At Issue: Experts agree extended wear contact lens patients need close monitoring
Every 6 months
James D. Atwood, MD: I see all of my extended wear contact lens patients, both soft and RGP (rigid gas-permeable), every 6 months. They are told from the beginning that if they sleep with their lenses they are going to have to be seen more frequently, and the 6-month interval is not suggested but mandatory.
Our computer system keeps track of patients who do not make their regularly scheduled appointments. If they do not respond to repeated requests, via mail and telephone to schedule a follow-up exam, they are sent a certified letter stating that they are now beyond the 6-month limit. The letter also stresses the importance for an extended wear patient to be seen every 6 months and states if they don't comply with the request, they will have to seek the services of another practitioner. With few exceptions, most patients comply at this point.
At their visit, the importance of 6-month check-ups is again stressed and so noted in their chart. I firmly believe that if extended wear patients are told the importance of being checked every 6 months, they will comply. I fit soft contact lens patients for extended wear only with disposable contact lenses. As a result of this specific strategy, in 22 years of practice my patients have had very, very few severe complications.
Carmen F. Castellano, OD: We are well aware of the risks associated with extended wear contact lenses; however, we should also be aware of the tremendous benefit these lenses can provide for a large number of our patients. The fact is, the risks are not that great, especially when one considers that patients with high refractive errors can enjoy 24-hour freedom from their glasses, and active individuals can enjoy the convenience of not having to handle their lenses daily.
None of this is to say that the risks associated with extended wear should be ignored. On the contrary, patients must be selected wisely and provided with superior professional care, including thorough education regarding risk-to-benefit with extended wear. In our practice these patients are followed on a semi-annual basis. In the vast majority of cases, this allows us to monitor for subtle corneal physiological changes as well as stay in touch with the patient's removal and lens care habits. Where disposable lenses are concerned, we generally dispense a 6-month supply at a visit so that each visit will coincide with the patient's need for more lenses. In this way, power changes may be made appropriately.
Complete eye health examinations are recommended yearly with a 6-month contact lens progress evaluation scheduled in between. We have found this semi-annual schedule sufficient in keeping extended wear complications to a minimum and keeping our patients educated. In addition, these regular patient encounters increase potential for sales in other revenue centers such as solutions, sun wear and prescription eye wear.
Consider risk factors
Joseph P. Shovlin, OD, FAAO: The use of extended wear lenses dramatically increases the patient's risk for sight-threatening and less significant complications when lenses are worn over night. Generally, I favor a conservative wearing schedule, preferably daily wear. However, there are some who do not function well or do not wish to remain in a daily wear modality. These patients need to be followed closely and each individual carries a unique core of risk factors. For example, the aphake who wears a thicker lens is usually an older individual with some lid concerns, altered tear film characteristics and often an increased dose-related response. For this reason, this group has the most frequent and impressive occurrence of infections.
Although any patient who posed significant risk for ulcerative keratitis should be limited to a daily wear modality, those who are aphakic or cosmetic wearers with some risk profile who choose to wear a lens overnight should be followed every 3 to 4 months. The young, healthy cosmetic extended-wear patient with no apparent risk factors (other than wearing a lens overnight) should be followed on a 4- to 6-month basis.
Hypoxia, inflammation and infection remain the major concerns in overnight wear. The concern for infection remains our most significant complication of lens wear and is the least likely to be eliminated, even with close follow-up. This is the main reason I remain selective in those who wear a lens overnight.
On any follow-up exam it is crucial to monitor for signs of exhaustion, including mid-morning striae, significant keratopathy, neovascularization and an unacceptable number of microcysts. Most complications relate to the reduced amount of oxygen flux provided by the current options we have in overnight wear.
Although most events of significant sequelae cannot be eliminated since none of the previously mentioned conditions are needed to impart an infection, close monitoring can help reduce the stress the cornea is under by reducing wearing time or refitting into a material with greater Dk/L values.
Unfortunately, a better understanding of factors that promote biocompatibility between contact lenses and ocular tissues is essential to eliminate the additional risks of hypoxia, inflammation and infection during extended wear. It is clear that lenses with increased oxygen potential for the cornea currently being developed will provide some increase in the margin of safety, but close follow-up will always be essential in order to provide for reasonable assurance of safety and efficacy. Close follow-up remains paramount to address issues of noncompliance, problem prevention and solving.
Peter Bergenske, OD, FAAO: Extended wear patients clearly require closer monitoring than do their daily wear counterparts. With the tremendous shift toward disposable lenses many practitioners, myself included, have reduced the frequency at which we feel we need to see daily wear patients.
On the other hand, extended wear has been made, at best, only marginally safer by the introduction of disposable lenses, thus these patients still need more frequent observation for signs of hypoxia that might lead to compromise.
For patients routinely and successfully wearing lenses on an extended wear basis, I recommend they be seen at 6-month intervals to monitor for signs of long-term hypoxic stress such as microcysts and neovascularization. Unfortunately, no schedule short of daily evaluation is likely to avoid the more threatening acute events that simply happen more frequently with extended wear than they do with daily wear.
Daily self-monitoring by the well informed patient along with prompt notification of the doctor in the event of abnormality, and then prompt and appropriate action, are still the only true safeguards against potentially sight-threatening complications.
Practitioners prescribing contact lenses for extended wear must accept higher levels of responsibility and availability or otherwise stick with daily wear. I know I sleep better if my patients take their lenses out before going to bed.
Every 3 months
Robert L. Davis, OD, FAAO: Extended wear contact lenses are associated with greater convenience than daily wear. Avoiding the inconvenience of having to insert, remove and care for lenses on a daily wear basis makes extended wear contact lenses attractive to more patients. Continuing concerns about safety render many practitioners reluctant to prescribe extended wear. As health care providers it is our duty to identify and understand the variables that put our patients at risk.
Patients and practitioners are opting to have laser procedures rather than deal with the inconvenience of daily wear contact lenses. The question remains concerning the safety and risks associated with the extended wear modality. Attention to oxygen permeability and mechanical properties of soft lenses and frequent follow- up visits should solve the problems with extended wear.
Corneal ulcers, persistent problems of infiltrative, acute red eye and papillary conjunctivitis have raised suspicion about extended wear. These problems were thought to be related to the build-up of material on and under the contact lens.
Frequent replacement minimized complications, giving fewer incidences of dirty lenses, poor vision, discomfort, acute red eye and keratitis. Hence two important determining characteristics are the level of oxygen supplied and waste removed during closed-eye lens wear.
Success with extended wear depends on appropriately selecting patients and giving them proper instruction, fitting and follow-up care. Frequent and thorough follow-up care every 3 months is critical in the proper care of an extended wear patient. Each visit serves as an opportunity to assess and indoctrinate patients on compliance and to detect potential problems and abuse before they progress to major complications.
Schedule the first extended wear follow-up visit following the first night of overnight wear in the morning. At the examination, assess the fit and corneal response to overnight wear.
Pay particular attention to the corneal reaction and the patient's subjective response the first half hour after the patient awakens. If the patient reports any haziness, gritty sensation or sensitivity to light, lens material permeability and lens fitting characteristics must be modified. If no problems arise, extended wear may continue with repeated examination in 1 week, 2 weeks, 1 month, 3 months and every 3 months thereafter.
Remind patients at each visit to remove their lenses and seek immediate care if they experience any redness, pain, photophobia, discharge or a change in their vision. Remember: your patients seek your guidance to lead them to successful contact lens extended wear.