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.
Taking Action
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.
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TABLE
1 |
|
Clinical Tests for
Dry Eye
• Palpebral
Aperture Size
• Blink Patterns
• Lid Closure
• Lid Margin Evaluation
• Lid/punctal Apposition
• Tear Volume
• Ocular Surface Evaluation
Staining Patterns
• TBUT/Tear Stability
• Meibomian Gland Evaluation
• Drainage System
|
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
Consulting Associates.
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.
Contact Lens Spectrum, Issue: January 2006