Are we being too complacent with compliance?

Nancy Keir - BSc OD Centre for Contact Lens Research, University of Waterloo Nancy Keir is currently a Research Associate at the Centre for Contact Lens Research at the University of Waterloo in Ontario, Canada, where she is responsible for conducting clinical research in the areas of contact lenses and refractive surgery. She graduated with honours in Optometry from the University of Waterloo and is currently working towards her PhD Degree in Vision Science on a part-time basis.

Review of the paper entitled: Self Evaluation of Contact Lens Wearing and Care by College Students and Health Care Workers

Paulo Ricardo de Oliveira, M.D., Ph.D., Edméa Rita Temporini-Nastari, Ph.D.,
Milton Ruiz Alves, M.D., Ph.D., and Newton Kara-José, M.D., Ph.D.
Eye & Contact Lens 29(3): 164–167, 2003

Compliance can be one of the most challenging aspects of managing contact lens patients. Since poor compliance can lead to complications and discontinuations, improving performance in this area is extremely important. There are several crucial aspects for practitioners to consider with respect to contact lens compliance, including cleaning, storing, disinfecting, lens replacement, wearing schedule, seeking medical help in a timely manner, lifestyle habits (for example swimming with contact lenses), and general health, to name a few.

The paper entitled Self Evaluation of Contact Lens Wearing and Care by College Students and Health Care Workers, by Paulo Ricardo de Oliveira and co-authors, is an attempt to understand the reasons behind non-compliance. This study investigated the responses of students and health care workers to various questions regarding their lens care knowledge and practices. In total, 201 contact lens wearers were interviewed and answers to a standard questionnaire were collected. Age ranged between 17 and 52 years, with a mean age of 23.5 years, and 69.2% were women. The background of the subjects in the study included university students (71.1%), university graduates (23.9%), and high school graduates (5%).

The results of this study found that the three main reasons for self-reported non-compliance were: not performing adequate cleaning of the contact lenses or lens cases (44.3%), non-compliance with medical recommendations (15.1%) and excessive wearing of lenses (12.3%). Overall, 79.1% of participants disclosed some form of non-compliance when it came to properly caring for their lenses, identifying their behaviour as "more or less correct" "not very correct" or "not at all correct." Approximately 30% felt that they were not properly instructed with respect to these procedures.

Considering the fact that the study population consisted of educated individuals who were likely aware of the importance of ocular health, it’s interesting to see such a high degree of self-reported non-compliance. This study provides insight into the importance of reinforcing compliance with our patients, particularly in the area of lens care and disinfection. Additional publications have also found lens care and disinfection to be problematic, with reports of a greater risk of microbial keratitis with non-compliance in this area.[1]

The second most common reason for self-reported non-compliance was non-compliance with medical recommendations. Davidson and Akingbehin [2] state that patients forget within minutes from one third to one half of what is said to them in a medical appointment, especially instructions and recommendations. They go on to state that the most important factor is the doctor–patient relationship. Although findings like these make reinforcement seem like an uphill battle, it is still something that should be performed at every contact lens follow-up. This is especially important for new and young wearers, so that good CL practices are instilled early. Thinking of novel ways to promote compliance, and developing good follow-up practices, such as asking patients to bring in their lens cases and solutions to their follow-up appointments, can be helpful. This not only lessens the chance of failure with CLs, but also serves to improve the doctor-patient relationship. Providing written instructions, as well as verbal instructions, has been shown to be beneficial.[3]

Wearing lenses past the recommended replacement schedule has been shown to be associated with contact lens-related complications, such as corneal inflammation.[4] Choosing a replacement schedule that best suits each individual is advisable. Daily disposables are also an option. Discussing why it is important to replace lenses according the manufacturer’s recommendations could help patient’s understand why this is necessary and ultimately lead to improved compliance.

Of course we have to keep in mind that this article is looking at self-reported non-compliance. According to Koetting et al., 27% of the non-compliant patients were unaware that their behaviour was incorrect.[5] Therefore, the relevance of patient education becomes paramount. Silicone hydrogel lenses have greatly reduced the effects of hypoxia; however complications and problems still occur. Although work continues to be conducted to make CL wear easier and safer (antimicrobial contact lens cases and antimicrobial contact lens materials, for example), we can’t forget that compliance is still just as important and needs our constant attention. Although this paper highlights a few key areas that need extra attention, all areas of compliance are important and should be routinely evaluated.

References:

1. Weissman BA, Mondino BJ. Risk factors for contact lens associated microbial keratitis. Cont Lens Anterior Eye. Mar 2002;25(1):3-9.
   
   
2. Davidson SI, Akingbehin T. Compliance in ophthalmology. Trans Ophthalmol Soc U K. Jul 1980;100(Pt 2):286-290.
   
   
3. Cardona G, Llovet I. Compliance amongst contact lens wearers: comprehension skills and reinforcement with written instructions. Cont Lens Anterior Eye. Jun 2004;27(2):75-81.
   
   
4. Nilsson SE. Ten years of disposable contact lenses--a review of benefits and risks. Cont Lens Anterior Eye. 1997;20(4):119-128.
   
   
5. Koetting RA CC, Wartmann R. Patient compliance with EW instructions. Contact Lens Spect. 1986;1:23–30.