DRY EYE TREATMENT
Relief for Contact Lens-related Dry Eye
For some patients, alleviating dry eye and lens-related dry eye may be just a drop away.
By Scot Morris, OD, FAAO, & Jennifer E. Davis, OD
Are you losing patients from dry eye and associated contact lens dropout? Contact lens dropouts often seek refractive surgery, wear eyeglasses or seek alternative eye care. Regardless of which option they choose, you lose income and likely the patient. Let's discuss how to keep these patients in contact lenses and in your practice.
Granted, many types of lenses are available that may increase patient comfort through improved wettability, enhanced Dk characteristics and material improvements, but you're doing your patients a disservice if you don't treat the underlying problem.
What Causes Dry Eye?
We can better treat dry eye if we're familiar with its etiology. Studies show that many forms of chronic dry eye are inflammatory in nature. The lacrimal glands undergo androgenic-related inflammation that results in subsequent T-cell activation. As a result, cytokines accumulate on the ocular surface and deleterious changes occur in both mucin production and cell function that affect the afferent neurosecretory pathways. This results in a decrease in tear production, surface desiccation and, ultimately, uncomfortable contact lens wear.
History The first step is to realize that dry eye exists and that you need to deal with it or potentially lose patients. How do you know they have it? Ask! Almost half of all contact lens wearers will have contact lens-related dryness symptoms at some point. A good history is the key to sleuthing out dry eye as the culprit in a contact lens dropout case. Burning, light sensitivity, blurred vision, foreign body sensation or tired eyes, especially toward the end of the day, or decreased wearing time can all be classic symptoms of dry eyes. Gather as much information as possible as it relates to ocular comfort, visual status and environmental or lifestyle issues.
Clinical Testing The scope of clinical testing that you should perform is beyond the scope of this article. We've included a few quick tips for diagnosing dry eye, though no single test exists for this condition. It takes a little detective work and careful observation of the test results listed in Table 1.
Getting to the Source
Artificial tears help, but patients may have to use them often to attain adequate comfort. Because many forms of dry eye have an underlying pathology, immunomodulators such as cyclosporine 0.05% (Restasis, Allergan) have become a mainstay of treatment for our dry eye patients, both lens wearers and non-wearers alike. Rather than adding artificial tear supplements or punctal occlusion, which don't remove the cytokines from the surface, we work to relieve the cause of dry eye. Restasis is the first drug clinically shown to restore natural tear production.
Be sure to present Restasis realistically to your patients while many patients experience a response within the first four weeks, for some it can take up to 12 weeks to have full effect.
The following abbreviated cases show how Restasis helped a few of our patients remain in contact lens wear.
Clinical Tests for Dry Eye
Palpebral Aperture Size
Lid Margin Evaluation
Ocular Surface Evaluation
Meibomian Gland Evaluation
Case #1 Patient PK was a 43-year-old female who suffered from increasing discomfort with her Proclear (CooperVision) lenses. She inquired about LASIK because she could no longer comfortably wear her contact lenses. She reported using artificial tears every hour with little relief.
Objectively, PK had moderate fluorescein staining on the intrapalpebral bulbar conjunctiva and nasal cornea and moderate injection on the palpebral conjunctiva. Schirmer I scores were 4 OD and 6 OS with a tear break-up time (TBUT) of four seconds in each eye. We started her on Restasis q12h and asked her to continue using artificial tears.
As expected, PK felt mild improvement at her six-week follow-up visit, reported that she was wearing her lenses with increased comfort and had reduced her artificial tear use to as needed. She was free of all staining and symptoms at 14 weeks.
Case #2 Patient KM was a 34-year-old female who had ceased wearing her Night & Day (CIBA Vision) lenses because of chronic red, burning eyes. Her only medication was an oral contraceptive. She reported using Visine to "get the red out" at least six times a day.
Clinically, KM had moderate palpebral and bulbar conjunctival injection with a severe follicular reaction of her palpebral conjunctiva. Schirmer I scores without her contact lenses were 8/10 respectively, she had a TBUT of six seconds OU and mild inferior nasal corneal staining. We suspected chronic dry eyes and prescribed Restasis.
By her eight-week visit, KM noticed significant improvement and reported that she had started to wear her contact lenses comfortably the week prior.
Case #3 Patient AM was a 35-year-old male who had chronic dry eye that had prevented him from comfortable lens wear for 10 years. He suffered from chronic burning, reflex tearing and constant irritation, and he'd given up hope that he would ever wear contact lenses again. Though free of ocular surface staining, lissamine green showed significant mucus in both eyes. We started AM on Restasis q12h OU. For this more severe patient, we also prescribed a topical steroid q6h for three weeks to provide a slightly more rapid control of the acute inflammation.
He returned for follow up six weeks later to monitor for any possible IOP changes related to the steroid. At the six-week follow-up visit, AM reported significant improvement in his symptoms and lissamine green testing showed that he was free of mucus. At 14 weeks we fit him with PureVision (Bausch & Lomb) lenses on a daily wear schedule. At 21 weeks, he was still using Restasis q12h and was wearing his lenses comfortably.
Dosing and Cost
Though we haven't experienced any problems resulting from patients using Restasis with their contact lenses, many report that their vision is blurred for a few minutes from the emulsion. To alleviate this concern, instruct your extended wear users to remove their lenses for at least five to 10 minutes after administering Restasis. The package insert recommends 15 minutes. We instruct daily wear users to instill Restasis 10 minutes before applying their lenses in the morning and again after they remove the lenses at night.
Patients or practitioners may perceive Restasis as expensive. However, most co-pays are around $30 per box, and dry eye patients typically spend at least that much each month for artificial tears and they still can't wear their lenses.
In conclusion, using available resources to ensure that patients can continue to wear their lenses can go a long way toward achieving satisfaction. CLS
Dr. Morris is director of Eye Consultant of
Colorado and the managing partner of Morris Education and
Dr. Davis is an adjunct assistant clinical professor at Pacific University College of Optometry and was selected as Young Optometrist of the Year by the Colorado Optometric Association in 2004.