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Compliance and hygiene behaviour among soft

contact lens wearers in the Maldives

ARTICLE in CLINICAL AND EXPERIMENTAL OPTOMETRY MAY 2013

Impact Factor: 1.26 DOI: 10.1111/cxo.12069 Source: PubMed

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 C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY
RESEARCH PAPER

Compliance and hygiene behaviour among soft contact lens

wearers in the Maldives

Clin Exp Optom 2013 DOI:10.1111/cxo.12069

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,
School of Medicine, Flinders University,
Bedford Park, South Australia, Australia
E-mail: gyawali.rajendra@gmail.com
Submitted: 27 July 2012
Revised: 5 February 2013
Accepted for publication: 13 February 2013
Results: Out of 107 participants, 79 (74.8 per cent) were interviewed in the office and the
rest via telephone. The majority of lens wearers were female, office workers and students,
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.
Conclusion: A significant number of Maldivian contact lens wearers exhibited poor levels of
hygiene and compliance with contact lenses and lens care systems. An effective educational
reinforcement strategy needs to be developed to modify lens wearers non-compliance.

Key words: compliance, contact lens, hygiene, Maldives

Contact lenses are considered a widely
accepted modality for refractive correction,
cosmetic enhancement and other therapeu-
tic reasons. With an increasing number of
lens wearers, the prevalence of lens-related
complications is also rising and is reported
to be as high as 57 per cent of the lens users
presenting to contact lens clinics.1 These
complications range from mild discomfort
to severe microbial keratitis and may pose a
risk of sight loss and significant financial
burden on lens wearers.2 Among the identi-
fied risk factors associated with such com-
plications, some are non-modifiable, such
as gender, age and socio-economic status,
whereas others are modifiable, for instance,
poor hand cleaning and lens case hygiene.35
A recent study suggested a potential cor-
relation between increased incidence of
contact lens-related complications and
non-compliant behaviour.6
Non-compliance is a significant clinical
problem in contact lens practice, with
overall non-compliance rates ranging from
40 to 91 per cent.79 Some of the contri-
buting factors to these disturbingly high
rates include unawareness of non-compliant
behaviour and its potential adverse results,
effort required to maintain an optimal
cleaning regime, predominantly preventive
nature of practitioners recommendations
and variable and ambiguous recommenda-
tions from practitioners.7,10,11
Although no definite statistics are avail-
able regarding contact lens use in the
Maldives, it is observed that an increasing
number of the Maldivian population use soft
contact lenses for refractive correction and
cosmetic purpose. Many of these lens users
presenting to optometric clinics report non-
compliant behaviour. To improve compli-
ance, it is essential to identify the scope of
hygienic behaviour and the demographic
profile of lens wearers. This study was under-
taken to investigate the hygiene practice and
non-compliant behaviour among Maldivian
soft lens wearers through a set of structured
questions.
METHODS
Consecutive soft lens wearers attending a
private optometric clinic and a government
eye-care facility in Male, the capital city of

2013 The Authors Clinical and Experimental Optometry 2013

Clinical and Experimental Optometry 2013 Optometrists Association Australia 1
Compliance and hygiene behavior in soft contact lens wearers in the Maldives Gyawali, Mohamed, Bist, Kandel, Marasini and Khadka
Demographic factors (n = 107)
Gender Female
Male
Age group (years) 1625
2635
3645
Education Secondary level
Higher secondary level
Graduate level
Profession Office workers (Managers/ professionals/ sales persons)
Students
Field worker/ plant and machine operators
Armed forces occupations
Others
Not available
Table 1. Demographic characteristics of participants
the Maldives, from February to March, 2012
were invited to participate in this survey.
Patients under the age of 15 years, therapeu-
tic lens users and those who had used lenses
for less than four weeks were excluded from
the study. The participants presenting to the
private eye clinic were interviewed in-office
before the examination procedure, while
a telephone interview was conducted for
those scheduled for an aftercare visit in the
government eye-care facility prior to their
scheduled examination. Informed consent
was obtained from all the participants before
the interview.
An interviewer-administered question-
naire on hygiene behaviour and compliance
to practitioners recommendations, based
on a previous study,12 was developed by a
focus group of contact lens practitioners.
There were 12 items with five response cat-
egories ranging from 0 to 4 with higher
scores indicating better hygiene behaviour
and compliance. Participants were ques-
tioned regarding their hand-washing habits,
cleaning of the lenses before insertion,
replacement of lenses on the recommended
schedule, overnight wear and short naps or
dozing while wearing lenses, frequency of
water activities with lenses, use of tap water to
clean lenses, reusing or topping off the dis-
infecting solution, awareness on aftercare
visits and frequency of cleaning and replac-
Clinical and Experimental Optometry 2013
2 Clinical and Experimental Optometry 2013 Optometrists Association Australia
Number
(percentage)
75 (70.1)
32 (29.9)
84 (78.5)
18 (16.8)
5 (4.7)
45 (42.0)
16 (15.0)
46 (43.0)
47 (43.9)
34 (31.8)
13 (12.2)
5 (4.7)
6 (5.6)
2 (1.9)
ing the lens storage cases. For statistical
analysis, a score between 0 and 2 was consid-
ered non-compliant, whereas that between
3 and 4 was considered as compliant behav-
iour. At the end of the interview, participants
were also asked to rate themselves as good,
average or poor contact lens users based
on self-perception of their hygiene and
compliance to clinicians recommenda-
tions. No specific criteria were provided to
define good, average or poor user and
the response was completely subjective. The
questionnaire was pretested, reviewed and
revised by the focus group to ensure ease
of comprehension and completeness.
Demographic details including age,
gender, education and occupation were
obtained from all the participants. Detailed
information on lens wear, including dura-
tion and average hours of lens use, practi-
tioners recommended wearing modality
and replacement schedule of the lens, dura-
tion since the last aftercare visit, brand
of lens and disinfection solution and any
history of lens-related complications was
also obtained from the participants. Differ-
ent lens and disinfection solutions available
in local optical outlets in Male were pre-
sented to the participants who could not
remember the brand name of their lens
and/or solution and were asked to identify
the brand.
The data were managed and analysed
using SPSS software (SPSS Statistics, Version
19; IBM Corporation, Armonk, NY, USA).
Simple frequencies and relationships be-
tween variables were calculated. Multivariate
logistic regression was used to determine
the factors associated with non-compliant
behaviour. Chi-square test was used as the
test of significance and a p-value less than
0.05 was considered statistically significant at
the 95% level of confidence.
RESULTS
A total of 129 contact lens users were invited
to participate in this survey, of who 107
agreed to participate (response rate: 89.9
per cent). Among these 107 participants, 79
(73.8 per cent) were interviewed in the office
during their aftercare visit and the remain-
ing via telephone.
Lens wearer profile
Mean age of participants was 20.64 4.4
years (range: 16 to 42 years). Other socio-
demographic characteristics of the partici-
pants are presented in Table 1.
The mean duration of contact lens use was
28.048.36 months (range: 3 to 72 months).
The mean lens use per day was 8.5 3.3
hours (range: 3 to 16 hours) and 6.5 0.9
days per week (range: 4 to 7 days). Partici-
pants with graduate level education used
lenses for a longer duration per day (9.7
3.6 hours) compared to the participants with
higher secondary (6.7 4.6 hours) and sec-
ondary or lower level of education (7.8 1.4
hours) (p < 0.05). Almost all the participants
(103, 96.26 per cent) reported being pre-
scribed lenses on a daily wear basis and
the remaining four were on an extended
wear basis. The majority (86.9 per cent) of
the lens wearers were using spherical soft
lenses for distance correction followed by
toric lenses (8.4 per cent). Only three (2.8
per cent) participants were using lenses as
monovision correction for presbyopia.
The most commonly used contact lens
brand was Freshlook Colorblends (CIBA
Vision) (46.7 per cent) followed by Acuvue
(Johnson and Johnson). Other brands re-
ported were from Flexcon, Bausch & Lomb
and Biomedics (CooperVision). Three re-
ported multipurpose solutions were Solo-
Care Aqua (CIBA Vision), OptiFree Express
(Alcon) and AquaSoft MPS, of which Solo-
Care Aqua was the most commonly used
(83.2 per cent).
2013 The Authors
 Compliance and hygiene behavior in soft contact lens wearers in the Maldives Gyawali, Mohamed, Bist, Kandel, Marasini and Khadka
Hygiene practice
Regarding hand washing habits, 12 partici-
pants (11.2 per cent) reported never
washing their hands before handling the
contact lenses. Out of 95 participants who
reported washing hands, only 42 (44.2 per
cent) regularly used cleaning detergent
or soap. When asked about cleaning
their lenses, 21 (20.5 per cent) participants
admitted not cleaning the lenses with the
rub and rinse technique before insertion.
Sixty-four participants (59.8 per cent)
reported cleaning their lens cases at least
once every week. Thirty-four participants
(31.8 per cent) cleaned their lens cases once
a month and the remaining nine (8.4 per
cent) did not clean their lens cases at all.
Regarding the replacement frequency of
lens storage cases, 85 participants (79.4 per
cent) reported replacing lens cases within
six months. On the other hand, four partici-
pants (3.7 per cent) had not replaced the
cases for more than a year. None of the
participants reported using saline or other
homemade solutions to clean or store their
lenses; however, 16 participants (15.0 per
cent) reported reusing or topping up the
solution on a regular basis to store the
lenses.
Wearing modality, replacement
schedule and water exposure
The majority of the participants reported
replacing lenses on or within one week
of the recommended schedule; however,
almost one-quarter of participants (26,
24.3 per cent) admitted over-using their
lenses for more than a week longer than
recommended.
Out of 103 participants who were using
lenses on a daily wear basis, 26 (25.2 per
cent) reported sleeping with lenses, which
included overnight wear, daytime naps or
dozing. Similarly, 38 participants (35.5 per
cent) reported water activities (swimming
and taking a shower) while wearing lenses,
but none of them used daily disposable
lenses or protective goggles.
Aftercare awareness
and self-evaluation
Nearly two-thirds of participants (79, 73.4
per cent) reported having an aftercare visit
within the last six months.
Forty-two (39.3 per cent) did not remem-
ber the recommended aftercare visit sched-
ule or they reported that no such advice was
given by the practitioner. Forty-one lens
2013 The Authors
Clinical and Experimental Optometry 2013 Optometrists Association Australia
Self evaluation Number
(n = 107) (percentage)
Good wearer 53 (49.5)
Average wearer 51 (47.7)
Poor wearer 3 (2.8)
Table 2. Self-evaluation as a contact
lens wearer
wearers (38.3 per cent) reported a history of
lens-related complications, which led them
to visit eye-care practitioners.
More than 90 per cent of the participants
considered themselves average or good
lens wearers (Table 2). No demographic
variables were associated with participants
self-rating as lens wearers (Chi-square test:
age-group, p = 0.266; gender, p = 0.514;
education, p = 0.61). Also, no statistically
significant difference in self-rating was
observed between participants interviewed
in the office and via telephone (Chi-square
test: p = 0.67) regarding self-evaluation.
The major forms of non-compliant behav-
iour reported by the participants in this
study are summarised in Table 3. Interest-
ingly, no socio-demographic factors were
associated with hygiene or compliant behav-
iour, except the observation that females
were more likely to stretch their lens use
than males (Chi-square test, p < 0.005).
Furthermore, no statistically significant dif-
ference was noted between participants
interviewed in the office and via telephone
(Chi-square test: hand washing, p = 0.214;
cleaning lenses, p = 0.505; overnight wearing
and dozing, p = 0.942; over-use of lens, p =
0.299; water exposure, p = 0.629; reusing and
topping up solution, p = 0.451; aftercare
awareness, p = 0.65; storage case replace-
ment, p = 0.115; and lens case cleaning,
p = 0.45).
DISCUSSION
The use of contact lenses is ever increasing
and the Maldivian population is no excep-
tion; however, no studies on any aspect
of contact lenses have been reported from
this small, isolated contact lens community.
Therefore, this study was conducted to
explore contact lens-wearing habits, compli-
ance, and issues of hygiene from a wearers
perspective and to provide the earliest
insights into these aspects.
In our study, the majority of participants
were young females with graduate or higher
levels of education and managerial occupa-
tions. In general, lens wearers are from rela-
tively higher socio-economic classes,9,11,12 as
they may feel more comfortable with the
expenses involved in contact lens fitting,
aftercare consultation and the supply of
lenses and care products.
Although lenses from regional manufac-
turers (China, Thailand and Korea) are also
available in the Maldives, none of the partici-
pants in this study reported using lenses
from those manufacturers. The most com-
monly used lenses were from CIBA Vision
and Johnson & Johnson Vision Care. Most of
the participants were using spherical daily
wear lenses and only a few were wearing
toric, presbyopic or extended/continuous-
wear lenses. Informal communication with
contact lens practitioners in the Maldives,
including those in a focus group, revealed
no prescribing of lenses on an extended or
continuous-wear basis or multifocal lenses.
This may be because of factors such as
poor availability of these lenses in the local
market, cost factors, less satisfactory visual
outcome, practitioners hesitation due to
increased risk of complications and lack
of proper skills in fitting special lenses.
A significant number of participants in
this study exhibited poor hygiene and non-
compliant behaviour regarding lens care.
Although, the specific nature of recommen-
dations provided by practitioners to the lens
users during their last consultation was not
investigated, it was assumed that stand-
ard recommendations were provided. Lens
users who did not follow these recommenda-
tions were considered non-compliant. None
of this non-compliant behaviour and poor
hygiene demonstrated by our participants
had any correlation with socio-demographic
factors of the participants, except for the
association between female gender and
overuse of the lenses. Similar findings have
been reported in a review, where Claydan
and Efron7 summarised various studies
showing factors such as socioeconomic
status, education, occupation, gender and
previous experience of lens-related compli-
cations having no influence over non-
compliance. While Sokol and colleagues9
reported poor compliance in cosmetic lens
users, our findings do not indicate any dif-
ference in compliance and hygiene between
wearers of coloured and transparent lenses.
This may be because most of our coloured
lens users were wearing coloured corrective
Clinical and Experimental Optometry 2013
3
Compliance and hygiene behavior in soft contact lens wearers in the Maldives Gyawali, Mohamed, Bist, Kandel, Marasini and Khadka

Non-compliant behaviour (n = 107) Number (percentage)

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)

Table 3. Non-compliant behaviour reported by lens wearers

lenses and those with pure cosmetic col-
oured lenses were very few.
Aftercare visits are important in contact
lens wear and allow practitioners to detect
early ocular physiological changes and
reinforce proper hygiene and compliance.
Although almost two-thirds of the partici-
pants reported an aftercare visit within the
last six months, nearly 40 per cent of these
lens wearers failed to remember the practi-
tioners recommended aftercare schedule.
While it is possible that no advice on after-
care visits may have been provided to the
wearers, failure to recognise the importance
of regular aftercare examinations and per-
sonal negligence of the wearer might be the
main reasons for this poor aftercare aware-
ness. On the other hand, while internet
purchase of lenses has been shown to be
associated with poor aftercare awareness,5,11
none of the participants in this study
reported purchasing lenses over the inter-
net. To increase the aftercare awareness,
salespersons or dispensers at optical outlets
can be trained to recommend contact lens
costumers undergo a regular examination
from an eye-care practitioner.
Poor hand hygiene is the most common
non-compliant behaviour found in Maldiv-
ian lens users. Although the majority of the
participants reported washing hands prior
to handling their lenses, only a few of them
used soap or cleaning detergents. So, alto-
gether more than 60 per cent of the partici-
pants in our study demonstrated no or
inadequate hand-washing behaviour. This is
particularly worrying as poor hand hygiene
is one of the major risk factors for lens-
related complications.13 The reported rates
of non-compliance for hand hygiene range
from 14 to 50 per cent9,11,13,14 and vary with
the phrasing of the questions used (whether
the use of soap or cleaning agent is specified
or not). This shows the significance of
a thorough description of hygienic pra-
ctices, when advising lens wearers in clinical
practice.
We evaluated water exposure to lenses in
two aspects, namely, use of tap water to clean
or store the lenses and exposure through
water activities, such as swimming and taking
a shower while wearing lenses. As an encour-
aging finding, none of the participants
reported using tap water or homemade
saline solution to clean or store lenses. On
the other hand, over one-third of the partici-
pants reported water activities while wearing
the lenses without proper protective meas-
ures, such as goggles and daily disposable
lenses. Studies have shown a consistently
high number of lens wearers engaging in
water activities while wearing their lenses.912
Swimming and other water activities with
soft lenses play significant roles in acan-
thamoebic keratitis and other microbial con-
taminations.15 To avoid these complications,
lens wearers must be educated to abstain
from such activities and be informed about
the potential adverse effects. If the lens
wearer must use the lenses during water
sports, they should be advised to use daily
disposable lenses and proper water goggles.
In a review following an acanthamoeba
outbreak in the US, Butcko and colleagues16
described laboratory studies showing the
importance of rubbing of lenses during dis-
infection and proposed that it should be
reinstated as a standard step even though the
clinical literature is slightly less conclusive
on the topic. One-fifth of our participants
reported that they did not clean the lenses
(with the manual rub and rinse technique)
before insertion. Moreover, almost 15 per
cent of the participants reported reusing or
topping up the solution to store their lenses.
It should be particularly noted that topping
up was a behaviour implicated in the 2005
Fusarium outbreak with ReNu MoistureLoc
disinfecting solution, resulting in loss of
sight and a worldwide recall of the disinfect-
ing solution.17
Lens storage cases are common sources
of microbial contamination and the impor-
tance of regular lens case replacement
should be emphasised to lens users.18,19
Wu and colleagues20 observed that lens cases
that were replaced more frequently than
every nine months had significantly lower
levels of contamination than the cases
replaced less often. A significant number
of our participants reported frequent lens
case replacement in comparison to previous
studies.14,17,21,22 This may be attributed to the
complimentary lens storage case provided
with every purchase of multipurpose solu-
tion; however, around one-third of the par-
ticipants did not pay attention to cleaning
of their lens cases. It has been pointed out
that the current guidelines for lens case
hygiene are not standardised and sometimes
are contradictory between manufacturers
and practitioners.23 Yung and colleagues21
have suggested that providing clear written
instructions to the users may significantly
improve lens case hygiene.
Overnight wear of soft lenses is a known
risk factor for microbial keratitis3,4 and
corneal infiltrates.15,23 One-quarter of the
participants in our survey admitted an
unscheduled and non-prescribed overnight

Clinical and Experimental Optometry 2013 2013 The Authors

4 Clinical and Experimental Optometry 2013 Optometrists Association Australia
 Compliance and hygiene behavior in soft contact lens wearers in the Maldives Gyawali, Mohamed, Bist, Kandel, Marasini and Khadka
wear or dozing while wearing their lenses.
These participants were prescribed lenses
on a daily wear basis and did not have any
special instructions for extended wear. Over-
night wear by itself cannot be classified as
non-compliant behaviour, when lenses are
prescribed for extended or continuous wear
but it should be supported by a different lens
replacement schedule and added education
about the associated risks.
Failure to replace lenses on the recom-
mended schedule is associated with a higher
rate of self-reported contact lens-related
problems.6 Around one-third of the lens
wearers in our survey exhibited low compli-
ance with practitioner recommendations
about the replacement schedule. Similar
findings have been reported in a study con-
ducted in Canada and the US.25 The partici-
pants in our study were recruited during
their aftercare visit and lacked anonymity.
Thus, this study would be less likely to
include patients who stretch their replace-
ment frequency as compared to an anony-
mous survey.17 Interestingly, the compliance
rate regarding lens replacement did not
differ between the participants interviewed
in the office and via telephone. To maximise
the likelihood of replacement compliance,
strong practitioner recommendations, writ-
ten instructions, regular reinforcements and
reminder services would be helpful.17
The majority of the participants in our
survey considered themselves to be average
or good contact lens users; however; most of
them reported some form of non-compli-
ance or poor hygiene. This is consistent with
findings of a previous study in health-care
workers wearing contact lenses in Brazil.8
It has been reported that, although the
majority of patients consider themselves to
be compliant with standard practitioners
guidelines for lens wear and care practices,
most exhibited behavioural non-compli-
ance.10 Lack of awareness, personal negli-
gence and insufficient information provided
by the practitioner may be some of the
reasons for this finding.8
Assessment of compliance, based on sub-
jective responses in a relatively small sample
that lacks anonymity may not truly reflect the
situation of all lens users in this part of the
world. Moreover, only the lens users attend-
ing the eye clinics for an aftercare examina-
tion were included, excluding a significant
number of lens wearers who purchase lenses
from optical outlets without any dispens-
ing examination. The hygiene practices and
compliance to standard lens care may be
2013 The Authors
Clinical and Experimental Optometry 2013 Optometrists Association Australia
poor in these wearers and warrant a separate
study to evaluate these aspects. On the other
hand, the extent of practitioners recom-
mendations and instructions imparted to
lens wearers should be established before a
participant can be labelled as non-compli-
ant. For a more precise analysis of compli-
ance, a further survey evaluating practition-
ers instructions about hygiene and lens care
given to the wearers is warranted. While
waiting for confirmation from a population-
based study, the results of this study should
serve as a useful reference on hygiene and
compliance among contact lens wearers
in this previously unexplored Maldivian
population.
CONCLUSION
A significant level of poor hygiene and non-
compliance is seen in Maldivian contact lens
wearers. This study identified the major
areas of non-compliance arising mainly due
to lack of awareness and personal negli-
gence. Regular educational reinforcement
strategies may be helpful to modify such
behaviour. At the same time, precise and
standard recommendations need to be deve-
loped and provided to lens wearers to re-
duce the risk of lens-related complications.
ACKNOWLEDGEMENT
The authors are thankful to all those who
volunteered to participate in the interviews.
They also thank Mr Nabin Paudel, University
of Auckland and Ms Saajidha Majid, Tribhu-
van University for their contribution during
manuscript preparation and revision.
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