CLINICAL

  contact lenses

Listen and Look

How to identify contact lens intolerance vs. DED

JASON R. MILLER, O.D., M.B.A., F.A.A.O.

Contact lens intolerance and dry eye disease (DED) may be difficult to differentiate at times.

In fact, according to the Canadian Journal of Optometry, contact lens and solution-induced problems may mimic the symptoms associated with DED, such as foreign body sensation, watery eyes, visual fluctuation and corneal staining.

The good news: Identifying contact lens intolerance and contact lens solution sensitivity can be accomplished by following these two steps.

Subtle corneal staining is evident after removing contact lenses. This patient was wearing his reusable contact lenses too long. He was fit in a daily disposable lens, which eliminated this corneal irritation.

1 Listen

Before your over-refraction and fit assessment, listen for specific symptoms related to dry eyes, such as:

• “My eyes burn and get red at the end of the day.”

• “I need to use rewetting drops throughout the day in order to see clearly.”

• Other keywords to listen for include “eye discomfort,” “watery eyes,” “visual fluctuations” and “over-the-counter drops.”

To identify these possible red flags, make it a habit to ask your contact lens patients questions about their daily wearing experience and routine.

Take it a step further and listen for specific symptoms or concerns related to their contact lenses, such as:

• “I am taking my lenses out immediately after getting home from work because of eye fatigue and irritation.”

• “I am having a difficult time focusing on the computer screen throughout the day” (even for your pre-presbyopic contact lens wearers).

• “My contact lenses feel suctioned to my eyes at the end of the day.”

These symptoms could easily be related to an underlying DED, but take the time to try to differentiate these symptoms with contact lens intolerance.

First, ask patients whether these symptoms continue on days they wear their spectacles. If so, consider taking them out of contact lenses for a week and then bringing them back for a dry eye work-up.

Assess their symptoms and corneal signs to see whether they have improved without contact lens wear. If so, their symptoms are most likely related to their specific contact lenses, which are actually causing this condition.

2 Look

Take the time during the contact lens examination, whether an initial exam or follow-up, to thoroughly look at the ocular surface. Specifically, evaluate:

• The eyelids, their eyelashes, the patient’s blink and lid closure.

• The tear film, corneal staining and tear break-up time with the use of fluorescein or lissamine green strips.

Any positive findings could be an underlying DED condition or induced from either (a) mechanical trauma from the contact lens or (b) hypoxia induced by the contact lenses or hypersensitivity to the solutions that were prescribed. Again, these two conditions’ clinical signs may be difficult to differentiate unless you perform further questioning and order a dry eye work-up after removing the patient from his or her lenses for a period of time.

A strategic approach

Depending on the nature of the patient complaint or clinical signs, create a strategic approach to solving the problem. This begins with improving the ocular surface, if applicable, by enhancing his or her meibomian gland function, decreasing any inflammation and lubricating the ocular surface with the appropriate ocular lubricant. In some situations, prescription pharmaceuticals may also be necessary to restore the ocular surface to a more normative state.

Once the ocular surface has improved, the next step is to prescribe a different contact lens material, solution or modality that may improve the contact lens wearing experience.

Your protocol may be different than mine, but I start with changing the modality. Daily disposables have created a very positive improvement for these patients within my practice, and this is the first thing I change if they are not in that modality.

There are many options to consider. However, the correct combination will improve the ocular surface and create a positive wearing experience.

Providing solutions

Although it is difficult to predict which patients will develop contact lens intolerance and which lenses or solutions will cause these symptoms ahead of time, working to identify these patients is critical to reducing dropout and increasing patient satisfaction. OM

DR. MILLER IS A PARTNER AT EYECARE PROFESSIONALS OF POWELL, A MEMBER OF VISION SOURCE, IN POWELL, OHIO, AND IS AN ADJUNCT FACULTY MEMBER FOR THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. TO COMMENT ON THIS ARTICLE, VISIT TINYURL.COM/OMCOMMENT.