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Contact lens wearers with dry eye need multimodal treatment plan

Patients need disease management, proper fit, wear/care education

Dr. Gromacki
Enabling successful contact lens (CL) wear in patients with dry eye requires a multipronged approach involving attention to the ocular surface disease, lens selection, and patient education on lens wear and care. These issues were discussed recently by Susan J. Gromacki, OD, MS, in practice in West Point, NY, and Lisa Badowski, OD, MS, a private practitioner in Denver.

Reviewing the importance of managing dry eye, Dr. Gromacki said that because the CL inserts itself into the tear film, ea wearer with a deficient or dysfunctional tear film may become symptomatic.

"Improving the quality of the tear film will keep the patient more comfortable and prevent lens-induced damage to the cornea," Dr. Gromacki said.

Diagnosis and treatment

Management of dry eye begins with proper diagnosis, which involves patient case history taking to uncover common symptoms—for example, dryness, redness, grittiness, excessive tearing, burning, and stinging—together with clinical evaluation to identify diagnostic signs. Clinicians should keep in mind, however, that patient symptoms may not correlate with the clinical findings.

Lisa M. Badowski, OD, MS Phone: 303/355-1496 E-mail: Dr. Badowski is a member of the Alcon Speakers Alliance.
Once the diagnosis is made, possible exacerbating environmental factors should be sought and addressed. Variables to consider include adequacy of daily water intake; exposure to drafts from ceiling fans, car vents, or wind; indoor humidity levels; and computer screen height, which affects lid aperture and tear film evaporation. A complete medication history also is important because there is a long list of agents that can cause or exacerbate dry eye and for which an appropriate alternative might be identified through consultation with the prescribing physician. Alcohol, smoking, and certain foods also may aggravate dry eye, Dr. Gromacki said.

Treatment is tailored to the severity of the dry eye disease and to the etiology, if it can be identified. Artificial tears are used in most patients as a first line of therapy, she said, and preservative-free products or those formulated with newer, transient preservatives are preferred. Understanding whether the patient primarily `has an aqueous deficient or evaporative dry eye condition can help guide selection among the various artificial tear formulations available.

For more moderate disease, thicker gel or drop formulations of artificial tears are preferred, and an ointment can be added at bedtime, she said. Punctal plugs may play a role. However, any existing inflammation should be addressed first because punctal plugs will prolong ocular surface exposure to inflammatory cytokines in the tear film, according to Dr. Gromacki.

"For patients with severe dry eye disease, artificial tears or even lubricant ointments may be needed frequently during the day," she said. "These patients probably need to discontinue CL wear, and the reality is that we may not be able to get them all back into their lenses."

Meibomian gland dysfunction

Identification and treatment of existing meibomian gland dysfunction (MGD) also is essential in the effective management of dry eye, Dr. Gromacki said. Treatment involves lid hygiene with warm compresses, digital massage, and exfoliation. Lid scrubs with baby shampoo should not be used because the surfactants in the shampoo will break up the lipid secretions from the meibomian glands, she added.

Short-course treatment with oral doxycycline or minocycline also may play a role, and there is emerging evidence that lower doses offering anti-inflammatory activity without an antibiotic effect may be effective, she said. Dr. Badowski noted, however, that she reserves oral doxycycline treatment as a last resort in the interest of avoiding photosensitivity reactions for patients in her geographic area, where there is sunshine 300 days of the year. For patients with MGD, nutritional supplementation with omega-3 fatty acids also can be beneficial to improve the quality of the lipid secretions, she said.

Other issues to consider are the presence of ocular allergy, which should be treated with a dual-acting antihistamine/mast cell stabilizer or topical corticosteroid, such as loteprednol etabonate (Alrex or Lotemax, Bausch & Lomb) as needed, Dr. Gromacki said. Recognition of the role of inflammation in the etiology of dry eye has been a major breakthrough in recent years, and inflammation can be managed with loteprednol etabonate or cyclosporine ophthalmic emulsion (Restasis, Allergan), she said.

Observing patients for the quality of their blink also is worthwhile, Dr. Gromacki said. "A good, complete blink that effectively restores a fresh tear film layer over the ocular surface is important and something that we can train patients to do," she explained.

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