Recommend contact lenses based on evidence rather than myth
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When we follow the abundance of literature on soft contact lenses, we can take advantage of the broad range of materials and wear schedules to meet patients’ needs — from children to seniors.
But research has shown that about 30% to 40% of patient care does not reflect current scientific evidence (Eccles M, et al.). Doctors may not be keeping up with the most recent and pertinent literature and applying it to patient care. Among optometrists, a 1992 study showed that disproven myths were guiding attitudes about soft contact lenses (Efron et al. 1992, Efron et al. 1992). To see whether that is still the case, I coauthored a paper that revisited those myths (Walsh et al.). Surprisingly, we found that 30 years later, many of these same myths and misconceptions are still alive and well.
How can we make sure patient care follows current evidence and optometrists do not cling to the same myths for another 30 years? We need to bust the myths head-on. Read on to learn about eight persistent myths — and the realities that can benefit both patients and practitioners.
Myth No. 1: As oxygen transmissibility increases, so does comfort
Reality: When silicone hydrogel (SiHy) lenses were introduced, we thought they would improve comfort and dryness. Now we know from studies of both reusable and daily disposable lenses that SiHy lenses have not shown any significant comfort advantage compared to hydrogels (Cheung et al., Fonn et al., Diec et al., Lazon et al.). In fact, evidence specifically shows that higher oxygen transmissibility does not correlate with increased comfort (Guillon; Jones et al.; Stapleton et al.; Efron et al., 2020).
Thus, with so many other parameters to consider when recommending a lens, oxygen transmission should be a low priority, although in my opinion oxygen transmission should be a viable factor when recommending lenses for the small number of patients who refuse to stop wearing lenses overnight.
Myth No. 2: Patients do better in low-deposition lenses
Reality: Tear film lipids and proteins provide several critical functions for the ocular surface, including playing a protective role. The literature tells us there is no relationship between higher protein deposits and discomfort (Jones et al.), but it does note a rise in discomfort associated with the amount of protein (lysozyme) denaturation (Subbaraman et al., 2012).
Lens materials are more comfortable when they do not alter the natural (active) composition of tear film proteins. Evidence shows that some FDA group 4 materials (eg, etafilcon A) maintain high levels of natural proteins with very little denatured lysozyme (Suwala et al.; Subbaraman et al., 2010; Ng et al.; Omali et al., 2018; Omali et al., 2021). Lipid deposition data does even more to bust this myth — people with comfortable eyes have more lipid deposition than those with contact lens intolerance.
Myth No. 3: Doctors should not fit hydrogels anymore
Reality: There seems to be an assumption that “newer is always better.” Globally, SiHy lenses make up 73% of soft contact lens fittings and 63% of daily disposables (Morgan et al.).
Although we have had SiHy options for 20-plus years, we are still prescribing hydrogels 27% of the time, and new hydrogels continue to enter the market. Why? Because oxygen transmission is not as important as we predicted when SiHy came along, hydrogels continue to be a frequent choice for new and existing wearers.
Myth No. 4: Children do not do well in contact lenses
Reality: There are advantages to fitting children aged 8 years and older with contact lenses. Compared with children with glasses alone, those with contact lenses are more confident about their appearance and feel more athletic and socially accepted (Walline et al., 2009; Plowright et al.). I have personally seen the benefit of fitting children in contact lenses for sports, dancing and most outdoor activities.
Data show that children as young as 8 years can insert and remove lenses quickly and easily and wear daily disposables independently. Also, training time for children aged 8 to 11 years takes only about 15 minutes longer than training for those aged 13 to 17 years (Walline et al., 2007).
There is a substantial opportunity to be more proactive about offering contact lenses to children who would benefit from them.
Myth No. 5: Spherical lenses work fine for low astigmatism
Reality: This is simple: I would never leave 0.75 D or 1 D of astigmatism out of an eyeglass prescription, thus, I do not think relying on a spherical equivalent in contact lenses is “good enough.”
The literature shows that this outdated approach negatively impacts near and distance visual acuity, reading speed and fluency, stereoacuity, comfort and ocular surface health, and it increases headaches associated with screen use (Wolffsohn et al., Wills et al., Al-Qahtani et al., Rosenfield et al., Madonado-Codina et al.).
Myth No. 6: It is difficult to fit multifocal lenses
Reality: In a maturing population, optometrists serve a lot of patients with presbyopia, and getting them better results is a great opportunity for any practice. Despite the many new designs, lens materials and fitting innovations, just 52% of presbyopic contact lens wearers have multifocal lenses; 38% of have single-vision distance lenses, and 10% have monovision (Morgan et al.). However, presbyopes who have tried multifocal contact lenses prefer them over single vision (Woods et al., Richdale et al.).
Some doctors say they do not fit more multifocal lenses because they do not understand them very well, so their fittings are slow and often unsuccessful (Morgan et al.). The good news: When we educate doctors in how to fit new generation multifocals using the fit guide, they tell us the lenses are as easy to fit as a toric lens and require no more time. Our newest designs can fit more than 94% of patients with just one or two sets of lenses.
Myth No. 7: When a patient has discomfort, it is best to switch contact lenses immediately
Reality: Contact lenses can become uncomfortable for a number of reasons, such as the fit and the combination of lens material and cleaning products.
To ensure success, we need to ask questions and identify the problem. Perhaps the patient could benefit from a switch to a different lens material and a daily disposable schedule, but if a generic BAK-preserved solution is to blame, patients can change solutions and stay in the lens that has worked for them for years.
Myth No. 8: You cannot grow a practice with contact lenses
Reality: Practitioners who doubt the profitability of contact lenses often think fitting is time consuming, and patient dropout happens too often. Both challenges can be overcome with education, which is readily available. Offering both contact lenses and spectacles puts patients’ needs and lifestyles at the center of every recommendation and helps retain them in the practice.
When we recommend contact lenses based on evidence rather than myth, we prescribe the best lens for each patient. It really does not take a lot of time, and happy patients tell their friends.
References:
- Al-Qahtani H, et al. Saudi J Ophthalmol. 2018;doi:10.1016/j.sjopt.2018.09.001.
- Cheung SW, et al. Clin Exp Optom. 2007;doi:10.1111/j.1444-0938.2006.00107.x.
- Diec J, et al. Eye Contact Lens. 2018;doi:10.1097/ICL.0000000000000363.
- Eccles M, et al. J Clin Epidemiol. 2005;doi:10.1016/j.jclinepi.2004.09.002.
- Efron N, et al. Optician. 1992;204:12-14,23-24.
- Efron N, et al. Cont Lens Anterior Eye. 2020;doi:10.1016/j.clae.2020.03.015.
- Fonn D, et al. Eye Contact Lens. 2003;doi:10.1097/00140068-200301001-00028.
- Guillon M. Eye Contact Lens. 2013;doi:10.1097/ICL.0b013e31827cb99f.
- Jones L, et al. Invest Ophthalmol Vis Sci. 2013;doi:10.1167/iovs.13-13215.
- Lazon de la Jara P, et al. Optom Vis Sci. 2018;doi:10.1097/OPX.0000000000001304.
- Maldonado-Codina C, et al. Cont Lens Anterior Eye. 2021;doi:10.1016/j.clae.2020.11.007.
- Morgan PB, et al. Cont Lens Anterior Eye. 2015;doi:10.1016/j.clae.2014.07.014.
- Morgan P, et al. Cont Lens Spectr. 2021;36:32-38.
- Ng A, et al. J Biomed Mater Res B Appl Biomater. 2013;doi:10.1002/jbm.b.32927.
- Omali NB, et al. Cont Lens Anterior Eye. 2018;doi:10.1016/j.clae.2018.03.005.
- Omali NB, et al. Cont Lens Anterior Eye. 2021;doi:10.1016/j.clae.2020.05.006.
- Plowright AJ, et al. Optom Vis Sci. 2015;doi:10.1097/OPX.0000000000000454.
- Richdale K, et al. Optom Vis Sci. 2006;doi:10.1097/01.opx.0000216098.62165.34.
- Rosenfield M, et al. Ophthalmic Physiol Opt. 2012;doi:10.1111/j.1475-1313.2011.00887.x.
- Stapleton F, et al. Eye Contact Lens. 2017;doi:10.1097/ICL.0000000000000318.
- Subbaraman LN, et al. J Biomater Sci Poly Ed. 2010;doi:10.1163/156856209X415873.
- Subbaraman LN, et al. Optom Vis Sci. 2012;doi:10.1097/OPX.0b013e318269e583.
- Suwala M, et al. Eye Contact Lens. 2007;doi:10.1097/01.icl.0000244155.87409.f6.
- Walline JJ, et al. Optom Vis Sci. 2009;doi:10.1097/OPX.0b013e3181971985.
- Walline JJ, et al. Optom Vis Sci. 2007;doi:10.1097/OPX.0b013e3181559c3c.
- Walsh K, et al. Clin Exp Optom. 2021;doi:10.1080/08164622.2021.2003693.
- Wills J, et al. Optom Vis Sci. 2012;doi:10.1097/OPX.0b013e3182429c6b.
- Wolffsohn JS, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2010.09.022.
- Woods J, et al. Eye Contact Lens. 2009;doi:10.1097/ICL.0b013e3181b5003b.
For more information:
Kurt Moody, OD, FAAO, is director of North America professional education at Johnson & Johnson Vision in Jacksonville, Florida.
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