contact lens complications

Troubleshoot Common Contact Lens Complications

A look at the most prevalent problems and how to solve them

LINDSEY GETZ, contributing editor

Given a considerable percentage of an optometrist’s practice revenue comes from contact lens fittings and sales, it’s essential you’re aware of the most common contact lens complications and how to solve them so you can prevent patients from ceasing wear.

Here, contact lens specialists address this.

Contact Lens Associated Red Eye (CLARE)

To manage this condition, assess the lens fit, says Susan Kovacich, O.D., associate clinical professor in the Cornea and Contact Lens Clinic at the School of Optometry at Indiana University.

“A lens fit too tight can cause CLARE, as it doesn’t allow the metabolic waste to be cleared from underneath the lens,” she explains.

If the fit is adequate, ask the patient: “Have you been sleeping in your lenses?” Dr. Kovacich suggests.

“Sleeping in lenses, and not blinking, also enables metabolic waste to build up under the lenses, which can cause CLARE,” she explains.

If, the patient answers “no” to the over-wear question, ask him:

“Can you please explain, step-by-step, how you’ve been cleaning your lenses?” Dr. Kovacich recommends.

“This is an important question, as missing a cleaning step or failing to properly follow one can also result in the build up of debris on the lens and lead to CLARE,” she points out.

To manage CLARE, first determine whether its cause is a tight-fitting lens or improper contact lens care.

Once you’ve determined the CLARE cause, tell the patient:

“I want you to throw out the CLARE lenses, and wear glasses until your eye is completely better (regardless of whether a topical soft steroid or steroid antibiotic for corneal infiltrates is prescribed),” she explains. “It’s really important you follow my directions because if you put in a pair of new lenses too soon, the problem can return.”

The second part of this script is crucial, as patients have been known to insert a new pair of lenses once they begin to see the redness fade, Dr. Kovacich says. Finally, the patient needs to know that, before resuming contact lens wear, something will need to change to prevent a recurrence of CLARE, such as improving the fit if the lens is too tight, and not sleeping in the lenses, she explains.

Dry eye disease

Determine the cause(s) by following a step-by-step protocol that begins with the patient’s ocular history followed by a dry eye disease (DED) evaluation, says Glenda Secor, O.D., F.A.A.O., of Huntington Beach, Calif.

Once you determine the cause or causes, develop an action plan, explain it to the patient, and have the patient schedule a follow-up visit, so you can assess its success, she says.

“For instance, if you note a lid hygiene problem, you may say to the patient: ‘I’m seeing some redness or debris on your lids, which may be impacting adequate tear flow. As a result, I’d like you to improve your lid hygiene by placing a warm, wet washcloth for a few minutes on your eyelids and then gently massage them at least two times a day,’” Dr. Secor explains. “’Next, clean your lids and lashes with a prepared lid scrub product twice a day, as doing so offers additional hygiene.’”

Additional steps, such as oral medications, can be added for more severe cases, if needed, she says.

Because you’ve briefly explained the cause and how your prescribed management will alleviate it, you’re more likely to get the patient to adhere to your directions, say those interviewed.

“Sometimes, this [determining the cause(s)] can be a long and drawn out process, but in following it, you have an excellent chance of solving the problem, and therefore, keeping the patient in contact lens wear,” Dr. Secor says.

S. Barry Eiden, O.D., F.A.A.O., who practices in Deerfield, Ill., and is an assistant clinical professor at the University of Illinois, Chicago, Department of Ophthalmology, cornea and contact lens service, acknowledges that while DED can occur post-contact lens wear, you have a great chance of preventing its onset by assessing the patient’s tear film and ocular surface status in advance.

“In our practice we perform an initial contact lens diagnostic evaluation for every existing and prospective lens wearer, and part of that evaluation includes a tear film and ocular surface assessment,” he explains. “We take various measures of tear film function and observe carefully under the biomicroscope for evidence of ocular surface disease and tear film anomalies. We then consider a number of management options, including the solution system, contact lens material, frequency of lens replacement and medical therapies to ensure patient comfort. It’s a customized process for each patient.”

Foggy or filmy lenses

Start by asking the patient: “Have you been using hand cream or any products that contain oils or lotions?” recommends Edward S. Bennett, O.D., M.S.Ed, co-chief of the University of Missouri-St. Louis College of Optometry’s Contact Lens Service.

“This is an important question because patients who use lanolin-containing products, such as hand lotions or creams, don’t realize they’re actually transferring the residue from these products to their lenses, and these can be difficult to remove and cause their lenses to film up,” he explains. “If this is observed, the use of an extra-strength cleaner should be prescribed, as it is effective in removing these oils and residue off of the lens surface. If, understandably, a patient customarily uses lanolin-containing products, instruct him or her to use a clean towel to thoroughly clean their hands of the soap/lotion prior to handling their lenses.”

Also, ask the patient: “Can you take me through your lens-cleaning process?” suggests Dr. Secor.

“This is a crucial question because many patients still passively clean their lenses, meaning they just stick their lenses in their solution,” she explains. “This poor cleaning method can result in foggy and/or filmy lenses. The contact lens industry has responded to this by taking off the ‘no rub’ indication on solution packaging. As a result, I think patients are starting to realize that rubbing their lenses to clean them is a necessity, but we, as their eye doctors must make a point of educating patients about this as well.”

If neither lanolin-based product use or passive cleaning practices are causing the foggy and/or filmy lenses, Dr. Bennett recommends you assess the patient for aqueous tear deficient DED.

“As tear volume decreases with age, the aqueous component of the tear film decreases, and the tear film mucin can dry out and become mucous-like in between blinks. This can result in a mucoprotein film, causing variable vision,” he explains. “It is not uncommon for an individual, such as a post-menopausal female, to notice that their new lenses film up quicker than their previous ones…”

It is often believed that foggy or filmy lenses is a material issue, but today’s fluoro-silicone/acrylate(F-S/A) materials all exhibit better surface wettability and scratch resistance than their predecessors, explains Dr. Bennett.

“As most lenses today come from the laboratory plasma-treated to remove all manufacturing-related polishes and residues, good initial and short-term wettability is often achieved. If this problem [foggy or filmy lenses] has occurred over time, the aforementioned extra-strength cleaners can be used,” he says. “In addition, patients should be advised to clean the lenses immediately upon removal every night and store the lenses in fresh disinfecting solution. Having a small bottle of the wetting/conditioning solution to use as a lubricant during the day should also assist in reducing this problem. When in doubt never hesitate to communicate with your contact lens laboratory about the problem.”

Dissatisfactory vision

Prescribe disposable prefabricated lenses, says Dr. Eiden. “Today, disposable lenses are by far the most frequently prescribed contact lens modality,” he says. “With advancing technologies for vision correction, such as toric, aspheric and multifocal designs, they have come a long way in meeting the visual needs of our patients.”

In cases in which you can’t optimize vision with disposable lenses, other options should be considered, such as GP lenses, hybrid lenses and custom designed soft contact lenses, Dr. Eiden says.

“For example, manipulation of astigmatic axis of as little as 3° for a highly toric soft lens patient can be the difference between success and failure,” he explains. “Custom soft toric lenses can be manufactured with as small as 1° axis steps.”

Patient non-compliance

Use a proactive approach to prevent contact lens problems by encouraging compliance from the first visit, and reinforce good lens disinfection practices and correct wearing and replacement schedules at each visit, Dr. Kovacich says.

“I always ask patients how they wear their lenses, and how often they replace their lenses,” she explains. “I also make sure that the patient uses fresh disinfection solution daily and doesn’t ‘top-off’ their solution. Non-compliance with solutions is a big part of contact lens-related issues.”

Provide patient education on the long-term complications that can result from their non-compliance, says Dr. Secor.

“We tell patients: ‘The lenses prescribed are designed with frequent replacement to reduce complications. Stretching those boundaries increases the risk of problems. It is like driving your car at 100 mph. You may be fine for awhile, but eventually you are going to crash and burn much harder and faster than someone going 50 mph,’” she explains. “’You exponentially increase your risk of problems that in the long run don’t balance the benefits of changing your lenses more regularly.’”

Have patients repeat your lens wear-and-care instructions to you, suggests Dr. Bennett.

“Say to the patient: ‘I want to make sure I’ve covered everything correctly, so could you please repeat the instructions I just gave you?’” he explains. “This way, you can feel confident they know the routine, as you want them to do it, and because you’ve personally asked them to repeat the instructions, they know it’s very important,” he says.

The bottom line

By reviewing the aforementioned common complications and how to solve them, you not only have an excellent chance of preventing patients from dropping out of contact lens wear, and thus, maintaining your practice revenue, but you also instill patient loyalty. This is because patients stick with doctors who can solve their problems. OM

Lindsey Getz is a Philadelphia-area-based freelance writer, who has written for several consumer and trade magazines. She is also a former editor of Eyecare Business magazine (a sister publication of Optometric Management). E-mail her at lindsey.getz@yahoo.com, or send comments to optometricmanage ment@gmail.com.