A survey of UK practitioner attitudes to the fitting of rigid gas permeable lenses

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<ul><li><p>A survey of UK practitioner attitudes to thefitting of rigid gas permeable lenses</p><p>Felicity R. Gill, Paul J. Murphy and Christine Purslow</p><p>Cardiff University, School of Optometry and Vision Sciences, Contact Lens and Anterior Eye</p><p>Research, Maindy Road, Cardiff CF24 4LU, UK</p><p>Abstract</p><p>Purpose: Rigid gas permeable (GP) contact lenses may provide the safest option for lens wear, but</p><p>prescribing rates are in decline. This study investigated the effect of practitioner attitudes on GP lens</p><p>prescribing.</p><p>Methods: A questionnaire was developed using a focus group and a pilot study. Questions</p><p>addressed clinical time spent fitting GP lenses, specialist equipment requirements and perceived</p><p>safety and comfort. With ethical approval, the questionnaire was sent to 1000 randomly selected UK</p><p>registered eye care practitioners (ECPs).</p><p>Results: In general, ECPs enjoy the challenge of fitting GPs, although fitting takes longer than soft</p><p>lens fitting. There is a difference in attitude between longer qualified andmore recently qualified ECPs.</p><p>Longer qualified ECPs more frequently reported enjoyment of the fitting challenges, recommended</p><p>GP lenses to patients and were less likely to believe that GP lenses were becoming obsolete. ECPs</p><p>are in strong agreement on the ocular health advantages of fitting GPs. They do not feel specialist</p><p>equipment is generally needed, although some reported a topographer to be advantageous. The large</p><p>majority of ECPs do not have access to the specialist equipment they perceive to be normally</p><p>associated with GP fitting (radiuscope, V-gauge). They believe that initial fitting discomfort of GP fitting</p><p>is a major drawback to their fitting, and while they feel this greatly improves with adaptation, they do</p><p>not feel it reaches soft lens wear comfort. A total of 30.3% of ECPs feel it is clinically acceptable to use</p><p>topical anaesthetic during GP fitting, but only 1.4% of ECPs regularly do so.</p><p>Conclusions: ECPs are aware of the benefits that GP lenses provide in terms of ocular health. They</p><p>find GPs take longer to fit, but they enjoyed the challenge of fitting, which suggests that they are not</p><p>lacking in clinical skill, nor any specialist equipment. However, they are unhappy with initial patient</p><p>comfort, and are not yet prepared to use topical anaesthetics during initial fitting. As a consequence,</p><p>ECPs believe that GP lenses are becoming obsolete. Negative practitioner attitudes toward various</p><p>aspects of GP fitting may mean fewer recommendations to patients and reduced GP prescribing.</p><p>Keywords: contact lens, prescribing, rigid gas permeable, survey</p><p>Introduction</p><p>Following the introduction of soft contact lenses in1970, Atkinson predicted their success and a consequentdecline in rigid lens prescribing. In 1976, he reported</p><p>that soft lenses already made up 50% of all contact lensts recorded in the UK (Atkinson, 1976). Although rigidgas permeable (GP) prescribing did decrease, thereduction was gradual, and, by 1991, 39% of newcontact lens ttings were still GP lenses (Pearson, 1998).In 1996, a survey, designed to investigate prescribing</p><p>trends, was randomly distributed to 1000 UK ECPs whowere asked for details about 10 consecutive contact lensts (Morgan and Efron, 2006). This survey has sincebeen distributed annually, both in the UK and interna-tionally, to monitor contact lens prescribing trends(Morgan et al., 2002; Morgan and Efron, 2006; Morganet al., 2006). In 1996, 23% of new contact lens ts were</p><p>Received: 18 November 2009</p><p>Revised form: 17 June 2010</p><p>Accepted: 19 June 2010</p><p>Correspondence and reprint requests to: Christine Purslow</p><p>Tel.: 02920 876316; Fax: 02920 874859.</p><p>E-mail address: purslowc@cardiff.ac.uk</p><p>Ophthal. Physiol. Opt. 2010 30: 731739</p><p> 2010 The Authors. Ophthalmic and Physiological Optics 2010 The College of Optometrists doi: 10.1111/j.1475-1313.2010.00790.x</p></li><li><p>GP, indicating a marked reduction in GP prescribingbetween 1991 and 1996, and in subsequent publicationsof the survey results, a relatively steady decline in rigidlens prescribing has been recorded (Figure 1). By 2007,just 3% of new ts were GP; however 16% of rets wereGP (Morgan, 2007). This may indicate that GPs areoften retted to existing GP wearers or in cases were softtting is unsuccessful.It is clear that rigid lens prescribing is, at best, static or</p><p>in decline in the UK. This may be logically attributed to avariety of factors including perceived GP disadvantagessuch as initial discomfort, increased chair time, and theincreased skill required to t and manage such patients.Also, major investment has been made in developing andpromoting new soft lens materials and designs.However, there is no published evidence regarding</p><p>practitioner attitudes to contact lens or, specically, GPlens prescribing. Therefore, it is not known whethercontact lens prescribing trends are associated withpractitioner misgivings about GP lenses. These mightinclude the increased time, skill and specialised equip-ment required to t GP lenses; that use of topicalanaesthetic (TA) to aid tting is an unacceptablepractice; and perceived comfort issues with GP lenses.Without an understanding of practitioner attitudes to</p><p>GP lenses, it is not possible to hypothesise what partECPs, and indeed, their experience and environment,have played in the decline of GP prescribing. The aim ofthis study was to survey a large number of UK-basedECPs in order to determine their current practice andattitudes.</p><p>Methods</p><p>Questionnaire design</p><p>Since no existing questionnaire was available to obtainthe desired information, a questionnaire was designed</p><p>for this purpose. Initially a literature review wasundertaken followed by focus group meetings andinterviews with optometrists. The questionnaire designwas discussed to ensure that each item was relevant,appropriate and elicited all the required information.Results from this process were collated and a pilotquestionnaire produced; this was completed by a num-ber of optometrist colleagues. The pilot results wereassessed to identify unnecessary items and the question-naire was gradually rened to the nal format.The questionnaire comprised 20 questions</p><p>(Appendix 1). Questions 19 asked for general demo-graphic information about the practitioner. The remain-ing 11 questions asked the practitioner to consider astatement with respect to contact lenses in general, andthen with respect to GP lenses specically. A Likert-typeresponse scale was employed. This provided the respon-dent with a 7 point response scale to indicate level ofagreement or disagreement with a statement (Likert,1932). Psychometricians advocate 7 or 9 point scales asthey produce better internal reliability than those withfewer categories (Masters, 1974). The responses e.g.strongly agree through to strongly disagree werecoded numerically from 0 (strongly disagree) to 6(strongly agree). A score of 0, 1 or 2 was considered toindicate disagreement, 3 indicated neither agreement ordisagreement and a score of 4 or more indicatedagreement with the statement.</p><p>Subject recruitment</p><p>Ethical approval for the study was obtained from theCardiff School of Optometry and Vision SciencesEthical Committee. The questionnaires were posted to1000 randomly selected UK eye care practitioners(including optometrists and contact lens opticians) onthe General Optical Council registers in April 2007.Each questionnaire was accompanied by a covering</p><p>Figure 1. Between 1999 and 2009, a relatively steady decline in rigid lens prescribing has been recorded (adapted from Morgan et al., 2002,</p><p>2006, 2010).</p><p>732 Ophthal. Physiol. Opt. 2010 30: No. 6</p><p> 2010 The Authors. Ophthalmic and Physiological Optics 2010 The College of Optometrists</p></li><li><p>letter, explaining the purpose of the study and invitingECPs to complete the questionnaire and return it to theinvestigator, in the stamped, addressed envelope pro-vided.Data produced from Likert response scales are</p><p>considered to be ordinal and therefore non-parametricstatistics were employed for analysis. Results weretabulated within SPSS and examined using statisticaltests, including Wilcoxon Rank and Pearson ChiSquare.</p><p>Results</p><p>Demographic information</p><p>Demographic information relating to questionnaireresponses is found in Table 1: the length of timepractitioners have been qualied is shown in Figure 2.Responses from practitioners not involved in contactlens tting were excluded from the contact lens ttingstatistics, but their subjective responses were included inthe remaining opinion-based analyses. The number ofpractitioner responses used in the analysis for eachquestion is given in Tables 24. Contact lens opticians(CLO) accounted for 4.4% of our respondents, which issomewhat less than the anticipated 10.7% on the GOCregisters.</p><p>Frequency of contact lens practice</p><p>The average number of contact lens patients seen perquarter showed large variation amongst ECPs (130,02275; median, range). Predictably, CLOs tended to seemany more contact lens patients than the optometrists,</p><p>as their clinical time is dedicated to contact lens work.Approximately 89% of all contact lens appointmentsare devoted to soft contact lens work and 11% to GPwork (Figure 3).</p><p>Practitioner attitudes to contact lenses</p><p>Generally, ECPs reported that they enjoyed the chal-lenges involved in both general lens tting and specif-ically GP tting (Table 2). However the ECPs responseswere more positively skewed towards general CL ttingcompared with GP tting (Wilcoxon Rank test,p &lt; 0.05). More experienced ECPs, those qualied for10 years or more, tended to respond more positively tothe statement I relish the challenges involved in GPtting compared with the less experienced practitioner(qualied or </p></li><li><p>Table 2. Practitioner responses regarding CL practice</p><p>n Statement</p><p>0 1 2 3 4 5 6 %</p><p>Agree</p><p>(4,5&amp;6)Disagreement Agreement (%)</p><p>438 I relish the challenges of fitting Contact lenses generally 1.1 1.1 6.8 15.6 25.6 31.1 18.7 75.4</p><p>436 RGP lenses 5.5 7.3 16.1 17.7 18.8 21.3 13.3 53.4</p><p>254 I relish the challenges of RGP fitting Qualified 10 years 4.1 4.6 10.3 17.9 19.5 24.1 19.5 63.1</p><p>441 It is time-consuming to fit contact lenses Contact lenses generally 7.5 16.3 22.9 20.9 21.3 8.2 2.9 32.4</p><p>439 RGP lenses 2.3 3.9 13.7 14.1 29.4 24.1 12.5 66.0</p><p>442 I frequently recommend Contact lenses generally 0.7 1.6 3.2 11.2 23.8 33.0 26.5 83.3</p><p>437 RGP lenses 6.9 19.7 24.7 25.6 13.5 4.8 4.8 23.1</p><p>255 I frequently recommend RGP lenses Qualified 10 years 6.3 14.9 25.9 27.1 14.9 5.2 5.7 25.8</p><p>257 RGP lenses are becoming obsolete Qualified 10 years 13.0 9.6 18.1 19.2 19.8 15.8 4.5 40.1</p><p>Table 3. Practitioner responses regarding CL patient health and comfort</p><p>n Statement</p><p>0 1 2 3 4 5 6 %</p><p>Agree</p><p>(4,5&amp;6)Disagreement Agreement (%)</p><p>436 Poor initial comfort discourages me from</p><p>fitting</p><p>Contact lenses generally 29.8 33.0 22.2 9.6 2.1 2.8 0.5 5.4</p><p>435 RGP lenses 9.2 14.0 18.4 17.3 17.0 17.0 7.1 41.1</p><p>432 It is clinically acceptable to use anaesthetic</p><p>during RGP fitting</p><p>15.0 11.8 17.6 25.3 16.2 9.0 5.1 30.3</p><p>438 Anterior eyes are generally healthy in</p><p>established</p><p>Contact lenses generally 0.2 1.1 5.0 24.7 34.0 26.3 8.7 69.0</p><p>439 RGP lenses 0.2 0.7 2.7 15.1 32.3 35.8 13.2 81.3</p><p>444 Patients report good comfort levels once</p><p>adapted to</p><p>Contact lenses generally 0.0 0.0 0.2 5.0 18.0 52.0 24.8 94.8</p><p>437 RGP lenses 0.0 0.0 1.2 8.9 27.0 46.0 16.9 89.9</p><p>Table 4. Practitioner responses regarding equipment for contact lens practice</p><p>n Statement</p><p>0 1 2 3 4 5 6 %</p><p>Agree</p><p>(4,5&amp;6)Disagreement Agreement (%)</p><p>416 Now that fitting sets are not commonly used,</p><p>I fit fewer RGP lenses</p><p>All practitioners 14.4 12.3 13.0 15.2 16.3 17.5 11.3 45.1</p><p>179 Qualified &gt;8 years 15.9 15.9 17.4 11.8 15.9 13.0 10.1 39.0</p><p>440 A slit lamp and keratometer are sufficient kit</p><p>for successfully fitting</p><p>Contact lenses generally 0.5 1.1 6.6 22.3 44.5 24.8 0.2 69.5</p><p>438 RGP lenses 1.1 1.4 8.2 18.8 24.4 30.8 15.3 70.5</p><p>400 A topographer is advantageous in fitting Contact lenses generally 3.8 9.5 18.5 34.8 19.3 9.8 4.3 33.4</p><p>403 RGP lenses 2.7 4.2 6.2 22.6 26.6 23.6 14.1 64.3</p><p>2.36%</p><p>8.92%</p><p>Soft fittingSoft aftercareGP fittingGP aftercare</p><p>24.64%</p><p>64.08%</p><p>Figure 3. Summary of time spent on soft and GP lens practice.</p><p>Figure 4. Practitioner response to the statement Anterior eyes aregenerally healthy in established wearers.</p><p>734 Ophthal. Physiol. Opt. 2010 30: No. 6</p><p> 2010 The Authors. Ophthalmic and Physiological Optics 2010 The College of Optometrists</p></li><li><p>proxymetacaine is the most common drug selection,used by 51.8% of those ECPs, followed by benoxinate,used by 42.6% of ECPs. The remaining 5.6% ofpractitioners use amethocaine (3.7%) and lignocaine(1.9%).The questionnaire also asked about practitioner</p><p>opinion regarding the use of topical anaesthetics (TA)during routine GP tting. Practitioner responses regard-ing TA use were varied (Table 3, Figure 6). Approxi-mately 25% of ECPs neither agreed nor disagreed with astatement describing TA use as acceptable, 15% ofECPs strongly disagreed with TA use for routine tting,and only 5% strongly agreed with its use.When asked whether contact lens tting in general is</p><p>time-consuming, practitioner responses were normallydistributed, indicating neither strong agreement nordisagreement with this statement. With respect to GPtting specically, there was a statistically signicantskew toward agreement with the statement (WilcoxonRank test, p &lt; 0.05) (Table 2).ECPs were asked whether the withdrawal of trial lens</p><p>sets traditionally used to aid GP tting had inuencedthe tting rate of GP lenses. ECPs who qualied after1999 (n = 237) would not have been exposed to regulartting set use, therefore their responses have beenexcluded to produce the second set of gures (Table 4).Remaining practitioner opinions were varied, indicatingneither strong agreement nor disagreement with the</p><p>statement. Comparison of responses indicated nosignicant difference between ECPs qualied beforeand those qualied after 1999 (MannWhitney test,p = 0.25).ECPs strongly agreed that a slit-lamp and keratom-</p><p>eter are sufcient for successful GP tting. However,practitioner agreement was statistically less strong withrespect to application of a slit-lamp and keratometer forgeneral contact lens tting (Wilcoxon Rank test,p &lt; 0.05) (Table 4). When asked whether a topogra-pher would be advantageous for contact lens tting,Table 4 results indicate that practitioner responses forcontact lenses generally were normally distributed, whileresponses for GP tting were positively skewed indicat-ing statistically stronger agreement with this statement(Wilcoxon Rank test, p &lt; 0.05). Table 5 gives anoverview of the equipment ECPs had available withintheir practice. Although ECPs generally believed atopographer would be advantageous in GP tting, theresults demonstrate that just 9.6% of ECPs had atopographer available to them in practice. Equipmentsuch as a radiuscope and v-gauge, associated with GPwork, do not appear to be standard practice equipment.ECPs agreed that patients report good comfort levels</p><p>in both adapted GP and general CL wearers (Table 3,Figure 7). However, ECPs are more likely to agree thatpatients in the gen...</p></li></ul>

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