May 2009

Striving for Value in Treatment of Dry Eye

History and Presentation

KW, a 44-year-old woman, presented with complaints of dryness with contact lens wear. She had no visual complaints and reported good performance with a 1.00D plus bias OS for near vision (monovision).

She reported good compliance with daily wear of her 2-week replacement hydrogel contact lenses and a one-bottle care system. She also reported a history of environmental allergies and was taking fluticasone nasal (Flonase, GlaxoSmithKline) as needed. She also takes metoprolol (Toprol, AstraZeneca) for cardiac arrhythmia.

Clinical Examination

Binocular visual acuity with contact lenses was 20/20-1 at distance and J2 at near. Slit lamp examination revealed good lens centration and movement OD and OS. Following lens removal, I observed clear corneas and mild injection of the superior tarsal plate in each eye.

I recommended that KW be refit with silicone hydrogel contact lenses, and she agreed. Lenses of the following parameters were fit and dispensed:

BC PWR
R 8.4 mm –3.25
L. 8.4 mm –2.50

Follow-up

KW returned for follow-up 1 week later, reporting good vision but complaining of discomfort OD over the previous 2 days. Both lenses appeared clean on the eye, in addition to centering and moving well. After lens removal, I observed light fluorescein staining adjacent to the superior limbus OD and OS, somewhat heavier in the right eye.

I dispensed a fresh pair of duplicate lenses and recommended that KW switch to a hydrogen peroxide-based care system.

KW returned 9 days later, again reporting good vision but reduced comfort, now with each eye. Superior corneal staining was improved significantly, but because of the patient’s persistent complaints of discomfort, I refitted her with lenses designed to improve symptoms of discomfort from dryness. I instructed the patient to return in 1 week.

At the follow-up visit, KW reported good vision and adequate comfort. Slit lamp examination revealed a good fit and physiological response. The patient was released for 1 year, and she purchased a 3-month supply of lenses.

Three months later, KW telephoned our office to report she felt there was no significant difference in her vision or comfort with the new lenses compared to her original lenses. She wanted to go back to wearing her original lenses due to cost savings. We prescribed these lenses.

One Year Later

KW returned for her annual examination and again reported dryness with contact lens wear. She did not feel her symptoms had progressed significantly over the prior year.

Slit lamp examination revealed good lens centration and movement OD and OS. Following lens removal, I observed clear corneas. Lissamine green revealed significant conjunctival staining in each eye (see photo).

I prescribed cyclosporine ophthalmic emulsion (Restasis, Allergan Inc.) for each eye twice a day, before and after contact lens wear. I also prescribed loteprednol (Lotemax, Bausch & Lomb) for each eye twice a day for 1 month, followed by once a day for 2 weeks, after which she was to discontinue therapy. I instructed the patient to return for follow-up in 6 weeks.

The patient called our office 5 weeks later, indicating she had not filled either prescription for drops. She reported her contact lenses felt “OK,” and she simply wanted to refill her prescription for her original lenses. I prescribed the lenses, and we scheduled the patient to return 1 year later for her annual examination.

Discussion

Despite our best efforts, KW has chosen to tolerate contact lens-related dryness rather than invest in treatment strategies designed to alleviate such symptoms. I will continue to monitor her condition on a regular basis and inform her of my findings. As I offer treatment strategies, I hope to arrive at an option that provides value that meets this patient’s financial, as well as ocular, requirements.

By Thomas G. Quinn, OD, MS, FAAO
Athens, Ohio

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