Following the Fusarium and Acanthamoeba keratitis outbreaks among contact lens wearers, much awareness has been brought to the topics of contact lens care, compliance and contamination.

Almost four years after the first outbreak, papers continue to be published, educating practitioners, scientists and patients alike on all aspects of lens care.1-9
In this article, I will review the findings of some of the most recent publications and provide insight on how some of our leading colleagues are addressing contact lens care and compliance in their own practices.

Practitioner Tips to Enhance Contact Lens Care Compliance

• Communication is the key. We go over which solution patients are using and how they are using it every time they come in. If they are noncompliant, we have a discussion about complications.
—Carolyn Davis, O.D., Troy, Ohio

• I prescribe a rub regimen to every patient. I give them the analogy that just soaking lenses is like just soaking dishes and then drying them without actually wiping off the food and grease before reusing.
—Theresa Solaski, O.D., Waldorf, Md.

• I always educate patients to the highest level on contact lens care. That way, if compliance levels fall with the rub regimen, patients will hopefully at least perform a rinse step. If they don’t do this, hopefully they will still replace their solution every day. 
—Mile Brujic, O.D., Bowling Green, Ohio

• I begin educating my patients on lens care from my examination room. This adds credence to the detailed information my staff will provide them. I also make sure that my staff is educating patients to the same level of lens care that I would.
—Susan J. Gromacki, O.D., M.S., West Point, N.Y.

• I prescribe rubbing regimens to all patients who use multipurpose solutions. I have also started prescribing hydrogen peroxide systems to almost all of my soft lens patients.
—Clarke D. Newman, O.D., Dallas, Tex.

• In my practice, we always give patients both verbal and written instructions.  Then we reconfirm the information at all follow-up visits.
—Glenda Secor, O.D., Huntington Beach, Calif.

Whose Advice Should We Follow?
A recent study systematically and scientifically investigated one of the issues that can lead to patient noncompliance with proper contact lens care: the mixed message.2

Compliance was defined as “the behavior of following a given set of instructions.” Researchers noted that, before establishing the level of compliance in lens wearers, it is necessary to understand the directions that patients are initially given. They then analyzed the current contact lens and contact lens case hygiene recommendations from the three potential advisory sources for lens care instruction: manufacturers of contact lens disinfecting solutions, The United States Food and Drug Administration (FDA) and eye care practitioners who prescribe contact lenses.

With regard to lens storage case hygiene, four of the five solution manufacturers recommended via their boxes or package inserts to rinse the lens cases with disinfecting solution—i.e., AQuify (CIBA Vision), Complete (Abbott Medical Optics), ReNu Multiplus (Bausch + Lomb) and OptiFree RepleniSH (Alcon). The only exception to these instructions was CIBA Vision’s ClearCare, which carries the instructions to rinse the case with sterile saline. The manufacturers’ replacement recommendations varied from no instructions given to one to three months.

The FDA website states that contact lens cases should be replaced every three to six months.10 Like the manufacturers’ instructions, no directions are given as to whether a rub regimen is needed. But, among the eye care practitioners (n=77, New South Wales, Australia), 30% educate patients to rub their lens cases to clean them. Fifty-two percent instruct patients to rinse their cases with disinfecting solution, and 77% recommend air-drying cases after rinsing them. Seven of the practitioners even recommended cleaning the case with a toothbrush every week. The practitioners’ instructions for case replacement ranged from one to six months.2

Regarding contact lens hygiene, the manufacturers’ suggested rub time ranges from none to 10 seconds per side.2 Abbott Medical Optics discourages rubbing in a circular motion.2 The FDA’s website, meanwhile, educates patients to “rub and rinse” all lenses with any lens care products. Lastly, 92% of practitioners instruct their patients to rub their lenses to clean them, although 23% admitted that they were unsure about exactly how long a rubbing step should last.2

The authors noted that the inconsistencies among the various manufacturer recommendations may reflect the differences in the antimicrobial potencies and compositions of the individual solution formulations. In addition, it goes without saying that products perform best when used as indicated. As a result, improper use of a cleaning system may lead to lens contamination and potential eye infection.

Therefore, eye care practitioners need to be familiar with the care instructions for each and every product they prescribe. As the authors wrote, “It is impractical to assume that all lens wearers read product inserts thoroughly before use of solution.” They continue on to state that it is eye care professionals’ responsibility to communicate standard hygiene practices to lens wearers.2

They also make pertinent observations regarding case care. There are no standardized, descriptive, case-cleaning or replacement instructions on the part of the manufacturers, the FDA or practitioners—and there should be. Nearly 30% to 80% of cases show contamination with pathogens, and contaminated cases predispose lens wearers to ocular complications.9-13 Without consistent instructions, only 26% of patients replace their cases in one month or less, almost 50% replace them after five months or longer, and 10% never replace them.7

The Missing Link?
A literature review of contact lens case contamination concluded that it may contribute to the development of microbial keratitis in contact lens wearers.3 A lens case can act as a vector for the adhesion and formation of “biofilms,” the report noted. These multicellular formations of organisms can aid in bacterial adhesion and colonization by secreting substances that act as a scaffold. The biofilms may contain multiple species of organisms and can render resistance to the biocide properties of lens care products. In addition, biofilms are most responsible for the transfer of resistant organisms from the lens case to the contact lens itself.4

The authors described three methods of reducing case contamination:

• Antimicrobial cases. Silver is an antimicrobial agent that has been infused into the Pro-Guard contact lens storage case (CIBA Vision). It disrupts disulfide bonds in bacterial cells, reducing gram-positive case contamination rates by 63% to 67%.14

• Appropriate case hygiene. The authors quoted studies that found noncompliance rates with contact lens and case care ranging from 28% to 87%.15,16 First, research must determine the most appropriate lens case care. Second, practitioners need to better communicate these instructions. And finally, patients need to do better at complying with these directions. A survey by the Contact Lens Council found that although close to 75% of practitioners advised cleaning cases after each use, only 50% of patients actually did.17

• Frequency of case replacement. The authors found the FDA’s recommendation to replace cases every three to six months curious, given that most studies recommend replacing cases monthly or more frequently.17-19 To combat this problem, the authors suggested that the contact lens industry should provide a new case with each bottle of solution. In addition, patients should adopt some form of automatic reminder for their case replacement schedule, such as LensAlert!, a countdown timer.

Where Do We Go from Here?

The manufacturers, the FDA, patients and practitioners all have a great deal of work to do. There will be new solutions entering the marketplace this year and next. For this new crop of care products, the emphasis must be on safety. In addition, research must determine the optimum case care protocols and disposal intervals. Once these are established, manufacturers need to allocate resources to properly communicate case care instructions to practitioners and patients alike. For now, supplying a lens case with every new bottle of solution purchased would be a good place to start.

As for the FDA, it needs to ensure that the new care products will be safe—even when accounting for patient misuse. In June 2008, the FDA Ophthalmic Device Advisory Panel advised a new or modified disinfection efficacy test that would take into account “real-world” consumer use conditions. The FDA needs to accept this recommendation soon and institute testing of products under noncompliant conditions in the presence of a lens and a case, the latter of which is not always required in the current set of testing regulations.
Unfortunately, some patients will fail to fully comply with lens care instructions, even when educated thoroughly; it may be human nature, to some extent. But, there are various methods we can employ in our practices to enhance patient compliance (see “Practitioner Tips to Enhance Contact Lens Care Compliance,” above, for helpful suggestions from a panel of contact lens experts).20-22

As practitioners, we must make lens and case care priorities in our practices. Patient communication must occur not just upon dispensing lenses for the first time, but at every subsequent contact lens patient visit. In addition, proper lens care education needs to be the responsibility of every patient care provider in the practice—including the doctor—not just one chosen staff member. Lastly, it is imperative for us to provide high-quality, consistent education on contact lens care, cleaning and replacement. It is our responsibility to provide our patients with what is best for their eyes; it is the reason they seek our care, and it is what they deserve. 

Dr. Gromacki is a diplomate in the Cornea, Contact Lens and Refractive Technologies Section of the American Academy of Optometry. She is Chief Research Optometrist at Keller Army Community Hospital, West Point, New York.

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2. Wu Y, Nicole Carnt N, Willcox M, et al. Contact lens and lens storage case cleaning instructions: whose advice should we follow? Eye Contact Lens. 2010 Mar;36(2):68-72.
3. Hall BJ, Jones L. Contact lens cases: the missing link in contact lens safety? Eye Contact Lens. 2010 Mar;36(2):101-5.
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16. Yung AMS, Boost MV, Cho P, et al. The effect of a compliance enhancement strategy (self-review) on the level of lens care compliance and contamination of contact lenses and lens care accessories. Clin Exp Optom. 2007 May;90(3):190-202.
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19. Pinna A, Sechi LA, Zanetti S, et al. Aeromonas caviae keratitis associated with contact lens wear. Ophthalmology. 2004 Feb;111(2):348-51.
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