What`s the Solution? Update on Contact Lens Care and Compliance

What’s the Solution? Update on
Contact Lens Care and
Compliance
Susan J. Gromacki, OD, MS, FAAO
Diplomate
Cornea, Contact Lenses and Refractive Technologies
The American Academy of Optometry
Taylor’s Story
• 16 yo AAF
• Straight-A student; volleyball player
• Great kid!
• KC OS>>OD
• CXL OU
• VA sc OD 20/25
OS 20/100
New Scleral CL Fit OS
• VA specs OD 20/20-2
OS 20/50
• VA scleral CL OS (msd, 4.6/-1.62/15.8)
20/20-2
(no CL OD)
Follow-up Care
• Dispensing visit: lens fit well and she demonstrated good insertion,
removal, and care techniques
• 1st progress evaluation: uneventful
• 1 month follow-up visit: diffuse 1-2+ SPK OS only.
“How do you care for your contact lens?”
• Cleaning and disinfection were performed as prescribed (Boston dc
and Conditioning/Disinfecting solution)
• But…she had resorted to filling the lenses with the Conditioning
solution prior to application in the AM
Take Home Message
• Noncompliance with contact lens care (or poor instruction) can
negate a good fit outcome
• There is always the potential for non-compliance, even among the
intelligent! (Ask at each and every visit!)
• There are many good solutions to disinfect a GP scleral CL overnight,
but what you fill it with prior to insertion is critical
Scleral GP Lenses
Gromacki SJ. How Are We Caring for Scleral GP Contact Lenses? In: Care
Solution Corner, Contact Lenses Today 2013; June 9:3.
Filling the Lens:
• Non-preserved solution
• Unit-dose 0.9% sodium chloride inhalation/irrigation solution
• Unit-dose artificial tears
• dry eye/ provide extra lubrication and
corneal protection for patients whose lenses may exhibit areas of touch or minimal
clearance
•
Large (4 oz.) bottle of saline (e.g. Unisol)
**All options are considered off-label by the US FDA
Unit-dose 0.9% sodium chloride
inhalation/irrigation solution
• 3 or 5 mm vials
• At pharmacy or online at Amazon.com
• By definition a non-prescription item but some pharmacies require one
anyway
• insurance coverage
• educate pharmacists on scleral lenses
• Today’s standard of care
Gromacki SJ. Is Nonpreserved Saline a Prescription Medication? Ask your Pharmacist. In:
Care Solution Corner, Contact Lenses Today 2013; September 22:3.
Gromacki SJ. Scleral Lens Application: Filling the Lens. In: Care Solution Corner, Contact
Lenses Today 2013; September 8:3.
Handling
• Tripod method
• Large suction cup (DMV Corp.)
• Ezi Scleral Lens Applicator (QCase Inc.)
• O-ring (#8, hardware stores, GP
lens manufacturers)
Photo courtesy of Scleral Lens
Education Society
Photo courtesy of Acculens, Inc..
Photo courtesy of Acculens, Inc..
Special Application
“See Green Lens Inserter”
(Dalsey Adaptives, Springfield, MA)
Preventing Air Bubbles under the Lens
• Ensure that patient’s head is
parallel to the ground
• Fill the lens to its edge or rim
• Refresh Celluvisc (Allergan)
Photo courtesy of Greg DeNaeyer, OD
Surface Cleaning
Daily Cleaners
•Boston Cleaner (B+L)
•Abrasive
•Opti-Free (Alcon)
•Boston Advance
•Mildly Abrasive
•Optimum by Lobob ESC
•Non-Abrasive
Miraflow Replacements approved with GP
CL:
*same formulations
• Sereine Extra-Strength Daily Cleaner (Optikem International)
• Walgreens Extra Strength Daily Cleaner (Optikem International)
• Lens Fresh (Orion Vision Group)
Miraflow Replacements
•Same ingredients as MiraFlow:
• isopropyl alcohol, purified water, poloxamer407, and amphoteric-10
•Alcon: NOT a private label MiraFlow
•no data on whether it has the same or
similar efficacy profile as MiraFlow
Rinsing
Rinsing
• US FDA: “Do not expose your contact lenses to any
water: tap, bottled, distilled, lake or ocean.”
• Saline
• multidose preserved
• multidose non-preserved
• Potential for contamination
• aerosol
• unit dose
• expensive; tendency to under-rinse
Disinfection
GP CL Disinfecting Solutions: MPS
• Unique pH (Menicon)
Opti-Free GP (Alcon)
• Boston Simplus (B+L)
• Menicare GP (Menicon)
• Same as Optimum CDS but w/o
the daily cleaner
• Must be rinsed off (red cap)
GP Lens Care Systems
•Boston Conditioning
•Boston Advance
Conditioning
•Optimum CDS
Rinse or no rinse in the Morning…
• Each patient is different
• Leave conditioning solution on the surface:
• Enhances wettability
• May lead to under-lens debris
• Rinse with non-preserved saline or AT
• Sensitive/ allergic patients
• Patients already demonstrated under-lens debris
• NO tap water rinse in the morning!
Menicon Deluxe Care System
• Menicon Unique pH
• daily multipurpose solution for cleaning,
conditioning, and disinfecting. Rub and
rinse.
• Menicon PROGENT
• biweekly intensive cleaner, soaked
w/o digital rub, to remove protein
deposition and provide disinfection.
Previously available in the US for inoffice use only, now FDA-cleared for
home use with practitioner
approval.
Progent (Menicon)
• Mix vials A+B.
A= sodium hypochlorite
B= potassium bromide
• Wait 30 minutes.
• MUST rinse off.
• Now, larger case for sclerals
Hydrogen Peroxide:
Disinfection
•Oxidizing agent
•Neutralized via platinum disc
to non-preserved saline
•benefit for scleral CL patients
Enzymatic Cleaners
Enzymatic Cleaners
• Opti-Free SupraClens (Alcon)
• Pancreatin (porcine protease)
• Boston One Step Liquid Enzymatic Cleaner (B+L)
• Ultrazyme (AMO)
• Unizyme (Alcon)—d/c
• Subtilisin A
Scleral Lens
Troubleshooting
Initial Scleral Lens Non-wetting
• Why more frequent?
• Theory: since the lens blank
for sclerals is larger than for small
corneal lenses, the
diamond lathe
makes contact with the lens blank for a greater
amount of time, thus
creating additional heat and resulting in
nonwetting
present whether plasma-treated or not
Makeup Contamination and Scleral Lenses
•Why more frequent?
• makeup wand can more easily
graze their front surface
• thicker (2-5X)
• protrude more (300u corneal
clearance)
•Not easily removed with
over-the-counter daily
cleaners
Eliminating Non-wetting or Deposits
• Boston Laboratory Cleaner or
alcohol-based daily cleaner
then rinse, then
rub surface with a SCL MPS
• Progent
• Polish with an in-office
modification unit
• All will negate the effect of plasma tx
• Order a new contact lens for the
patient
Soft Contact Lens Care
Who Needs a Daily Cleaner?
• Heavy depositors
• Miraflow enthusiasts
• 3 mo. SCL replacement or more
• Specialty CL wearers
• Gromacki SJ. What to do when you Need Miraflow. In: Care Solution
Corner, Contact Lenses Today 2013; April 7:3.
• Gromacki SJ. Soft Lens Daily Cleaners. Contact Lens Spectrum 2013;
28(9):17.
Hybrid Lenses
Gromacki SJ. Cleaning and Disinfecting the New UltraHealth Hybrid Contact
Lens. In: Care Solution Corner, Contact Lenses Today 2013; April 21:3.
Hybrid Lenses
• Digitally rub with a SCL daily cleaner
• Rinse with NP saline
• Replace q 6 mos.
Patients must digitally
clean their lenses daily.
Duette and
UltraHealth (SynergEyes)
SynergEyes “highly recommends”:
• Clear Care® (Alcon)
Duette also approved for use with:
• Biotrue (recommended) (B+L)
• Complete Easy Rub (AMO)
• ReNu fresh (B+L)
• GP cleaners and solutions contraindicated
ClearKone (SynergEyes):
• Disinfection:
• Clear Care® (Alcon)
• Oxysept® Ultracare® Formula (AMO)
• Rinsing: only preservative-free saline,
e.g. Unisol®4 (Alcon)
Care for Specialty Soft Lenses
Soft Lenses for Keratoconus
• NovaKone (Alden) soft lens for KC: daily cleaner + H2O2
• KeraSoft IC (UltraVision CLPL, Bausch + Lomb, Art Optical): any MPS
or H2O2
• If MPS, rinse off with sterile rinsing soln before insertion
• Both: digital rubbing step (Kerasoft in b/w fingers)
Daily Cleaners for Soft Lenses
• Miraflow replacements
• Opti-Free Daily Cleaner (Alcon)
• Sensitive Eyes Daily Cleaner (Bausch + Lomb)
• Sof/Pro-Clean (SA) (Lobob)
Questions Patients Ask
Is my generic solution the same as the
sample you gave me?
Is my generic solution the same as the
sample you gave me?
No.
Can I clean my GP lens with______?
• Windex, lighter fluid, saliva, baby shampoo…
• No.
Can I use the “Brown Bottle” H2O2?
• cleared by the US FDA for ophthalmic use
• extensive clinical trial testing as well as
analytical (preclinical) testing, which
includes shelf-life stability and disinfection efficacy
• not micro-filtered, purified or sterile
• may also contain heavy metals or stabilizers
not suitable for ophthalmic use and may
discolor contact lenses; these impurities and
stabilizers remain after neutralization
Brown Bottle H2O2
• May vary in %
• No neutralization
• Hypotonic, which may cause lenses to bind to the
cornea upon insertion
• Not buffered: pH can be as low as 3.5
• disinfection and neutralization may be inconsistent or
inadequate:
• burning, stinging, lens discoloration, and other problems
• Does not contain surfactants: aid in the cleaning
and comfort of contact lenses
Can I carry my CL solution onto a
plane?
Contact Lens Solutions and U.S. Air Travel
• United States Transportation
Security Administration (TSA)
• will not pass through 3 ounces
of solution in a 12 oz. bottle
Don’t Let Your Patients..
Contact Lens Case
(Contact Solution)
• Holds “up to 3 weeks” of “your
favorite brand solution” inside
the case
• Patented “one-touch design”
dispenses solution from inside
the case
• “TSA-approved” for air travel
• “Provides microbial
protection”
$11.95
What Your Patients Can Do:
• Purchase travel-sized bottle:
• Most brands have them
• Request a sample care kit from your office
• Declare MPS as an “over-the-counter medication,” bypassing the 1
quart bag altogether
• Check it through
The FDA’s Reactions to the
Outbreaks of 2005-2007:
Meetings:
• Ophthalmic Device Panel Meeting, 2008
• Microbiological Testing for Contact Lens Care
Products, 2009
• Ophthalmic Devices Panel of the Medical Devices
Advisory Committee, May 2014
• Contact Lens Microbiology Workshop, Sept. 2014
FDA Activities
• 8 papers published in Eye & Contact Lens, Nov. 2012
• SiHy now have their own group (V) and lens care products should be tested
with them
• Rub and Rinse regimen (2010)
• No tap water with contact lenses
Still no new guidance document
last updated 1997 (17 years ago!)
Compliance Rates and
Consequences
Will Patients Ever Comply?
• Joslin CJ. Patient Compliance Issues & The New FDA Lens Care
Guidelines. Global Specialty Lens Symposium, January 29, 2010.
• Obesity Trends* Among U.S. Adults:
• Increased every year from 1989 to 2005
• <10-14% to 25-29%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Predicting Noncompliance
• The only independent significant factor predicting noncompliance
with CL care:
• risk taking propensity
Carnt N, Keay L, Willcox M, et al. Higher risk taking propensity
of contact lens wearers is associated with less compliance. Cont
Lens Anterior Eye. 2010 Nov. [Epub ahead of print]
Strategies to Improve Patient
Compliance
The psychology of non-adherence
• Szabo MM, Enlow PT and Duncan CL.
Understanding the psychology of non-adherence.
Rev Corn CL 2013 June:14-17.
• The factors in non-adherence:
• insufficient knowledge of the lens care regimen
• the interaction of the perceived severity of illness, health benefits,
and motivation
• Gromacki SJ. How to Improve Patient Adherence to your Contact Lens Wear and Care
Instructions. In: Care Solution Corner, Contact Lenses Today 2013; August 18:3.
• Gromacki SJ. Understanding the Psychology of Non-Adherence. In: Care Solution Corner,
Contact Lenses Today 2013; August 4:3.
To Improve Patient Non-Adherence:
• Improve communication skills. Adherence rates are higher when
physicians communicate well. The authors report that patients whose
physicians received additional training in patient communication
demonstrated greater adherence.
• Take a patient-centered approach. Involving the patient in his/her
health care decisions helps reinforce the recommendations.
• Ascertain compliance information by asking specific questions in a
nonjudgmental way, in an effort to receive the most honest and
accurate information.
• Tailor your lens and lens care recommendations to your individual
patient’s needs and personality.
Strategies to Improve Compliance with CL Care:
• Provide good educational handouts/ written material
• Provide instructional in-office videos
• Dispense solutions from your office (e.g. Sauflon)
• Monitors compliance with:
• formulation prescribed
• amount used
Gromacki SJ. Promoting Adherence to Your Prescribed Care Regimen, Part 2. Contact Lens Spectrum 2010;24(2):21.
Gromacki SJ. Solution Confusion. Review of Cornea and Contact Lenses 2010;147(1):22-25.
Gromacki SJ. Promoting Adherence to Your Prescribed Care Regimen, Part 1. Contact Lens Spectrum 2009;23(12):19.
Gromacki SJ. Written Educational Materials Improve Lens Compliance. Contact Lens Spectrum 2012;28(11):17.
Prescribe a Solution
• “Prescribe,” not recommend
• Write your prescription on an Rx pad
• Provide a detailed written handout with the
solution name
• Review the advantages of prescribed product
• “If you deviate from this solution, you run the risk
of compromising comfortable, long-term wear.”
• Communication is the key!
The Future is Bright!
Thank you!