American Academy of Optometry Microbial Keratitis Think Tank.

SIGNIFICANCE: Think Tank 2019 affirmed that the rate of infection associated with contact lenses has not changed in several decades. Also, there is a trend toward more serious infections associated with Acanthamoeba and fungi. The growing use of contact lenses in children demands our attention with surveillance and case-control studies. PURPOSE: The American Academy of Optometry (AAO) gathered researchers and key opinion leaders from around the world to discuss contact lens-associated microbial keratitis at the 2019 AAO Annual Meeting. METHODS: Experts presented within four sessions. Session 1 covered the epidemiology of microbial keratitis, pathogenesis of Pseudomonas aeruginosa, and the role of lens care systems and storage cases in corneal disease. Session 2 covered nonbacterial forms of keratitis in contact lens wearers. Session 3 covered future needs, challenges, and research questions in relation to microbial keratitis in youth and myopia control, microbiome, antimicrobial surfaces, and genetic susceptibility. Session 4 covered compliance and communication imperatives. RESULTS: The absolute rate of microbial keratitis has remained very consistent for three decades despite new technologies, and extended wear significantly increases the risk. Improved oxygen delivery afforded by silicone hydrogel lenses has not impacted the rates, and although the introduction of daily disposable lenses has minimized the risk of severe disease, there is no consistent evidence that they have altered the overall rate of microbial keratitis. Overnight orthokeratology lenses may increase the risk of microbial keratitis, especially secondary to Acanthamoeba, in children. Compliance remains a concern and a significant risk factor for disease. New insights into host microbiome and genetic susceptibility may uncover new theories. More studies such as case-control designs suited for rare diseases and registries are needed. CONCLUSIONS: The first annual AAO Think Tank acknowledged that the risk of microbial keratitis has not decreased over decades, despite innovation. Important questions and research directions remain.

Adverse event rates in the retrospective cohort study of safety of paediatric soft contact lens wear: the ReCSS study.

PURPOSE: To ascertain the safety of soft contact lens (SCL) wear in children through a retrospective chart review including real-world clinical practice settings. METHODS: The study reviewed clinical charts from 963 children: 782 patients in 7 US eye care clinics and 181 subjects from 2 international randomised clinical trials (RCTs). Subjects were first fitted while 8-12 years old with various SCL designs, prescriptions and replacement schedules, and observed through to age 16. Clinical records from visits with potential adverse events (AEs) were electronically scanned and reviewed to consensus by an Adjudication Panel. RESULTS: The study encompassed 2713 years-of-wear and 4611 contact lens visits. The cohort was 46% male, 60% were first fitted with daily disposable SCLs, the average age at first fitting was 10.5 years old, with a mean of 2.8 ± 1.5 years-of-wear of follow-up observed. There were 122 potential ocular AEs observed from 118/963 (12.2%) subjects; the annualised rate of non-infectious inflammatory AEs was 0.66%/year (95% CI 0.39-1.05) and 0.48%/year (0.25-0.82) for contact lens papillary conjunctivitis. After adjudication, two presumed or probable microbial keratitis (MK) cases were identified, a rate of 7.4/10 000 years-of-wear (95% CI 1.8-29.6). Both were in teenage boys and one resulted in a small scar without loss of visual acuity. CONCLUSION: This study estimated the MK rate and the rate of other inflammatory AEs in a cohort of SCL wearers from 8 through to 16 years of age. Both rates are comparable to established rates among adults wearing SCLs.

Thirty years of 'quiet eye' with etafilcon A contact lenses.

Frequent replacement contact lenses made from the etafilcon A hydrogel lens material were introduced onto the market over 30 years ago, and etafilcon A remains the most widely used hydrogel lens material today. Although the prescribing of silicone hydrogel lenses is increasing, millions of lens wearers globally have been wearing hydrogel lenses for many years and exhibit a physiologically-stable 'quiet eye', with a low profile of adverse events. Hydrogel lenses are demonstrated to maintain a low inflammatory response and infection risk profile during daily wear, which in the case of etafilcon A, may be related to its low modulus, and the naturally-protective, anti-microbial, non-denatured lysozyme absorbed into the lens from the tear fluid. Although improved corneal physiology from decreased hypoxia with silicone hydrogel lenses is well accepted, equivalent levels of corneal oxygenation are maintained during daily wear of low to medium powered hydrogel lenses, which do not impede the daily corneal de-swelling process, and do not induce clinically significant changes in ocular health. Therefore, hydrogel lenses remain an important alternative for daily wear in modern contact lens practice.

The Case for Using Hydrogen Peroxide Contact Lens Care Solutions: A Review.

Despite their established disinfection and safety benefits, the use of hydrogen peroxide (H2O2) lens care systems among today's wearers of reusable contact lenses remains low in comparison with multipurpose solution (MPS) use. Multipurpose solution systems, however, present several potential drawbacks that may impact patient outcomes, including the use of chemical preservatives for disinfection, biocompatibility issues, and challenges with respect to lens care compliance. Given their unique composition and mechanism of action, one-step H2O2 systems offer the opportunity to avoid many of the challenges associated with MPS use. This article reviews the evolution of H2O2 lens care systems and examines the current scientific and clinical evidence regarding the relative ease of use, lens and tissue compatibility, disinfection efficacy, and ocular surface safety of H2O2 systems. Evaluation of the available data indicates that in comparison with MPS, one-step H2O2 systems tend to promote more favorable compliance, efficacy, comfort, and ocular surface outcomes for a wide range of contact lens-wearing patients. Based on the current published evidence, the authors recommend that eye care practitioners consider making one-step H2O2 systems their first-line contact lens care recommendation for most wearers of reusable lenses.

Multicenter Testing of a Risk Assessment Survey for Soft Contact Lens Wearers With Adverse Events: A Contact Lens Assessment in Youth Study.

PURPOSE: To test the ability of responses to the Contact Lens Assessment in Youth (CLAY) Contact Lens Risk Survey (CLRS) to differentiate behaviors among participants with serious and significant (S&S) contact lens-related corneal inflammatory events, those with other events (non-S&S), and healthy controls matched for age, gender, and soft contact lens (SCL) wear frequency. METHODS: The CLRS was self-administered electronically to SCL wearers presenting for acute clinical care at 11 clinical sites. Each participant completed the CLRS before their examination. The clinician, masked to CLRS responses, submitted a diagnosis for each participant that was used to classify the event as S&S or non-S&S. Multivariate logistic regression analyses were used to compare responses. RESULTS: Comparison of responses from 96 participants with S&S, 68 with non-S&S, and 207 controls showed that patients with S&S were more likely (always or fairly often) to report overnight wear versus patients with non-S&S (adjusted odds ratio [aOR], 5.2; 95% confidence interval [CI], 1.4-18.7) and versus controls (aOR, 5.8; CI, 2.2-15.2). Patients with S&S were more likely to purchase SCLs on the internet versus non-S&S (aOR, 4.9; CI, 1.6-15.1) and versus controls (aOR, 2.8; CI, 1.4-5.9). The use of two-week replacement lenses compared with daily disposables was significantly higher among patients with S&S than those with non-S&S (aOR, 4.3; CI, 1.5-12.0). Patients with S&S were less likely to regularly discard leftover solution compared with controls (aOR, 2.5; CI, 1.1-5.6). CONCLUSIONS: The CLRS is a clinical survey tool that can be used to identify risky behaviors and exposures directly associated with an increased risk of S&S events.

Water Exposure is a Common Risk Behavior Among Soft and Gas-Permeable Contact Lens Wearers.

PURPOSE: To understand soft contact lens (SCL) and gas-permeable (GP) lens wearers' behaviors and knowledge regarding exposure of lenses to water. METHODS: The Contact Lens Risk Survey (CLRS) and health behavior questions were completed online by a convenience sample of 1056 SCL and 85 GP lens wearers aged 20 to 76 years. Participants were asked about exposing their lenses to water and their understanding of risks associated with these behaviors. Chi-square analyses examined relationships between patient behaviors and perceptions. RESULTS: GP lens wearers were more likely than SCL wearers to ever rinse or store lenses in water (rinsing: 91% GP, 31% SCL, P < 0.001; storing: 33% GP, 15% SCL P < 0.001). Among SCL wearers, men were more likely to store (24% vs. 13%, P = 0.003) or rinse (41% vs. 29%, P = 0.012) their lenses in water. Showering while wearing lenses was more common in SCL wearers (86%) than GP lens wearers (67%) (P < 0.0001). Swimming while wearing lenses was reported by 62% of SCL wearers and 48% of GP lens wearers (P = 0.027). Wearers who rinsed (SCL; P < 0.0001, GP; P = 0.11) or stored lenses in water (SCL; P < 0.0001, GP P = 0.007) reported that this behavior had little or no effect on their infection risk, compared with those who did not. Both SCL (P < 0.0001) and GP lens wearers (P < 0.0001) perceived that distilled water was safer than tap water for storing or rinsing lenses. CONCLUSIONS: Despite previously published evidence of Acanthamoeba keratitis' association with water exposure, most SCL, and nearly all GP lens wearers, regularly expose their lenses to water, with many unaware of the risk.

Patient-Reported Wearing Experience From Hydrogel Daily Disposable Wearers Older Than 40 Years From the TEMPO Registry.

OBJECTIVES: To describe the patient-reported wearing experience over time among wearers of hydrogel daily disposable (HydDD) contact lenses (CLs) in the TruEye and Moist Performance Overview (TEMPO) Registry (NCT01467557). METHODS: Registered wearers older than 40 years who were recently fit with 1-DAY ACUVUE MOIST HydDDs completed self-administered questionnaires four times during a year-long Registry. Overall opinion of CLs, replacement schedules, Contact Lens Dry Eye Questionnaire (CLDEQ-8), and compliance were queried. Data were analyzed with analysis of variance and signed rank tests. RESULTS: A total of 86 subjects (24% men, age 50.2±7.1 years) completed the Registry. Approximately 76% were new to daily disposable lenses, and 8% were neophytes. Overall opinion of CLs improved significantly after refitting with HydDDs (baseline 57% excellent/very good vs. 69%-79% at follow-ups, P<0.05 all vs. baseline). Changing to HydDDs maintained average and comfortable wear time (P>0.05), and it did significantly improve CLDEQ-8 scores at all follow-ups (baseline, 11.2±7.3 vs. 2 weeks, 7.8±5.8, P<0.0001; 4 months, 8.6±6.5, P=0.0006; 12 months, 9.3±6.5, P=0.01). Self-assessment of compliance was excellent/very good for 80% at baseline, and improved to 92% to 98% at follow-ups (P<0.0001). More than 90% never slept in their HydDDs, although compliance to daily replacement diminished from 2-week to 4-month surveys (93% vs. 84%, P=0.007). CONCLUSIONS: After refitting with HydDDs, older wearers reported significantly higher overall opinions of their lenses, better CLDEQ-8 symptom scores, and most were compliant with proper daily disposable lens use. Diminishing daily replacement rates from 2 weeks to 4 months indicate a need to reinforce that recommendation. Wearers of HydDD CLs older than 40 years experienced many benefits from refitting with these daily disposable lenses.

Characterizing Contact Lens-Related Corneal Infiltrates: A Pilot Study.

PURPOSE: To document the time course and resolution of contact lens-related corneal infiltrative events (CIEs) comparing slit-lamp images with anterior segment ocular coherence tomography (AS-OCT) images. METHODS: Six silicone hydrogel (SiHy) soft contact lens (SCL) wearers presenting with newly diagnosed symptomatic CIEs were monitored with slit-lamp images, detailed drawings, and AS-OCT until the resolution of the CIE. A final follow-up visit was completed 4 weeks after CIE resolution to determine whether scar formation was present. Positive controls were 2 SiHy SCL wearers with established (inactive) corneal scars, and negative controls were 2 SiHy SCL wearers with clear corneas. High- and low-contrast logMAR visual acuities were measured, and subjective symptom questionnaires were completed at all visits. RESULTS: Clinical signs, vision, and symptoms improved in tandem with the resolution of the CIEs as measured by imaging methods. Calibrated measures of infiltrate width from a slit-lamp biomicroscope appear to be similar to calibrated images from AS-OCT. CONCLUSIONS: Although further studies are needed to develop standardized procedures, AS-OCT can be a useful tool to characterize the development, progression, and resolution of corneal infiltrates as an objective measure of resolution and scar formation.

Is purchasing lenses from the prescriber associated with better habits among soft contact lens wearers?

PURPOSE: To compare the habits of United States (US) soft contact lens (SCL) wearers who bought SCLs from their eye care practitioner (ECP), on the internet/telephone, or at retail (not where they were examined) to test the effect of proximity to the prescriber on SCL wear and care practices. METHODS: Adult SCL wearers completed an adapted Contact Lens Risk Survey (CLRS) online that queried items related to risk factors for SCL-related complications. Responses from subjects who purchased at the ECP, via the internet/telephone, or at a retail store were compared (Chi-Square). RESULTS: Purchase sources were: ECP 646 (67%, 44±12 yrs, 17% male), Retail 104 (11%, 45±13 yrs, 28% male), and Internet/telephone 218 (23%, 45±12 yrs, 18% male); age (p=0.51), gender (p=0.021). Internet purchasers had fewer annual eye exams (79% ECP, 83% retail, 66% internet/telephone, p=0.007), purchased more hydrogel SCLs (34% ECP, 29% retail, 45% internet/telephone, p=0.0034), and paid for SCLs with insurance less often (39% ECP, 29% retail, 19% internet/telephone, p<0.0001). Other behaviors were similar across groups (p>0.05). CONCLUSIONS: In this sample, the purchase location of SCL wearers had limited impact on known risk factors for SCL-related complications. Internet purchasers reported less frequent eye exams and were more likely to be wearing hydrogel SCLs. Closer access to the ECP through in-office SCL purchase did not improve SCL habits or reduce the prevalence of risk behaviors.

Soft Contact Lens-Related Symptoms in North America and the United Kingdom.

PURPOSE: To characterize and compare the prevalence of soft contact lens-related (SCL) dryness symptoms in large populations of SCL wearers in North America (NAm) and the United Kingdom (UK). METHODS: SCL wearers from NAm (n = 1443) and UK (n = 932) sites completed self-administered questionnaires on SCL symptoms and wearing experiences. A categorization for contact lens-related dry eye (CL-DE) was applied that combined Contact Lens Dry Eye Questionnaire (CLDEQ) items on dryness frequency and intensity at the end of the day (CL-DE+ = constantly/frequently/sometimes plus intensity = 3-5, and CL-DE- = never/rarely plus intensity = 0-1, Marginal = all other ratings). Data were analyzed across regions and categories, with p-values <0.05 significant. RESULTS: Compared to UK wearers, those in NAm wore fewer toric and multifocal designs, and reported significantly longer average and comfortable wearing times (p < 0.001) but similar levels of general and end-of-day comfort. The prevalence of CL-DE+ differed between the UK and NAm: CL-DE+: 31 vs. 39%, Marginal CL-DE: 13 vs. 14%, and CL-DE-: 56 vs. 47%, p = 0.0001. Although daily disposable (DD) lenses were worn more commonly in the UK than NAm (33 vs. 10%, p < 0.0001), their use did not impact the overall prevalence of dryness symptoms. Between regions, NAm wearers reported significantly more frequent and intense end-of-day discomfort and dryness (p < 0.0001) and were significantly more likely to use treatments for CL-related symptoms yet experienced a lower degree of relief. CONCLUSIONS: SCL wearers in NAm reported longer hours of wear with significantly more symptoms of dryness and discomfort. NAm wearers used dryness treatments more often, but experienced less relief than UK wearers. In both regions, the CL-DE categorization was useful to predict poorer comfort, shorter comfortable wearing time, and increased use of treatments. These results highlight the need to benchmark SCL performance locally or regionally to understand and focus on the challenges to the lens wearing experience.

Cutoff score and responsiveness of the 8-item Contact Lens Dry Eye Questionnaire (CLDEQ-8) in a Large daily disposable contact lens registry.

PURPOSE: To report (1) results of the 8-item Contact Lens Dry Eye Questionnaire (CLDEQ-8) among a large sample of SCL wearers before and during 1 year after fitting with one of 2 daily disposable (DD) lenses (etafilcon A or narafilcon B) in the TEMPO Registry, (2) the cut-off score to identify highly symptomatic SCL wearers and (3) the clinically important difference (CID) in the CLDEQ-8 score. METHODS: Demographics, CL history and patterns of SCL use were documented. Construct validity of the CLDEQ-8 was tested versus overall opinion (OO) of habitual SCLs, eye dryness and eye sensitivity at baseline. Responsiveness to change in OO was tested. Cutoff score, CID, and predictive accuracy were analyzed with general linear mixed models, adjusting for clustering by site with Bonferoni correction for multiple comparisons. RESULTS: Baseline CLDEQ-8 data from 977 habitual SCL wearers showed significant association with OO, eye dryness and sensitivity (p<0.0001, all). CLDEQ-8 scores improved significantly after refitting and reflected change in OO over time (p<0.0001). Diagnostic cutoff of≥12 and CID of 3 points performed best. CONCLUSIONS: The CLDEQ-8 score of ≥12 points is proposed to identify SCL wearers who could benefit from clinical management of their CL-related symptoms. The clinically important difference was ±3 points. Refitting to these DD lenses in the TEMPO Registry provided significant and stable reduction in SCL-related symptoms across the year of follow-up. Use of the CLDEQ-8 in clinical practice and clinical research will help quantify and standardize symptom measures in SCL wearers.

Rate of change and predictive factors for increasing minus contact lens powers in young myopes.

BACKGROUND: Understanding the factors associated with myopic progression is critical to properly recruit subjects into clinical trials for control of myopia. The purpose of this study is to describe the rate of change in soft contact lens (SCL) power and the associated predictive factors in a young clinical population from the Contact Lens Assessment in Youth study. METHODS: Data from a retrospective chart review of myopic SCL wearers aged eight to 22 years were analysed for rate of progression of myopia and associated characteristics using multivariate methods. RESULTS: Myopic subjects (n = 912) with at least six months of follow-up were observed (4,341 visits, mean follow-up 25 months, 37 per cent hydrogel and 63 per cent silicone hydrogel SCLs). During observation, 36 per cent of subjects experienced a change in soft contact lens power of -0.50 D or more. Significant predictors of future increase in minus lens power were: ages eight to 13 years, shorter time to the first increase in minus power and hydrogel soft contact lens material. The mean annualised increase in minus decreased with age (-0.31D per year for eight to 13 year olds to -0.10 D per year for 20 to 22 year olds, p < 0.0001). Increases in minus were less common among users of silicone hydrogel materials than hydrogel daily disposable lenses after controlling for age (p = 0.039). CONCLUSION: In this retrospective chart review of young soft contact lens wearers, the mean annualised rate of increase in minus soft contact lens power decreased with age, longer time to first increase in power and was greater with hydrogel soft contact lenses. The rates observed were similar to progression rates in prospective myopia clinical trials that employed cylcoplegic autorefraction.

Rates of adverse events with hydrogel and silicone hydrogel daily disposable lenses in a large postmarket surveillance registry: the TEMPO Registry.

PURPOSE: To report annualized adverse events (AEs) including corneal infiltrative events (CIEs) with use of silicone hydrogel (SiHyDD) and hydrogel daily disposable (HydDD) soft contact lenses (SCLs) in the 1•DAY ACUVUE TruEye or 1•DAY ACUVUE MOIST Performance Overview (TEMPO) Registry (NCT01467557). METHODS: Annualized incidence of symptomatic daily disposable (DD)-related AEs was calculated from 3064 surveys from 1171 subjects (601 SiHyDD and 570 HydDD, 31.8 ± 13.5 years, 68% female) during 1 year. Three independent experts adjudicated potential AE cases. Demographics were compared between wearers with and without AEs. RESULTS: The registry tracked 960.3 years of lens wear: SiHyDD 489.4 years and HydDD 470.9 years. In that period, the 601 SiHyDD wearers reported eight AEs with office visits (1.6%/y; 2 CIEs, 0.4%/y), eight (1.6%/y) without office visits, and four AEs unrelated to SCLs (0.8%/y) (SiHyDD wearers with AEs; 44.8 ± 12.5 years; 75% female). The 570 HyDD wearers reported three AEs with office visits (0.6%/y; no CIEs), five without office visits (1.1%/y), and one non-SCL-related AE (0.2%/y) (HydDD wearers with AEs; 26.3 ± 8.0 years; 100% female). These CIE rates are significantly lower than the lowest estimate of 3.3% from prior studies. Wearers with SiHyDD-related AEs were significantly older than unaffected wearers (P = 0.02), but not for HydDD-related AEs. CONCLUSIONS: The CIE rates of 0.4% and 0% with these DD lenses are significantly lower than rates reported with reusable SCLs (3%-4%/y), indicating improved safety outcomes with these DD lenses. Compared to unaffected wearers, SiHyDD lens wearers with AEs requiring clinical visits were significantly older. (ClinicalTrials.gov number, NCT01467557.).

Age, behavior, environment, and health factors in the soft contact lens risk survey.

PURPOSE: Previous studies have reported that the risk of corneal infectious and inflammatory events (CIEs) with soft contact lens (SCL) wear is highest in late adolescence and early adulthood. This study assesses the associations between patient age and other factors that may contribute to CIEs in young SCL wearers. METHODS: After ethics approvals and informed consent, a nonclinical population of young SCL wearers was surveyed in five US cities. Data from 542 SCL wearers aged 12-33 years were collected electronically. Responses were analyzed by age bins (12-14, 15-17, 18-21, 22-25, 26-29, and 30-33 years) using chi-square test. RESULTS: The cohort was 34% male and balanced across age bins. There were several significant associations between survey response and age (in bins). Wearers aged 18-21 years reported more recent nights with less than 6 hours of sleep (p < 0.001), more colds/flu (p = 0.049), and higher stress levels (p < 0.001). Wearers 18-21 and those 22-25 years were more likely to wear SCLs when showering (p < 0.001) and also reported more frequent naps with SCLs (p < 0.001). They reported sleeping in SCLs after alcohol use (p = 0.031), when traveling (p = 0.001), and when away from home (p = 0.024). Lower rates of regular hand washing before lens application (p = 0.054) was also associated with these groups. In addition, the relationship between reactive replacement and recommended replacement was dependent on age (p < 0.0001). CONCLUSIONS: Patient age influences lens wearing behaviors, environmental exposures, and other determinants of health that may contribute to increased CIEs in younger wearers. Targeted, age-specific education should be considered for both new and established SCL wearers.

Correlation of tear osmolarity and dry eye symptoms in convention attendees.

PURPOSE: To assess the correlation between tear osmolarity readings and symptoms of dry eye in a nonclinical convenience sample and to determine how well symptoms and osmolarity correlate with the self-assessment of dry eye. METHODS: Two hundred forty-nine attendees in the exhibit hall at an optometric educational meeting agreed to participate in a dry eye study. Contact lens wearers were excluded. Volunteers supplied demographic information and completed a 5-item Dry Eye Questionnaire (DEQ-5) and answered the question "Do you think you have dry eye" with a yes or no response. Osmolarity testing was done using the TearLab instrument on the right eye, then on the left eye. Pearson correlation analyses were performed to determine the relationship between variables. RESULTS: There was no correlation between DEQ-5 scores and average tear osmolarity (correlation coefficient, 0.02) and highest osmolarity (correlation coefficient, 0.03). The mean DEQ-5 score was significantly higher among subjects who self-reported dry eye (mean, 11.3; p < 0.0001) compared with those who did not (mean, 5.4; p < 0.0001). No differences were observed between the yes and no self-reported dry eye groups and average osmolarity (p = 0.23) and highest osmolarity (p = 0.14). CONCLUSIONS: In this nonclinical population, there was no significant correlation between tear osmolarity and ocular symptoms as reported or between tear osmolarity and the self-assessment of dry eye.

Geographic and temporal risk factors for interruptions to soft contact lens wear in young wearers.

OBJECTIVES: This was a secondary analysis of an existing dataset of soft contact lens wearers age 8-33 years, who received eye care outside of a clinical trial. The aim was to identify geographical and temporal factors associated with interruptions to contact lens wear. METHODS: Data from six academic centers in North America captured 522 events in 3549 patients. Cases were analyzed overall and in subcategories of allergic, and serious and significant adverse events. General estimating equations were used to model the effect of geographic (Northwest, West, Central, Northeast, Southeast) and temporal (season, month, day of the week) factors, along with previously identified risk factors associated with interruptions in lens wear (patient age, contact lens material, overnight wear, lens care system, replacement schedule, and years of contact lens wear). RESULTS: After controlling for established risk factors, both region and temporal factors disrupted the patients' ability to maintain contact lens wear. About 4% of all visits had complications that led to an interruption in wear. Allergic events were highest in the Central region. Serious and significant adverse events peaked in the Southeast during the Autumn and Winter months (September, October, December). Day of the week was not significant in any model. CONCLUSIONS: This study provides evidence of seasonal and regional challenges to contact lens wear. As the use of soft contact lenses expands for both cosmetic and medical reasons, practitioners must examine ways to maintain continuous, safe, and healthy use of contact lenses across all patients.