Contact lens wear has been a safe and successful modality for millions of patients over the last several decades. It’s an accomplishment and a source of pride for everyone involved. But clinicians, manufacturers and regulatory agencies all have a stake in continually striving to reduce adverse events. Do your efforts to encourage compliance and mitigate risk reflect the latest consensus guidelines? Perhaps some new initiatives from the Centers for Disease Control and Prevention (CDC) can help.

Recently, the CDC closely collaborated with the FDA, eye care providers, manufacturers and academic institutions to create the Healthy Contact Lenses Program, an initiative to reduce the burden of contact lens-associated eye infections in the United States. Since July 2013, the CDC and partners have worked to increase awareness of behaviors and risk factors that can affect the eye health of contact lens wearers by developing and disseminating recommendations about the proper wear, care and maintenance of contact lenses. These recommendations address key risk factors for corneal infections among contact lens wearers. 

Microbial keratitis. Photo: Christine Sindt, OD

Corneal Infections in Contact Lens Wearers 
Improper wear and care of contact lenses can significantly increase the risk of corneal infections, including microbial keratitis.1,2 With rates of noncompliance with contact lens wear and care recommendations ranging anywhere from 40% to 91%, many contact lens users are at risk for these painful, sometimes blinding eye infections as a result of inadequate lens hygiene.3.4  

Poor contact lens sanitation habits have been implicated in multi-state outbreaks of microbial keratitis. Outbreak investigations of Fusarium and Acanthamoeba keratitis in 2006 and 2007 identified specific multipurpose solutions with inadequate disinfection capabilities that were consequently recalled from the market.5-7 However, further investigation also pointed to noncompliant contact lens wear and care practices as additional contributing factors to these outbreaks. 

Behavioral risk factors for contact lens-related corneal infections are well known to many eye care providers; these include sleeping in contact lenses, poor storage case hygiene, “topping off” of solution in the storage case and exposing contact lenses to water, among others.5,7-16 Eye care providers play an important role in educating patients on proper wear and care practices that can reduce the risk of serious eye infections; however, the CDC and its partners identified several factors that suggested the need for a coordinated effort to promote healthy wear and care: persistence of contact lens-related eye infections, continued high rates of non-compliant behaviors and lack of consistent messaging around proper wear and care practices.18-20 Factors driving noncompliant behavior remain for the most part poorly understood, but economics, time requirements and regimen complexity are all thought to play a part.17

Encouraging Lens Health
The CDC's Healthy Contact Lenses Program was implemented in July 2013 using financial sup­port from the nonprofit Contact Lens Institute* with the mission of developing clear and consistent contact lens wear and care recommendations. The program team at CDC, within the Waterborne Disease Prevention Branch, convened a workgroup of experts in eye health, contact lenses and epidemiology to advise program activities. With assistance from this advisory group, the CDC continues to work on creating data-driven recommendations and health promotion materials that are available on the CDC Healthy Contact Lens Wear and Care website (www.cdc.gov/contactlenses). 

The website provides a range of information on the care of contact lenses, including decorative lenses, and the peer reviewed, microbiologic, epidemiologic and clinical studies that provide scientific evidence for these recommendations. Data on germs, infections and eye complications related to contact lens wear and promotional materials geared towards certain target audiences, including parents of children who are either current or potential contact lens wearers, are also available. Eye care providers can also use the health promotion materials to assist with patient education in their practice. 

In addition to the website, the CDC expanded its contact lens health promotion efforts by implementing the first annual Contact Lens Health Week campaign, which took place the week of Nov. 17-21, 2014. The goal of this campaign was to actively promote healthy contact lens wear and care among older teens and young adults, a group predisposed to an increased risk of corneal inflammatory events related to contact lens wear.21 Healthy contact lens wear and care messages were disseminated through social media channels popular among older teens and young adults, such as Twitter, Facebook, Instagram and Pinterest. These messages conveyed the risks of improper contact lens use as well as tips for avoiding infection, such as keeping water away from contact lenses, cleaning and replacing storage cases and visiting an eye care provider on an annual basis. 

The CDC also collaborated with university campus groups, eye health organizations and the contact lens industry to distribute campaign materials and messages to young adult contact lens wearers and their eye care providers. Materials developed for the campaign include a toolkit for professional eye care organizations, college campuses, members of the contact lens industry, public health organizations and non-profit organizations; a video collaboration with Medscape and podcasts on keratitis and contact lens use; promotional material distributed through Twitter, Google+, Pinterest and other CDC social media channels; a feature article on healthy contact lens wear and care on the CDC’s website; and the Morbidity and Mortality Weekly Report (MMWR), which covered the estimated burden of keratitis in the US. The authors of the MMWR article analyzed insurance claims data from 2010 and found that Americans made nearly one million doctor and emergency department visits per year for keratitis and contact lens-related diagnostic codes, resulting in $174.9 million in direct healthcare costs and the use of over 250,000 hours of clinician time. The authors also referenced poor contact lens hygiene as an important risk factor for keratitis and provided tips for contact lens wear and care to reduce the risk of keratitis. 

Thanks to support from partner organizations and media coverage from the MMWR, the CDC successfully achieved the following outcomes:

• 20 partners from clinical, regulatory, public health, academic, industry and non-profit sectors helped promote the Contact Lens Health Week campaign

• 13 reporters called in to CDC’s media briefing on the MMWR keratitis article, including the Associated Press, National Public Radio and The Washington Post.

• 463 news articles on contact lens health were published by top news sources, including The Examiner, The Washington Post and Reuters

• 2,493 tweets about contact lens health were sent from CDC and external groups 

• 727 Facebook posts about contact lens health were generated

• One Twitter chat on contact lens health occurred with Good Morning America’s Rich Besser

This campaign was the first coordinated effort to distribute CDC’s newly developed contact lens health recommendations and materials to the public and resulted in an estimated reach of 48.6 million individuals—including eye care providers and the general public—through traditional and social media. Campaign efforts also contributed to a 427% increase in traffic to the CDC contact lenses website, indicating a significant increase in the program’s visibility. While resources were not available to collect information on behavior, attitudes and awareness with regards to contact lens hygiene prior to the campaign, the CDC aims to collaborate with other partner organizations in the future to field an online survey of contact lens wearers that will establish a baseline for these outcome measures. A follow-up survey after subsequent contact lens health campaigns could then provide information on changes in behavior, attitudes and awareness as a result of the health promotion efforts. 

Since the conclusion of the Contact Lens Health Week campaign, CDC has continued to work on promoting healthy habits among contact lens wearers. Plans are in place to make this campaign an annual event and to promote contact lens health and patient education throughout the year. Please join CDC in this effort by visiting www.cdc.gov/contactlenses, downloading contact lens health promotion materials and teaching your patients how to properly wear and care for their contact lenses. Together, we can help prevent eye infections linked to poor contact lens hygiene.

*The Contact Lens Institute’s member companies include Alcon, Bausch + Lomb, Cooper-Vision and Johnson & Johnson Vision Care. The Department of Health and Human Services/Centers for Disease Control and Prevention does not endorse any particular company, product, activity or enterprise.   

Ms. Rao is a health communications specialist and the coordinator of the Healthy Contact Lenses Program at the Centers for Disease Control and Prevention. She received her Master of Public Health degree from Emory University in Atlanta.

1. Keay, L, Stapleton F, and Schein O. Epidemiology of contact lens-related inflammation and microbial keratitis: a 20-year perspective. Eye Contact Lens, 2007. 33(6 Pt 2): p. 346-53, discussion 362-3.
2. Stapleton, F. Contact lens-related microbial keratitis: what can epidemiologic studies tell us? Eye Contact Lens, 2003. 29(1 Suppl): p. S85-9; discussion S115-8, S192-4.
3. Sokol, JL, Mier MG, Bloom S  and Asbell, PA. A study of patient compliance in a contact lens-wearing population. CLAO J, 1990. 16(3): p. 209-13.
4. Claydon, BE and Efron N. Non-compliance in contact lens wear. Ophthalmic Physiol Opt, 1994. 14(4): p. 356-64.
5. Chang, DC et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA, 2006. 296(8): p. 953-63.
6. Ross, J et al. Clinical characteristics of acanthamoeba keratitis infections in 28 States, 2008 to 2011. Cornea, 2014. 33(2): p. 161-8.
7. Verani, JR et al. National outbreak of Acanthamoeba keratitis associated with use of a contact lens solution, United States. Emerg Infect Dis, 2009. 15(8): p. 1236-42.
8. Stapleton, F et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology, 2008. 115(10): p. 1655-62.
9. Dart, JK et al. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology, 2008. 115(10): p. 1647-54, 1654 e1-3.
10. Poggio, EC et al. The incidence of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. N Engl J Med, 1989. 321(12): p. 779-83.
11. Schein, OD et al. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. A case-control study. Microbial Keratitis Study Group. N Engl J Med, 1989. 321(12): p. 773-8.
12. Stapleton, F et al. Risk factors for moderate and severe microbial keratitis in daily wear contact lens users. Ophthalmology, 2012. 119(8): p. 1516-21.
13. Visvesvara, GS, Moura H, and Schuster, FL. Pathogenic and opportunistic free-living amoebae: Acanthamoeba spp., Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea. FEMS Immunol Med Microbiol, 2007. 50(1): p. 1-26.
14. Hammersmith, KM. Diagnosis and management of Acanthamoeba keratitis. Curr Opin Ophthalmol, 2006. 17(4): p. 327-31.
15. Joslin, CE et al. The association of contact lens solution use and Acanthamoeba keratitis. Am J Ophthalmol, 2007. 144(2): p. 169-180.
16. Mena, KD and CP Gerba, Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol, 2009. 201: p. 71-115.
17. Bui, TH, Cavanagh, HD and Robertson DM. Patient Compliance During Contact Lens Wear: Perceptions, Awareness and Behavior. Eye Contact Lens. Nov 2010; 36(6): 334–339.
18. Yoder, J.S. et al. Acanthamoeba keratitis: the persistence of cases following a multistate outbreak. Ophthalmic Epidemiol, 2012. 19(4): p. 221-5.
19. Dumbleton, K., D. Richter, P. Bergenske, and L.W. Jones, Compliance with lens replacement and the interval between eye examinations. Optom Vis Sci, 2013. 90(4): p. 351-8.
20. Bui, T.H., H.D. Cavanagh, and D.M. Robertson, Patient compliance during contact lens wear: perceptions, awareness, and behavior. Eye Contact Lens, 2010. 36(6): p. 334-9.
21. Chalmers 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(9):p.6690-6.