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
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.
REFERENCES
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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.
