Although the presence of risky SCL wearing behaviors does not imply a causal relationship, the prevalence of specific behaviors by age mirrors the age-related risk of having an inflammatory event from a previous study.7–9 Thus, these behaviors could be key indicators of potential behaviors to target. These initial comparisons suggest that further work is needed to directly correlate age-related behaviors and risks of contact lens complications. Some characteristics did not vary significantly across age and are likely driving CIEs across all ages of wearers. Specifically, factors such as topping-off solution, overnight wear, and rinsing or storing SCLs in water are likely driving the rate of CIEs upwards for all wearers but may not be related to the spike in complications for 15- to 25-year-olds. These factors that were independent of age have been associated with some of the most serious SCL-related lens complications such as Fusarium and Acanthamoeba keratitis.26,53
The frequency of many other noncompliant SCL-related behaviors was highly associated with patient age, with the highest prevalence being reported by 15- to 25-year-olds, the age group that in previous studies also carried the highest risk for CIEs7 and other complications.8 Behaviors such as napping in SCLs, unplanned sleeping with SCLs when away from home or after alcohol consumption, and wearing SCLs in the shower were more common in that at-risk age group.
The CLAY CLRS also explored some biological factors that could influence risks for adverse events, although we were unable to perform clinical tests in this nonclinical sample. In general, the older teen and young adult age groups were more likely to report behaviors indicative of “burning the candle at both ends”, as they reported fewer than 6 hours sleep per night, more frequent napping, higher levels of stress, and suffered colds and flu more often than younger and older SCL wearers. Previous studies have suggested that these physiological factors may reflect a compromised immune system that can lead an individual to be more susceptible to infections and inflammatory responses,27,28 although this has not been directly tested in SCL wearers.
Although napping while wearing SCLs is not often assessed in clinical studies or queried in routine clinical care, the closed-eye environment could increase the risk of SCL complications especially with lenses that are not designed for closed eye wear.29,30 Napping while wearing modern SCLs with high oxygen transmissibility may also allow the wearer to experience reasonable comfort after waking and encourage subsequent unplanned overnight use of lenses.
Older teen and young adult wearers also reported sleeping in lenses when traveling, not sleeping at home, and after alcohol use, possibly indicating poor planning or a more impulsive lifestyle at that age. Healthy behaviors and risk avoidance have been cited as important determinants of health in adolescents.31 College student alcohol consumption and the environmental conditions that promote it are well described in the literature; alcohol consumption is reported to have a significant negative impact on behavior and health32 although its relationship to complications with SCLs has not been explored previously. Questions related to alcohol consumption were included following the clinical chart review of CIEs and focus groups, an important aspect of the development of the CLRS.
The fact that adult wearers were less likely to report purchasing lenses from their eye care provider is also of interest. Previous investigators have reported increased risks of microbial keratitis36 as well as a decreased awareness of the prescribed contact lens follow-up schedule37 among individuals who purchase from a source other than their eye care provider.
The living environment where SCL wearers care for and handle their lenses (e.g., living with multiple roommates and sharing a bathroom with many people) may have some impact on their risk of developing CIEs. Wearers who live in crowded living settings may not have control over the cleanliness and level of contamination of their general living environment such as doorknobs, desk, and bathroom surfaces. Touching contaminated surfaces could facilitate the transfer of microorganisms on the hand from the lens to the eye and potentiate the development of SCL-related corneal infiltrates. Shared bathroom facilities, especially in college, may be an incremental risk factor for complications in this age group as the bathroom environment can harbor pathogens in a moist environment and may interfere with the patient’s ability to maintain a hygienic space to handle their lenses.38 The majority of the children and younger teens in the sample also shared a bathroom; however, we speculate that the cleanliness of the family home is likely very different than shared college facilities. In addition to exacerbating the transmission of disease,39–43 it is believed that crowding contributes to stress, which in turn is also a contributor to illness and a lowering of immunity.44
Ft. Lauderdale, FL 33328
Heidi Wagner, OD, MPH (Co-Chair 2009-present); Robin L. Chalmers, OD (Co-Chair 2009–2012); Kathryn Richdale, OD PhD (Co-Chair 2012-present); G. Lynn Mitchell, MAS (2009-present).
Luigina Sorbara, OD, MSc, University of Waterloo School of Optometry and Vision Science, Waterloo, ON, Canada; Robin L. Chalmers, OD, Atlanta, GA.
This project was supported by an unrestricted grant from Alcon Research, Ltd., as well as Nova Southeastern University (Pilot testing: Chancellors Research and Development Grant; Health Professions Division Research Grant). The CLAY Study team also received logistical support from the American Academy of Optometry Research Committee and the American Optometric Association Council on Research. Portions of this work were presented at the American Academy of Optometry (AAO) annual meeting in October 2012, Phoenix, Arizona, E-abstract #120976.
Submitted: August 27, 2013; accepted November 6, 2013.
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