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Contact lens prescribing trends: Efron, Morgan and Woods's 14th annual survey of Australian contact lens prescribing habits

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Dr Nathan Efron PhD DSc
Research Professor, Institute of Health and Biomedical Innovation, and School of Optometry, QUT

Dr Philip B Morgan PhD
Professor and Director, Eurolens
Research, the University of
Manchester, Manchester UK

Dr Craig A Woods PhD
Associate Professor, School of Medicine (Optometry), Deakin University

 

The 14th annual survey of Australian contact lens prescribing was conducted between January and April 2013. The same format as in previous years was employed. About 3,000 practising members of Optometrists Association Australia were sent an e-mail message with a link to a downloadable questionnaire and a request that this be accessed, printed and completed to provide details of the first 10 patients fitted with contact lenses after receipt of the questionnaire.

The questionnaire was designed to be straightforward while capturing key information about the patients' prescribed contact lenses. Practitioners were asked general questions about themselves, and for each contact lens fitting, they were requested to complete the following details: date of fitting, new fitting or refitting, age and sex of patient, lens material, lens design, frequency of replacement, times per week of wear, modality (daily or extended wear) and care system. Practitioners were asked to return the questionnaire by fax or post.

Completed questionnaires relating to 459 contact lens fittings were received. Each fitting was given a rating based on the number of lenses fitted per year by the practitioner (based on the date information on the form). This means that data generated by practitioners who conducted many contact lens fittings were afforded a higher rating than those performing fewer fittings.

The discussion below will concentrate primarily on data relating to new lens fittings, as opposed to refittings. We believe that new fittings are a more sensitive barometer of current patterns and future trends, whereas refittings are more indicative of previous fitting behaviours.

Demographics

As in previous years and in keeping with other markets around the world, a majority of lenses in Australia (66 per cent) were fitted to females. The average age of contact lens wearers continues to edge upwards. This year, the mean ± standard deviation age at fitting was 38.2 ± 15.9 years, varying from nine to 76 years.

Soft lenses

As has been the case for the past 30 years, soft lenses accounted for the majority of new fittings (96 per cent). Figure 1 is a composite of pie charts detailing the key findings of the 2013 survey in relation to soft lenses. Silicone hydrogels represented 77 per cent and 67 per cent of materials prescribed as new fittings and refittings, respectively—Dan increase over the 2012 data1 (68 per cent and 62 per cent). The balance of lens materials comprises largely mid-water content hydrogel materials. Low and high water content lenses accounted for only three per cent and four per cent of new fittings, respectively, although these lenses were fitted at a higher rate for lens refittings (seven per cent  and 10 per cent, respectively).

Ph 790 Trend Figure 1

Figure 1. Detailed results for soft lens prescribing in the 2013 Australian survey.
Si-H: silicone hydrogel, WC: water content

Figure 2 shows fitting trends in relation to soft lens materials in Australia between 2000 and 2013. It is evident that the extent of silicone hydrogel lens fitting rapidly expanded between 2000 and 2007 and stabilised thereafter, although there appears to have been a further slight increase in fitting this material over the past three years.

The four major categories of lens designs are spherical, toric, multifocal and anti-myopia. Monovision is an alternative fitting strategy, but such fittings are generally performed using spherical lens designs. Grouping monovision fittings in the spherical design category, we find that the majority of soft lens designs prescribed are spheres, which represent 54 per cent and 58 per cent of new fittings and refittings, respectively.

Ph 790 Trend Figure 2

Figure 2. Percentage of soft lens fittings prescribed for silicone hydrogel (Si-H),
high-, mid- and low-water content (WC) lenses in Australia between 2000 and 2013

There has been a slight decrease in the prescribing of soft lenses for the correction of astigmatism in 2013, with 32 per cent of soft lens new fittings being toric designs, versus 39 per cent 2012.1 The current level of toric lens prescribing in Australia suggests that nearly all `clinically significant' astigmatism (> 0.75 D) is being corrected (the accepted target in this regard is about 35 per cent of lenses2).

Multifocal lenses appear to be favoured by practitioners over monovision around the world in recent years,3 and presbyopia fitting practices in Australia are generally consistent with this trend. There were more presbyopic new fittings with multifocal lenses (13 per cent) compared with monovision lenses (nine per cent). There were no recorded new fittings with coloured (tinted) soft lenses in this survey.

Over the past five years, there has been a great deal of interest in anti-myopia lenses. These are specially-designed soft lenses that alter the image profile in the lens periphery to arrest the progression of myopia. Preliminary research suggests that these lens designs do seem to have some efficacy in arresting myopia progression, albeit limited and somewhat unpredictable.4 Despite these promising advances, only one per cent of new fittings at the present time are with this form of lens. This is probably a result of a combination of initial practitioner resistance or caution, and the fact that these products are not readily available currently in Australia.

Daily disposable lenses continue to be popular in Australia, although the proportion of daily disposable lens new fittings decreased from 42 per cent of all soft lens fittings in 2012 to 38 per cent in 2013.

The fitting of monthly replacement lenses as new fittings increased sharply from 32 per cent in 2012 to 47 per cent in 2013. This dramatic change appears to have been at the expense of one-to-two week replacement lenses, which dropped from 24 per cent of new fittings in 2012 to 15 per cent in 2013. The practice of replacing lenses less frequently than monthly has been in steady decline since we began surveying the Australian market in 2000. It has now reached the point where there were no such lenses were prescribed for new fittings in 2013; that is, we now have a market that is exclusively frequent lens replacement (in other words, at least monthly).

The extent to which the Australian market has shifted to single use lenses is illustrated in Figure 3. `Single use' simply means that the lens is inserted and removed once only before being discarded and as such, this means daily disposable and extended wear lenses. Although extended wear has often been touted in the past as the ultimate form of convenient lens wear, this modality has rarely exceeded a `glass ceiling' of about 15 per cent of soft lenses prescribed anywhere in the world.5

Ph 790 Trend Figure 3

Figure 3. Percentage of soft lens fittings prescribed as reusable, single use extended
wear (EW) and single use daily disposable (DD) lenses between 2000 and 2013

Extended wear lenses represented seven per cent of soft lens fittings in 2013, and all single use lenses (in other words, extended wear and daily disposable lenses combined) represented 36 per cent of all soft lens fittings in 2013. This overall level of single use fittings has remained fairly constant since 2007.

Multi-purpose solutions account for 92 per cent of prescribed care regimens, with the balance comprising peroxide systems.

Rigid lenses

Non-orthokeratology and orthokeratology rigid contact lenses represented five per cent and zero per cent, respectively, of all contact lens fittings. As has been the case in recent years, our data set for non-orthokeratology rigid lens fitting is so sparse that it is statistically untenable to break the data down into sub-categories of materials, designs and replacement frequencies. The level of orthokeratology fitting is apparently nonexistent at present, although orthokeratology did represent four per cent of fittings in 2012. This apparent volatility in orthokeratology fitting may in part be attributed to the wide confidence intervals (and thus lack of precision) inherent in surveying such rare fitting behaviours.

Australia versus New Zealand

We started conducting contact lens prescribing surveys in the UK in 1996 and have progressively included more countries over the years to the point where we now survey about 40 countries annually.5 This provides an opportunity to benchmark Australian trends against international colleagues, and this year we compare Australian contact lens prescribing with that of our neighbour, New Zealand. The current pattern of contact lens fitting in these two countries in shown in Figure 4. Six key categories of lens type are represented. The outer and inner rings show the Australian and New Zealand data, respectively.

Overall, Figure 4 reveals that contact lens prescribing patterns are remarkably similar between the two nations. This is perhaps unsurprising, as the two nations are in the same geographical region and have similar demographics, social and political systems and economic profiles. As well, some of the major contact lens companies have joint or shared trans-Tasman management and distribution arrangements. Therefore, there are commonalities in the promotion, marketing and distribution of contact lenses in the two countries. In addition, the trend towards true globalisation of the contact lens market over the past decade means that the vast majority of soft lenses sold worldwide rests in the hands of a small group of companies that operate in virtually all countries.

Ph 790 Trend Figure 4

Figure 4. Percentage of all contact lenses prescribed in Australia (outer ring) ­
compared with New Zealand (inner ring). OK: orthokeratology, DW: daily wear,
Si-H: silicone hydrogel, EW: extended wear.

The only real differences between Australia and New Zealand are in the fitting of rigid lenses and the prescribing of soft lenses for extended wear. The extent of rigid lens fitting is apparently three times greater in New Zealand compared with Australia. This may reflect the traditional approach to contact lens fitting in New Zealand, fuelled by loyalty to the remaining active rigid lens laboratories—Contact Lens Corporation and Precision Contact Lenses, both of which are in Christchurch.6

There has been a progressive merging and/or closing down of rigid lens companies in Australia. Eycon, CooperVision-Hydron and NuContacts have ceased operation in the past five to 10 years. Only three Australian rigid lens laboratories remain in business: Australian Contact Lenses (Melbourne), Gelflex (Perth) and Capricornia (Brisbane). The fact that three rigid lens laboratories operate in Australia and two in New Zealand—although Australia has more than five times the populationÐreflects the relative dearth of rigid lens fitting by Australian practitioners.

The level of orthokeratology fitting is very low in New Zealand (one per cent) and as noted above, is apparently non-existent in Australia at present. At best, orthokeratology remains a niche market in both countries, as is indeed the case in the vast majority of countries we survey.

In contrast to rigid lens fitting, 3.5 times more soft extended wear lenses are fitted in Australia compared with in New Zealand. The reason for this is unclear but again may relate to the more conservative approach adopted by New Zealand practitioners.

Conclusions

Perhaps the most notable finding of our 2013 survey of Australian contact lens prescribing is the increasing dominance of silicone hydrogel lenses. It is remarkable to observe that a specific product innovation—which was introduced to the world market only at the turn of the century—could have such a huge impact on a global retail market valued at approximately $8 billion annually.

The other significant change this year has been the decline in one-to-two weekly lens replacement to only 15 per cent. This indicates that Australia is rapidly moving towards a two-modality market of daily or monthly disposable lens replacement.

Full correction of astigmatism remains to be the norm, with continuing high levels of practitioner confidence in toric lens fitting. Multifocal soft lenses are still the preferred form of correction for presbyopes over monovision. Rigid lens prescribing continues to be low and there is little current interest in orthokeratology. The contact lens demographic continues to trend towards older age, typically female wearers.

  1. Efron N, Morgan PB, Woods CA. Trends in Australian contact lens prescribing 2012. Australian Optometry (Contact Lenses Supplement) 2012; 33: 11: 3-5.
  2. Holden BA. The principles and practice of correcting astigmatism with soft contact lenses. Aust J Optom 1975; 58: 279-299.
  3. Morgan PB, Efron N, Woods CA, The International Contact Lens Prescribing Survey Consortium. An international survey of contact lens prescribing for presbyopia. Clin Exp Optom 2011; 94: 87-92.
  4. Sankaridurg P, Holden B, Smith E 3rd, Naduvilath T, Chen X, de la Jara PL, Martinez A, Kwan J, Ho A, Frick K, Ge J. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest Ophthalmol Vis Sci 2011; 52: 9362-9367.
  5. Efron N, Morgan PB, Woods CA, The International Contact Lens Prescribing Survey Consortium. International survey of contact lens prescribing for extended wear. Optom Vis Sci 2012; 89: 122-129.
  6. Morgan PB, Woods CA, Tranoudis IG, Helland M, Efron N, Orihuela GC, Grupcheva CN, Jones D, Tan KO, Pesinova A, Ravn O, Santodomingo J, Malet F, Sze L, Cheng P, Végh M, Erdinest N, Ragnarsdóttir JB, Montani G, Davila-Garcia E, Itoi M, Chu BS, Bendoriene J, van der Worp E, Awasthi S, Lam W, Casablanca J, González-Méijome JM, Johansson O, Silih MS, Hsiao J, Nichols JJ. International contact lens prescribing in 2012. Contact Lens Spectrum 2013; 28: 1: 31, 32, 34, 36-38, 44.


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