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Eye Care Professionals (ECPs) recognize of the benefits of silicone hydrogel daily disposable (1 day) lenses.
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ECPs rated the highest levels of agreement to perceptions in the Health and Patient Experiences categories of the survey.
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The main barrier to ECPs prescribing continues to be the perceived higher cost of these lenses.
Abstract
Purpose
To gain a better understanding of eye care professionals’ (ECPs) perceptions regarding the benefits of silicone hydrogel (SiH) daily disposable contact lenses (DDCL), particularly with respect to health, comfort and patient satisfaction.
Methods
A survey was conducted with 300 ECPs in the United States, United Kingdom and Japan during November 2017. The survey comprised 34 statements relating to SiH DDCLs, to which the ECPs provided their level of agreement using a 6 point Likert scale. A minimum of 70% agreement was set to define majority agreement. Categories of statements included Health, Comfort, Patient Experience, and Standard of Care.
Results
ECPs rated the highest levels of agreement to perceptions within the Patient Experiences and Health categories. The six statements receiving the highest ratings were “Silicone hydrogel 1 day lenses satisfy today’s patients’ demanding lifestyles” (93% agreement); “Silicone hydrogel 1 day lenses are the best choice to safeguard my patients’ eye health related to contact lens wear” (92%); “Silicone hydrogel 1 day lenses provide the best benefits to my patients” (92%); “Silicone hydrogel 1 day lenses provide better long term eye health for my patients than hydrogel 1 day lenses” (91%); “Silicone hydrogel is the healthiest lens material for my daily disposable patients” (90%); and “Silicone hydrogel 1 day lenses provide a better wearing experience for my patients than hydrogel 1 day lenses” (90%).
Conclusion
ECPs perceive that SiH DDCLs offer long-term eye health and comfort for the patient and although the ECPs surveyed would not necessarily prescribe SiH DDCLs to all their patients, they would prescribe them to most of their patients. The results support the premise that while ECPs consider SiH 1 day contact lenses as the current “standard of care”; the principal barrier continues to be the perceived higher cost of these lenses.
]. A single use modality is able to offer many advantages over reusable lenses including convenience and no requirement for supplemental care solutions, and has also been reported to be beneficial for patients with seasonal allergies [
] The rates of corneal infiltrative events with daily disposable contact lenses have also been reported to be significantly lower than with reusable lenses [
]. Initially daily disposable contact lenses were only manufactured in conventional hydrogel materials. Although hydrogel materials were originally considered to be able to provide sufficient oxygen for daily wear, more recently it has been reported that soft contact lenses manufactured from these materials may be unable to meet both the central and peripheral thresholds required to avoid swelling of the cornea [
Silicone hydrogel (SiH) contact lenses have been available since 1999. They were originally developed for overnight lens wear for periods of up to 30 days, but the high oxygen transmissibility afforded by these materials have also resulted in widespread popularity in the daily wear modality [
]. Currently 65% of all soft contact lenses fitted are SiH, with all but one of the markets evaluated in a recent survey prescribing at least 41% of soft contact lenses in SiH materials [
]. Furthermore, the vast majority of SiH materials are being prescribed for daily wear. By prescribing these materials, hypoxic complications have effectively been eliminated for the vast majority of patients [
Discontinuation from contact lens wear continues to have a negative impact on the contact lens industry and large numbers of patients “drop-out” from contact lens wear each year, primarily as a result of discomfort and vision related issues [
]. In a study conducted by Dumbleton et al, the rate of drop-out was reported to be slightly lower in wearers of SiH materials, but slightly higher in daily disposable wearers [
]; however, it is important to recognize that these data were collected prior to the widespread use of daily disposable contact lenses and at the time many ECPs were prescribing these lenses either for part-time wearers, or for patients who were already experiencing problems with their lenses, both groups being more likely to lapse from lens wear [
]. Furthermore, at the time that the study was conducted, SiH daily disposable contact lenses were not prevalent in the study population evaluated, and therefore assessment of the role of these lenses on discontinuation from contact lens wear was not possible. A recent study has reported a slightly higher rate of drop-out in new wearers of SiH materials when compared with hydrogels, but no differences in rates were found according to replacement frequency and SiH daily disposable contact lenses were not specifically evaluated in the analyses [
Combining the high oxygen transmission properties of SiH lenses with the 1 day modality of wear has become a natural progression, which is able to offer the advantages of both technologies for patients. Daily disposable contact lens wearers report an average of 14 h of lens wear each day [
], and lens materials should to be able to meet the demands of full time wear. There are currently at least five SiH daily disposable contact lenses available on the market, delefilcon A (spherical and multifocal contact lens designs), narafilcon A (spherical design only), senofilcon A (spherical and toric lens designs), somofilcon A (spherical, toric and multifocal contact lens designs) and stenfilcon A (spherical and toric designs). Despite the increased oxygen transmission advantage of SiH over hydrogel single use lenses, ECPs are not necessarily prescribing them for the majority of their daily disposable contact lens patients, nor at the rate they are prescribing for reusable lens wearers [
]. The purpose of this research study was to gain a better understanding of ECPs’ perceptions regarding the benefits of daily disposable SiH lenses, particularly with respect to health, comfort and patient satisfaction.
2. Methods
2.1 Survey participants
Invitations to participate in an online survey were sent to 13,572 eye care practitioners (ECPs) in the United States (US), United Kingdom (UK) and Japan. The ECPs were all registered members of “OpinionSite Health's Community”, a worldwide group of licensed medical professionals who had registered to be contacted regarding survey opportunities within their specific discipline. The survey was conducted during November 2017 by Cello Health Insight, an independent market research service. Surveys were administered in English for ECPs in the US and UK, and in Japanese in for the ECPs in Japan. 1326 respondents were initially screened using a series of preliminary questions relating to their modality of eye care practice and prescribing practices, to determine their eligibility to participate. Participating ECPs had to be experienced in fitting contact lenses, be responsible for selecting contact lens brands, and fit at least 25 patients each month, of which at least 20% were fitted with daily disposable lenses. The full eligibility criteria are listed in Table 1.
Table 1Eligibility Criteria.
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Ophthalmologist (Japan), Optometrist (UK and US), Ophthalmic Optician (UK), Optician qualified to fit contact lenses (UK and US) or Nurse, Orthoptist or other medical worker responsible for contact lens fitting (Japan)
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Work at an independent practice, contact lens specialist store or chain, multiple retailer or ophthalmology clinic (Japan)
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3–35 years of experience in fitting contact lenses
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Personally responsible for fitting contact lenses and selecting the contact lens brands within practice
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Fit at least 25 patients with contact lenses (new and refits) in a typical month, of which at least 20% are fitted with daily disposable lenses
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Not affiliated with a contact lens or any other health care manufacturer or serving as a clinical investigator, consultant or researcher
Three hundred ECPs met these eligibility requirements and went on to complete the online survey (100 in each of the three countries participating). These respondents received a modest honorarium, in the form of an E-gift card or PayPal payment, in return for the time taken to complete the survey. Participation in the survey was confidential and no personal identifying information was disclosed to the study sponsor.
2.2 Survey design
The survey comprised a series of 34 statements relating to SiH daily disposable (1 day) contact lenses, grouped into 5 categories: Patient’s eye health; patient comfort; patient satisfaction; standard of care and a series of other general statements. Within each category the sequence in which the statements were presented was randomized; however, all statements in a given category were displayed simultaneously. For each statement, respondents were asked to rate their level of agreement using a 1 to 6 point Likert scale, where 1 = strongly disagree, 2 = moderately disagree, 3 = slightly disagree, 4 = slightly agree, 5 = moderately agree and 6 = strongly agree [
]. At the conclusion of the survey respondents were also asked to rank in order which of the following were most important to them when deciding to prescribe a SiH lens; health benefits, comfort benefits or overall experience and satisfaction.
2.3 Sample size
A sample size of 100 in each of the three countries was determined to be sufficiently robust to reflect opinions in each market and to provide the statistical power needed to make comparisons across markets. With a confidence level of 95% and a +/- 10% margin of error, it was determined that ≥ 61% of sampled ECPs would have to agree with any of the tested statements in order for there to be majority agreement with the statement; however, for additional confidence the minimum threshold for a majority agreement was set to 70%.
3. Results
Globally, 169 optometrists (56%), 99 ophthalmologists (33%), 31 opticians qualified to dispense contact lenses (10%) and one nurse who was responsible for fitting contact lenses (<1%, Japan) completed the survey. Forty-five percent were in independent practice, 37% in a specialist chain and 18% in ophthalmology clinics (Japan only). The mean number of fits per month was reported to be 117 (71 in the UK, 118 in the US and 163 in Japan). The mean percentage of 1 day fits was 53% overall (47% US, 51% Japan and 62% UK).
The percentage of ECPs who agreed with each of the statements presented was very similar across the three countries and therefore only the global data are presented for greater clarity.
3.1 Health
All six statements relating to the health benefits associated with SiH 1 day contact lenses reached the threshold for majority agreement (≥70% selecting 4 to 6 on the 6 point Likert scale). The percent agreement ranged from 72% to 92%. The highest level of agreement was for the statement “Silicone hydrogel 1 day lenses are the best choice to safeguard my patients’ eye health related to contact lens wear”, and the lowest was for “By prescribing silicone hydrogel 1 day lenses, all contact lens oxygen-related problems are eliminated”. These results for all the health related statements are presented in Table 2.
Table 2Survey statements and percentage agreement reported by Eye Care Practitioners.
The three statements relating to the comfort benefits associated with SiH 1 day contact lenses all exceeded the threshold for majority agreement. Eighty-eight percent agreed with the statements “Silicone hydrogel 1 day lenses provide better long term wearing comfort for my patients than hydrogel 1 day lenses” and “Silicone hydrogel 1 day lenses are more comfortable than hydrogel 1 day lenses”, while 80% agreed with the statement “Silicone hydrogel 1 day lenses dehydrate less than hydrogel 1 day lenses”. These results are also presented in Table 2.
3.3 Overall patient experience and satisfaction
All four statements relating to the overall patient experience and satisfaction benefits associated with SiH 1 day contact lenses also exceeded the threshold for majority agreement with percent agreement ranging from 88% to 93%. The highest percentage agreement was for “Silicone hydrogel 1 day lenses satisfy today’s patients’ demanding lifestyles” and the lowest for “Patients who wear silicone hydrogel 1 day lenses are more satisfied/have higher level of satisfaction with their contact lenses than patients who wear hydrogel 1 day lenses”. These results are summarized in Table 2.
3.4 Standard of care
There were ten statements relating to the standard of care for the daily disposable modality and all exceeded the threshold established for majority agreement (72% to 89%). The highest level of agreement was with the statement “If I were to create the perfect 1 day lens, this lens would be in silicone hydrogel material” and the lowest with the statement “Silicone hydrogel material reduces chair time for 1 day contact lens patient follow up”. The complete set of results are summarized in Table 2.
3.5 Other statements
In addition to the statements relating to health, comfort, standard of care and overall patient experience and satisfaction, ECPs were also asked to rate their level of agreement with a series of 11 other statements associated with SiH 1 day contact lenses. Ten of the eleven statements exceeded the threshold for majority agreement with ≥ 75%. There was almost universal agreement (95%) among the ECPs that “If cost was equivalent, I would choose silicone hydrogel over hydrogel for my 1 day patients”. Only one statement: “There is no such thing as allergy to silicone in silicone hydrogel materials” did not reach the threshold for majority agreement, with only 43% of respondents globally agreeing with the statement. The results for percentage agreement by ECPs with these statements are presented in Table 2.
3.6 Overall ranking of categories
Health benefits of 1day lenses were ranked to be the most important to ECPs when deciding to prescribe a SiH lens, with 49% selecting this attribute. This was followed by Experience and Satisfaction at 33% and Comfort at 18%. The ranked data are presented in Fig. 1.
Fig. 1Overall ranking of categories considered most important to Eye Care Practitioners when deciding to prescribe a silicone hydrogel 1 day contact lens.
The benefits of SiH contact lenses in delivering higher levels of oxygen than hydrogel materials, and therefore diminishing the concerns with respect to anoxia, are well recognized by ECPs and the eye care industry [
]. The results from this study appear to support ECPs’ understanding of the oxygen transmissibility benefits of SiH daily disposable (1 day) lenses in terms of long-term eye health for their patients. There was majority agreement for all six health-related statements included in the survey. This is not surprising since there is very strong evidence in the literature of the oxygen-related health benefits associated with SiH contact lens materials [
]. The rates of inflammation and infection with re-usable SiH contact lenses have been reported to be higher than with their hydrogel counterparts, particularly when worn on an overnight basis [
]; however, the annualized incidence rates for corneal infiltrative events was reported to be only 0.4% with daily disposable SiH lenses in a large registry study [
Eighty seven percent of the ECPs expressed agreement that patients wearing SiH 1 day lenses had fewer eye problems or complaints than those wearing hydrogel 1 day lenses. Notwithstanding this result, the evidence in the literature to support this statement is somewhat equivocal. In a recent publication, a retrospective analysis was conducted to compare SiH and hydrogel daily disposable contact lenses [
]. No clinically relevant differences in physiological response or the prevalence of adverse events were found between the SiH and hydrogel lenses over a three-month period. However, it should be recognized that only three SiH materials (delefilcon A, somofilcon A and narafilcon A) and two hydrogel materials (omafilcon A and nelefilcon A) were worn by the subjects and differences between specific materials were not reported. In a separate prospective study, subjects wore SiH and a hydrogel daily disposable soft lenses in a cross-over design for a period of one month [
]. Greater levels of conjunctival and corneal staining were recorded when the hydrogel lenses were worn; however, the levels of staining were all low and therefore the differences may not be clinically important. Increased mechanical adverse events were reported with the first generation of SiH reusable contact lenses [
], but current SiH materials, particularly those used for daily disposable lenses, have lower moduli, as compared to their SiH predecessors, and therefore few mechanically induced complications would be expected to occur with daily wear of these lenses [
Interestingly, the statement with the lowest level of agreement (but still over the 70% deemed to represent majority agreement by the ECPs) was: “By prescribing silicone hydrogel 1 day lenses, all contact lens oxygen-related problems are eliminated.” Given that all the currently available SiH 1 day lenses would significantly exceed the oxygen transmissibility requirements for daily wear, it is somewhat unexpected that a higher proportion of the ECPs were not in agreement with the statement. It is possible that some of the ECPs were considering other contact lens related problems such as discomfort or corneal infiltrative events, which have not been reported to be related to hypoxia [
Several factors have been objectively reported to be associated with improved contact lens comfort including edge design, tightness of fit and possibly coefficient of friction [
]. This is largely because of deficiencies in study design relating to inadequate masking and controls, in addition to the significant number of confounding variables which are almost impossible to overcome when comparing comfort with different lens materials and designs [
]. In this survey there was strong agreement with all three statements relating to comfort with 88% agreeing with the statements that SiH 1 day lenses provide better long term wearing comfort (C1) and less dehydration (C3) when compared with hydrogel 1 day lenses. Agreement with the statement that SiH 1 day lenses are generally more comfortable than hydrogel 1 day lenses was slightly lower, at 80% (C2).
Since this survey was specifically investigating perceptions with respect to single use SiH lenses, it is arguably more important to consider studies in which the comfort with these lenses and single use hydrogel lenses have been compared. In a study conducted by Shah et al, significantly higher overall comfort and less dryness were reported with stenfilcon A SiH 1 day lenses than with etafilcon A (hydrogel) 1 day lenses [
]. Another study evaluated comfortable wearing time and comfort during the day with delefilcon A (SiH) and nelfilcon A (hydrogel) lenses and reported superior comfort when the SiH lenses were worn [
]. However, in a more recent retrospective analysis of data collected during a series of studies, no difference in comfortable wearing time, or comfort on insertion, during the day or at the end of the day was found between wearers of SiH and hydrogel 1 day lenses [
]. These conflicting findings may be due to differences in overall design, as well as the surface and bulk materials of the specific daily disposable lenses evaluated. Similarly, ECPs perceptions are likely affected according to which lens materials they prescribe for their patients in their practices.
4.3 Overall patient experience and satisfaction
Patient satisfaction with contact lenses is extremely important in order to avoid discontinuation [
]. All the statements relating to the ECPs’ perception of patient experience and satisfaction met the 70% majority agreement threshold, with at least 88% of ECPs reporting agreement. The statement with the highest level of agreement was: “Silicone hydrogel 1 days lenses satisfy today’s patients/ with demanding lifestyles” at 93%. One of the most noticeable challenges for today’s patients is the amount of time that they spend every day using digital devices, such as smartphones, tablets, e-readers and computers [
]. These conditions can be even more demanding for a contact lens wearer and therefore maintenance of a stable pre-lens tear film throughout the day is extremely important [
]. One gauge of success for contact lens wearers is the ability to wear their lenses for a full day, and longer total wearing times have been reported with SiH contact lenses [
]. Similarly high agreement was achieved with the statement that: “Silicone hydrogel 1 day lenses provide the best benefits to my patients” at 92%. To date, no studies have been conducted to compare quality of life assessments with different soft contact lens materials; however, in this survey there was strong agreement with the statements specifically comparing SiH 1 day lenses with hydrogel 1 day lenses with respect to them providing “better wearing experience” and “higher level of satisfaction”.
4.4 Standard of care
In general there was widespread agreement with the statements relating to standard of care (72% to 89%). The highest level of agreement was with the statement relating to the perfect 1 day lens being a SiH material (S8: 89%). This was followed by the first choice being a SiH if only one type of daily disposable were fitted (S2: 88%) and the first choice for daily disposables in general (S1: 87%). One statement specifically stated that “Silicone hydrogel material should be the standard of care for 1 day contact lens patients” (S10: 82% agreement). It is noteworthy that while the vast majority of the ECPs completing this survey were in agreement that SiH lenses should be the standard of care for the daily disposable modality, this is not reflected in the currently reported prescribing practices, with only just over half of 1 day lenses currently prescribed being in SiH materials [
]. The reason for this disconnect may relate to the generally higher cost of SiH daily disposable lenses, and ECPs perceiving this to be a more of a barrier for their patients than may in fact be the case. As a result, they may not be presenting single use contact lenses in more advanced and newly developed SiH materials as an option. A similar challenge was faced by ECPs when the 1 day contact lenses were becoming more popular [
]. While there is no direct evidence in the literature to support this view, there are reports relating to the extremely variable frequency that discussion of treatment cost occurs between patients and their health care providers [
]. Unfortunately, there appears to be a reluctance to advocate for a superior lens with a higher price because of the possible risk of upsetting the patient and jeopardizing their retention in the practice. In reality, the ECP should be aware that their patient may be disappointed that they are not being recommended newer technology contact lenses that are able to offer many benefits for their wearing experience. In a recent online survey of 1520 adult contact lens wearers, 68% of respondents said that they would expect their ECP to recommend the contact lens that provides 100% of the oxygen their eyes need regardless of cost, and 75% of respondents indicated that they would follow their ECP’s contact lens recommendation regardless of the cost of the lens [
4.5 General statements relating to contact lens wear
The final section of the survey presented additional statements relating to SiH 1 day contact lenses. The statement that had the highest level of agreement (95%) was included in this section and was: “If cost was equivalent, I would choose silicone hydrogel over hydrogel for my 1 day patients”. This appears to support the previously discussed assessment relating to the possible barriers to prescribing SiH 1 day lenses for more patients. Another statement of interest relates to 1 day contact lens wearers occasionally napping or sleeping in their lenses (O8) and 90% of respondents agreed that they believed that this was the case. Closed-eye wear has been reported previously by daily disposable contact lens wearers in a multi-country study with 75% reporting occasionally napping and 28% occasionally sleeping while wearing their lenses [
Two of the questions in the final section related to dropping out of contact lens wear. Eighty-seven percent of ECPs agreed that if they wanted to keep patients from dropping out of contact lens wear, they refit them with 1 day SiH lenses (O11) and 78% agreed that 1 day SiH lens wearers have lower drop out rates than wearers of other types of contact lenses (O10). While previous studies have reported conflicting results relating to the drop-out rates with different lens materials and replacement frequencies [
], to date there are no published reports on drop out rates with SiH daily disposable contact lenses. Although there is currently no evidence to support lower drop out rates, it is nonetheless reassuring that ECPs have confidence that 1 day SiH contact lenses are playing a positive role in lessening drop out in their practices.
Soft toric contact lens designs require a stabilization system, which results in lenses with a significant thickness differential as compared to spherical soft lenses. Increased lens thickness decreases oxygen transmissibility and therefore a more oxygen transmissible material is superior in toric designs. Despite the statement relating to toric lens designs being assertive, saying that “All toric 1 day contact lens wearers should be fit with toric silicone hydrogel 1 day lenses”, three quarters of the ECPs agreed that with the statement that SiH should be the material of choice. ECPs were also presented with a similar statement relating to multifocal designs and once again three quarters of the ECPs agreed that SiH should be the material of choice for their multifocal patients. These results appear to support the belief that lenses with necessarily thicker designs should be prescribed in higher oxygen transmissibility materials [
When ECPs first started transitioning their patients into SiH materials there were occasional anecdotal reports of red eyes, discomfort and itchiness, which were, incorrectly, attributed to a possible silicone allergy. An appraisal of the literature at the time found no evidence to support this proposition [
]. In order to assess the current views of ECPs with respect to this issue, one of the additional statements included in the survey related to allergy to silicone. Interestingly, 57%% of ECPs disagreed with the statement: “There is no such thing as allergy to silicone in silicone hydrogel materials”, suggesting that this “urban myth” still exists, at least among some ECPs. Silicon is the second most abundant element on the earth, after oxygen, and is in widespread used in many fields including medicine; however, true silicone allergies are extremely rare. The inflammatory responses that have been reported to occur in some patients who are fitted with SiH materials are actually attributable to inflammatory reactions that can occur in response to antigens that can accumulate on or within these silicone biomaterials [
]. In order for SiH 1 day lenses to be prescribed more frequently, it is important that ECPs are better informed with respect to this concern.
4.6 Overall ranking
Perhaps not surprisingly, ECPs ranked health benefits as being the most important category when deciding to prescribe a 1 day SiH lens. ECPs see themselves as responsible for the eye health of their patients, however they must also balance this against the need of their patients’ satisfaction with their lenses. Indeed, the second ranking category was the patient experience and satisfaction that is achieved with these lenses. Comfort was ranked third overall; however, it should be recognized that patient satisfaction is strongly linked with comfort and vision [
], and therefore these benefits are highly correlated.
4.7 Study design and possible limitations
As with many studies that involve the use of surveys, it should be acknowledged that there are some limitations to this investigation. Since the purpose was specifically to gain a better understanding of ECPs’ perceptions regarding the benefits of daily disposable SiH lenses, the statements were phrased with an emphasis on SiH materials and their possible benefits over hydrogel materials, particularly in the daily disposable modality. Further, a large number of statements in the survey were similar; this was intentional, since by gaining a better understanding of the specific beliefs relating to SiH 1 day lenses, a better understanding may also be gained regarding the barriers that ECPs face in prescribing them to more of their patients. Presenting a large number of statements relating to the health, comfort and patient satisfaction benefits of daily disposable SiH lenses has provided an interesting perspective on ECPs’ opinions of these lenses.
Level of agreement with the statements was made on a Likert scale [
]. These scales provide respondents with a fixed number of ranked answer alternatives. The optimum number of alternatives has been reported to be between four and seven [
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]. In this study a six-point scale was selected in order to provide a “forced choice” between either agreement or disagreement with the statements, and the degree (slight, moderate or strong). It could be argued that ECPs who reported a “slight” agreement with a statement should not have been included in the calculations for overall agreement; however, since a relatively conservative approach was taken and only agreement levels of 70% or more of the sample were needed to say that a majority agreed with a statement, this is not considered pertinent.
5. Conclusions
Although SiH contact lenses have been shown to provide superior oxygen transmissibility as compared to HEMA lenses, there is currently no clear evidence in the literature to support SiH 1 day lenses being superior to hydrogel 1 day lenses with respect to adverse events, wettability or comfort. Despite this, the results of this study appear to support ECPs’ confidence in the benefits of SiH 1 day contact lenses in terms of long-term eye health and comfort for their patients. While all the ECPs surveyed were not necessarily in agreement about prescribing SiH 1 day lenses to all their patients, they did confirm that they would prescribe them to most of their patients. One of the top three barriers is considered to be financial, and the statement with the overall highest level of agreement was: “If cost was equivalent, I would choose silicone hydrogel over hydrogel for my 1 day patients.” This supports the premise that while ECPs may consider SiH 1 day contact lenses as the current “standard of care”, a significant barrier continues to be the perceived higher cost of these lenses.
Declaration of interest
Dr. Gary Orsborn is an employee of CooperVision Inc. Dr. Kathy Dumbleton is a paid consultant of CooperVision Inc.
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