Article Review: Challenges to the New Soft Contact Lens Wearer and Strategies for Clinical Management

Doerte LuensmannDoerte Luensmann is a Senior Clinical Scientist at the Centre for Ocular Research & Education, conducting clinical contact lens and vision research. Dr. Luensmann is also involved in clinical trial management for multisite studies conducted in Canada and worldwide to support the development of study designs and management of clinical sites.

Morgan PB, Sulley AL. Challenges to the new soft contact lens wearer and strategies for clinical management. Cont Lens Anterior Eye. 2023;46:101827.  

Over the past couple of decades the global contact lens market has seen many innovations in material composition, optical design choice and wear modality. However, soft contact lenses are worn by only about 2% of the global population, even though 50% require some type of vision correction, revealing a substantial untapped market.1

When lens wearer discontinuations occur, this is often seen as a clinical failure and reflects lost investment in time and resources for the eye care professional (ECP) and the contact lens industry. Various reasons could be responsible for this decision, which appears to differ between new wearers and experienced users. New wearers are more likely to discontinue early—particularly within the first 60 days2—and often cite vision and handling issues, rather than discomfort, as their primary concerns.2,3

Morgan and Sulley have summarized key reasons for these lens discontinuations and describe clinical management approaches to increase lens wear success.

1. Vision

Optimal visual performance through accurate refractive correction is crucial. Even minor uncorrected astigmatism or incorrect power choices can negatively impact acuity.4,5 Multifocal lenses and toric designs for astigmatism add complexity and require careful patient-specific fitting and management. Additionally, visual satisfaction does not always align with clinical measures like visual acuity, emphasizing the importance of eliciting reports relating to subjective performance and wearer expectations.6

Clinical management
Perform a detailed visual task analysis, account for vertex distance in prescriptions, and proactively follow up with patients, particularly new wearers. Early intervention, such as follow-up calls or supportive messages, can significantly reduce discontinuation rates. For instance, phone calls7 made one-week post-fitting and supportive SMS messages8 have led to notable retention improvements.7,8

2. Discomfort

Discontinuation due to discomfort tends to be more prominent among experienced users9 compared to neophytes. The most common form of discomfort is “end-of-day” discomfort, where comfort decreases progressively over the course of the day.10 The reasons behind this decline are not fully understood, although it has been shown that lens movement, edge design, and material properties such as lubricity and coefficient of friction appear to influence comfort.11 Lenses with tapered edges and those that are associated with greater conjunctival indentation staining tend to provide better comfort.12,13 Other contributing factors include lens care solution, with daily disposables often being preferred over reusable lenses due to comfort benefits.14

Clinical management
While different lens factors can impact comfort, keep in mind that patient-specific factors are also at play. Age and gender (worse in younger individuals and females) are non-modifiable factors; however, lifestyle choices such as smoking, diet (omega-3 and omega-6 supplementation), or conditions like meibomian gland dysfunction could be addressed.15,16 Environmental conditions like low humidity and extended screen time are also associated with reduced comfort and should be discussed with the patient.17

Changing the lens brand or material, particularly to those that reduce movement and have improved surface properties, can also be beneficial.12,18 For reusable lens users, switching solutions or moving to daily disposables can also help.14 Notably, starting new wearers with a reduced wear-time schedule has not shown clinical or comfort advantages compared to starting full-day wear immediately.19

The “silent sufferer” has been described as a new wearer who experiences dissatisfaction with comfort but does not report their problems.20 These patients may adjust their habits, such as removing lenses early or using eye drops, without consulting their ECP, putting them at higher risk of discontinuation. Proactive communication that fosters openness and ongoing feedback from patients is critical.

3. Lens handling

Struggling with lens application, difficulty determining whether lenses are inside-out, lens adhesion to fingers, problems opening blister packs, and concerns about contamination are all factors that can lead to lens discontinuation.21

Both lens material and design can affect handling. High-modulus silicone hydrogel lenses are generally easier to handle due to their stiffness, but this is not universally true, as other properties, like edge design and surface treatment, may also play a role. Packaging innovations, handling tints, and inversion indicators may improve handling, though evidence is limited.22

Clinical management
The ability of a new lens wearer to handle contact lenses is affected by the careful observation and communication skills of the person in charge of training them, the location (e.g. private room versus communal area), and the method of delivery (e.g. verbal versus video instructions). Practices with better in-clinic procedures have higher retention rates,2 which highlights the importance of customizing teaching schedules to your patients’ needs and addressing early handling challenges right away.

4. Inconvenience and loss of interest

Some patients discontinue lens wear due to perceived inconvenience or declining interest, however underlying factors such as lens discomfort, problems with vision, or handling, lifestyle changes or mental health concerns may be the actual reasons.2

It turns out that all different wear modalities have been described as challenging by some wearers: Daily disposable lenses that are typically considered convenient, are sometimes viewed as burdensome.3 Extended wear lenses reduce daily effort but pose a higher risk for complications.23 Reusable lenses are often seen as inconvenient due to the numerous care steps required.24

Clinical management
Shifting patients from reusable to daily disposable lenses may alleviate inconvenience; however, listen carefully to your patient’s concerns to understand their motivation to wear lenses in order to select the best wear modality for them. Patients may also experience lifestyle changes, mental health challenges, or reduced need to wear their lenses, and may therefore decide to switch back to spectacles for some time.

5. Ocular health concerns

Concerns about ocular health can deter prospective wearers or lead to temporary discontinuation due to complications.2 While educating new wearers about potential health risks with lens wear is crucial, this can cause anxiety in some and may lead to the decision not to pursue lens wear.

Clinical management
Transparent communication about risks, hygiene protocols, and safer lens options like daily disposables can help manage patient concerns.23 Microbial keratitis can be devastating; however, this only impacts 2 in 10,000 cases annually with daily disposable lenses.23 Remind your patient to reach out if any complications arise, in order to receive timely treatment and care.

6. Cost

Although cost is less commonly cited, it can still impact wearers, especially if lens expectation in comfort, vision, or handling is not met.2,3 Multifocal and toric lenses are more expensive due to their design complexity. Silicone hydrogels are also more expensive than hydrogels, but are often selected for clinical benefits rather than cost.25

Clinical management
Address cost concerns and explain options such as daily disposable lenses for part-time use or offer reusable lenses for full-time wearers if clinically appropriate. Keep in mind that cost concerns may be uncomfortable for some patients to discuss.

7. Environmental concerns

Plastic waste from daily disposables is a rising concern amongst users26 and is a shift in perception from earlier eras, when disposability was seen positively for clinical hygiene.

Clinical management
Patients can be reassured that the environmental impact of contact lenses is minimal—about 0.2% of an adult’s annual waste.26 In most regions, daily disposables are recyclable through household or specialist services.26,27 Moreover, some manufacturers are implementing greener production practices. 26,27 Such information can help reduce environmentally driven concerns or discontinuation.

Conclusion

Lens discomfort and dryness account for nearly half of all cases of contact lens discontinuation, followed by vision issues, handling difficulties, cost, and health concerns. While some factors, like age and sex are non-modifiable, other factors such as lens material, fit, care routines, and patient education can be addressed by eye care professionals.

To improve patient satisfaction and retention, especially in new wearers, remember that communication is key –  be proactive and follow-up with your patient throughout their lens wear journey. Listen and observe carefully, and offer tailored management strategies by walking in your patient’s shoes. Review and optimize current protocols and procedures in your office to ensure long-term success.

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