Dry eye and contact lens wear
Follow these tips to keep your patients more comfortable
Over three-quarters of our patients will discontinue contact lens (CL) wear at one time or another due to discomfort.1 We’ve known for a long time that CLs may cause or aggravate dry eye.2 Patients with CL-related dry eye (CLIDE) may complain of dryness, discomfort, grittiness, irritation, burning or foreign body sensation.3 Up to 50% of soft CL wearers complain of dryness.4 There are about 35 million CL wearers in the United States, which suggests that as many as 17 million CL wearers experience significant dry eye symptoms.5 We know our CL patients report more ocular symptoms than do our patients who don’t wear CLs, and their complaints of dryness often increase with wearing time.
How do we keep our CL patients who suffer from dry eye comfortable in their CLs? First, be proactive. Diagnose and treat dry eye before attempting CL wear. Start by gathering the patient’s medical history to understand general systemic health and medical therapies. Medications that cause ocular surface dryness (e.g., oral antihistamines, anticholinergics, antihypertensives, cardiac antiarrhythmics, antidepressants and oral contraceptives) should be minimized. Advise your patient that alcohol and smoking will worsen dry eye symptoms.6
Perform a complete dry eye work-up. Include:
• Sodium fluorescein staining of the cornea and conjunctiva
• Tear film break-up testing
• Lissamine green staining of the cornea and conjunctiva
• Schirmer’s or phenol red thread testing
• Tear meniscus height evaluation
• Tear film osmolarity testing or lactoferrin microassay evaluation
Assess meibomian gland function—meibomian gland disease (MGD) is the most common cause of contact lens intolerance.7 Look for conjunctival parallel folds and lid wiper epitheliopathy because they appear to be the most predictive of dry eye.8 Lid wiper epitheliopathy is damage at the upper eyelid edge from repeated blinking over a poor tear film, seen when stained with lissamine green.9 Lid parallel conjunctival folds are small folds in the lower quadrant of the bulbar conjunctiva parallel to the lower lid margin.10
Treating underlying dry eye
Once a diagnosis of dry eye has been made, treat the dry eye before attempting CLs. Absent a stable precorneal tear film, the patient attempting CL wear is doomed to failure. Concomitant lid disease needs to be addressed as well.
Inflammation is a critical component in dry eye, and short-term topical corticosteroids will provide immediate relief as well as address the underlying cause. The patient may need to begin lid scrubs and warm compresses to treat plugged meibomian glands and blepharitis. Omega-3 fatty acids interact with the fatty acid metabolism of the meibomian glands and enhance their secretions.11 This helps stabilize the lipid layer and the pre-corneal tear film.
The use of 0.5% cyclosporine A (Restasis, Allergan) in CL patients before applying CLs and after lens removal can also significantly increase comfortable wearing time.12 A study by Hom showed a significant reduction in CL intolerance with the use of Restasis when the medication was used before and after CL wear.13 Oral doxycycline may be of benefit in the treatment of dry eye. Doxycycline modifies the fatty acid metabolism within the meibomian glands and enhances the lipid layer of the tear film. Topical azithromycin is another option. Both drugs are commonly used in the treatment of MGD, although their use is off label.
Lenses and care solutions
All soft CLs dehydrate on the eye, most likely through evaporation. Use of artificial tears and rewetting drops are the mainstay of treatment. Rewetting drops are a temporary solution, although they do offer some relief. Instruct your patient remove her lenses about halfway through the day and place them in a case with fresh saline for half an hour while also rehydrating her eyes using non-preserved artificial tears. This step allows the lens to rehydrate and can extend the wearing time of patients with more severe dry eye.14
Consider refitting your patients into silicone hydrogel CLs. They are low water content, high oxygen permeable lenses for which evaporation and dehydration appear to be significantly less of a problem than for their conventional hydrogel counterparts.15 Remember that an improper lens fit can cause symptoms that can be misdiagnosed as a dry eye. Allow the lenses to settle on the eye, then carefully evaluate the fit, centration, and movement of the lenses on the eye.
An easy way to avoid lens care solution interaction in CLIDE is to eliminate care solutions. Changing the patient to a daily disposable lens may be your best alternative. For those patients for whom this isn't an option, changing the care regimen to a preservative-free hydrogen peroxide disinfection system is another choice. Let the patient know he may not see any immediate relief because it can take up to 2 weeks to purge the residual effects from previous lens care products.ODT
1. Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. ICLC. 1999;26(6);157-162.
2. Farris RL. The dry eye: its mechanisms and therapy, with evidence that contact lens is a cause. CLAO J. 1986;12(4) 234-46.
3. Begley CG, Caffrey B, Nichols KK, et al. Responses of contact lens wearers to a dry eye survey. Optom Vis Sci. 2000:77(1):40-6.
4. Doughty MJ, Fonn D, Richter D, et al. A patient questionnaire approach to estimating the prevalence of dry eye symptoms in patients presenting to optometric practices across Canada. Optom Vis Sci. 1997;74:624-631.
5. McMahon TT, Zadnik K. Twenty-five years of contact lenses: the impact on the cornea and ophthalmic practice. Cornea. 2000;19:730-740.
6. ltinors DD, Akea S, Akova YA, et al. Smoking associated with damage to the lipid layer of the ocular surface. Am J Ophthalmol. 2006;141(6):1016-1021.
7. Foulks G. Contact lens-induced dry eye. Eyecare educators. Available at: http://www.eyecareeducators.com/site/contact_lens_induced_dry_eye.htm. Accessed 9/22/2013.
8. Pult H, Purslow C, Berry M, et al. Clinical tests for successful contact lens wear: relationship and predictive potential. Optom Vis Sci. 2008;85(10):E924-9.
9. Korb DR, Herman JP, Greiner JV, et al. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers. CLAO J. 2002;28(4):211-6.
10. Höh H, Schirra F, Kienecker C, et al. Lid-parallel conjunctival folds are a sure diagnostic sign of dry eye. Ophthalmologe. 1995;92(6):802-8.
11. Miljanovic B, Trivedi KA, Dana MR, et al. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr .2005;82(4):887-893.
12. Nichols KK, Nichols JJ. The Latest Research and Treatment Options for Lens-Related Dry Eye. Contact Lens Spectrum. September 2006.
13. Hom MM. Use of cyclosporine 0.05% ophthalmic emulsion for contact lens-intolerant patients. Eye Contact Lens. 2006;32:109-111.
14. Boland MR, et al. Troubleshooting dry eye. Rev Optom 2002; 139:11.
15. Patton C. Dry eye alleviated with senofilcon A contact lenses. Optometry Times. April 2009.
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