The current number of contact lens (CL) wearers worldwide has been estimated around 175 million,1 revising the figures of 140 million used as reference for more than a decade.2 Despite this, it could be argued that the diffusion of CLs among potential wearers is more likely showing a flattening of the market penetration curve rather than a significant growth. The growth of the CL market currently reported by CL manufactures3 may be the result of the expansion of specific sectors, such as silicone hydrogel surpassing hydrogel in soft daily CLs market share4 and the resurgence of scleral lens fittings.5 This contradiction could be explained by practitioners fitting different types of CLs than increasing the number of wearers in CLs.

The current availability of new materials and technological advancements offers valid tools in the management of CL fittings. Despite this, the rate of CL discontinuation eye care practitioners (ECPs) face has remained approximately constant over the past few decades,6 mainly because of the role of CL discomfort7 and the clinical challenges linked to its multifactorial nature.8 Even considering that a small reduction of CL drop out can produce a dramatic increase in CL wearers,9 it is still advisable to also focus on engaging potential new wearers to ensure the CL market grows.

The large proportion of world population requiring refractive correction,10 and the estimates of increasing prevalence of myopia11 and presbyopia,12 indicates an extraordinary growth opportunity for CL diffusion. Proactivity is a key strategy for increasing number of CL wearers among the public. For instance, providing CLs during frame selection was associated to an increased interest in wearing CLs and to new fittings.13 Conventional recommendation (proposing and discussing CLs use) was found even more efficient than providing CL to select spectacle frames, in conversion rate from first trial to a final CL prescription in new wearers,14 in line with what was previously reported,15 suggesting that proactive approaches can raise the market penetration of CLs.

An understanding of what drives proactivity among ECPs is therefore an important aspect of optimizing this approach to growing the contact lens market. Such knowledge could help to plan effective strategies to increase the number of CL wearers worldwide.

The aim of this study was to evaluate the characteristics of CL practices, practitioners' attitudes, and their effect on rate of new CL fittings per month. In addition, the potential interventions felt more relevant by CL practitioners were identified to help delineate promising strategies to favor CL practice growth.

MATERIALS AND METHODS Survey Distribution and Design

A self-administered, anonymized survey was developed including questions on demographic characteristics, features, and attitudes of CL practitioners and their CL practice.16 In addition, the opinion of practitioners on 10 potential interventions to help CL practice growth over the next 5 years was investigated. The questionnaire was originally constructed in English and then translated into different languages (Spanish, Italian, French, Korean, Russian, and Simplified Chinese). To ensure meaning equivalence, a forward–backward translation method was adopted involving native dual linguists and independent reviewers. The survey was distributed online (via social media platforms such as LinkedIn, Facebook, WhatsApp, and mailing lists, and a paper-based version was used in Russia). Reputed international professional bodies and educational institutions were involved in disseminating the survey. The end point was reached when the survey responses plateaued. Please refer to supplementary survey in Supplemental Digital Content 1, https://links.lww.com/ICL/A223 for questionnaire.

The online survey could only be completed once from any device to reduce accidental bias from multiple completion. The survey was circulated between November 2019 and March 2020 (it should be noted that this was before the effects of the global COVID-19 pandemic).

Statistical Analysis

The statistical analysis was performed using SPSS (V 26, IBM, New York). Following samples distribution appraisal (Shapiro–Wilk; Kolmogorov–Smirnov), nonparametric comparisons test (Mood median test) were performed. Only responses from countries with 30 or more replies17 were included in the analysis. Statistical significance was taken as P-values lower than 0.05, adjusting for multiple comparisons with Bonferroni correction. Only relevant and significant comparisons have been reported for the sake of conciseness. Unless diversely specified, all the average scores have been reported following as medians (and interquartile ranges).

RESULTS Responses

A total of 2,222 valid surveys were analyzed. Number of responders was similar between women (53%) and men (47%). The median age of practitioners was 37.0 years, ranging from 19 to 82 years old, with distribution skewed toward lower values. The distribution by geographical areas was: Africa 3.2% (n=70), Asia 32.4% (n=721), Australasia 1.8% (n=41), Europe 35.7% (n=793), Middle East 10.8% (n=241), North America 7.6% (n=169), and South America 8.4% (n=187; Fig. 1).

FIG. 1.:

Number of replies received from each country, grouped in geographical areas.

The distribution of responses as per profession, type of practice, and experience in contact lens practice is depicted in Table 1. Notably, the responding ophthalmologists were mostly located in Russia (n=72) and China (n=42), respectively accounting for 58.5% and 34.1% of the overall replies for that profession. The median working experience in CL prescribing was 11.0 years (IQR: 18.0, 4–22 years), grouped in categories representing the duration of professional experience as depicted in Table 1.

TABLE 1. - Distribution of ECPs on Type of CL Fitted Categories, Expressed by Profession, Type of Practice, and CL Practice Length Groups Basic Advanced Speciality None Total Profession  Optometrist 55.3% (1,006) 22.4% (407) 21.8% (396) 0.6% (11) 81.9% (1820)  Ophthalmologist 43.9% (54) 31.7% (39) 22.0% (27) 2.4% (3) 5.5% (123)  Contactologist/CL specialist 17.6% (30) 42.9% (73) 39.4% (67) 0.0% (0) 7.7% (170)  Optician 72.1% (62) 15.1% (13) 12.8% (11) 0.0% (0) 3.9% (86) Type of practice  Stand-alone/independent 52.0% (550) 22.4% (237) 25.4% (268) 0.2% (2) 47.6% (1,057)  National/regional retail chain 70.3% (182) 17.0% (44) 12.7% (33) 0.0% (0) 11.7% (259)  Local retail chain 73.8% (223) 16.6% (50) 9.6% (29) 0.0% (0) 13.6% (302)  Hospital based 27.5% (104) 38.1% (144) 33.3% (126) 1.1% (4) 17.0% (378)  University based 43.6% (82) 30.3% (57) 22.3% (42) 3.7% (7) 8.5% (188) Years of CL practice  <2 65.3% (145) 15.8% (35) 14.4% (32) 4.5% (10) 10.0% (222)  2–5 56.9% (263) 24.2% (112) 18.8% (87) 0.0% (0) 20.8% (462)  6–10 51.1% (206) 26.6% (107) 21.8% (88) 0.5% (2) 18.1% (403)  11–25 52.1% (386) 23.8% (176) 24.0% (178) 0.1% (1) 33.3% (741)  More than 25 39.1% (150) 28.6% (110) 32.0% (123) 0.3% (1) 17.3% (384)  Total 52.2% (1,159) 24.3% (540) 22.9% (509) 0.6% (14) 100% (2,222)

Values are reported as percentage (and number) within the groups.

CL, contact lens; ECP, eye care practitioner.

Eye care practitioners were also requested to indicate the type of CL fitted in their practice, with the possibility to select multiple options among soft spherical, soft toric, soft multifocal, any kind of rigid corneal, scleral, and other types of CL. The options chosen by ECPs were subsequently grouped into three categories, distinguishing fitting level of practice between: basic, exclusively soft CL (without any distinction among spherical, toric, and multifocal CLs); advanced (any rigid corneal CLs, exclusively or in association with soft lenses); and speciality (scleral CLs and any other type of CLs alone or combined to the ones already mentioned). The break-up as per category is provided in Table1.

According to the breakdown analysis of CL types (Table 1), among the professions the highest rate of CL practitioners fitting solely basic CLs was found among optometrists (55.3%, n=1,006), whereas contactologist/CL specialists reported the highest rate of advanced CLs (any rigid corneal lenses) (42.9%, n=73), and speciality CL fittings (e.g., scleral) (39.4%, n=67). Basic CL fittings were more frequently reported by ECPs working in chains, with national/regional (70.3%, n=182) and local (73.8%, n=223) diffusion, whereas among professionals working in hospital settings was found the highest rate of advanced (38.1%, n=144) and speciality (33.3%, n=126) CL fittings. In addition, the majority novice practitioners reported to manage basic CL fittings (65.3%, n=145) and those with longest working experience, that is, more than 25 years—were found more frequently fitting advanced (28.6%, n=110) and speciality CLs (32.0%, n=123).

Practitioners Attitudes

Practitioners were asked to indicate the frequency at which they encourage the use of CL to patients not demonstrating evident contraindications to CL wear. More than half of practitioners (61.6%, n=1,483) reported always encouraging CL wear, followed by responders who reported to propose CLs sometimes (36.6%, n=881) and never (1.8%, n=44). Furthermore, the reasons underlying a nonsystematic encouragement of CL wear was investigated, requesting respondents to select one or more alternatives among the options provided (reported in Fig. 2). Notably, the responses were received also from a fraction of the practitioners (4.9%, n=108) who indicated to always promote CL wear. The most frequent reason was assuming patients are not interested in CL wear (n=336, 15.1% of the total responders), whereas the least selected option was the discomfort felt by ECPs in counselling patients to start CL wear (n=55, 2.5% of the total).

FIG. 2.:

Reasons reported for not always encouraging CLs to potential wearers (percentage is referred to the total number of replies). CL, contact lens.

The viewpoint of the professionals about the future of their own CL practice was also explored, by requesting them to select the option best representing their feeling on a 5-items scale from very hopeful to very worried. Of the ECPs responding, 22.9% (n=509) declared themselves to be very hopeful, 45.1% (n=1,002) hopeful, 21.6% (n=500) unsure, 7.7% (n=184) worried, and 2.7% (n=61) very worried. Aside, the level of practitioner's proactivity was tested by asking responders to report on a scale from 0 (not at all) to 10 (highly), the level at which they proactively recommend CLs in their practical settings. In addition, the scores were used to identify three profiles of the responders: proactive (self-reported scores of eight or more), active (scores between five and seven), and inactive/reactive (scores of four or below). The median value of proactivity was 7.0 (IQR: 2.0, 6.0–8.0). According to the categorization described, 46.7% (n=1,037) of the ECPs were identified as proactive, 41.6% (n=925) as active, and 11.7% (n=260) as inactive/reactive.

New Contact Lens Fittings Per Month

Practitioners were asked to report an estimate of the average number of new CL fittings performed and the overall median was found to be 5.0 (IQR: 7.0, 3.0–10.0) new fittings per month. A similar number of new fittings was reported by optometrists and opticians (Median: 5.0), both significantly lower than values reported by ophthalmologist (Median: 10.0) and CL specialists (Median: 15.0) (all P<0.001). In hospital settings, the average number of new fittings (Median: 10.0) was higher than in independent practices (Median: 5.0, P<0.001), universities (Median: 5.0, P<0.001), local chains (Median: 5.0, P<0.001), and in national retail chains (Median: 7.0, P<0.05). Average fitting number in national retail chains was also higher than independent practices (P<0.01). The rate of new CL fittings varied for novice professionals, with significant differences between the value reported by ECPs working for less than 2 years (median: 4.0) and those in practice from 2 to 5 years (median: 5.0), from 6 to 10 years (Median: 7.0), from 11 to 25 years (median: 5.0), and those working for more than 25 years (median: 6.0) (all P<0.001). The average number of new fittings was higher in speciality practitioners (median: 10.0) than in advanced (median: 7.0) and basic (Median: 5.0) groups. The difference between advanced and basic fitters was also significant (all P<0.001).

Practitioners who “always” suggested CLs to their patients reported a higher rate of new fittings per month (median: 7.0) than the value reported by ECPs proposing CLs sometimes (median: 5.0, P<0.001), and by those never promoting CLs (median: 3.0, P<0.05). The most proactive practitioners also demonstrated a higher number of new CL fittings per month (median: 8.0), than those defined as the active group (Median: 5.0), which in turn was higher than the reactive practitioners (median: 3.0) (all P<0.001). Finally, ECPs expressing that they were “very hopeful” reported a higher number of new CL fittings per month (median: 10.0), than those “hopeful,” “unsure,” “worried,” and “very worried” (all median 5.0, P<0.001).

Potential Interventions

The average scores for potential interventions by country, grouped by geographical areas are provided in Table 2. Globally, among the potential interventions proposed to help CL practice growth in the future, the continuous update of knowledge and skills and the need of competencies in managing CL-related complications were identified as the leading priorities among CL practitioners (median score: 9/10 for both), whereas the implementation of social media marketing campaigns was perceived slightly less relevant (median: 7/10).

TABLE 2. - Potential Intervention Average Scores (Medians and Interquartile Ranges) by Country, Grouped by Geographical Areas A B C D E F G H I J Kenya 8 6–9.5 8 7–9.5 8 7–9 8 6.5–10 8 6.5–9 7 7–9 8 6.5–9 8 7–9 8 7–10 8 6–9 South Africa 8 6–9 9 8–10 8 6.5–9.5 9 8–10 8 7.5–10 8 7–10 8 7.5–9.5 8 8–10 8 7–9.5 8 6.5–9 Africa 8 6–9 8.5 7–10 8 7–9 8 7–10 8 7–10 8 7–9 8 7–9 8 7–9.25 8 7–10 8 6–9 China 8 7–10 8 8–10 8 7–10 8 7–9 8 7–9 8 7–10 9 8–10 8 8–10 8 7–9 8 6–9 Hong Kong 8 6–9 8 7–9 7 6–9 7 6–8 7 5–8 7 5.75–8 7 5–8 8 6–9 7 5–8.25 6 3.75–8 India 8 7–10 9 7–10 8 7–10 9 8–10 8 7–10 9 7–10 9 8–10 8 7–10 8 7–10 8 6–10 Indonesia 8 7.25–9.75 9 8–10 9 8–10 8 8–9 8 7–9 8 7–9 8 7–9 8 7–9 8 7.25–9 8 5.5–9 Malaysia 8 7–10 9 7–10 8 7–10 8 7–9 8 6–10 9 7–10 8 7–10 8 7–10 8 6–10 8 5–9 Nepal 7.5 6.25–9.75 8 6–10 6.5 4.25–9.75 7.5 5.25–9 7 4–8 7 5.25–9.75 6.5 5–9 7.5 6–8.75 8 5–10 7 4.25–9 Singapore 8 6–8 8 7–9 8 7–9 8 7–9 8 7–9 8 7–8 8 7–9 8 7–9 8 7–9 8 6–8 South Korea 8 6–9 8 7–10 8 7–9 8 7–9 7 6–8 7 5–9 7 6–9 8 7–9 5 4–7 7 5–8 Asia 8 7–9 8 7–10 8 7–9 8 7–9 8 6–9 8 7–9 8 7–9 8 7–9 8 6–9 8 5–9 Australia 7 5–8 8 7–9.5 7 5.5–9 9 7–10 9 7–10 7 5–9 8 6–9 9 7.5–10 7 5–9 7 5–8.5 Australasia 7 5–8 8 7–9.5 7 5.5–9 9 7–10 9 7–10 7 5–9 8 6–9 9 7.5–10 7 5–9 7 5–8.5 France 8 6.25–9 8.5 8–10 8 6.25–10 9 8–10 9 8–10 9 8–10 9 8–10 8.5 7.25–10 6 5–8 7 4.25–9 Italy 9 7–10 10 9–10 9 8–10 9 8–10 9 8–10 9 8–10 9 8–10 10 9–10 7 6–9 7 5–9 Netherlands 8 7–9 9 8–10 8 8–9 8 8–9 8 8–9 8 7–9 8 7–9 9 8–9 7 6–8 7 6–8 Russia 10 7–10 10 9–10 10 7–10 5 2–8 10 8–10 10 7.25–10 10 7.25–10 10 8–10 8 5–10 7 5–10 Spain 8 7–10 9 8–10 8 7–10 9 7–10 9 7–10 8 6–9 9 8–10 9 8–10 7 5–9 6 4–8 United Kingdom 7 5–8 8 7–10 8 7–9 8 7–9 8 7–9 7 5–10 8