events. Emotional factors, such as denial or rebellion, have also been reported as detrimental to young adults’ health;28 these factors may manifest as feelings of invincibility and the misperception of risks associated with SCL wear. Furthermore, a higher risk-taking propensity has been associated with less compliant lens behavior.29
In summary, patient age is associated with unique lens wearing behaviors, environmental exposures, general wellness, access to care and other determinants of health that may contribute to increased adverse events in younger adult wearers. These findings support the need for targeted education and proactive planning to promote safe and healthy SCL wear during a period characterized by change and exploration.
- Lam DY, Kinoshita BT, Jansen ME, et al. Contact lens assessment in youth: methods and baseline findings. Optom Vis Sci 2011;88: 708-715.
- Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci 2011;52: 6690-6696.
- Wagner H, Chalmers RL, Mitchell GL, et al. Risk factors for interruption to soft contact lens wear in children and young adults. Optom Vis Sci 2011;88: 973-980.
- Stapleton F, Dart JK, Minassian D. Risk factors with contact lens related suppurative keratitis. CLAO J 1993;19: 204-210.
- McNally JJ, Chalmers RL, McKenney CD, Robirds S. Risk factors for corneal infiltrative events with 30-night continuous wear of silicone hydrogel lenses. Eye Contact Lens 2003;29: S153-156.
- Chalmers RL, McNally JJ, Schein OD, et al. Risk factors for corneal infiltrates with continuous wear of contact lenses. Optom Vis Sci 2007;84: 573-579.
- Chalmers RL, Keay L, McNally J, Kern J. Multicenter case-control study of the role of lens materials and care products on the development of corneal infiltrates. Optom Vis Sci 2012;89: 316-325.
- Chalmers RL, Keay L, Long B, et al. Risk factors for contact lens complications in US clinical practices. Optom Vis Sci 2010;87: 725-735.
- Sauer A, Bourcier T. Microbial keratitis as a forseeable complication of cosmetic contact lenses. Acta Ophthalmol 2011;89: e439-442.
- Wagner H, Richdale K, Mitchell GL, et al. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optom Vis Sci 2014;91: 252-261.
- American College Health Association. National College Health Assessment Spring 2013 Canadian Reference Group Executive Summary. http://www.acha-ncha.org/docs/ACHA-NCHA-II_CANADIAN_ReferenceGroup_DataReport_Spring2013.pdf Accessed 06/19/2015.
- American College Health Association. National College Health Assessment Spring 2014 Reference Group Executive Summary. http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Spring2014.pdf Accessed 06/19/2015.
- Arnett JJ, Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol 2000;55: 469-480.
- Awwad ST, Petroll WM, McCulley JP, et al. Updates in Acanthamoeba keratitis. Eye Contact Lens 2007;33: 1-8.
- Radford CF, Minassian DC, Dart JK. Acanthamoeba keratitis in England and Wales: incidence, outcome, and risk factors. Br J Ophthalmol 2002;86: 536-542.
- de Oliveira PR, Temporini-Nastari ER, Ruiz Alves M, et al. Self-evaluation of contact lens wearing and care by college students and health workers. Eye Contact Lens 2003;29: 164-167.
- White C, Kolble R, Carlson R, et al. The impact of a health compaign on hand hygiene and upper respiratory illness among college students living in residence halls. J Am Coll Health 2005;53: 175-181.
- Martin M, Turco JH, Zegans ME, et al. An outbreak of conjunctivities due to atypcial Streptococus pneumoniae. N Engl J Med 2003;348: 1112-1121.
- Moe CL, Christmas WA, Echols LJ, et al. Outbreaks of acute gastroenteritis associated with Norwalk-like viruses in campus settings. J Am Coll Health 2001;50: 57-66.
- Wu Y. The effect of contact lens hygiene behavior on lens case contamination. Optom Vis Sci 2015;92: 167-174.
- Chalmers RL, Hickson-Curran SB, Keay L, et al. Rates of adverse events with hydrogel and silicone hydrogel daily disposable lenses in a large postmarket surveillance registry: The TEMPO Registry. Invest Ophthalmol Vis Sci 2015;56: 654–663.
- Schein OD, Glynn RJ, Poggio EC, et al. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. N Engl J Med 1989;321: 773-778.
- Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115: 1655-1662.
- Schnider CM, Jedraszczak AM. The “pantry load” effect—can it help drive more compliant contact lens replacement? Optom Vis Sci 2012;89: E-abstract 120652.
- Bylund CL, Imes RS, Baxter LA. Accuracy of parents’ perceptions of their college student children’s health and health risk behaviors. J Am Coll Health 2005;54: 31-37.
- Thornton A, Orbuch TL, Axinn WG. Parent-child relationships during the transition to adulthood. J Fam Issues 1995;16: 538-564.
- Wdowik MJ, Kendall PA, Harris MA, et al. Expanded health belief model predicts diabetes self-management in college students. J Nutr Educ 2001;2001: 17-23.
- Wdowik MJ, Kendall PA, Harris MA. College students with diabetes: using focus groups and interviews to determine psychosocial issues and barriers to control. Diabetes Educ 1997;23: 558-562.
- Carnt N, Keay L, Wilcox M, et al. Higher risk taking propensity of contact lens wearers is associated with less compliance. Cont Lens Anterior Eye 2011;34: 202-206.