Times they are a-changin for contact lens practice

Abstract

This time a year ago the editorial in CLAE suggested the world was in the middle of a global pandemic [[1]Zeri F. Naroo S.A. Contact lens practice in the time of COVID-19.Cont Lens Anterior Eye. 2020; 43: 193-195https://doi.org/10.1016/j.clae.2020.03.007Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar]. It now seems that was a little optimistic as a year ago was probably the start of the global pandemic, especially now that some countries are reporting a third wave and fears of more to come with the possibility of new variants of the virus. The world has changed due to the pandemic and has had to adapt to a new way of working where possible. In the field of contact lens education there was a rapid response to the global lockdown with a move to teaching online where possible [[2]Naroo S.A. Morgan P.B. Shinde L. Ewbank A. The impact of COVID-19 on global contact lens education.J Optom. 2020; (EPUB)https://doi.org/10.1016/j.optom.2020.11.002Crossref PubMed Scopus (2) Google Scholar]. Health care education has for many years adapted a blended-learning approach, using a combination of lectures, small-group tutorials, practical and clinical training [[3]Zeri F. Cervio R. Mosci M. Tavazzi S. Naroo S. Optometry students’ and educators’ perceptions of group work and peer assessment in italian higher education.Scand J Optom Vis Sci. 2020; 13: 10-18https://doi.org/10.5384/sjovs.vol13i1p10-18Crossref Google Scholar]. More recent years have seen the introduction of the ‘flipped classroom’ approach where the key didactic material is included in a pre-recorded narrated lecture supplemented by problem solving in a seminar scenario. Going forward there seem to be lessons learnt from this forced moved online that may help teachers to deliver more efficiently [[4]Naroo S.A. Morgan P.B. Shinde L. Lee C. Ewbank A. Contact lens education for the practitioners of the future.Ophthalmic Physiol Opt. 2021; (EPUB)https://doi.org/10.1111/opo.12791Crossref PubMed Scopus (2) Google Scholar]. Certainly, it seems that lectures online work well in most cases, especially when the session is also recorded for later playback. There are advantages and disadvantages to both online lectures and live lecture theatre sessions. The lack of engagement that exists online is certainly an issue, but the convenience of a recorded session is a definite plus. The clinical or practical training required in healthcare professions is more difficult to move online but clever uses of virtual patient software or navigating through clinical case scenarios are useful. The early phases of the pandemic reported, of particular concern for ophthalmic practitioners, that SARS-CoV-2 had been detected in the tears and conjunctival secretions in COVID-19 patients with conjunctivitis [5Khavandi S. Tabibzadeh E. Naderan M. Shoar S. Corona virus disease-19 (COVID-19) presenting as conjunctivitis: atypically high-risk during a pandemic.Cont Lens Anterior Eye. 2020; 43: 211-212https://doi.org/10.1016/j.clae.2020.04.010Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 6Wu P. Duan F. Luo C. Liu Q. Qu X. Liang L. et al.Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China.JAMA Ophthalmol. 2020; 138: 575-578https://doi.org/10.1001/jamaophthalmol.2020.1291Crossref PubMed Scopus (517) Google Scholar, 7Colavita F. Lapa D. Carletti F. Lalle E. Bordi L. Marsella P. et al.SARS-CoV-2 isolation from ocular secretions of a patient with COVID-19 in Italy with prolonged viral RNA detection.Ann Intern Med. 2020; 173: 242-243https://doi.org/10.7326/M20-1176Crossref PubMed Scopus (155) Google Scholar, 8Xia J. Tong J. Liu M. Shen Y. Guo D. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARS-CoV-2 infection.J Med Virol. 2020; 92: 589-594https://doi.org/10.1002/jmv.25725Crossref PubMed Scopus (565) Google Scholar, 9Bin Sun C. Wang Y.Y. Liu G.H. Liu Z. Role of the eye in transmitting human coronavirus: what we know and what we do not know.Front Public Health. 2020; 8: 1-7https://doi.org/10.3389/fpubh.2020.00155Crossref PubMed Scopus (62) Google Scholar]. Additional concerns about the role of hand-eye contact and hygiene issues, as seen in other inflammatory events [[10]Fonn D. Jones L. Hand hygiene is linked to microbial keratitis and corneal inflammatory events.Cont Lens Anterior Eye. 2019; 42: 132-135https://doi.org/10.1016/j.clae.2018.10.022Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar], lead to some early advice for patients to cease contact lens wear [[11]Cho P. Maureen Boost M. COVID 19—an eye on the virus.Cont Lens Anterior Eye. 2020; 43: 313-314https://doi.org/10.1016/j.clae.2020.05.011Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. Although, counter arguments suggested that contact lens was safe [[12]Jones L. Walsh K. Willcox M. Morgan P. Nichols J. The COVID-19 pandemic: important considerations for contact lens practitioners.Cont Lens Anterior Eye. 2020; 43: 196-203https://doi.org/10.1016/j.clae.2020.03.012Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar] and particular attention should be paid to evidence-based sources [[13]Orsborn G. The importance of credible information about contact lens wear during pandemic.Cont Lens Anterior Eye. 2020; 43: 214-215https://doi.org/10.1016/j.clae.2020.04.008Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. Nonetheless, an overall reduction in contact lens wear was seen largely due to people were not engaging in their normal work practice or leisure activities [[14]Morgan P.B. Contact lens wear during the COVID-19 pandemic.Cont Lens Anterior Eye. 2020; 43: 213https://doi.org/10.1016/j.clae.2020.04.005Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] and certainly it is these activities that were ceased during lockdown that may be the main reasons for wearing contact lenses in the first place [[15]Naroo Sa Shah S. Kapoor R. Factors that influence patient choice of contact lens or photorefractive keratectomy.J Refract Surg. 1999; 15: 132-136PubMed Google Scholar,[16]Gupta N. Naroo Sa Factors influencing patient choice of refractive surgery or contact lenses and choice of centre.Cont Lens Anterior Eye. 2006; 29: 17-23https://doi.org/10.1016/j.clae.2005.10.006Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar]. On a positive note the pandemic time resulted in a higher level of compliance among contact lens wearers [[17]Bakkar M.M. Alzghoul E.A. Assessment of contact lens wearers’ attitude toward contact lens wear and care during Coronavirus Disease 2019 (COVID-19) pandemic: a cross-sectional online survey.Cont Lens Anterior Eye. 2021; (S1367-0484(21)00009-6)https://doi.org/10.1016/j.clae.2021.01.005Abstract Full Text Full Text PDF Scopus (1) Google Scholar,[18]Vianya-Estopa M. Wol J.S. Beukes E. Trott M. Smith L. Allen P.M. Soft contact lens wearers’ compliance during the COVID-19 pandemic.Cont Lens Anterior Eye. 2020; (S1367-0484(20)30155-30157)https://doi.org/10.1016/j.clae.2020.08.003Abstract Full Text Full Text PDF Scopus (5) Google Scholar]. As contact lens practitioners exited the first lockdown and returned to work, they were grateful that their contact lens busines survived due to monthly payment schemes for regular replacement lenses [[19]Patel N.I. Naroo S.A. Eperjesi F. Rumney N.J. Customer loyalty among daily disposable contact lens wearers.Cont Lens Anterior Eye. 2015; 38: 15-20https://doi.org/10.1016/j.clae.2014.08.003Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. Precautions were in place, such as slit lamp guards, additional cleaning between patients, and personal protective equipment [[20]Pult H. COVID-19 Pandemic: Survey of future use of personal protective equipment in optometric practice.Cont Lens Anterior Eye. 2020; 43: 208-210https://doi.org/10.1016/j.clae.2020.04.006Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,[21]Wang H. Kong W. Zhang W. Fan Q. Letter to the editor: contact lens practice in the time of COVID-19.Cont Lens Anterior Eye. 2020; 43: 217https://doi.org/10.1016/j.clae.2020.04.012Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. Chair time became more precious after lockdown and most practices reserved appointments slots for emergency and priority patients. These patients were often triaged through a telemedicine type approach [[22]Nagra M. Vianya-Estopa M. Wolffsohn J.S. Could telehealth help eye care practitioners adapt contact lens services during the covid-19 pandemic?.Cont Lens Anterior Eye. 2020; 43: 204-207https://doi.org/10.1016/j.clae.2020.04.002Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Patients were called on the telephone or via a video-chat system and symptoms were heard so that priority patients could be categorised and booked in for face-to-face appointments. One of the groups to be categorised as lower priority would certainly be the routine contact lens aftercare patients, especially those that were asymptomatic. The recent Contact Lens Evidence-Based Academic Reports (CLEAR) reported the latest information in all aspects of contact lenses [[23]Wolffsohn J.S. Morgan P.B. Barnett M. Downie L.E. Jacobs D.S. Jones L. et al.Contact lens evidence-based academic reports (CLEAR).Cont Lens Anterior Eye. 2021; 44: 129-131https://doi.org/10.1016/j.clae.2021.02.011Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] but in the report that dealt with contact lens practice there is little current evidence related to the frequency of aftercare [[24]Wolffsohn J.S. Dumbleton K. Huntjens B. Kandel H. Koh S. Kunnen C.M.E. et al.CLEAR - Evidence-based contact lens practice.Cont Lens Anterior Eye. 2021; 44: 368-397https://doi.org/10.1016/j.clae.2021.02.008Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. Only one paper suggests the safe aftercare interval and recommends a minimum period of 24 months for soft daily disposable, every 12 months for soft daily reusable and rigid daily wear, and every 6 months for soft and rigid overnight wear, with the proviso that these periods may need shortening if refractive changes are predicted, such as progressive myopia or advancing presbyopia [[25]Efron N. Morgan P.B. Rethinking contact lens aftercare.Clin Exp Optom. 2017; 100: 411-431https://doi.org/10.1111/cxo.12588Crossref PubMed Scopus (16) Google Scholar]. However, the actual evidence behind these suggested aftercare intervals is unclear and will be disputed by many clinicians, often preferring an annual or bi-annual aftercare. Moreover, since many contact lens adverse events are initially asymptomatic and if they are managed during this phase then no longer-term effects will occur. A recent BCLA webinar by one of authors of this editorial (RK) suggested that the steps involved in a contact lens fitting appointment (assuming a recent full eye examination has been performed) could be broken down into the following steps:1Initial enquiry as to whether the patient is suitable for contact lenses2Relevant history and symptoms3Slit lamp examination of the cornea4Preliminary measurements, including corneal curvature5Contact lens trial on the eyes6Appointment to teach application and removal of contact lenses, plus cleaning regimen7Routine aftercare (for a new contact lens wearer there would be more initial aftercare appointments and then a regular schedule would be reached)8Unscheduled aftercare to deal with a problem Chair time in the consulting room is precious in contact lens clinical practice and if it is to be used more efficiently in the post-pandemic era, then steps 1 and 2 could certainly be performed remotely and the use of video-calling would be a very efficient way to undertake these steps. Steps 3, 4 and 5 would require a face-to-face clinical appointment and current technology is not adequate to substitute these. In the case of a new contact lens wearer step 6 is likely to require a face-to-face clinical appointment but this could be supplemented with a video-call before or after the face-to-face clinical appointment. For an established contact lens wearer step 6 could be undertaken remotely by video-call. An early aftercare appointment for a new contact lens wearer would need a face-to-face clinical appointment and again this could be supplemented with a video-call before or afterwards. However, for an asymptomatic established wearer a video-call appointment may suffice, complemented with at least alternating face-to-face clinical appointments. However, not seeing a patient physically for over 24 months would not be advised under any circumstance. For example, an established, asymptomatic contact lens wearer using daily disposable lenses could be contacted via video-chat every 6-months post-collection of new lenses. Then, at the 24 months' appointment the patient could return to the practice for a full eye examination and full contact lens appointment. It should be noted that any unscheduled aftercare that needs to address a problem will require a face-to-face appointment but could be supplemented with a pre-visit video-call to establish the relevant history and symptoms. Similarly, complex contact lens aftercare may not be so simple to manage with video-calls. The pandemic has certainly made the world re-assess the way certain tasks are conducted. Many administrative roles may involve people working from home in the future. Clearly, the ‘new normal’ will not be the same as pre-pandemic and the pandemic has accelerated the use of technology. This is clear in education and healthcare and it would be unwise to try and revert to ‘old ways’ and instead embrace the things that have worked well. Unpublished data from the Birmingham and Midland Eye Centre at the City Hospital in Birmingham found that telephone-triaging of patients, employed during the pandemic era, reduced the likelihood of patients not attending or cancelling an appointment. This led to a more efficient patient management due to less vacant slots in the diary. The fact that many new contact lens wearers drop out of contact lens wear during the first few months of wear is well known and is a problem that contact lens practitioners need to address [[26]Naroo S.A. Contact lens dropouts – must try harder.Cont Lens Anterior Eye. 2012; 35: 195https://doi.org/10.1016/j.clae.2012.08.002Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. One tactic to reduce this drop out rate would be regular communication with the patient in those first few weeks, to alleviate fears and concerns and remind the patient of key tips and messages to ensure successful contact lens wear. The video-call appointment, scheduled or not, would be the ideal way to connect with new contact lens wearers in the first few weeks of wear. The video-call appointment is likely to become an integral tool in the armoury of contact lens clinical appointments. Large optical practices with multiple practitioners may utilise a practitioner, or suitably trained member of staff, whose job it is to deal with triaging and video-calls. This practitioner could even be working from home and the role may be rotated amongst the practitioners in a large practice. For the sole-practitioner type of practice the clinician may spend part of the day undertaking this task themselves or training another member of the team to take this responsibility. It may even be that online suppliers of contact lenses embrace this approach and refer patients to a network of optical practices when a face-to-face appointment is required. As Bob Dylan eloquently penned ‘Times they are a-changin’.