Targeting Medical Conditions
Your therapeutic interventions can be
critical to continued contact lens wear. Here's what to consider.
By Clarke Newman, OD, FAAO (Dipl)
To keep patients in contact lenses,
you'll need to manage any advanced inflammatory situations that might arise. Here,
I'll discuss therapeutic management tips that you should find helpful in these situations.
First Stop: Corneal
When you look
for ocular infection, first check for corneal involvement. Clinically, one of the
quickest ways to determine if you're dealing with infectious red eye, particularly
bacterial, is to look at the tear meniscus. Just as you find cells and flare in
the anterior chamber when diagnosing iritis, you'll see cells in the tear film in
these cases, particularly if you're dealing with a corneal ulcer.
determine if an ulcer is sterile or infectious, look at the meniscus at high magnification.
You'll see it right away, without having to order a battery of tests.
see if the patient has discharge and, if so, whether it's mucopurulent or serous.
Obviously, if a patient has a serous ulcer, you're not dealing with contact lens
dryness, although dryness could have played a role in the ulcer's development. You
want to diagnose his most serious problem and treat it, as soon as possible.
The new Proclear
bifocal is a great addition to our contact lens armamentarium. A patient experiencing
lens problems often will complain vaguely of poor acuity. When lenses dry out, vision
decreases. The bifocal patient is already visually compromised. If his vision is
further compromised by a drying lens, he'll be even more likely to stop wearing
lenses. We've taken a lot of patients who were bifocal dropouts in the Frequency
55 Multifocal, switched them into the Proclear material, and they're doing well
are acute, so treat them before they become a problem and cause your patients long-term
discomfort. This is doubly important for contact lens patients. When you have a
new patient, or even an existing one, take a very careful history. Nothing will
save you more time down the line. A good technician can take a thorough history
before you enter the room.
you find out a patient has seasonal allergies, address them right away. Write a
prescription for olopatadine hydrochloride ophthalmic solution (Patanol 0.1%), or
whatever medication you prefer, so the patient can wear his contact lenses during the allergy season.
When a patient
has perennial allergies, you need to remember that he suffers chronic symptoms.
This is the atopic patient who has self-tolerance issues. When you look at his tarsal
conjunctiva, you'll see mature as well as new follicles. You can put this patient
in new lenses and change his solutions, but if he's experiencing ocular inflammation,
you're not going to resolve the underlying issue.
perennial allergies, the condition comes and goes, but it's always there, waiting
to erupt beneath the surface. If you ask the patient the right questions, you'll
get the right answers. This patient tends to coat lenses, no matter what solution
to Solutions and Materials
Back when we
used soft lenses made of polymacon along with multiple-component care systems, the
last element to touch the eye was essentially saline. There weren't a lot of solution
Now we have very complex Group 4 materials that are primarily designed to be moldable
and not biocompatible. Because of this, we deal with very complex chemistries. We
combine these chemistries with a patient's tear chemistry and very complex
solution chemistries that clean, rinse, disinfect and provide protease activity.
All of this creates a much more complicated interplay. As a result, solutions interact
differently with different lenses on different patients. You can have a magic bullet
solution combination with a particular lens material that works great on one patient
but not so well on another.
Solutions interact differently
with different lenses on different patients. You can have a magic bullet solution
combination with a particular lens material that works great on one patient but
doesn't on another.
lens margin. One way to ferret out these
problems is to give a patient new lenses and prescribe unit-dose saline solution
for a week. If he still can't wear the lenses with saline, he won't be able to wear
them with any solution. If he can wear the lenses, then you can try a different
give up on a lens until you've exhausted your solution options. And don't be afraid
to go back to an older solution system, such as hydrogen peroxide, unless it is
contraindicated with the use of the newer lenses.
a footnote, material allergy is very rare, but when it does present, you'll see
a diffuse keratitis beneath the lens. Patients will say, "I'm allergic to this contact
lens," and in fact, this will be the case. You'll know it's time to change the material.
Dryness is an
issue in GPC, but the condition also can have an inflammatory component when contact
lenses challenge a patient's immune system. We're seeing an increase of GPC with
use of silicone hydrogel lenses. The modulus of these lenses is higher, making them
harder on the underside of the eyelid.
I recommend you
take these patients out of their lenses and treat them with corticosteroids and
mast cell inhibitors. I prefer to use a mild steroid, such as loteprednol etabonate
0.5% (Lotemax) or fluorometholone acetate 0.1% (Flarex). After you've treated the
GPC, you'll need to address the dry eye and lens fit issues that have caused the
give up on a lens until you've exhausted your solution options.
Acute Red Eye
The acute red
eye associated with contact lens wear is the result of a complex immune response.
The patient has developed memory cells from autologous proteins that have rejected
the lens system. At times, a secondary risk of infection may exist.
lens wear and treat the patient aggressively with a combination anti-infective/anti-inflammatory
medication, such as dexamethasone 0.1%/tobramycin 0.3% (TobraDex). It's important
to knock out inflammation quickly while eliminating any underlying infectious conditions,
because poorly controlled inflammation may lead to ocular damage.
you've quieted the eye, you'll need to refit the patient into another contact lens.
Use the FDA groups as described by Norman Leach, OD, MS, FAAO, on page 5. You want
to prescibe a material that's as different chemically from the previous lens as
possible. Some lenses work better with drier eyes and tend to be chemically unique,
such as the Benz material and the Proclear materials. These are good to try when
you're trying to fool the immune system.
If you use these
guidelines when managing inflammatory conditions, you'll successfully care for more
contact lens patients.
new materials, and treat patients aggressively when you see acute problems. Prescribe
anti-allergy medications early, clean up the lids, and you'll head off problems
at the pass.
specializes in cornea, contact lenses and refractive surgery consultation at his
practice in Dallas. He is the immediate past president of the Texas Optometric Association.
Contact Lens Spectrum, Issue: April 2005