Clinician's Update

Clinical Approaches to Ocular Dryness in the Contact Lens Patient

By Loretta Szczotka-Flynn, OD, MS, FAAO

What is your approach to treating dry eye patients with contact lenses?

The first differentiation I make is between patients with clinically evident dry eyes who want to wear contact lenses and patients who become symptomatic only after they start wearing them. The first have true dry eye and the second develop the symptoms but rarely progress to true dry eye. The treatment relates to the cause of the symptoms.

What about patients with dry eye before starting contact lenses?

In patients with clinically evident dry eye, first treat the dry eye using the required regimen for the patient's type and severity of dry eye. I start with artificial tears. Artificial tears in multi-use containers are fine as long as they have a disappearing preservative. Then I move onto cyclosporine ophthalmic emulsion, punctal occlusion, Omega-3 fatty acid supplements and/or lid hygiene as needed. These are all effective and well-tolerated in the contact lens patient population.

What about the patient who develops dry eye after starting contact lenses?

Rewetting drops are added while the contact lenses are in the eye. They provide comfort and lessen the irritation sometimes felt during contact lens wear. I often select a drop that's approved for use on both rigid and soft contact lenses (such as Blink Contacts®) because I do a great deal of piggyback fitting. I look for drops that incorporate a viscosity agent for comfort with either no preservatives or a disappearing preservative in their formula.

What are the steps beyond that?

There are three options I approach in this order — certainly you can mix and match:

1. Re-evaluate your base curve. Remember we have options in this category! Dehydrated lenses tighten up on the conjunctiva/sclera first causing impingement and conjunctival awareness. I've had success simply refitting in a flatter base curve or lower sagittal depth design.

2. Change the material. Some function better with silicone hydrogel and others with traditional low Dk materials.

3. Change the solution. Hydrogen peroxide is effective for many. Products with preservatives may increase dryness.

Do you have one or two preferred contact lens modalities for the dry eye patient?

Silicone hydrogel lenses can work well in patients with either evaporative or aqueous deficient dry eye, because the dehydration profile of the silicone lens is much less than a high-water thin hydrogel lens. However, excessive lipid deposition on silicone hydrogel lenses can be a concern with patients who have dry eye and associated meibomian gland dysfunction. In that case, I may switch a patient to daily disposable lenses. Recently, I've also had success in switching dry eye patients to some of the contact lenses that incorporate additional wetting agents, such as 1-Day Acuvue Moist (Johnson & Johnson Corporation) and the Air Optix Aqua line (CIBA Vision, Duluth, GA).

What about patients who develop dry eye only after they started wearing contact lenses?

For patients with no dry eye signs or symptoms before wearing contact lenses, I treat other possible reasons for discomfort. Few in this patient population will cross over to true dry eye. Certainly, there are a few patients who have borderline dry eye and become symptomatic after starting contact lenses, but I find the majority of patients can be treated by simply managing discomfort.

What type of patients do you see in your practice?

In my hospital-based setting, I see many diseased corneas in need of medically necessary contact lenses. Many of these patients use semi-scleral or large diameter rigid lenses. I advise them to add a contact lens rewetting drop inside the bowl of the contact lens before putting it on the eye. This has more staying power and comfort than saline alone.

Do you have recommendations for ocular hygiene that would benefit the contact lens wearer with dry eye?

It's important to keep the lenses clean and bacteria off the lens surface. The lid margins often have high levels of commensal organisms that could cause problems if they are trapped behind the lens or adhere to the posterior lens surface. Even normal resident gram-positive organisms can trigger an immune response on the cornea. Therefore, routine lid scrubs are a good idea in addition to heat therapy for plugged meibomian glands if needed.

What about environmental causes of ocular dryness in contact lens wearers?

One strategy is to become aware of your environment and take a proactive approach. See the table below for some easy-to-implement strategies to prevent ocular dryness and discomfort.

Preventing Contact Lens Dropouts — the Clinician's Challenge

More than 100 million patients have worn contact lenses over the last few decades. Coincidentally, the same number of people have discontinued contact lens wear over the same period of time. Yes, you read this correctly! Fortunately, various reports show there are 30-40 million contact lens wearers in the United States and more than 120 million contact lens wearers worldwide, according to Jason J. Nichols, OD, editor of Contact Lens Spectrum.

Patients choose these healthcare devices for many reasons — improved appearance, spectacle independence, enhanced visual acuity, better binocularity and other therapeutic advantages.

Then why do so many of these formerly enthusiastic individuals give up on contact lenses?

As clinicians, we know dropout usually isn't caused by a single factor. It may not be related to health care, but rather to financial and/or environmental reasons. However, let's focus on one important potential issue — dry eye.

The scientific data on dry eye-related contact lens problems have been reported by many. Ocular discomfort and dryness were the most common reasons for dropouts from contact lens wear in numerous studies^1-8 over the better part of a decade (See table). Guillon and Maissa¹ showed that contact lens wear affects tear film evaporation, and this may be a contributing factor in contact lens-induced dry eye.

These studies emphasize the importance of careful diagnosis, treatment and management of dry eye and ocular surface disease. If high rates of ocular discomfort and dryness are reported consistently, then it should be imperative to address their clinical concerns.

In 2007, The Ocular Surface journal reported 3-year data from 60 international professionals who participated in the Dry Eye Workshop Study (DEWS).8 They looked at an evidence-based classification of data to formulate a broader treatment consideration. They found the primary reasons for contact lens intolerance were discomfort and dryness.

Careful assessment of dry eye symptoms can help maintain ocular comfort for contact lens wearers. Here are some suggestions for evaluating patients:

■ Office questionnaires
■ Patient history
■ In-office communication of the practitioner and staff
■ Diagnostic tear film testing
■ Treatment and follow-up of clinical management changes.

I encourage you to recommend a comfortable, lubricious eye drop to improve the contact lens-wearing experience for your patients.

Sincerely,

References

1. Guillon M, Maissa C. Contact lens wear affects tear film evaporation. Eye & Contact Lens. 2008;34:326-330.
2. Begley CG, Caffery B, Nichols KK, Chalmers R. Responses of contact lens wearers to a dry eye survey. Optom Vis Sci 2000;77:40-46.
3. Vajdic C, Holden BA, Sweeney DF, Cornish RM. The frequency of ocular symptoms during spectacle and daily soft and rigid contact lens wear. Optom Vis Sci. 1999;76:705-711.
4. Guillon M, Styles E, Guillon JP, Maissa C. Preocular tear film characteristics of nonwearers and soft contact lens wearers. Optom Vis Sci. 1997;74:273-279.
5. Doughty MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon K. 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.
6. Schlanger JL. A study of contact lens failures. J Am Optom Assoc. 1993;64:220–224.
7. Brennan NA, Efron N. 7. Symptomatology of HEMA contact lens wear. Optom Vis Sci. 1989;66:834-838.
8. Research in dry eye: report of the Research Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5:76-77.