a survey of uk practitioner attitudes to the fitting of rigid gas permeable lenses

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A survey of UK practitioner attitudes to the fitting of rigid gas permeable lenses Felicity R. Gill, Paul J. Murphy and Christine Purslow Cardiff University, School of Optometry and Vision Sciences, Contact Lens and Anterior Eye Research, Maindy Road, Cardiff CF24 4LU, UK Abstract Purpose: Rigid gas permeable (GP) contact lenses may provide the safest option for lens wear, but prescribing rates are in decline. This study investigated the effect of practitioner attitudes on GP lens prescribing. Methods: A questionnaire was developed using a focus group and a pilot study. Questions addressed clinical time spent fitting GP lenses, specialist equipment requirements and perceived safety and comfort. With ethical approval, the questionnaire was sent to 1000 randomly selected UK registered eye care practitioners (ECPs). Results: In general, ECPs enjoy the challenge of fitting GPs, although fitting takes longer than soft lens fitting. There is a difference in attitude between longer qualified and more recently qualified ECPs. Longer qualified ECPs more frequently reported enjoyment of the fitting challenges, recommended GP lenses to patients and were less likely to believe that GP lenses were becoming obsolete. ECPs are in strong agreement on the ocular health advantages of fitting GPs. They do not feel specialist equipment is generally needed, although some reported a topographer to be advantageous. The large majority of ECPs do not have access to the specialist equipment they perceive to be normally associated with GP fitting (radiuscope, V-gauge). They believe that initial fitting discomfort of GP fitting is a major drawback to their fitting, and while they feel this greatly improves with adaptation, they do not feel it reaches soft lens wear comfort. A total of 30.3% of ECPs feel it is clinically acceptable to use topical anaesthetic during GP fitting, but only 1.4% of ECPs regularly do so. Conclusions: ECPs are aware of the benefits that GP lenses provide in terms of ocular health. They find GPs take longer to fit, but they enjoyed the challenge of fitting, which suggests that they are not lacking in clinical skill, nor any specialist equipment. However, they are unhappy with initial patient comfort, and are not yet prepared to use topical anaesthetics during initial fitting. As a consequence, ECPs believe that GP lenses are becoming obsolete. Negative practitioner attitudes toward various aspects of GP fitting may mean fewer recommendations to patients and reduced GP prescribing. Keywords: contact lens, prescribing, rigid gas permeable, survey Introduction Following the introduction of soft contact lenses in 1970, Atkinson predicted their success and a consequent decline in rigid lens prescribing. In 1976, he reported that soft lenses already made up 50% of all contact lens fits recorded in the UK (Atkinson, 1976). Although rigid gas permeable (GP) prescribing did decrease, the reduction was gradual, and, by 1991, 39% of new contact lens fittings were still GP lenses (Pearson, 1998). In 1996, a survey, designed to investigate prescribing trends, was randomly distributed to 1000 UK ECPs who were asked for details about 10 consecutive contact lens fits (Morgan and Efron, 2006). This survey has since been distributed annually, both in the UK and interna- tionally, to monitor contact lens prescribing trends (Morgan et al., 2002; Morgan and Efron, 2006; Morgan et al., 2006). In 1996, 23% of new contact lens fits were Received: 18 November 2009 Revised form: 17 June 2010 Accepted: 19 June 2010 Correspondence and reprint requests to: Christine Purslow Tel.: 02920 876316; Fax: 02920 874859. E-mail address: [email protected] Ophthal. Physiol. Opt. 2010 30: 731–739 ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists doi: 10.1111/j.1475-1313.2010.00790.x

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A survey of UK practitioner attitudes to thefitting of rigid gas permeable lenses

Felicity R. Gill, Paul J. Murphy and Christine Purslow

Cardiff University, School of Optometry and Vision Sciences, Contact Lens and Anterior Eye

Research, Maindy Road, Cardiff CF24 4LU, UK

Abstract

Purpose: Rigid gas permeable (GP) contact lenses may provide the safest option for lens wear, but

prescribing rates are in decline. This study investigated the effect of practitioner attitudes on GP lens

prescribing.

Methods: A questionnaire was developed using a focus group and a pilot study. Questions

addressed clinical time spent fitting GP lenses, specialist equipment requirements and perceived

safety and comfort. With ethical approval, the questionnaire was sent to 1000 randomly selected UK

registered eye care practitioners (ECPs).

Results: In general, ECPs enjoy the challenge of fitting GPs, although fitting takes longer than soft

lens fitting. There is a difference in attitude between longer qualified and more recently qualified ECPs.

Longer qualified ECPs more frequently reported enjoyment of the fitting challenges, recommended

GP lenses to patients and were less likely to believe that GP lenses were becoming obsolete. ECPs

are in strong agreement on the ocular health advantages of fitting GPs. They do not feel specialist

equipment is generally needed, although some reported a topographer to be advantageous. The large

majority of ECPs do not have access to the specialist equipment they perceive to be normally

associated with GP fitting (radiuscope, V-gauge). They believe that initial fitting discomfort of GP fitting

is a major drawback to their fitting, and while they feel this greatly improves with adaptation, they do

not feel it reaches soft lens wear comfort. A total of 30.3% of ECPs feel it is clinically acceptable to use

topical anaesthetic during GP fitting, but only 1.4% of ECPs regularly do so.

Conclusions: ECPs are aware of the benefits that GP lenses provide in terms of ocular health. They

find GPs take longer to fit, but they enjoyed the challenge of fitting, which suggests that they are not

lacking in clinical skill, nor any specialist equipment. However, they are unhappy with initial patient

comfort, and are not yet prepared to use topical anaesthetics during initial fitting. As a consequence,

ECPs believe that GP lenses are becoming obsolete. Negative practitioner attitudes toward various

aspects of GP fitting may mean fewer recommendations to patients and reduced GP prescribing.

Keywords: contact lens, prescribing, rigid gas permeable, survey

Introduction

Following the introduction of soft contact lenses in1970, Atkinson predicted their success and a consequentdecline in rigid lens prescribing. In 1976, he reported

that soft lenses already made up 50% of all contact lensfits recorded in the UK (Atkinson, 1976). Although rigidgas permeable (GP) prescribing did decrease, thereduction was gradual, and, by 1991, 39% of newcontact lens fittings were still GP lenses (Pearson, 1998).

In 1996, a survey, designed to investigate prescribingtrends, was randomly distributed to 1000 UK ECPs whowere asked for details about 10 consecutive contact lensfits (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 fits were

Received: 18 November 2009

Revised form: 17 June 2010

Accepted: 19 June 2010

Correspondence and reprint requests to: Christine Purslow

Tel.: 02920 876316; Fax: 02920 874859.

E-mail address: [email protected]

Ophthal. Physiol. Opt. 2010 30: 731–739

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists doi: 10.1111/j.1475-1313.2010.00790.x

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 fits were GP; however 16% of refits wereGP (Morgan, 2007). This may indicate that GPs areoften refitted to existing GP wearers or in cases were softfitting is unsuccessful.

It is clear that rigid lens prescribing is, at best, static orin 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 fit 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 regardingpractitioner attitudes to contact lens or, specifically, 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 fit GP lenses; that use of topicalanaesthetic (TA) to aid fitting is an unacceptablepractice; and perceived comfort issues with GP lenses.

Without an understanding of practitioner attitudes toGP 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.

Methods

Questionnaire design

Since no existing questionnaire was available to obtainthe desired information, a questionnaire was designed

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 refined to the final format.

The questionnaire comprised 20 questions(Appendix 1). Questions 1–9 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 specifically. 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.

Subject recruitment

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

Figure 1. Between 1999 and 2009, a relatively steady decline in rigid lens prescribing has been recorded (adapted from Morgan et al., 2002,

2006, 2010).

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ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

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

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.

Results

Demographic information

Demographic information relating to questionnaireresponses is found in Table 1: the length of timepractitioners have been qualified is shown in Figure 2.Responses from practitioners not involved in contactlens fitting were excluded from the contact lens fittingstatistics, 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 2–4. Contact lens opticians(CLO) accounted for 4.4% of our respondents, which issomewhat less than the anticipated 10.7% on the GOCregisters.

Frequency of contact lens practice

The average number of contact lens patients seen perquarter showed large variation amongst ECPs (130,0–2275; median, range). Predictably, CLOs tended to seemany more contact lens patients than the optometrists,

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).

Practitioner attitudes to contact lenses

Generally, ECPs reported that they enjoyed the chal-lenges involved in both general lens fitting and specif-ically GP fitting (Table 2). However the ECPs� responseswere more positively skewed towards general CL fittingcompared with GP fitting (Wilcoxon Rank test,p < 0.05). More experienced ECPs, those qualified for10 years or more, tended to respond more positively tothe statement �I relish the challenges involved in GPfitting� compared with the less experienced practitioner(qualified <10 years) (Wilcoxon Rank test, p < 0.05)(Table 2).

ECPs tended to agree with the statement that the�anterior eyes are generally healthy� in both the generalcontact lens wearing population and the GP wearingpopulation. However, significantly more ECPs agreedwith this statement with regard to GP wearers specif-ically than the general CL wearing cohort (WilcoxonRank test, p < 0.05) (Table 3, Figure 4).

Initial discomfort in lens fitting was not found todiscourage ECPs from fitting contact lenses generally.However, practitioner responses for the same statementwith respect to GP fitting indicated that reduced initialcomfort with GP lenses does significantly discourage(some) ECPs from fitting this lens type (Wilcoxon Ranktest, p < 0.05) (Table 3, Figure 5).

Predominantly, UK ECPs do not use topical anaes-thetic (TA) when fitting GPs: 12.4% of ECPs use TAsome of the time when they fit GP lenses, and just 1.4%of ECPs routinely use TA for fitting. Statistically, therewas no correlation between practitioner experience interms of topical anaesthetic use when comparing thosequalified for > or <10 years. Of ECPs that use TA,

Table 1. Demographic information

Questionnaire responses n %

Questionnaires posted 1000 100

Completed questionnaires 451 45.1

Blank questionnaires returned 19 1.9

Not returned 530 53.0

Responses from optometrists 431 95.6

Responses from CLO 20 4.4

Practitioners seeing CL patients 434 96.2

Practice type

Multiple 192 42.6

Franchise 18 4.0

Independent 183 40.6

Hospital 6 1.3

Mixed 52 11.5

Median, range

Patients seen per day 15 (3–40)

Number days worked/weekly 5 (1–7)

Average length qualified (years) 7 (0–64)

Figure 2. Length of time practitioners had been qualified.

UK practitioner attitudes to RGP fitting: F. R. Gill et al. 733

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

Table 2. Practitioner responses regarding CL practice

n Statement

0 1 2 3 4 5 6 %

Agree

(4,5&6)Disagreement fi Agreement (%)

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

436 RGP lenses 5.5 7.3 16.1 17.7 18.8 21.3 13.3 53.4

254 I relish the challenges of RGP fitting Qualified <10 years 6.6 9.3 19.5 17.5 18.7 19.1 9.3 47.1

176 Qualified >10 years 4.1 4.6 10.3 17.9 19.5 24.1 19.5 63.1

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

439 RGP lenses 2.3 3.9 13.7 14.1 29.4 24.1 12.5 66.0

442 I frequently recommend Contact lenses generally 0.7 1.6 3.2 11.2 23.8 33.0 26.5 83.3

437 RGP lenses 6.9 19.7 24.7 25.6 13.5 4.8 4.8 23.1

255 I frequently recommend RGP lenses Qualified <10 years 7.4 23.3 23.6 24.3 12.4 4.7 4.3 21.4

176 Qualified >10 years 6.3 14.9 25.9 27.1 14.9 5.2 5.7 25.8

257 RGP lenses are becoming obsolete Qualified <10 years 6.2 11.2 14.2 15.8 25.0 18.8 8.8 52.6

180 Qualified >10 years 13.0 9.6 18.1 19.2 19.8 15.8 4.5 40.1

Table 3. Practitioner responses regarding CL patient health and comfort

n Statement

0 1 2 3 4 5 6 %

Agree

(4,5&6)Disagreement fi Agreement (%)

436 Poor initial comfort discourages me from

fitting

Contact lenses generally 29.8 33.0 22.2 9.6 2.1 2.8 0.5 5.4

435 RGP lenses 9.2 14.0 18.4 17.3 17.0 17.0 7.1 41.1

432 It is clinically acceptable to use anaesthetic

during RGP fitting

15.0 11.8 17.6 25.3 16.2 9.0 5.1 30.3

438 Anterior eyes are generally healthy in

established

Contact lenses generally 0.2 1.1 5.0 24.7 34.0 26.3 8.7 69.0

439 RGP lenses 0.2 0.7 2.7 15.1 32.3 35.8 13.2 81.3

444 Patients report good comfort levels once

adapted to

Contact lenses generally 0.0 0.0 0.2 5.0 18.0 52.0 24.8 94.8

437 RGP lenses 0.0 0.0 1.2 8.9 27.0 46.0 16.9 89.9

Table 4. Practitioner responses regarding equipment for contact lens practice

n Statement

0 1 2 3 4 5 6 %

Agree

(4,5&6)Disagreement fi Agreement (%)

416 Now that fitting sets are not commonly used,

I fit fewer RGP lenses

All practitioners 14.4 12.3 13.0 15.2 16.3 17.5 11.3 45.1

179 Qualified >8 years 15.9 15.9 17.4 11.8 15.9 13.0 10.1 39.0

440 A slit lamp and keratometer are sufficient kit

for successfully fitting

Contact lenses generally 0.5 1.1 6.6 22.3 44.5 24.8 0.2 69.5

438 RGP lenses 1.1 1.4 8.2 18.8 24.4 30.8 15.3 70.5

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

403 RGP lenses 2.7 4.2 6.2 22.6 26.6 23.6 14.1 64.3

2.36%

8.92%

Soft fittingSoft aftercareGP fittingGP aftercare

24.64%

64.08%

Figure 3. Summary of time spent on soft and GP lens practice.

Figure 4. Practitioner response to the statement �Anterior eyes are

generally healthy in established wearers�.

734 Ophthal. Physiol. Opt. 2010 30: No. 6

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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

opinion regarding the use of topical anaesthetics (TA)during routine GP fitting. 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 fitting,and only 5% strongly agreed with its use.When asked whether contact lens fitting in general is

time-consuming, practitioner responses were normallydistributed, indicating neither strong agreement nordisagreement with this statement. With respect to GPfitting specifically, there was a statistically significantskew toward agreement with the statement (WilcoxonRank test, p < 0.05) (Table 2).ECPs were asked whether the withdrawal of trial lens

sets traditionally used to aid GP fitting had influencedthe fitting rate of GP lenses. ECPs who qualified after1999 (n = 237) would not have been exposed to regularfitting set use, therefore their responses have beenexcluded to produce the second set of figures (Table 4).Remaining practitioner opinions were varied, indicatingneither strong agreement nor disagreement with the

statement. Comparison of responses indicated nosignificant difference between ECPs qualified beforeand those qualified after 1999 (Mann–Whitney test,p = 0.25).

ECPs strongly agreed that a slit-lamp and keratom-eter are sufficient for successful GP fitting. However,practitioner agreement was statistically less strong withrespect to application of a slit-lamp and keratometer forgeneral contact lens fitting (Wilcoxon Rank test,p < 0.05) (Table 4). When asked whether a topogra-pher would be advantageous for contact lens fitting,Table 4 results indicate that practitioner responses forcontact lenses generally were normally distributed, whileresponses for GP fitting were positively skewed indicat-ing statistically stronger agreement with this statement(Wilcoxon Rank test, p < 0.05). Table 5 gives anoverview of the equipment ECPs had available withintheir practice. Although ECPs generally believed atopographer would be advantageous in GP fitting, 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 levelsin both adapted GP and general CL wearers (Table 3,Figure 7). However, ECPs are more likely to agree thatpatients in the general CL wearing population experi-ence good comfort compared with those in the GPcohort (Wilcoxon Rank test, p < 0.05).

Figure 5. Practitioner response to the statement �Poor initial comfort

discourages fitting�.

Figure 6. Practitioner response to the statement �It is clinically

acceptable to use topical anaesthetic during GP lens fitting�.

Table 5. Equipment available to practitioners

Equipment

Practices with

equipment (%)

Slit lamp 100

Auto-refractor 47.4

Radiuscope 17.8

Focimeter 99.1

Keratometer 99.1

Topographer 9.6

V-gauge 13.6

Burton lamp 74.2

Figure 7. Practitioner response to the statement �Patients report

good comfort once adapted to lenses�.

UK practitioner attitudes to RGP fitting: F. R. Gill et al. 735

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

Despite practitioner opinion that GP wearers gener-ally have �healthier anterior eyes� than other lenswearing cohorts, negative practitioner perceptions to-ward GP fitting appears to result in a significantly lowerfrequency of GP recommendations to patients (Table 2)(Wilcoxon Rank test, p < 0.05). However, Table 2results also indicated that more experienced ECPs tendto recommend GPs more frequently than less experi-enced ones, although this is not statistically significant.

Finally, ECPs were asked whether they agree that GPlenses are becoming obsolete. Approximately half ofyoung ECPs (qualified <10 years) felt that this state-ment was true; while more experienced ECPs (qualifiedlonger than 10 years) were somewhat more optimistic,with 40% agreeing that GPs are becoming obsolete(Table 2).

Discussion

The use of GP lenses in UK contact lens practice hasundergone a gradual decline over the past decade, eventhough GP lenses can give superior clinical outcomescompared with alternative soft or silicone hydrogellenses (Bennett et al., 1998; Qu et al., 2003). This surveyhas confirmed that GP contact lens practice makes uponly a small part of UK contact lens practice (11%).This is supported by reports in the literature whichindicate a steady decline in GP prescribing in favour ofsoft lenses (Morgan et al., 2002; Morgan and Efron,2006, 2008a,b; Morgan, 2009). One explanation may bethat developments in soft lens designs and materials(material permeability; deposit resistance; wettability;improved toric and presbyopic options) have led ECPsto believe that GP lenses have been �superseded�.However, a clearer understanding of practitioner atti-tudes toward GP lenses may provide clearer hypothesesto explain the decline in GP prescribing.

This survey has allowed the examination of severalfactors that may play a part in the prevalence of GPprescribing. The idea that GP fitting is more demandingin time, clinical skill and equipment than soft lens fittingis supported by the results: most ECPs perceive GPfitting to be more time consuming than general contactlens fitting, even though they appear to enjoy thechallenge. However, less than one quarter of the samplewould frequently recommend GP lenses to theirpatients. So it would seem that the technical challengeof fitting the lenses is not a major factor in the decline ofGP fitting, at least in experienced ECPs.

The survey found that ECPs who trained or qualifiedafter 1999 held different attitudes to their longerpracticing counterparts. In June 1999, the UK Depart-ment of Health stated that contact lenses should be forsingle patient use only, due to the remote theoretical riskof cross-infecting patients with variant Creutzfeldt–

Jakob disease (vCJD) (Macalister and Buckley, 2002).Up until that time, ECPs were able to use fitting sets toefficiently assess the best fit before ordering the finalspecification lens. From the survey results, ECPs qual-ified for <10 years were less interested in the fittingchallenge – less than half of this group enjoyed fittingGP lenses, and they were more likely to think GPs werebecoming obsolete.

Generally, ECPs qualified longer than 10 years tendedto hold more positive attitudes toward GP lenses,compared with those qualified for a shorter period. Thissuggests that the more recently qualified have not hadthe same experience during their education and in theirearly, qualified years, in fitting GP lenses, as those whotrained and qualified before 1999. It has been reportedthat there is no shortfall in the education of GP fitting inUK optometry schools; however, there may be a lack ofpractical experience available to early career ECPs(Efron, 2001).

Most ECPs surveyed felt that specialist equipmentwas not essential for GP fitting, although many agreedthat instrumentation such as a topographer would bebeneficial to the fitting process. Published literaturesupports practitioner belief that topography may aid GPfitting, however clinical judgement remains a mandatoryelement in successful fitting (Postma et al., 1993;Szczotka et al., 1994; Bufidis et al., 1998).

Respondents demonstrated that TA use during GPfitting is not customary practice in the UK. Previousresearch has shown the use of TA during fitting to besafe, and effective in improving initial comfort and long-term patient success in GP wear (Bennett et al., 1998).The results represent an important finding becauseinitial lens discomfort is cited by ECPs as a disincentiveto GP prescribing. A second advantage of TA use is thatit reduces lacrimation and blepharospasm, allowingprompt fit assessment following insertion, and thus ashortened fitting process (Bennett et al., 1998). This ispotentially of significant benefit to UK practitionersbecause, as discussed earlier, ECPs find GP fitting takeslonger than alternative lens types. Practitioner opinionregarding the acceptability of using TA in contact lensfitting is varied, and only 1 in 3 of those surveyed believeit is safe practice.

The survey gave practitioners the opportunity topropose that initial and adapted comfort issues deterECPs from GP fitting. Comfort is a particularlyimportant issue for both contact lens wearers andcontact lens ECPs, because comfort-related issues arecited as the primary reason for contact lens dissatisfac-tion and discontinuation (Richdale et al., 2007). Theresults from the survey reveal an interesting paradox inpractitioner views. Although ECPs indicated that poorinitial comfort with GP lenses discourages them fromfitting this lens type, they acknowledged that adapted

736 Ophthal. Physiol. Opt. 2010 30: No. 6

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

GP wearers generally experience good comfort levels.Such adapted lens wear comfort has been confirmed inprevious research; no differences between a cohort ofadapted GP and soft lens wearers were reported(Morgan et al., 2003). These findings would supportthe supposition that compromised initial comfort is afactor in reduced GP fitting statistics. They also indicatethat it is the reservations of the practitioner regardingcomfort which affects subsequent advice and lensoptions presented to the patient. This is reflected inthe statistics which show GP lenses are not frequentlyrecommended to patients by ECPs.Despite some negative attitudes surrounding GP

lenses, this survey found that ECPs believe patients aremore likely to have a healthy anterior eye when wearingGP lenses compared with contact lenses generally. Thisbelief is in line with current education and researchwhich reports that GP lenses have statistically loweraverage number of complications compared with softlenses (Forister et al., 2009).There is a risk of bias in this survey, since the ECPs

who completed and returned the questionnaire may bethose with an interest or bias toward contact lenspractice. This may be reflected in the response fromECPs who positively supported the statement that theyrelish the challenges involved in fitting all types ofcontact lenses. However, even when practitionerresponses were compared between lens types, ECPsresponded significantly more positively with respect togeneral fitting relative to GP fitting. In the survey, ECPswere asked to report their approximate frequency offitting and aftercare consultations. The accuracy ofresponse is dependent on each practitioner�s reliability inreporting the type and quantity of contact lens consul-tations: possible incorrect reporting of these statisticsmay have influenced the accuracy of the results.Orthokeratology lens fitting is a specialised form of

GP fitting. In the UK, in 2008, <1% of all fits in UKwere with orthokeratology lenses. This type, and othermore specialised GP fitting such as post-graft andkeratoconic fitting, was beyond the scope of this study.However it would be interesting to further investigatepatient selection as we may find that practitioners selectGP lenses for specialist cases or when a problem solvinglens is required. This has been suggested in the literatureand it has been argued that although GP prescribing willnot disappear completely, it may become an activity foran elite specialist group of practitioners (Efron, 2000).To exert influence on these �negative� practitioner

attitudes toward GP prescribing, three areas need to beaddressed. Firstly, for those ECPs who qualified after1999 in the UK, some additional training may be of helpin developing their clinical skills in GP fitting. Similarly,contact lens training institutions should review their GPtraining provision to ensure it provides those in training

with the opportunity to develop their practical skills.Secondly, the use of topical anaesthetic in aiding theinitial comfort experience during GP lens fitting shouldbe investigated amongst a UK cohort to confirmwhether there is a long-term benefit to the patient incomfort and that no adverse clinical reactions areproduced. Thirdly, alternative GP lens designs, such aslarge diameter lenses, should be investigated as this mayimprove lens wear comfort while still providing thebenefits of GPs for ocular health (Bennett, 1999).

Conclusions

UK contact lens ECPs are aware of the benefits that GPlenses provide in terms of ocular health and opticalcorrection. While they accept that GP lenses take longerto fit, they enjoy the challenge of the fitting, whichsuggests that they are not grossly lacking in clinical skill,nor do they feel hindered by lacking any specialistequipment. However, they are unhappy with initialpatient comfort, and are not yet prepared to use topicalanaesthetics during initial fitting.As a consequence, ECPsbelieve that GP lenses are becoming obsolete. Undoubt-edly the initial comfort benefit of soft lenses has a largerole to play, but negative practitioner attitudes towardvarious aspects of GP fitting means fewer recommenda-tions to patients and reduced GP prescribing.

References

Atkinson, T. (1976) Farewell to hard times? Ophthalmic Opt16, 919–937.

Bennett, E. S. (1999) Improving patient success with RGPs.Optometry Today: 30/07/99: 42–44.

Bennett, E. S., Smythe, J., Henry, V. A., Bassi, C. J., Morgan,B. W., Miller, W. O., Jeandervin, M., Henderson, B., Elliott,L., Porter, K. S. and Barr, J. T. (1998) Effect of topical

anesthetic use on initial patient satisfaction and overallsuccess with rigid gas permeable contact lenses. Optom. Vis.Sci. 75, 800–805.

Bufidis, T., Konstas, A. G. and Mamtziou, E. (1998) The roleof computerized corneal topography in rigid gas permeablecontact lens fitting. CLAO J. 24, 206–209.

Efron, N. (2000) Contact lens practice and a very soft option.Clin. Exp. Optom. 83, 243–245.

Efron, N. (2001) The demise of rigid contact lenses. OptometryToday: 05/10/01: 22–25.

Forister, J. F. Y., Ye, P., Weissman, B. A., Yeung, K. K.,Chung, M. Y., Forister, E. F. and Tsui, A. (2009) Prevalenceof contact lens-related complications: UCLA contact lens

study. Eye Contact Lens 35, 176–180.Likert, R. (1932) A technique for the measurement ofattitudes. Arch. Psychol. 140, 5–53.

Macalister, G. O. and Buckley, R. J. (2002) The risk oftransmission of variant Creutzfeldt-Jakob disease via con-tact lenses and ophthalmic devices. Cont. Lens Anterior Eye

25, 104–136.

UK practitioner attitudes to RGP fitting: F. R. Gill et al. 737

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

Masters, J. R. (1974) The relationship between number of

response categories and reliability of Likert-type question-naires. J Educ Meas 11, 49–50.

Morgan, P. B. (2007) Trends in UK contact lens prescribing

2007. Optician 234, 16–17.Morgan, P. B. (2009) Trends in contact lens prescribing 2009.Optician 239, 20–21.

Morgan, P. B. and Efron, N. (2006) A decade of contact lensprescribing trends in the United Kingdom (1996-2005).Cont. Lens Anterior Eye 29, 59–68.

Morgan, P. B. and Efron, N. (2008a) Demographics of UK

contact lens prescribing. Cont. Lens Anterior Eye 31, 50–51.Morgan, P. B. and Efron, N. (2008b) The evolution of rigidcontact lens prescribing. Cont. Lens Anterior Eye 31, 213–

214.Morgan, P. B., Efron, N., Woods, C. A., Jones, D., Tranoudis,Y., van de Worp, E. and Helland, M. (2002) International

contact lens prescribing. Contact Lens Spectr. http://www.clspectrum.com/article.aspx?article=12086

Morgan, P. B., Maldonado-Codina, C. P. D. and Efron, N.(2003) Comfort response to rigid and soft hyper- transmis-

sible contact lenses used for continuous wear. Eye ContactLens 29(Suppl), S127–S130.

Morgan, P. B., Efron, N., Woods, C. A., Jones, D., Pesinova,

A., Grein, H. and Tranousis, I. G. et al. (2006) Internationalcontact lens prescribing in 2005. Contact Lens Spectr. http://www.clspectrum.com/article.aspx?article=12914

Morgan, P. B., Efron, N., Woods, C. A., Jones, D., Pesinova,A., Grein, H. and Tranousis, I. G. et al. (2010) Internationalcontact lens prescribing in 2009. Contact Lens Spectr. http://

www.clspectrum.com/article.aspx?article=103881Pearson, R. (1998) Contact lens fitting in the United Kingdom.Cont. Lens Anterior Eye 21, 147.

Postma, J. T., Postma, A. M. and Schnider, C. M. (1993) A

comparison between nomogram vs. trial fitting of rigid gaspermeable contact lenses. J. Am. Optom. Assoc. 64, 258–263.

Qu, J., Mao, C.-R., Lu, F. and Mao, X.-J. (2003) Study of

corrected visual performance and vision quality. ZhonghuaYan Ke Za Zhi 39, 325–327.

Richdale, K., Sinnott, L., Skadahl, E. and Nichols, J. (2007)

Frequency of and factors associated with contact lensdissatisfaction and discontinuation. Cornea 26, 168–174.

Szczotka, L. B., Capretta, D. M. and Lass, J. H. (1994)Clinical evaluation of a computerized topography software

method for fitting rigid gas permeable contact lenses. CLAOJ. 20, 231–236.

Appendix 1: Contact lens questionnaire

If you do not fit contact lenses, please pass thisquestionnaire to a colleague who does.

1) What is your job description?h Optometristh Contact lens optician

2) How long have you been qualified? ………years3) What type of practice do you work in? (Please tick

all appropriate answers)h Multipleh Own franchiseh Independenth Hospitalh Other (Please specify) ………………………………4) What City/Town do you work in? ………………

………………..5) How many days do you work as a clinician each

week? ………days6) Approximately how many patients do you see each

day? ………patients7a) Approximately how many contact lens patients

do you see? ………week/month/quarter(delete as appropriate)

b) How many rigid gas permeable (RGP) lenses doyou fit? ………week/month/quarter(delete as appropriate)

c) How many RGP aftercares do you do?………week/month/quarter(delete as appropriate)

d) How many soft contact lenses do you fit?………week/month/quarter(delete as appropriate)

e) How many soft contact lens aftercares do you do?………week/month/quarter(delete as appropriate)

8a) If you fit RGPs, do you use anaesthetic duringfitting? (Please tick all appropriate answers)

h Alwaysh Sometimesh Neverb) If yes, what type and concentration of anaesthetic

do you use?………………………………..9) What equipment do you have in your practice?

(Please tick all appropriate answers)h Slit lamph Auto-refractorh Radiuscopeh Focimeterh Keratometerh Topographerh V-gaugeh Burton lamp

738 Ophthal. Physiol. Opt. 2010 30: No. 6

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists

In the following questions, please choose and circle the most appropriate answer.

Strongly agree

Strongly

disagree

10) I relish the challenges of fitting

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

11) A slit lamp and keratometer are sufficient kit for successfully fitting

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

12) A topographer is advantageous in fitting

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

13) It is time-consuming to fit

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

14) Poor initial comfort discourages me from fitting

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

15) It is clinically acceptable to use topical anaesthetic

during RGP lens fitting

6 5 4 3 2 1 0

16) Now that fitting sets are not commonly

used, I fit fewer RGP lenses

6 5 4 3 2 1 0

17) I frequently recommend

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

18) Anterior eyes are generally healthy in established

a) Contact lens wearers 6 5 4 3 2 1 0

b) RGP lens wearers 6 5 4 3 2 1 0

19) Patients report good comfort levels once adapted to

a) Contact lenses generally 6 5 4 3 2 1 0

b) RGP lenses 6 5 4 3 2 1 0

20) RGP lenses are becoming obsolete 6 5 4 3 2 1 0

UK practitioner attitudes to RGP fitting: F. R. Gill et al. 739

ª 2010 The Authors. Ophthalmic and Physiological Optics ª 2010 The College of Optometrists