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23rd Annual Contact Lens Report Yes. We can manage the risks, and our patients deserve the option. Yes. We can manage the risks, and our patients deserve the option. by Burt Dubow, O.D., St. Cloud, Minn.
Many patients in this country really want the convenience of not having to remove their lenses every night. A great number already do so even without the approval of their doctors. We know, too, that many practitioners around the
country, despite the on-and-off publicity about extended wear, have never given up on that modality. I call them "closet" practitioners. They continue to take good care of their patients who sleep in their
contact lenses and they manage the risks of extended wear for those patients. The operative phrase is manage the risks. That entails a partnership between doctor
and patient that demands that we not just disclose the risks, but that we manage and minimize them in order to keep the patient happy and safe. We now have the ability to prescribe both ophthalmic devices like contact lenses
and medical treatments to deal with the complications that sometimes arise. As do other doctors who provide a cosmetic benefit to their patients, we have a dual
obligation to do what is best for each patient and not be afraid to encounter some risk in our daily lives. Optometry in the past has tried to be a "zero risk factor" profession. I don't believe
that's practical or, in fact, desirable for patient needs. If there's a defined contract between the doctor and the patient to provide what the patient wants, and if the
patient understands the risk of complications, we must deal with that by treating the occasional complication. We can manage most complications of extended wear very well. The incidence of
bacterial ulcers is quite rare. I have prescribed extended wear for thousands of patients over many years and have rarely seen a serious complication. Most of the
complications are the classic red eye caused by hypoxia or debris build-up, tight lens syndrome or overwear. Sometimes we see a non-infectious keratitis, but those
are manageable and don't leave the patient with permanent injury to their eyes or vision. I feel very comfortable offering the benefit of extended wear to my patients and
managing those risks. In fact, doctors who have a reputation for quality care and for prescribing extended wear enjoy enhanced standing among the community of
patients who want that service. This has been not only a practice-builder for me, it has been a long-term practice stabilizer as well. Patients don't have a lot of choices in doctors who will manage extended wear, so
they tend to congregate in my practice. And they spread the word. I have reaped the benefits not only in patient loyalty but also in a very strong contact lens practice,
partly based on my willingness to share and manage the risk of extended wear with my patients. The advent of disposability, at least in my clinical experience, has made extended
wear a safer modality for my patients. I have found a lower incidence of complications among those who wear disposable lenses, so that's what I try to prescribe. I also try to prescribe the super-oxygen or hyper-oxygen hyper-Dk RGP
lenses for adults and children. Many studies have shown that the contamination of contact lenses comes from either the patient's hands or the contact lens case. In children who use extended
lenses, particularly, you're minimizing their contact with both their hands and their contact lens case. I applaud the contact lens industry's efforts to develop higher Dk lenses that are
more resistant to deposits and are safer overall for the patient's long-term wearing. I also applaud the efforts of the contact lens companies to move to a 30-day lens. I
believe a 30-day extended wear lens with the news lens options can be done safely and can offer our patient population another option that gives them the convenience, comfort and safety that they want.
It can also help us provide another alternative to refractive surgery, which I fully support and believe in. I also know, though, that many of my patients don't want to
undergo surgery. Yet they want something that gives them that convenience. A 30-day lens, whether it's a soft lens or RGP, will be an important adjunct to our extended wear practice when it's approved. Dr. Dubow is in private practice and is the director of education for the EyeQuest Conference.Top No. Let's be sure we have it right this time. by Barry Weissman, O.D., Los Angeles Extended wear of contact lenses, especially of the hydrogels that we've had in our
armamentarium until now, magnifies all of the complications of contact lens wear. Corneal infection is of special concern. Most practitioners agree that hydrogel extended wear is still risky.
Manufacturers have made great strides in recent years, however, in developing materials that improve oxygen permeability. Higher oxygen- permeable lenses, both
rigid and soft, are either in our armamentarium now or they will shortly be in our hands. As those lenses become more widely available, there is renewed interest in
extended wear, along with an expectation that the FDA-approved seven-day maximum wearing schedule will be lengthened to as long as 30 days. The issue we must address is: Will we be able to recommend and fit those new
modalities with a safety factor equal to what we currently enjoy with daily wear? In 50 years of fitting contact lenses we've learned a lot about the relationship
between corneal health and contact lens wear. We know that daily wear is a relatively benign modality. Patients rarely experience severe complications. When
complications occur, they reverse course when patients discontinue contact lens wear. A small subset of contact lens patients do experience a microbial keratitis. Most of
those cases, however, involve patients who sleep with the lenses in their eyes or engage in some other inappropriate activity. But even after all this time, we don't really understand what keeps the healthy eye
from becoming infected. As many as half of contact lens patients don't care for their lenses well. If poor compliance alone were the cause of corneal infection, its incidence would be far
greater than it is. Clearly there is something else involved. For a long time, the idea has persisted that if we just get enough oxygen into the eye underneath the con- tact lens, we greatly reduce extended wear-related corneal
infections. That idea is not proven, though, and remains in the realm of educated guesses. The only way to prove it: Con- duct a study with at least 10,000 patients wearing the improved-oxygen lenses for a year or two.
My personal bias is that overnight lens wear does something to the ocular immunology. In some way it suppresses one or more aspects of ocular immunology. To my mind, it is not a purely oxygen-driven phenomenon.
On one hand, I hope that extended wear with these new lenses does move forward and receives appropriate attention in clinical trials. That's the only way we'll find out
whether or not oxygen, and oxygen alone, is the answer to the question. We cannot, however, afford to repeat the mistakes of the past. We have an especially good reason today to assure that extended wear is safe, and
that we don't over-promote the concept before we're certain of its safety. That reason is refractive surgery. If we rush to judgment on longer extended wear and
experience a similar level of complications to those of 20 years ago, with refractive surgery becoming a more and more a viable option for our patients, we may not
have another chance in the contact lens industry. I would be slow and cautious to embrace extended wear at this point. Let's be sure that we have a product that's
going to deliver, so we don't fall on our faces again. This may be our last chance for extended wear. Dr. Weissman is a professor of ophthalmology and Chief, Contact Lens Services, at the Jules Stein Eye Institute and Department of Ophthalmology at the UCLA School of Medicine.Top
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That the risks inherent in overnight wear of
contact lenses are greater than those of daily wear is indisputable. However, I strongly believe that by virtue of our training, education and position in the medical community and among the
public as vision care experts, doctors of optometry have a duty to provide the ultimate in convenience, comfort and safety for our patients. That includes offering the option of overnight wear.
Even after the negative publicity and serious
complications associated with extended wear of contact lenses almost two decades ago, both clinicians and contact lens wearers continue to express a high interest in this modality. As the doctors who must recommend the appropriate
wearing schedule for each patient and manage complications when they arise, we still face a dilemma when it comes to extended wear.