There is no one method for correction of refractive error that is either appropriate for or appealing to all patients. Some patients and practitioners choose spectacles as the best choice, whereas contact lenses or refractive surgery is the correction of choice in other circumstances.
To add further complexity, with the numerous technologic advances in contact lens materials and manufacturing, some patients may now wear lenses for 1 day and discard them, whereas others wear them for a month. The majority of patients use their lenses for 1 to 4 weeks before replacement, although some keep lenses for a year or more on a conventional replacement schedule. Another use dimension that offers flexibility (or confusion) is in the lens-wearing schedule; patients may wear lenses only while awake; or may sleep in lenses a few nights a week, for an entire week, or for 30 continuous nights, depending on lens type and practitioner recommendation. The overnight wear factor is of particular interest because it has been cited as a factor for the success of lens wear and, conversely, in the development of complications such as corneal infections. Researchers in the contact lens field have strived to learn how patients regard their contact lenses and about their patterns of use to improve patient success with contact lenses.
A survey conducted at the Contact Lens and Primary Care Clinics of Indiana University during the spring of 2002 showed that contact lens patients and spectacle wearers alike were less interested in 7-day extended overnight wear (EW) and 30-day continuous overnight wear (CW) contact lenses than laser in situ keratomileusis (LASIK) or orthokeratology (OK) when the treatments were described in a hypothetical model in which cost was not a factor. At the time of that survey, in the United States, 30-day CW wear silicone hydrogel lenses had been only recently made available and 7-day EW lenses remained relatively unchanged for over a decade in terms of materials, lens designs, and prescribed replacement schedules.
Early in this decade, there was an increase in the amount of direct advertising for LASIK, thus, patients in eye care offices very likely had less information about overnight wear of contact lenses than they had received about LASIK. Whether the patients would actually choose LASIK more than overnight wear of CW or EW contact lenses when the real-world factors of differences in cost, predictability, reversibility, and vision quality were incorporated is impossible to determine. It is possible, however, to measure whether there have been any significant changes in the degree of interest in or use of overnight wear with contact lenses after the introduction of new contact lens technology in the past few years by surveying two groups of patients presenting for eye care in 2002 and 2004.
Not surprisingly, the 2002 survey showed that current use of contact lenses was associated with more positive attitudes toward all nonspectacle methods of refractive correction. The survey also showed that gender had a significant influence on the reported amount of overnight contact lens wear at that time, with significantly more males reporting overnight wear of contact lenses. Men in that survey also indicated a significantly higher opinion about the health and safety of and interest in 7- and 30-day overnight wear lenses compared with women. Patients with a high amount of refractive error were not found to have any different attitudes and preferences for refractive error correction in that study compared with those with lower refractive errors.
Measuring patient attitudes and satisfaction with medical treatments is important because the patients' degree of satisfaction has been shown to correlate with utilization of healthcare. If patients have positive attitudes and a high level of satisfaction, they are more likely to use or continue use of medication, a device, or service provider. Measurement of attitudes among patients who do not use a particular refractive treatment can help practitioners understand whether patients have a realistic understanding and expectation of that treatment.
Measurement of attitudes among patients who have previously undergone a procedure more directly measures satisfaction with the procedure. Sequential surveys of practitioners' prescribing habits and preferred treatment methods have been used to assess the clinical community's uptake of newly introduced treatment paradigms. The current study was conducted in a noncorporate, neutral clinical setting among patients who were seeking eye care on that day, making them a particularly appropriate group to survey.
The purpose of this study was to assess the lens-wearing patterns and patient attitudes toward six methods of refractive error correction and track changes over time. Sequential surveys in the same clinical setting were conducted approximately 2 years apart to determine whether there shift in use patterns and attitudes had occurred over time, taking patient age and gender into account.
DISCUSSION
Patients who are seeking options for correction of their refractive error in the new century have a vast array of information sources to draw on. As stated by Ursula Vogt, MD, in the 2003 Kersley Lecture at the International Medical Contact Lens Symposium regarding information sources for patients, “They may look on the Internet, even buy their contact lenses there, but then they turn to you (practitioner) for guidance.” However, before they turn to an eye care practitioner, patients will have received abundant, often sound yet conflicting information that is difficult for them to dissect as it relates to their individual refractive and ocular condition.
Fortunately, unlike patients, clinicians are trained to recognize the complex factors that contribute to suitability for the various methods of refractive correction, the patient's age and refractive error, the condition of their ocular surface, and pupil size to name just a few.
Refractive surgery practices have widely adopted the use of educational seminars and direct advertising to communicate the benefit of LASIK to potential patients. Regardless of the method of initially reaching potential patients, a recent study of the rejection rate among patients screened for LASIK concluded that 13% of patients were rejected from surgery, regardless of whether they were screened by telephone or an educational seminar before they presented for examination.
Most of the rejections were the result of the presence of cataract or for a lack of acceptance or understanding of presbyopia; two concepts that are somewhat difficult for patients to grasp on their own and are of particular importance to patients above age 40. That study and others concluded that the most important element in the process of assisting patients in the right choice of refractive error correction was for a “qualified eye care professional to examine the patient in a thorough and critical manner” and that the patient is rather ill-equipped to self-diagnose their own suitability for a refractive surgical procedure.
Eye care patients' negative attitudes about EW contact lenses have been forged for many years by conscientious practitioners who were informing patients of the increase in risk of corneal infections from low dK hydrogel lenses. That cautious message was appropriate to reflect the clinical knowledge available at the time. Recent direct advertising to patients about CW silicone hydrogel lenses has attempted to reintroduce the patient to benefits that new lens technology offers that was lacking in the earlier contact lens materials. The specific change in attitudes toward the health and safety of 7 and 30 days overnight contact lens wear among women (especially those under age 30) in our recent survey could be the result of targeted messages in magazines and advertising aimed at young women. The change in use of EW, however, was significantly greater even when controlling for the change in age of the surveyed population. Interestingly, the distribution of lens replacement schedules did not change during the period between surveys.
Although serious infections have been reported with silicone hydrogel lenses, the rate of infections or risk factors with CW silicone hydrogel lenses is as yet not established as it was with low oxygen transmission lenses. The case series have thus far implicated pathogens already known to also be associated with infections with low transmissibility lenses, but the number of cases have not been high enough to establish any difference in the rate of infections. Postmarket studies will be required to provide that information for CW silicone hydrogel lenses. On the positive note, clinical studies abound that have shown an improvement in corneal and ocular surface physiology resulting from higher oxygen from silicone hydrogel lenses.
The patients in this study did not report any significant shift in their attitudes toward OK over the 2-year period. At the time of our previous survey, modern OK was in early stages of reintroduction to the ophthalmic community as a method for refractive correction, with overall promising early clinical and technical results. Because that time a number of reports of corneal ulceration associated with OK have emerged, primarily from China and the United States. There is always a possibility that infectious complications are induced by local factors; the safety and quality of the air and water supply in China may be important factors in these events along with the higher use rate of OK associated with the epidemic of myopia. The U.S. case series, however, also included two cases that were presumed infectious. Over the next few years, because OK is more widely used, clinicians will be better able to verify the safety of the corneal reshaping modality.
Our study shows that significantly fewer subjects over age 30 in the recent survey reported a high degree of interest in LASIK. Perhaps the problematic outcomes with monovision or uncorrected presbyopia have patients aware that older patients may have more difficulty with LASIK, are more likely to need retreatment, or to be rejected as candidates for the treatment. Hill found that of 200 consecutively surveyed LASIK patients (mean age 38 years), 24.5% required reading glasses at least some of the time after their LASIK procedure, notwithstanding their overall satisfaction with the procedure.
From another point of view, the proportion of refractive surgery practitioners who would wait rather than conduct a refractive surgery procedure rose dramatically with increasing patient age and degree of hyperopia in hypothetical models in a recent survey. Although the patient populations for LASIK are older than the typical contact lens wearer, presbyopia remains a complicating factor in the success of LASIK. Our survey shows that at least older female patients may be becoming aware of some complications of presbyopia (higher rate of second procedures or “enhancements”) and LASIK and that this may be dampening their enthusiasm for the procedure. In a very recent manuscript, Miranda and Krueger state that “Despite this growth (in LASIK) presbyopia remains a challenge for refractive surgery.”
The diminished size of the 2004 survey may have hampered our ability to show changes that may be occurring in attitudes or contact lens-wearing habits. For that reason, the proportion of wearers who responded from each survey is shown in the figures, allowing the reader to interpret the findings beyond the restriction of smaller sample size in some of the variables. A global statement about the degree to which the later study limits the statistical power is not possible, because the number of respondents changes with each variable investigated.
Generally, in cases in which we found nonsignificant changes by statistical analysis, the trend was insufficient to overcome the smaller sample size in the later survey. Ideally, this study would have been conducted with a sample of equivalent size in the 2004 survey. In addition, some small proportion of those surveyed might appear in both surveys, although this information was not collected at the 2004 survey.
CONCLUSION
The factors that influence patient attitudes toward new technologies that correct refractive error are manifold. Patients today must sift through information that comes to them through advertising, Internet information, government publications, messages prepared by provider organizations, lay magazines, and television news each day to determine what they think of the safety or suitability of contact lenses or refractive surgery.
Regardless of all these influences, this study found that patients, particularly females, have more positive attitudes to overnight wear of lenses compared with 2 years ago and that the enthusiasm of older patients has dampened toward LASIK. Eye care providers remain the most trusted source of recommendation and information and, as such, are burdened with the responsibility to keep abreast of the latest information regarding the safety, effectiveness, and suitability of new and established methods of refractive correction to best serve their diverse patient base.
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