CLINICAL

  ANTERIOR

PREVENT OSD-CAUSED DROPOUT

LOOK FOR OCULAR SURFACE DISEASE BEFORE PRESCRIBING CONTACT LENSES

JOSH JOHNSTON, O.D., F.A.A.O.

YEARS AGO, I had a 49-year-old patient, with a low amount of hyperopia and presbyopia, present for a refund because the multifocal contact lenses I prescribed caused discomfort and unclear vision. I had seen her four times in two months, so I suspected the problem may be with the lens design.

At this visit, her BCVA was limited to 20/30 OU. Wondering whether ocular surface disease (OSD) could be the problem, I stained her eyes with NaFL and examined them through the slit lamp. The culprit was significant central punctate keratitis.

That day, I learned the importance of evaluating patients interested in contact lens wear for OSD prior to prescribing lenses.

Here, I discuss the symptoms, clinical signs and management options for the two forms of OSD: dry eye disease (DED) and ocular allergy.

DED SYMPTOMS

• Blurred or fluctuating vision

• Burning

• Decreased comfort with contact lenses

• Dryness

• Fatigue

• Foreign-body sensation

• Grittiness

• Itching

• Stinging

DED CLINICAL SIGNS

• Conjunctival staining

• Corneal staining

• Decreased aqueous production

• Decreased TBUT

• Hyperemia

• Increased osmolarity

• Increased inflammation

• Meibomian gland dysfunction

• Redness

DED TREATMENT OPTIONS

Options are listed by the least to most severe forms of DED:

• Artificial tears, gels and ointments

• Environmental changes (recommend decrease use of ceiling fans and the avoidance of low humidity environments, direct air vents and excessive visual tasking using computers, tablets and cellphones.)

• Immunosuppressive topical drops

• Topical steroids

• Punctal occlusion

• Warm compresses

• Alter systemic medications

• Amniotic membranes

• Nutritional supplements

• Topical antibiotics

• Combination steroid/antibiotic drops or ointment

• Meibomian gland expression

• Oral tetracyclines

• Autologous serum drops

• Oral cholinergic agonists

OCULAR ALLERGY SYMPTOMS

• Burning

• Itching

Pollen, as seen via this extreme close-up, is a notorious allergen that can cause ocular allergy which makes successful contact lens wear a challenge if not initially treated.

OCULAR ALLERGY SIGNS

• Chemosis

• Conjunctival injection

• Decreased contact lens comfort/wear time

• Epiphora

• Eyelid edema

• Tearing

OCULAR ALLERGY TREATMENTS

Treatments are listed by the least to most severe forms of ocular allergy:

• Eye wash/artificial tears

• OTC antihistamines

• Prescription anti-histamines/mast cell stabilizers

• Topical steroids

• Daily disposable contact lenses

• Oral medications/nasal sprays

THAT PATIENT

I had a candid conversation with the aforementioned patient about my failure to identify and treat her DED. To make it up to her, I gave her a professional discount. She not only stayed with my practice, she was also able to achieve comfort and clear vision with her contact lenses after treatment. OM

DR. JOHNSTON practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in co-managing cataract and refractive surgery patients. Email him at drj@gaeyepartners.com, or visit tinyurl.com/OMcomment to comment.