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6 AUTHORS, INCLUDING:
OPTOMETRY
RESEARCH PAPER
Rajendra Gyawali* BOptom Background: Significant levels of non-compliance and poor hygiene among contact lens
Fathimath Nestha Mohamed BOptom wearers have been reported previously from different parts of the world. This survey aimed
Jeewanand Bist BOptom at identifying the scope of hygiene and non-compliant behaviour of soft contact lens wearers
Himal Kandel|| BOptom in the Maldives.
Sanjay Marasini BOptom Methods: Established soft lens wearers attending two eye clinics in Male city, were inter-
Jyoti Khadka PhD viewed in office or via telephone. A set of interviewer-administered questions was used to
* Male Eye Clinic, Male, Maldives access the subjective response on compliance and hygiene behaviour (hand and lens case
Department of Ophthalmology, Indira Gandhi hygiene, water exposure, adherence to lens replacement schedule, dozing and overnight
Memorial Hospital, Male, Maldives
wear, awareness of aftercare visits and reuse of disinfecting solution). Participants were also
Eye Care Clinic, Male, Maldives
||
London School of Hygiene and Tropical Medicine, asked to rate themselves as a contact lens user based on their perceived compliance and
London, United Kingdom hygiene practices.
Department of Optometry and Vision Science, Results: Out of 107 participants, 79 (74.8 per cent) were interviewed in the office and the
School of Medicine, Flinders University, rest via telephone. The majority of lens wearers were female, office workers and students,
Bedford Park, South Australia, Australia
E-mail: gyawali.rajendra@gmail.com
with a mean age of 20.64 4.4 years. Mean duration of lens wear was 28.04 8.36 months.
Most of them were using spherical lenses (86.9 per cent) on a daily wear basis (96.3 per cent).
Major reported forms of non-compliance were poor hand hygiene (60.7 per cent), lack
of aftercare awareness (39.3 per cent), water exposure (35.5 per cent) and over-use of
lenses (24.3 per cent). While females were more likely to overuse their lenses than males
(p < 0.005), other socio-demographic factors were not associated with reported non-
compliance. Although around 90 per cent of the participants considered themselves average
or good contact lens wearers, most exhibited some form of non-compliant and poor hygienic
behaviour.
Submitted: 27 July 2012 Conclusion: A significant number of Maldivian contact lens wearers exhibited poor levels of
Revised: 5 February 2013 hygiene and compliance with contact lenses and lens care systems. An effective educational
Accepted for publication: 13 February 2013 reinforcement strategy needs to be developed to modify lens wearers non-compliance.
Contact lenses are considered a widely relation between increased incidence of number of the Maldivian population use soft
accepted modality for refractive correction, contact lens-related complications and contact lenses for refractive correction and
cosmetic enhancement and other therapeu- non-compliant behaviour.6 cosmetic purpose. Many of these lens users
tic reasons. With an increasing number of Non-compliance is a significant clinical presenting to optometric clinics report non-
lens wearers, the prevalence of lens-related problem in contact lens practice, with compliant behaviour. To improve compli-
complications is also rising and is reported overall non-compliance rates ranging from ance, it is essential to identify the scope of
to be as high as 57 per cent of the lens users 40 to 91 per cent.79 Some of the contri- hygienic behaviour and the demographic
presenting to contact lens clinics.1 These buting factors to these disturbingly high profile of lens wearers. This study was under-
complications range from mild discomfort rates include unawareness of non-compliant taken to investigate the hygiene practice and
to severe microbial keratitis and may pose a behaviour and its potential adverse results, non-compliant behaviour among Maldivian
risk of sight loss and significant financial effort required to maintain an optimal soft lens wearers through a set of structured
burden on lens wearers.2 Among the identi- cleaning regime, predominantly preventive questions.
fied risk factors associated with such com- nature of practitioners recommendations
plications, some are non-modifiable, such and variable and ambiguous recommenda- METHODS
as gender, age and socio-economic status, tions from practitioners.7,10,11
whereas others are modifiable, for instance, Although no definite statistics are avail- Consecutive soft lens wearers attending a
poor hand cleaning and lens case hygiene.35 able regarding contact lens use in the private optometric clinic and a government
A recent study suggested a potential cor- Maldives, it is observed that an increasing eye-care facility in Male, the capital city of
Lack of proper hand washing (hand washing before handling lenses: never, rarely, occasionally or at least with water) 65 (60.8)
Unaware of aftercare schedule (aftercare schedule: do not remember the recommendation or duration from last 42 (39.3)
aftercare visit more than 6 months)
Water exposure (water activities/swimming: occasional, regular or always or at least without proper protection) 38 (35.5)
Sleeping with lenses (sleeping with daily wear lenses: occasional, regular or always naps or overnight use) 27 (25.2)
Non-adherence to replacement schedule (overuse of lenses: for more than one week than recommended) 26 (24.3)
Not cleaning the lens before insertion (rubrinse of lens: never, rarely or occasionally cleaning the lens before insertion) 22 (20.6)
Reusing or topping up solution (reusing solution: occasional, regular or always) 16 (14.9)
Poor lens case hygiene
Not cleaning lens case for more than 1 month 9 (8.4)
Not replacing lens case for more than 1 year 4 (3.7)
lenses and those with pure cosmetic col- from 14 to 50 per cent9,11,13,14 and vary with reported that they did not clean the lenses
oured lenses were very few. the phrasing of the questions used (whether (with the manual rub and rinse technique)
Aftercare visits are important in contact the use of soap or cleaning agent is specified before insertion. Moreover, almost 15 per
lens wear and allow practitioners to detect or not). This shows the significance of cent of the participants reported reusing or
early ocular physiological changes and a thorough description of hygienic pra- topping up the solution to store their lenses.
reinforce proper hygiene and compliance. ctices, when advising lens wearers in clinical It should be particularly noted that topping
Although almost two-thirds of the partici- practice. up was a behaviour implicated in the 2005
pants reported an aftercare visit within the We evaluated water exposure to lenses in Fusarium outbreak with ReNu MoistureLoc
last six months, nearly 40 per cent of these two aspects, namely, use of tap water to clean disinfecting solution, resulting in loss of
lens wearers failed to remember the practi- or store the lenses and exposure through sight and a worldwide recall of the disinfect-
tioners recommended aftercare schedule. water activities, such as swimming and taking ing solution.17
While it is possible that no advice on after- a shower while wearing lenses. As an encour- Lens storage cases are common sources
care visits may have been provided to the aging finding, none of the participants of microbial contamination and the impor-
wearers, failure to recognise the importance reported using tap water or homemade tance of regular lens case replacement
of regular aftercare examinations and per- saline solution to clean or store lenses. On should be emphasised to lens users.18,19
sonal negligence of the wearer might be the the other hand, over one-third of the partici- Wu and colleagues20 observed that lens cases
main reasons for this poor aftercare aware- pants reported water activities while wearing that were replaced more frequently than
ness. On the other hand, while internet the lenses without proper protective meas- every nine months had significantly lower
purchase of lenses has been shown to be ures, such as goggles and daily disposable levels of contamination than the cases
associated with poor aftercare awareness,5,11 lenses. Studies have shown a consistently replaced less often. A significant number
none of the participants in this study high number of lens wearers engaging in of our participants reported frequent lens
reported purchasing lenses over the inter- water activities while wearing their lenses.912 case replacement in comparison to previous
net. To increase the aftercare awareness, Swimming and other water activities with studies.14,17,21,22 This may be attributed to the
salespersons or dispensers at optical outlets soft lenses play significant roles in acan- complimentary lens storage case provided
can be trained to recommend contact lens thamoebic keratitis and other microbial con- with every purchase of multipurpose solu-
costumers undergo a regular examination taminations.15 To avoid these complications, tion; however, around one-third of the par-
from an eye-care practitioner. lens wearers must be educated to abstain ticipants did not pay attention to cleaning
Poor hand hygiene is the most common from such activities and be informed about of their lens cases. It has been pointed out
non-compliant behaviour found in Maldiv- the potential adverse effects. If the lens that the current guidelines for lens case
ian lens users. Although the majority of the wearer must use the lenses during water hygiene are not standardised and sometimes
participants reported washing hands prior sports, they should be advised to use daily are contradictory between manufacturers
to handling their lenses, only a few of them disposable lenses and proper water goggles. and practitioners.23 Yung and colleagues21
used soap or cleaning detergents. So, alto- In a review following an acanthamoeba have suggested that providing clear written
gether more than 60 per cent of the partici- outbreak in the US, Butcko and colleagues16 instructions to the users may significantly
pants in our study demonstrated no or described laboratory studies showing the improve lens case hygiene.
inadequate hand-washing behaviour. This is importance of rubbing of lenses during dis- Overnight wear of soft lenses is a known
particularly worrying as poor hand hygiene infection and proposed that it should be risk factor for microbial keratitis3,4 and
is one of the major risk factors for lens- reinstated as a standard step even though the corneal infiltrates.15,23 One-quarter of the
related complications.13 The reported rates clinical literature is slightly less conclusive participants in our survey admitted an
of non-compliance for hand hygiene range on the topic. One-fifth of our participants unscheduled and non-prescribed overnight
wear or dozing while wearing their lenses. poor in these wearers and warrant a separate ment and contact lens-related problems in silicone
These participants were prescribed lenses study to evaluate these aspects. On the other hydrogel wearers. Cont Lens Anterior Eye 2011; 34:
216222.
on a daily wear basis and did not have any hand, the extent of practitioners recom- 7. Claydon BE, Efron N. Non-compliance in contact
special instructions for extended wear. Over- mendations and instructions imparted to lens wear. Ophthalmic Physiol Opt 1994; 14: 356364.
night wear by itself cannot be classified as lens wearers should be established before a 8. De Oliveira PR, Temporini-Nastari ER, Ruiz Alves
non-compliant behaviour, when lenses are participant can be labelled as non-compli- M, Kara-Jose N. Self-evaluation of contact lens
wearing and care by college students and health
prescribed for extended or continuous wear ant. For a more precise analysis of compli-
care workers. Eye Contact Lens 2003; 29: 164167.
but it should be supported by a different lens ance, a further survey evaluating practition- 9. Sokol JL, Mier MG, Bloom S, Asbell PA. A study of
replacement schedule and added education ers instructions about hygiene and lens care patient compliance in a contact lens-wearing popu-
about the associated risks. given to the wearers is warranted. While lation. CLAO J 1990; 16: 209213.
Failure to replace lenses on the recom- waiting for confirmation from a population- 10. Robertson DM, Cavanagh HD. Non-Compliance
with Contact Lens Wear and Care Practices: A Com-
mended schedule is associated with a higher based study, the results of this study should parative Analysis. Optom Vis Sci 2011; 88: 14021408.
rate of self-reported contact lens-related serve as a useful reference on hygiene and 11. Wu Y, Carnt N, Stapleton F. Contact lens user
problems.6 Around one-third of the lens compliance among contact lens wearers profile, attitudes and level of compliance to lens
wearers in our survey exhibited low compli- in this previously unexplored Maldivian care. Contact Lens Ant Eye 2010; 33: 183188.
12. Bowden T, Harknett T. Contact lens wearer profile
ance with practitioner recommendations population.
2004. Contact Lens Ant Eye 2005; 28: 3745.
about the replacement schedule. Similar 13. Yung MS, Boost M, Cho P, Yap M. Microbial
findings have been reported in a study con- contamination of contact lenses and lens care
ducted in Canada and the US.25 The partici- CONCLUSION accessories of soft contact lens wearers (university
pants in our study were recruited during students) in Hong Kong. Ophthalmic Physiol Opt
A significant level of poor hygiene and non- 2007; 27: 1121.
their aftercare visit and lacked anonymity. compliance is seen in Maldivian contact lens 14. Radford CF, Woodward EG, Stapleton F. Contact
Thus, this study would be less likely to wearers. This study identified the major lens hygiene compliance in a University popula-
include patients who stretch their replace- areas of non-compliance arising mainly due tion. J Br Contact Lens Assoc 1993; 16: 105111.
ment frequency as compared to an anony- 15. Stapleton F, Keay L, Jalbert I, Cole N. The epide-
to lack of awareness and personal negli- miology of contact lens related infiltrates. Optom Vis
mous survey.17 Interestingly, the compliance gence. Regular educational reinforcement Sci 2007; 84: 257272.
rate regarding lens replacement did not strategies may be helpful to modify such 16. Butcko V, McMahon TT, Joslin CE, Jones L. Micro-
differ between the participants interviewed behaviour. At the same time, precise and bial keratitis and the role of rub and rinsing. Eye
in the office and via telephone. To maximise standard recommendations need to be deve-
Contact Lens 2007; 33: 421423
the likelihood of replacement compliance, 17. Hickson-Curran S, Chalmers RL, Riley C. Patient
loped and provided to lens wearers to re- attitudes and behavior regarding hygiene and
strong practitioner recommendations, writ- duce the risk of lens-related complications. replacement of soft contact lenses and storage
ten instructions, regular reinforcements and cases. Cont Lens Anterior Eye 2011; 34: 207215.
reminder services would be helpful.17 18. Devonshire P, Munro FA, Abernethy C, Clark BJ.
ACKNOWLEDGEMENT Microbial contamination of contact lens cases in
The majority of the participants in our
The authors are thankful to all those who the west of Scotland. Br J Ophthalmol 1993; 77:
survey considered themselves to be average
volunteered to participate in the interviews. 4145.
or good contact lens users; however; most of 19. Gray TB, Cursons RT, Sherwan JF, Rose PR. Acan-
They also thank Mr Nabin Paudel, University
them reported some form of non-compli- thamoeba, bacterial, and fungal contamination of
of Auckland and Ms Saajidha Majid, Tribhu-
ance or poor hygiene. This is consistent with contact lens storage cases. Br J Ophthalmol 1995; 79:
van University for their contribution during 601505.
findings of a previous study in health-care
manuscript preparation and revision. 20. Wu YT, Zhu H, Harmis NY, Iskandar SY, Willcox M,
workers wearing contact lenses in Brazil.8 Stapleton F. Profile and frequency of microbial
It has been reported that, although the contamination of contact lens cases. Optom Vis Sci
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