Compliance behaviour change in contact lens wearers: a randomised controlled trial



Water exposure during contact lens wear has been associated with contact lens disease including microbial keratitis and sterile corneal infiltrates. Despite the documented risks, water exposure is common amongst lens wearers. This study aimed to determine the effect of water education in the form of “no-water” lens case stickers on water-contact behaviours and storage case contamination.


In a prospective, masked, randomised controlled trial, 200 daily lens wearers were randomised to either receive a storage case with a “no-water” sticker (test) or without a “no-water” sticker (control). Both groups received written compliance information. Participants completed a self-administered lens hygiene questionnaire at baseline and after 6 weeks. Microbial analysis of used storage cases, collected at both study visits, was conducted using ATP and limulus amebocyte lysate (LAL) assays for overall microbial contamination and endotoxin levels, respectively. A one-way ANCOVA and multiple logistic regression determined the change in water-contact behaviours and storage case contamination over time.


A total of 188 lens wearers completed both study visits; 128 females and 60 males; average age 29 ± 13 (range 18–78 years); 95 test and 93 control participants. After 6 weeks, the overall water exposure score and endotoxin levels reduced significantly in the test group compared with the control group (p < 0.05). There were no significant changes in individual water-contact behaviours or overall storage case contamination.


A no-water infographic on the contact lens case improved overall water-contact behaviours and reduced storage case endotoxin. Refining the messaging may be beneficial in future to improve other aspects of compliance.

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Fig. 1: “No-water” sticker, symbol; as endorsed by the Cornea and Contact Lens Society of Australia (permitted to be used for this clinical trial).
Fig. 2: Flow diagram of the study procedures including details of group allocation, discontinuation and analysis.
Fig. 3: Histogram representation of change in endotoxin levels by groups and visits.


  1. 1.

    Richdale K, Lam DY, Wagner H, Zimmerman AB, Kinoshita BT, Chalmers R, et al. Case-control pilot study of soft contact lens wearers with corneal infiltrative events and healthy controls. Investig Ophthalmol Vis Sci. 2016;57:47–55.

    CAS  Article  Google Scholar 

  2. 2.

    Stapleton F, Keay L, Jalbert I, Cole N. The epidemiology of contact lens related infiltrates. Optom Vis Sci. 2007;84:257–72.

    Article  Google Scholar 

  3. 3.

    Brown AC, Ross J, Jones DB, Collier SA, Ayers TL, Hoekstra RM, et al. Risk factors for Acanthamoeba keratitis—a multistate case-control study, 2008-2011. Eye Contact Lens. 2017;44 Suppl 1:S173–8.

    Google Scholar 

  4. 4.

    Lam JS, Tan G, Tan DT, Mehta JS. Demographics and behaviour of patients with contact lens-related infectious keratitis in singapore. Ann Acad Med Singap. 2013;42:499–506.

    PubMed  Google Scholar 

  5. 5.

    Cope JR, Collier SA, Schein OD, Brown AC, Verani JR, Gallen R, et al. Acanthamoeba keratitis among rigid gas permeable contact lens wearers in the United States, 2005 through 2011. Ophthalmology. 2016;123:1435–41.

    Article  Google Scholar 

  6. 6.

    Kilvington S, Gray T, Dart J, Morlet N, Beeching JR, Frazer DG, et al. Acanthamoeba keratitis: the role of domestic tap water contamination in the United Kingdom. Investig Ophthalmol Vis Sci. 2004;45:165–9.

    Article  Google Scholar 

  7. 7.

    Üstüntürk M, Zeybek Z. Microbial contamination of contact lens storage cases and domestic tap water of contact lens wearers. Wien klinische Wochenschr. 2012;124:17–22.

    Article  Google Scholar 

  8. 8.

    Wu YT, Tran J, Truong M, Harmis N, Zhu H, Stapleton F. Do swimming goggles limit microbial contamination of contact lenses? Optom Vis Sci. 2011;88:456–60.

    Article  Google Scholar 

  9. 9.

    Tilia D, Lazon de la Jara P, Zhu H, Naduvilath TJ, Holden BA. The effect of compliance on contact lens case contamination. Optom Vis Sci. 2014;91:262–71.

    PubMed  Google Scholar 

  10. 10.

    Minogue E, Tuite NL, Smith CJ, Reddington K, Barry T. A rapid culture independent methodology to quantitatively detect and identify common human bacterial pathogens associated with contaminated high purity water. BMC Biotechnol. 2015;15:6.

    Article  Google Scholar 

  11. 11.

    Hassan F, Bhatti A, Desai R, Barua A. Analysis from a year of increased cases of Acanthamoeba keratitis in a large teaching hospital in the UK. Contact Lens Anterior Eye. 2019.

  12. 12.

    Vijay AK, Willcox M, Zhu H, Stapleton F. Contact lens storage case hygiene practice and storage case contamination. Eye Contact Lens. 2015;41:91–7.

    Article  Google Scholar 

  13. 13.

    Department of Health, National Health Services. Contact lens safety—live well—NHS choices. Department of Health, National Health Services. 2016. Accessed 6 Jul 2018.

  14. 14.

    Center for Devices and Radiological Health. Contact lenses. Center for Devices and Radiological Health. 2019 Accessed 6 Jul 2018.

  15. 15.

    British Contact Lens Association. Do’s & dont’s factsheet for healthy contact lens care. British Contact Lens Association. 2017. Accessed 6 Jul 2018.

  16. 16.

    Legarreta JE, Nau AC, Dhaliwal DK. Acanthamoeba keratitis associated with tap water use during contact lens cleaning: manufacturer guidelines need to change. Eye Contact Lens. 2013;39:158–61.

    Article  Google Scholar 

  17. 17.

    Zimmerman AB, Richdale K, Mitchell GL, Kinoshita BT, Lam DY, Wagner H, et al. Water exposure is a common risk behavior among soft and gas-permeable contact lens wearers. Cornea. 2017;36:995–1001.

    Article  Google Scholar 

  18. 18.

    Carnt N, Stapleton F. Strategies for the prevention of contact lens-related Acanthamoeba keratitis: a review. Ophthalmic Physiol Opt. 2016;36:77–92.

    Article  Google Scholar 

  19. 19.

    Carnt N, Keay L, Willcox M, Evans V, Stapleton F. Higher risk taking propensity of contact lens wearers is associated with less compliance. Contact Lens Anterior Eye. 2011;34:202–6.

    Article  Google Scholar 

  20. 20.

    Radford CF, Minassian D, Dart JK, Stapleton F, Verma S. Risk factors for nonulcerative contact lens complications in an ophthalmic accident and emergency department: a case-control study. Ophthalmology. 2009;116:385–92.

    Article  Google Scholar 

  21. 21.

    Promega. BacTiter-Glo™ microbial cell viability assay. Promega. 2018 Accessed 18 Jun 2019.

  22. 22.

    Wu YT, Willcox MD, Stapleton F. The effect of contact lens hygiene behavior on lens case contamination. Optom Vis Sci. 2015;92:167–74.

    Article  Google Scholar 

  23. 23.

    Wu YT, Zhu H, Willcox M, Stapleton F. Removal of biofilm from contact lens storage cases. Investig Ophthalmol Vis Sci. 2010;51:6329–33.

    Article  Google Scholar 

  24. 24.

    Noda K, Goto H, Murakami Y, Ahmed ABF, Kuroda A. Endotoxin assay by bioluminescence using mutant firefly luciferase. Anal Biochem. 2010;397:152–5.

    CAS  Article  Google Scholar 

  25. 25.

    US_FDA. Guidance for industry: pyrogen and endotoxins testing: questions and answers | FDA. US_FDA. 2012 Accessed 18 Jun 2019.

  26. 26.

    Sakimoto A, Sawa M, Oshida T, Sugaya S, Hirono T, Ishimori A. Minimum endotoxin concentration causing inflammation in the anterior segment of rabbit eyes. Jpn J Ophthalmol. 2009;53:425–32.

    CAS  Article  Google Scholar 

  27. 27.

    Cao Y, Bindslev DA, Kjaergaard SK. Estimation of the in vitro eye irritating and inflammatory potential of lipopolysaccharide (LPS) and dust by using reconstituted human corneal epithelium tissue cultures. Toxicol Mech Methods. 2015;25:402–9.

    CAS  Article  Google Scholar 

  28. 28.

    Bowden T, Nosch DS, Harknett T. Contact lens profile: a tale of two countries. Contact Lens Anterior Eye. 2009;32:273–82.

    Article  Google Scholar 

  29. 29.

    Choo J, Vuu K, Bergenske P, Burnham K, Smythe J, Caroline P. Bacterial populations on silicone hydrogel and hydrogel contact lenses after swimming in a chlorinated pool. Optom Vis Sci. 2005;82:134–7.

    Article  Google Scholar 

  30. 30.

    De Beni R, Moè A. Imagery and rehearsal as study strategies for written or orally presented passages. Psychonomic Bull Rev. 2003;10:975–80.

    Article  Google Scholar 

  31. 31.

    Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician. 1996;53:205–11.

    PubMed  Google Scholar 

  32. 32.

    Ebrahimabadi M, Rezaei K, Moini A, Fournier A, Abedi A. Infographics or video; which one is more effective in asthmatic patients’ health? A randomized clinical trial. J Asthma. 2018.

  33. 33.

    Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005;58:63–70.

    Article  Google Scholar 

  34. 34.

    Stapleton F, Keay L, Katiyar S, Edwards K, Naduvilath T. Causative organisms and disease severity in contact lens related microbial keratitis in Australia. Investig Ophthal Vis Sci. 2006;47:4729–4729.

    Google Scholar 

  35. 35.

    Bourcier T, Thomas F, Borderie V, Chaumeil C, Laroche L. Bacterial keratitis: predisposing factors, clinical and microbiological review of 300 cases. Br J Ophthalmol. 2003;87:834–8.

    CAS  Article  Google Scholar 

  36. 36.

    Carnt NP, Hoffman JM, Verma S, Hau S, Radford CFP, Minassian DC, et al. Acanthamoeba keratitis: confirmation of the UK outbreak and a prospective case-control study identifying contributing risk factors. Br J Ophthalmol. 2018;102:1621–8.

    Article  Google Scholar 

  37. 37.

    Stapleton F, Naduvilath T, Keay L, Radford C, Dart J, Edwards K, et al. Risk factors and causative organisms in microbial keratitis in daily disposable contact lens wear. PLoS ONE. 2017;12:e0181343.

    Article  Google Scholar 

  38. 38.

    Lally P, Van Jaarsveld CHM, Potts HWW, Wardle J. How are habits formed: modelling habit formation in the real world. Euro J Soc Psychol. 2010;40:998–1009.

    Article  Google Scholar 

  39. 39.

    Middleton KR, Anton SD, Perri MG. Long-term adherence to health behavior change. AJLM. 2013;7:395–404.

    Google Scholar 

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This study was partially funded through an investigator-initiated study supported by Alcon Australia. MA was supported by joint doctoral scholarship from UNSW (tuition fee scholarship) and Higher Education Commission, Pakistan.

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Correspondence to Memoona Arshad.

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Arshad, M., Carnt, N., Tan, J. et al. Compliance behaviour change in contact lens wearers: a randomised controlled trial. Eye (2020).

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