Non-adherence to recommendations given by healthcare professionals has not changed significantly over the years. Adherence to long-term therapies: evidence for action – the landmark World Health Organization report presented two decades ago – stated non-adherence to be up to 50%.1 A recent systematic review of 178 studies found the level of non-adherence among patients with multiple conditions to range between 44.1% to 76.5%, depending on the assessment method.2 For contact lens wearers, the average rate of non-compliance can be as high as 50% to 99%.3 Non-adherence is a fluid and evolving behaviour that can constantly change for an individual over time.4

For most of us, daily hygiene habits, such as brushing our teeth or brushing our hair, are so ingrained over the years that we do not have to think about completing them. For new actions related to medical advice or following contact lens wear instructions, these habits need to be built.

Compliance, together with eye health and convenience, are key factors for eye care professionals (ECPs) when recommending daily disposable contact lenses.5 Nearly nine out of 10 believe daily disposable silicone hydrogel contact lenses are better overall for their patients,6 with the top reasons for this preference being firstly convenience, as lenses can just be thrown away at the end of the day, followed by eye health.7

Despite optometrists’ preference for daily disposables, 55% of contact lens wearers are still wearing reusable lenses.8 Comfort and vision are top priorities for patient success,9 but there is sometimes the need to balance lens wearing experience with affordability. Six out of 10 reusable lens wearers report selecting this modality due to cost.10

What strategies can be implemented to improve adherence to medical recommendations, and to what extent might these approaches support patients in maintaining compliance with contact lens wear, particularly among those for whom daily disposable lenses are not prescribed?

Maria Markoulli, Associate Professor at University of New South Wales (UNSW) Sydney, shared her insights:

“Successful compliance is most often achieved through clear, structured communication, and by actively engaging patients as partners in their care. Providing concise, evidence-based explanations, supported by succinct take-home materials, allows patients time to process and understand recommendations beyond the consultation.

“Visual tools are particularly powerful. Showing patients images of poorly fitting contact lenses, ocular surface compromise, or the progressive impact of dry eye disease helps make otherwise abstract concepts tangible. When patients can see the rationale behind a recommendation, they are more likely to understand its importance and adhere to it.”

Assoc Prof Markoulli also said, “Linking management strategies to intuitive daily habits and clearly explaining the ‘why’ behind each step fosters shared decision making and improves long-term compliance.”

Looking to the literature for inspiration, examples of these strategies are seen in the SIMPLE acronym discussed by Atreja and colleagues in ‘Strategies to enhance patient adherence: Making it simple’.11

The SIMPLE acronym provides the following steps:

SIMPLE

Simplify Regimen Characteristics

How can regimens be made straightforward? Healthcare practitioners can simplify timing, frequency, amount, and dosage of medications. Incorporating the use of adherence aids, such as medication boxes and setting reminder alarms on a smart phone, can further support compliance. Additionally, aligning schedules to patients’ daily routines and activities helps reduce complexities and integrate protocols into their lifestyle.11

With these suggestions, we can see how the development and innovation in contact lenses over time have supported this.

Eric Papas, Professor Emeritus from the Department of Optometry and Vision Science, UNSW Sydney, has spent his career

advancing contact lens technologies. He shared his insights into the impact of contact lens innovation.

“Like in all aspects of life, understanding drivers of change and ways to adopt and use new technologies is key to progress in healthcare. This is certainly the case in eye health and vision care, where the incredible evolution of contact lenses serves as an instructive example.

“Maybe the biggest technological innovation in contact lenses, since they became a practical reality over a century ago, has been making them soft and pliable. While Tuohy’s patent for corneal lenses in 195012 opened the possibility of spectacle-free vision for many, this came at the cost of discomfort, as wearers attempted to get used to having two bits of hard plastic on their eyes. The struggles of an undergraduate friend come to mind; even after weeks of slowly building wearing time, he retained the ‘popeyed’ stare, that betrayed his reluctance to blink.

“Soft lenses changed all that. Because they could be more easily adapted to, it’s no surprise that soft lenses served as the stimulus for a massive increase in the popularity of contact lenses in general.

“The first soft lenses were made from pHEMA, a material invented by Wichterle and Lim in the 1950s.13 That early polymer had some properties that remain important, even for contemporary lenses. First was its softness, due to a low modulus of elasticity, a property that supports better comfort. The downside, however, is that it can make lenses relatively fragile. Second, because the polymer takes up water, it has some permeability to oxygen and is reasonably wettable on-eye.”

Materials for a Better Wear Experience Prof Papas continued: “As uptake of early soft lenses became more widespread, it emerged that the amount of oxygen reaching the ocular surface was often inadequate. Starting around 1993, the SEE3 project aimed to generate a more oxygen-permeable soft lens material, and I was fortunate to be involved as one of its lead clinical scientists.

“Looking back on this project, it’s interesting how oxygen permeability, wettability, and softness were effectively in a three-sided tug-of-war. Frankly, getting oxygen through the lens was the easy part – to the polymer chemists, it was a simple matter of incorporating silicone into the material. Unfortunately, there were undesired consequences – many of the early trials produced lenses that had great oxygen permeability but were too stiff and/or hydrophobic. These prototypes had clinically unacceptable comfort, poor wetting, or both. Another difficulty was that, like the silicone elastomer materials that had been tried previously, there was a tendency for lenses to become stuck to the eye.

“Concerted efforts from a team of material scientists, polymer chemists, and clinicians, eventually allowed us to overcome these challenges14 and produce a polymer with oxygen permeability exceeding that of the conventional hydrogels at the time, and that was also soft and comfortable. The lenses were well-tolerated in clinical trials and free from the hypoxia-related complications that had become so familiar. There was also a quite unexpected bonus,” Prof Papas said.

“Conventional soft lens wear had typically been accompanied by slight limbal hyperaemia, which was generally seen as an unavoidable consequence of soft lens wear.15 Eyes wearing the new SiHy lenses seemed free from this effect and indeed, looked markedly whiter than expected.16 The revelation that soft lenses could be worn without accompanying limbal redness, provided they have sufficient oxygen transmissibility, has been one of the enduring benefits of SiHy lenses.”16

Optimise SiHys

As revolutionary as the first SiHy lenses were upon their introduction in 1998, Prof Papas said “they were not trouble-free”.

“Wearers of conventional lenses sometimes reported that their initial comfort with the new silicone hydrogel was slightly poorer than they were used to, and this was subsequently addressed with additional fitting increments to improve lens fit.

“It was not long before SiHy lenses with moduli comparable to conventional hydrogels were available. This achievement has led to a better understanding of how lens performance can be optimised by divorcing surface material properties from those of the main body of the lens. This can be seen in many of today’s lenses, for example, those with material properties that increase water content from the lens core to the outer surface. The prospect of a lens surface that looks and behaves like ocular tissue is tantalisingly attractive, offering the potential for improved compatibility. It may even help solve the puzzle of end-of-day discomfort, which remains problematic for many wearers and can lead to discontinuation of wear.

“Physiological aspects of contact lenses, however, are not the only factors governing success. Progress in manufacturing has helped make frequent replacement a reality. If daily disposal is not desired, lens characteristics can be adjusted for less frequent replacement schedules, any of which can support successful wear,” Prof Papas explained.

We can see, then, that the development of silicone hydrogel materials and manufacturing to support the frequent replacement of lenses have contributed greatly to compliance, leading into the first step of the SIMPLE acronym: Simplifying regimen characteristics.

Daily disposable lenses provide the most straightforward regimen with a new lens every day. If daily disposable lenses are not selected, how can we simplify the replacement schedule for our patient? Difficult to remember schedules are linked to lower compliance. Two-weekly wearers have been shown to be the least compliant, with between 52% and 66% admitting to not replacing their lenses when they should.17 Intuitive replacement schedules, such as the same date each month for monthly reusable lenses and even new replacement schedules of one week replacement, are now being made available in some countries, making the replacement of a reusable lens even easier to remember. This can be supported with reminders being set on the patient’s smartphone.

Figure 1. Total1 Starter Fit Kit 2025.

Impart Knowledge and Patient Communication

Effective healthcare provider communication significantly enhances patient adherence to treatment plans.18 The next steps in the SIMPLE acronym – Impart knowledge and jumping ahead to P: Patient communication – relate to providing clear, easy-to-understand and readily available information.11 The primary focus is to tailor information to the patient’s level of understanding, using plain language and avoiding technical jargon.11,19

Between 40–80% of medical information provided by healthcare practitioners is forgotten immediately, and almost half of the information that is remembered is incorrect.19 When medical instructions were given orally, only 14% of the information was remembered correctly, compared with over 80% when pictographs were used.19 Simple pictographs, with a clear and direct link between the picture and its meaning, are most effective.19

Therefore, supplementing verbal guidance with written materials, such as brochures or pamphlets, ensures patients have resources to refer to at home (Figure 1). Additionally, directing patients to reputable online sources, including manufacturer websites, can offer further educational content and practical tips. Ensuring the patient has found the correct online resource prior to leaving the practice may reduce the risk of researching incorrect information.

When making recommendations, also ensure the patient understands the purpose of those recommendations. For example, when discussing an aftercare schedule, ensure the patient understands the purpose of the visit – whether it is to monitor changes in prescription or to access eye health. For a dry eye follow-up, clarify that the appointment is required to assess changes in symptoms or monitor healing of the ocular surface. Similarly, when providing a list of ‘contact lens wear do’s and don’ts’, provide the context behind each point, so patients understand the benefits of following instructions (Figure 2).

Modify Patient Beliefs

Patients may have developed inaccurate beliefs, hold unfounded concerns, or conversely not appreciate the serious risks behind their behaviours. Information that supports a currently held belief is remembered more easily than information that is contrary to that belief, and new information is easier to remember than correcting preexisting knowledge for older patients.20 Therefore, an important part of communication is to ascertain what the patient believes, acknowledge what is accurate, and provide evidence to reinforce correct understanding.

Figure 2. Contact lens handling masterclass FAQ patient flyer.

Leave Bias Behind

Explore a patient’s lifestyle, preferences, and barriers to contact lens compliance, rather than assuming non-compliance is due to a patient’s demographics or lack of motivation.11 Tailor advice and solutions accordingly.

Evaluate Adherence

Non-adherence to contact lens protocols and replacement can have significant impact on patient success. Understanding why a patient may not be compliant allows clinicians to address the issue more effectively. Are their beliefs aligned with the evidence, for example? Knowing it is harder to change a belief than to provide new information, it may be necessary to provide additional information to mis-informed patients.

Questions regarding contact lens replacement also provide insight into the patient’s wearing experience. What is the reason for not replacing contact lenses when they should? If the replacement schedule is difficult to remember, changing to an intuitive replacement schedule may suit the patient better.

It is equally important to explore why patients are replacing lenses earlier than recommended, as unmet vision or comfort needs may lead to discontinuation of wear.

HABIT STACKING

If simply forgetting to follow a medical recommendation, from a dry eye management step to replacement of contact lenses is a problem, another way to build compliance is through ‘habit stacking’. Habit stacking is a technique made popular by author James Clear in his bestselling book, Atomic Habits.21 Habit stacking involves connecting a new habit to an existing one, assisting the new habit to become ingrained.21 Consider the opportunity to habit stack clinical advice and contact lens recommendations. Could reusable lens replacement be linked to a pre-existing habit in addition to a particular day of the week, for example?

This brings us back to the well-developed habit of brushing our teeth before we go to bed. Linking this to taking contact lenses out or instilling eye drops will help these actions to become automatic. The process of building a habit comes with four steps:21,22

1. The cue: the first thing that begins the process, like walking upstairs to bed,

2. The craving: the motivation that drives you to do something, like your eyes feeling tired,

3. The response: the habit that is performed, like instilling lubricating eye drops, and

4. The reward: your eyes feeling refreshed for using eye drops.

Habits can become routine within about two months, although the time required varies significantly across individuals.23 Habit stacking works best when the initiating cue is very specific.21

EVOLVING PRESCRIBING WITH EVOLVING TECHNOLOGY

In clinical practice, even recommendations of spectacle lens designs and contact lens brands can become habitual, with strong cues coming from our patients and clinical routines.

Assoc Prof Markoulli shared these insights: “In my experience, encouraging clinicians to adopt new technologies begins with evidence and relevance. Robust clinical data demonstrating improved safety, efficacy, comfort, or convenience compared with existing options is essential. Equally important are practical case examples that show how a new technology translates into better real-world patient outcomes.

“Seeing innovation as an opportunity for evolution, rather than a disruption to habits, helps clinicians view new technologies as tools that align with their existing goal of delivering the best possible patient experience. When clinicians understand how advances in material science, surface technology, or replacement schedules directly address longstanding challenges, they are generally open to trialling and adopting change.

“Patients in the Australia and New Zealand (ANZ) region increasingly expect high performance without compromise. In the past, patients may have accepted trade-offs between comfort, convenience, and vision – particularly for more complex prescriptions such as toric or multifocal lenses. That is no longer the case.

“With the breadth of advanced lens options now available, patients expect excellent vision, sustained comfort, and intuitive replacement schedules as standard. This competitive market has raised expectations, and rightly so – new products are increasingly able to deliver on all fronts. For ANZ patients, this shift underscores the importance of embracing modern technologies that align with their evolving lifestyle demands and expectations,” Assoc Prof Markoulli said.

“Through my years of research and clinical practice, I have seen the transformative power that the right contact lenses can have – the joy on a self-conscious teenager’s face when they are provided with an alternative to spectacle wear; or the relief of the outgoing presbyope who realises she can be less dependent on spectacles over the course of the day.

“Recent years have given us incredible lens technologies. This is a good thing, because our patients’ needs and expectations have evolved beyond ‘good vision’; comfort and convenience are priorities, and while there are still ‘places to go’ in the realm of contact lens technology, in many ways the future is already here.”

WETTABILITY IS THE KEY

Assoc Prof Markoulli continued: “Regardless of contact lens type and replacement schedule, interactions between the contact lens and the eyelid, tear film, and ocular surface are constant. Friction between the contact lens surface and eyelid margin can negatively impact comfort,24-26 so lens technologies that improve lubricity and wettability* are expected to support more comfortable wear. Lens wettability can be achieved with surface technologies that increase the water content of the outer surface, or the incorporation of specific wetting agents or surface treatments. Currently available lenses incorporate wetting agents through a variety of approaches. In all cases, the objective is to improve moisture spread and retention over the surface of the lens, ultimately enhancing comfort.”26

INNOVATING TODAY AND BEYOND

“As technology continues to evolve, we can expect to see more options for our patients,” Assoc Prof Markoulli continued. “Such options should consider factors such as replacement schedule, particularly for patients who do not quite fit the daily disposable schedule and want to remain in a reusable lens. We can also look forward to advances in material and lens surface technologies that support sustained, reliable lens surface moisture.

“Our patients’ demands are evolving and, therefore, so should both our technology and our enthusiasm as clinicians to embrace these advances. Contact lens technology has come a long way since I started both my clinical and lens-wearing careers, but the constant is the need to consider every patient’s unique visual and comfort demands, and to seek out and prescribe lenses that can meet these needs.

“Just as we should expect to see more of ‘personalised medicine’ thanks to artificial intelligence and advances in technology, so too we should expect to provide more ‘personalised contact lens care’ taking full advantage of the new generation in reusable lenses and their truly remarkable properties.

“As a clinician, my goal is to provide contact lens wearers with the best experience that I can. That means embracing modern technologies and replacement schedules. Over 25 years, I’ve taken every opportunity to improve my own lens wearing experience, moving from rigid gas-permeable lenses to hydrogel and silicone hydrogel materials. Improvements in surface technology and more intuitive replacement schedules have enhanced my lens-wearing experience immensely, and whether I’m wearing my clinician or patient hat, I expect the next steps in soft lens evolution to be just as impactful.”

* Based on in vitro measurements of unworn lenses.

This article is sponsored by Alcon. Prof Eric Papas and Assoc Prof Markoulli received honoraria for their time in contributing to the article.

Articles written for Alcon by Prof Eric Papas and Assoc Prof Markoulli were first published in Contact Lens Spectrum in March 2024 and May 2024 respectively, content used with permission.

ANZ-VC-PRA-2600004

References available at mieducation.com.au.