Compliance Factors Associated With

Contact Lens-Related Dry Eye
Padmapriya Ramamoorthy, B.S.Optom., M.S., Ph.D, Jason Jay Nichols, O.D., M.P.H., Ph.D.
Eye Contact Lens. 2014;40(1):17-22.

Abstract and Introduction
Objective: To determine if compliance factors are associated with contact lensrelated dry eye (CLDE).
Methods: The data were derived from subject responses to a compliance survey
administered in a cross-sectional study including 100 healthy, daily (nonovernight),
experienced soft contact lens wearers (50 normal and 50 with CLDE). Classification
into normal or CLDE groups was based on Contact Lens Dry Eye Questionnaire
scores, tear breakup time, and 2 hours difference between total and comfortable
daily lens wear hours. The compliance survey queried aspects of lens care, rub and
rinse practices, lens and lens case replacement frequency, solution replacement,
and sleeping with lenses. Statistical analysis of the data was performed using
unpaired T tests, χ2, and Fisher exact tests as applicable.
Results: The average age of all subjects was 24.8±4.4 years, and 60% were
women. Overall compliance rates were low for several variables including
recommended replacement of contact lenses (53%), rub and rinse practices (69%
and 45%, respectively), care solution topping-off (80%), and washing hands before
handling lenses (48%). However, almost no compliance factors were associated with
CLDE status, with the exception of perceived ease or difficulty with lens care, which
was rated as more difficult by the CLDE group (P=0.004).
Conclusions: Overall compliance rates with contact lens care practices are very
low, highlighting the need for more effective methods of patient education regarding
contact lens care and compliance. However, almost no compliance factors were
found to be associated with CLDE. Factors other than compliance likely play a
bigger role in CLDE.

5–9] Measures to improve compliance such as the introduction of simplified contact lens care systems. good compliance was defined as the fulfillment of three standardized criteria.25] despite the increased risk for contact lens contamination. not surprisingly. adherence to proper procedures for contact lens wear schedules.[30–42] Violations of prescribed regimens for replacement of lens and lens care components are currently widespread.[1.26–29] despite anecdotal and scientific reports of compromises in vision. correct use of a Food and Drug Administration (FDA)-approved care system.46] despite the potential risk for increased ocular bioburden. daily disposable contact lenses (which avoid lens care altogether).[1] Despite clear educational resources on contemporary contact lens care. recommended cleaning exercises for contact lenses such as the performance of rub and rinse practices are also compromised. and care of the contact lenses. microbial keratitis and corneal infiltrates.47–50]Perhaps. pamphlets.24. replacement schedules.25] and approximately 6% report unauthorized overnight wear of lenses.[17. [16–23] For example. hand washing before lens handling. and moderate-to-severe corneal staining with use of lenses beyond their MRRP.24. namely. [17–19. etc. As many as 75% to 77% lens wearers report being noncompliant with rubbing their lenses. [17.Introduction Compliance in the context of contact lens wear is a multifaceted issue including many factors such as good hand hygiene before handling contact lenses. comfort.[2–4] high rates of noncompliance in contact lens wearers have been recognized for many years.43–45] In addition. and additional patient education using various media (videos. and adherence to a daily wear schedule.[17–19.[10–16] Contact lens wearers are noncompliant with multiple aspects of contact lens wear despite awareness of heightened risks for potentially harmful clinical effects. 40% to 74% contact lens wearers do not replace lenses per the manufacturer's recommended replacement schedule (MRRP).) seem to have had little or no effect on patient compliance.[5. contact lens complications. outbreaks of infectious keratitis have occurred in recent years given that 13% to 57% contact lens wearers reported "topping off" practices and reuse of care solution. respectively.51] . For instance. only 53% to 77% contact lens wearers wash their hands before handling their lenses[17–19. [35–41.48. In prior years.

which led to two screen failures. Once subjects signed the informed consent. Informed consent was obtained from all subjects at enrollment. use of ocular medications containing active pharmaceutical agents involving or affecting the ocular surface. Given the high frequency of both noncompliance and CLDE in the contact lens wearing population. a review of inclusion and exclusion criteria was conducted. Subjects were required to be aged between 18 and 39 years (inclusive). More specifically. prior corneal refractive surgery. other ocular surgery that may affect the ocular surface. history of ocular infection.Contact lens-related dry eye (CLDE) continues to be a major issue affecting nearly half of all contact lens wearers. it is hypothesized that noncompliant practices may be associated with CLDE.[56– 61] Noncompliance with proper procedures for contact lens wear and care are likely to result in the wear of soiled and contaminated contact lenses. and systemic disease or medications that may affect the eye. Exclusion criteria included overnight lens wear. The inclusion criteria for the study included healthy. which may lead to compromise in the lens wearing experience. lactation. allergy within the past 6 months. . Subjects This was a cross-sectional study of 132 current soft contactlens wearers. Methods The study protocol was approved by an Institutional Review Board in accordance with the tenets of the Declaration of Helsinki. active ocular disease. wearing of soiled contact lenses could be associated with symptomatology and associated with CLDE in the noncompliant contact lens wearer. to wear their contact lenses for at least 6 hours per day and 5 days per week (on average) and to have a best-corrected visual acuity of at least 20/30 in each eye. daily disposable lens wear. The objective of this work was to determine the association between noncompliant practices with contact lens wear and care and CLDE.[52–55] Contact lens-related dry eye and alterations of the tear film in contact lens wearers are known to be associated with problems such as reduced visual performance and decreased lens wearing time. inflammation. daily (nonovernight). which may ultimately lead to discontinuation from contact lens wear altogether. pregnancy. experienced soft lens wear of at least 1 year.

that is. the subjects were examined and classified into one of the two groups—normal or CLDE—using the following criteria: Contact Lens Dry Eye Questionnaire classification. hand washing before handling contact lenses. Thus. Compliance Assessment A compliance survey was administered in this study and included questions on the following: difficulty or ease with contact lens care. monthly. solution replacement and topping off practice. no other limitations were placed on lens replacement schedules to allow study of any potential association between lens replacement cycle and dry eye status. Use of daily disposable lenses. removes the role of the contact lens and associated compliance in question. was also excluded in this study. Except for the abovementioned factors. and unprescribed napping or overnight contact lens wear. use of doctorrecommended or generic care solutions. rub and rinse practices. hence. This classification after informed consent also led to a reduction in the overall sample size of 132 to 100 analysis eligible subjects.[52]fluorescein-based tear breakup time values measured 5 minutes after contact lens removal (normal>7 seconds. although potentially useful in improving comfort. and quarterly replacement and one conventional unplanned lens wearers were eligible for participation in the study. subjects with biweekly. which could confound the testing of our hypothesis (in that we are not testing for additional complications but rather the relation between noncompliance and CLDE). CLDE≤7 seconds).Extended wear of contact lenses was excluded because it is associated with a whole host of issues on its own such as increased risk for corneal inflammatory events. contact lens and lens case replacement frequency. CLDE>2 or more hours difference). Following informed consent. and a difference between total average daily wear time and total average daily comfortable wear time (normal<2 hours difference. thus negating the ability to test our hypothesis and. Subjects were required to respond on a scale of 1 to 10 for the question on perceived difficulty or ease of care for and cleaning their contact lenses. Questions with "yes or no" response options included queries on whether subjects: . 29 subjects were deemed ineligible because of lack of fulfillment of all 3 criteria required for classification into either subject group and 1 subject was excluded because of ocular disease discovered during the examination.

particularly when a cell had less than five responses.  Rubbed both front and back of lenses. never. every year.  Rubbed their lenses during cleaning. For categorical variables. or always topped off the solution. Rinsed their contact lenses before storage in a case. Response options for the (actual) frequency of contact lens case replacement included every month. every 3 months. or other. very year. Unpaired T tests were used for assessing differences between subject groups on continuous variables. half the time. Response options for the question on (actual) contact lens replacement frequency included daily. responses for some survey questions were collapsed to overcome problems with insufficient cell data. or wipes before inserting or removing lenses from the eyes and  Whether their lens care system was recommended by their doctor. .  Slept with their contact lenses. Statistical Analysis Statistical analyses were performed using IBM SPSS version 17. every 3 months. subjects could indicate that they occasionally.  Washed hands with soap.0 as described later to test for differences in compliance characteristics between subjects classified by group status (normal and CLDE). every 2 weeks. and  Duration for which each side of the contact lens was rubbed and rinsed. most of the time. monthly. every 6 months. The χ2 and Fisher exact tests were used as appropriate for testing associations between categorical compliance variables and CLDE status.  Frequency of purchase of new contact lens solutions. or other.  Open-ended questions included queries on:  Frequency of sleeping with contact lenses. weekly. For the question on topping-off practices. antiseptic liquid.

3±2. The summary of these results is presented in Table 1 . P=0.9±4.1±4. respectively. respectively. Sixty-eight percent of the CLDE group was women compared with 52% in the normal group (χ 2=2.5 years. respectively. The percent of compliance with manufacturer-recommended contact lens replacement was 56% and 50% in the CLDE and normal groups. neither age nor gender was statistically associated with any other compliance-related variable. 21% reported care solution topping off. Subjects who topped off care solution 50% or more of the time were approximately 3 years younger on average compared with those who never or occasionally topped off (22. Similarly. 25. For example.9 years compared with 23.01).7±3. 47% subjects were not compliant with recommended contact lens replacement and 40% were not compliant with recommended lens case replacement. were not compliant with rub and rinse practices with their lens care regimen.6.7 years in the normal group (T=-2. whereas it was 26% and 20% for the use of generic care solutions in the CLDE and normal groups.Results Age and Gender The CLDE group was slightly older with a mean age of 25. and 52% did not follow proper hand hygiene practices. Overall Compliance Overall compliance rates were low for several self-reported compliance factors. T=-2. and the results are summarized in Table 1 .10). Regarding lens care regimen. P=0. respectively.P=0. However. 31% and 54%. Compliance and Contact Lens Dry Eye Analysis of categorical compliance variables did not reveal any significant associations between compliance factors and CLDE status.95. The accompanying χ 2statistic and P values for the above comparisons are presented in Table 1 .7. Compliance rates were similar between the normal and CLDE groups for compliance with rub and rinse practices and hand hygiene before handling contact lenses. .009).5 years vs. the percent of unprescribed napping or overnight contact lens wear in the CLDE and normal groups were 10% and 2%. The percent of the use of doctor-recommended lens care solutions was 54% and 64% in the CLDE and normal groups.

46.66] The reasons for such high rates of noncompliance are unclear with some studies citing lack of patient awareness of potential risks. Discussion Overall Compliance The overall compliance rates among contact lens wearers were found to be low for several factors including those related to contact lens.68] Compliance and Contact Lens-related Dry Eye Difficulty or ease of contact lens care was rated as significantly lower (more difficult) in the CLDE group. This finding may reflect that subjects with CLDE feel burdened by their lens care regimen.14. [20. Alternatively. and washing hands before handling lenses are comparable with the estimates from previous studies. care solution topping off. rub and rinse practices. possibly indicating a difference in patient attitude toward contact lens care. [13.. [20. It seems unlikely that the perceived difficulty toward lens care would lead to the development of CLDE. which may possibly include the need for additional efforts (e.62–65] In fact.[22.21.[17.26–28] Recent reports from the United States and elsewhere highlight a disturbing continued trend of widespread noncompliance. several recent surveys indicate contact lens wearer apathy to potential consequences of noncompliant behavior despite awareness of risk. removing and reinserting lenses if dry) or the need for specialized products (e.. the perceived difficulty in lens care of the CLDE group may also reflect that subjects with CLDE have a poor attitude or negativity toward the lens care regimen. care solution. however.28.23.g. contact lens case.46. which may be prompted by their CLDE status.21.67] The current noncompliance findings indicate a need for more effective methods of patient education and reinforcement of contact lens care and compliance. which range from 25% to 44%.25.Table 2 provides an overview of the differences in care and contact lens wear duration factors between the normal and CLDE groups. Compliance rates for several factors including recommended replacement of contact lenses. use of rewetting drops and hydrogen peroxide-based care systems) to help alleviate their CLDE problems. and even basic hygiene practices.g. particularly as subjects in this study had to exhibit both .42. noncompliance rates in contact lens wearers are well above those for other medical regimens such as adherence to physician-prescribed treatments for systemic disorders such as HIV disease and diabetes.

such practices continued over a prolonged period might increase the chance for clinical problems. a multifactorial pathophysiology cannot be overlooked in CLDE. One other possibility to explain the lack of association between noncompliance and CLDE status in this report is that cross-sectional study designs may not be ideal for capturing some clinical problems from noncompliant behavior.[69] However. Longitudinal study designs may be better suited to capture such effects from noncompliant behavior. Carnt et al.78] Compliance and Age and Gender Compliance factors were not associated with age or gender in this study.[27. [43] suggested poor patient-reported comfort and vision in patients wearing lenses that needed replacement.[67.[29. The role of other major causative factors ranging from ocular issues.63. ocular surface abnormalities. In other studies on patient characteristics such as mood. there are no other reports on compliance and dry eye-related problems in contact lens wearers. To expand on this idea. such as tear film.[77. except that subjects who topped off care solutions were half or most of the time slightly younger compared . Similar to dry eye in general. [71.73–76] However.symptoms and signs to be classified as having CLDE. and compliance.[70] reported that patients with personality traits of greater risk-taking propensity were associated with poor compliance practices.70] Age-related compliance analyses also showed very little relation between age and compliance.62] Few other reports have identified young male contact lens users as being more noncompliant. despite increased ocular bioburden resulting from poor lens care and case hygiene. A previous report by Dumbleton et al. and eyelid pathological findings including meibomian gland dysfunction. the eye and ocular surface appear to be very resilient to harm from noncompliant practices. consistent with some prior reports. mood was not associated with CLDE.72] As a result. lacrimal. to systemic disorders or medications known to cause ocular disturbances probably play a bigger role in the pathophysiology of CLDE. Compliance with recommended contact lens replacement was surprisingly not found to be associated with CLDE. To our knowledge.28. the ocular defense and protection mechanisms are known to be highly redundant to maximize protection from microbial and other causes. personality.

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