C L I N I C A L A N D E X P E R I M E N T A L
OPTOMETRY
Why are we still fitting reusable soft contact lenses?
Clin Exp Optom 2014; 97: 386388
Nathan Efron PhD DSc
Institute of Health and Biomedical Innovation and
School of Optometry and Vision Science, Queensland
University of Technology, Kelvin Grove, Australia
E-mail: n.efron@qut.edu.au
Whether the first daily disposable soft
contact lens to enter the market in 1994 was
the Premier lens (Award Technology, Scot-
land, UK; subsequently purchased by Bausch
& Lomb, Rochester New York, USA) or the
1-Day Acuvue lens (Johnson and Johnson
Vision Care, Jacksonville, Florida, USA) has
long been a matter of bitter dispute1 but
whatever the answer, this year marks the 20th
anniversary of the launch of this modality of
lens wear.
The concept of daily disposability has
been fully embraced by the contact lens
industry. All of the major global contact lens
companies and many smaller regional com-
panies now manufacture a variety of types of
daily disposable lenses. They are produced
in hydrogel and silicone hydrogel materials
and are available in spherical, toric and
multifocal designs. At the present time in
Australia, 25 daily disposable lens products
are available19 spherical, four toric and
two multifocal designs.2 Daily disposable
lenses are manufactured in a wide range
of parameters; for example, 1-Day Acuvue
Moist for Astigmatism (Johnson and
Johnson Vision Care, Jacksonville, Florida,
USA) is available in spherical powers from
+4.00 to -9.00 D, four cylindrical powers
from -0.75 to -2.25 DC and 10 cylinder axes.2
As such, only a tiny minority of potential
contact lens wearers would have refractive
errors that fall outside these currently avail-
able daily disposable lens parameters.
The fifth largest global contact
lens companySauflon Pharmaceuticals
(Twickenham, United Kingdom)has
recently repositioned its strategic direction
by almost exclusively manufacturing daily
disposable lenses.3 This has been achieved by
consolidating all of their daily disposable
lens manufacturing into a large-scale facility
Clinical and Experimental Optometry 97.5 September 2014
386
EDITORIAL
in Hungary,3 which every day produces over
150 million silicone hydrogel daily dispos-
able lenses in spherical, toric and multifocal
designs.
Despite the capacity for virtually all
ametropic contact lens wearers to be fitted
with daily disposable lenses, an international
survey of contact lens prescribing in 31
markets during 2013 revealed that these
lenses constitute only 31 per cent of fits4
(38 per cent in Australia4). In some markets,
the vast majority of fits are with daily dispos-
able lenses; for example, in Denmark, 65
per cent of all soft lens fits are with daily
disposable lensesa value that rises to 87
per cent if only daily wear spherical lenses
are considered.4
To my way of thinking, the benefits of daily
disposable lenses compared to reusable
lenses are overwhelming. This leads to the
obvious questionswhy are we still fitting
reusable soft contact lenses? Or considering
the antithesiswhy are we not fitting all
contact lens wearers with daily disposable
lenses? Let me first consider the benefits of
daily disposable lenses and then I shall
return to this question.
CONVENIENCE FOR LENS WEARERS
The convenience that daily disposability
offers to lens wearers is perhaps the most
obvious benefit and does not really need to
be spelled out to the informed readership of
this journal, but I shall restate the key issues
for completeness. Wearers of daily dispos-
able lenses do not need to concern them-
selves with tedious lens care, as is required
with reusable lenses, notwithstanding the
fact that lens maintenance procedures
have become somewhat simplified with mul-
tipurpose solutions. The requirements for
possessing and caring for lens cases are obvi-
ated. Daily disposable lenses are easy to
discard (any time, any place, without a
case). They are excellent for monovision
correction of presbyopia, as it is easy to
Clinical and Experimental Optometry 2014 Optometrists Association Australia
DOI:10.1111/cxo.12170
alternate between various lens combina-
tions. Daily disposable lenses are also espe-
cially useful for part-time wear, such as for
sporting activities. Compliance is easier
because there are fewer instructions to
remember.
Daily disposable lenses are convenient for
travel, as there is no need to carry bulky
lens-care solutions. Packaging of daily dis-
posable lenses has become more compact in
recent times, with a significant advance
being the wafer-thin flat pack (Miru,
Menicon, Japan), which is 12.5 per cent of
the thickness and 40 per cent of the volume
of a conventional disposable lens pack.5
ADVANTAGES FOR PRACTITIONERS
There are many advantages of daily dispos-
able lenses over reusable lenses from the
standpoint of the practitioner. Less chair
time is required for patient education, as
virtually no advice needs to be offered con-
cerning lens care. Less chair time is incurred
due to unscheduled visits relating to prob-
lems with lens care solutions (for example,
solution-induced corneal staining) or to
patient non-compliance with the use of lens
care systems. Less ancillary staff time is
required because there is no need for discus-
sions and sales advice relating to lens care
products. Lens wearers can be supplied with
an initial starter set of five pairs of lenses.
Practitioners can work with contact lens
manufacturers to effect timely and efficient
lens supply either via the practice or directly
to the lens wearers home.
ENHANCED VISION
The early literature showed that with the
prolonged wear of reusable soft lenses,
deposits such as protein and lipids gradually
build on the lens surface despite daily
lens cleaning.6 The greater the extent of
these deposits, the greater is the amount
2014 The Author
of visual degradation,6 although it is true
that reduced vision over four weeks of
lens wearwhich today is essentially the
longest time for lens wear prior to lens
replacementwould be difficult to detect
with a letter chart. Nevertheless, it stands to
reason that if vision decreases with increased
wearing time, then vision can be optimised
by more regular lens replacement, with daily
disposability representing the optimum
replacement frequency.
OCULAR HEALTH
Early controversial reports of adverse ocular
reactions to daily disposable lenses7 are now
thought to have been confounded by skewed
practitioner prescribing approaches and dis-
torted consumer demand behaviour that
can arise when new and exciting health
products enter the market. When daily dis-
posable lenses were introduced in 1994, they
were initially available in limited supply
and priced at a premium. Practitioners may
have adopted a conservative approach and
selected difficult or problem patients, who
perhaps were considered to derive what was
perceived to be the added health benefits of
such a product. As well, lens wearers who are
eager to try new untested products can be
considered to be risk takers. Such persons
may have accompanying personality and
behavioural traits that make them more sus-
ceptible to be non-compliant with the prin-
ciples underlying hygienic and meticulous
lens handling and wear.8 These factors could
explain the initial counter-intuitive findings
that daily disposable lenses induced a higher
rate of adverse reactions than reusable
lenses.7
Perhaps the most sensitive indicator of
an adverse ocular reaction to contact
lens wear is the appearance of corneal
infiltrative events, which represent a pro-
inflammatory reaction. A more recent 2012
study, in which the potentially confounding
effects of problem-patient prescribing and
risk-taking early adopters are obviated, has
demonstrated distinct health advantages
of daily disposability. Chalmers and col-
leagues9 identified cases with symptomatic
corneal infiltrative events in a retrospective,
multi-centre case-controlled study at five
academic eye care centres in the USA. They
reported that reusable soft lenses carried a
12.5 times greater risk of developing such
events compared with daily disposable
lenses.
2014 The Author
Clinical and Experimental Optometry 2014 Optometrists Association Australia
SO WHY NOT FIT DAILY DISPOSABLE
LENSES TO EVERYONE?
With the clear benefits of lens wearer con-
venience, ease of lens fitting and supply,
avoidance of lens deposition and visual deg-
radation, and superior ocular health, why
bother fitting reusable soft lenses?
Cost, I hear you shout!
There is a common perception that daily
disposable lenses are generally more
expensive than equivalent reusable lenses,
which limits the extent to which such
lenses are fitted. Well, let us consider the
cost issue from two perspectivesthe
broad perception of cost and its impact
on prescribing daily disposable lenses,
and whether these lenses really are more
expensive than reusable lenses. A strong
positive correlation has been demonstrated
between the rate of prescribing of daily dis-
posable lenses in different nations and the
gross domestic product of those nations.10
The gross domestic product of a nation is a
financial construct that essentially indicates
the average personal wealth of individuals
in that nation. Thus, the wealthier people
are in a country, the more daily disposable
contact lenses are fitted in that country. In
fact, this analysis showed that 55 per cent
of daily disposable lens prescribing can be
explained by cost considerations.10 So,
although other factors are involved in the
decision to fit daily disposable lenses, cost
is a major influence.
Is it true that daily disposable lenses are
more expensive than reusable lenses? This
question has been tested with the aid of a
cost-per-wear model11 and the results of this
analysis are revealing. Simply put, the cost-
per-wear model describes the cost of
wearing any specified lens brand each time
lenses are worn, in relation to the number of
times lenses are worn, on average, each
week. The model, which assumes that the
lens wearer is compliant with the specified
schedule of lens replacement and solution
usage (if reusable lenses are being worn),
takes into account all direct costs, including
the cost of the lenses, lens care solutions and
professional fees. The primary outcome of
the model is that daily disposable lenses cost
the same as reusable lenses when lenses are
worn five days per week, and are less expen-
sive when worn fewer days per week.11 Given
that 55 per cent of those using daily dispos-
able lenses wear their lenses five or less days
per week, it is clear that for the majority of
those wearing this modality, the costs of lens
Clinical and Experimental Optometry 97.5 September 2014
wear are actually less than for those wearing
reusable lenses.
So what about the increased cost to the
minority of daily disposable lens wearers
using lenses six or seven days per week
(which can be described as full time wear)?
I have a simple answer for this. Compared to
reusable lenses, the additional daily cost
incurred as a result of full-time daily dispos-
able lens wear is equivalent to the price of a
cappuccino coffee served up at your local
caf. I would argue that this is a price worth
paying for the sheer convenience, improved
vision and superior ocular health of this
form of lens wear.
DISPELLING OTHER CONCERNS
I have been espousing the virtues of daily
disposibility at practitioner conferences for
many years. Often, I pose the following ques-
tion to an audience: Putting aside the issue
of cost and assuming that a lens wearer falls
within the available range of parameters of
currently available products, can you think
of any reason why you might prescribe any-
thing other than daily disposable lenses?
This question is generally met with stony
silence, although one issue of concern that
has occasionally been raised is environmen-
tal impact. This refers to the notion that the
amount of waste material entering the envi-
ronment as a result of wearing daily dispos-
able lenses is greater than that with reusable
lenses.
A study of the environmental impact
of contact lens wear12 has confirmed that
slightly more waste is generated from usage
of daily disposable lenses compared with
reusable lenses; however, the amounts we
are dealing with are small, representing less
then 0.5 per cent of average domestic house-
hold waste and insignificant when compared
to environmental waste generated by major
activities/projects, such as large-scale manu-
facturing, civil engineering programs (con-
structing roads and railways) et cetera.12
Some cite the threat of unregulated lens
supply, such as via the internet, as a reason
to avoid fitting daily disposable lenses. Of
course, unregulated lens supply is of great
concern in view of the potential for lens
wearers to develop asymptomatic ocular
pathology, which may remain undetected
and lead to more serious ocular health prob-
lems.13 However, this issue is not specific to
daily disposable lenses and therefore is not a
valid reason for avoiding fitting of these
lenses.
387
CONCLUSION

Contact lens practitioners and lens wearers

alike derive far more benefit from daily dis-
posable lenses than reusable lenses. When
considered in terms of cost per-wear, the
overall cost of daily disposable lenses to the
lens wearer is not that much more, and in
many instances is considerably less, than the
cost of reusable lenses. I believe that it will
not be long before the four major global
contact lens companies follow the lead set by
Sauflon Pharmaceuticals and gear up their
production to exclusively produce daily
disposable lenses. I also believe that it is
now time for contact lens practitioners to
follow the lead set by our Danish colleagues
and fully embrace the concept of daily
disposability, relegating reusable lenses to
the annals of history.

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388 Clinical and Experimental Optometry 2014 Optometrists Association Australia