Ocular Surface Irritation in a Busy Specialty Practice
discomfort for visually compromised specialty lens patients may be easier than you
By Jeffrey Dougal, OD, FAAO
daily challenge exists in specialty contact lens practice trying to resolve
dry, itchy, red, stinging, burning and annoying eyes. I refer to this composite
of symptoms as ocular surface irritation or OSI.
The dilemma for practitioners in specialty practice
is that we face the already difficult procedures required to fit contact lenses
to existing compromised eyes that have conditions such as keratoconus, post surgical
LASIK and radial keratotomy, Intacs (Addition Technology), penetrating keratoplasty,
pellucid marginal degeneration, scarred and distorted corneas, etc. With so much
time and effort spent on fitting specialty patients, you need to learn how to efficiently
resolve the symptoms of OSI.
Causes of OSI
OSI can result from physiological factors that
include common systemic diseases such as Sjögrens disease, rheumatoid arthritis
and other dehydrating conditions.
Of course poor tear quality, poor tear production
and accelerated tear evaporation are strong underlying causes of ocular irritation.
Further compounding OSI is the use of systemic and ocular medications such as antihistamines,
decongestants, statins, muscle relaxants, oral contraceptives, HRT products, anti-acne
agents and a host of dehydrating medications.
Concurrently, environmental and vocational
issues can challenge our treatment skills. A regionally arid climate dehydrates
the eyes. Air conditioning or heating in the work place, home, or in transportation
vehicles saps the available moisture from the eyes and from the respective contact
lenses. Computer screens, reduced blink rate during extended periods of concentration,
high level fluorescent lighting and room fans all add to ocular dehydration.
Addressing OSI in Every Patient
Of course it's our job as eyecare practitioners
to resolve OSI for all patients. But time and convenience are critical for many
visually compromised patients who don't have the option to simply discontinue contact
lens wear and switch to spectacles because their vision is often too compromised.
Your first treatment protocol should be ocular
lubricants that are both effective and compatible with contact lenses and ocular
tissues. Suggesting alterations to patient habits and environments at home and in
the work place may help as well.
Reviewing and discussing effects of
medications and nutrition intake may be helpful, but seldom delineate altered action
on a long-term basis. Nutritional supplements may prove useful as treatment for
OSI related to dry eye conditions. Flaxseed oil, fish oil and other complex fatty
acid-based systemic products can be very helpful if taken regularly for a sustained
period of time.
Rewetting Drop Benefits
Regarding rewetting drops, a few on the market are effective in reducing symptomatic
OSI. Blink Contacts (Advanced Medical Optics) is one of the newer contact lens rewetting
products available, and I've found it one of the most effective and convenient.
Not only does this rewetting drop lubricate the ocular surface/contact lens interface,
it extends the tear breakup time (TBUT) as well.
In addition, we've found this product
is an excellent artificial tear when patients use it off-label without contact lenses
as an adjunct treatment for dry eye. Many patients are unwilling to use or are confused
by using one product to lubricate their eyes without their contact lenses and a
separate product to rewet their contact lenses and ocular surface during contact
lens wear. Being able to prescribe and recommend a single product for resolving
OSI with and without contact lenses is both convenient and great for compliance.
Of course, to be effective, patients
must regularly and frequently apply rewetting drops and artificial tears. Motivating
patients to instill lubrication before symptoms develop can help prevent or delay
symptoms. Hyaluronic acid, a naturally occurring viscoelastic substance and a key
ingredient in Blink Contacts, helps the product hold and release water on the ocular
Blink if You Have OSI
Most people are unaware of the severity of ocular dehydration that results from
reduced, infrequent or incomplete blinking. Patient consultation can be very effective
in altering poor blink activity. Recognizing that a normal and effective blink rate
is one about every 10 seconds, we should recommend that the suffering patient attempt
to comply with that frequency.
Also, bring attention to the fact that
extended concentration drastically reduces blink rate. Ask an affected patient to
observe the infrequency of blinking by others during computer activities, reading
a book, reviewing a lengthy document or watching television. Bringing this fact
to their attention may help them alter their deficient blink habit because they're
sure to notice that a concentrated stare is very common indeed.
Poor tear quality also exacerbates
ocular surface dehydration because of exposure evaporation. It makes sense that
if patients add lubricants and blink more often and more thoroughly, then they can
minimize ocular surface irritation. We see post-LASIK patients accrue their best
vision outcome when they keep their eyes moist during the long-term healing process.
Patients can accomplish the same thing by keeping OSI compromised ocular tissues
moist and spreading lubrication efficiently over the eye surface.
Contact Lenses and Lens Care
You also need to provide an overview of contact lens material and design options
as well as lens care products. New lens design options may help reduce ocular surface
irritation. Silicone hydrogels as well as newer high-water HEMA lenses can reduce
ocular surface dehydration. Fortunately, these options are available in single vision,
toric and multifocal designs. The benefit of silicone hydrogel in treating OSI is
reduced lens dehydration, which in turn reduces ocular tear degradation during lens
wear. If a patient reports ocular dryness or reduced wearing time, refitting to
this lens modality often provides relief from OSI. If tear and moisture evaporation
is not the basis for OSI suffering, then refitting the patient with lenses made
of omafilcon A or hioxifilcon A, both nearly 60 percent water, may provide an effective
Enjoy the Rewards
Even in a busy specialty contact lens practice
where time is a very scarce commodity, a persistent practitioner will find that
taking the time to resolve commonly occurring ocular surface irritation by
trying new eye care products and by maintaining an extensive inventory of contact
lens and contact lens care products is rewarding and appreciated.
Dr. Dougal is in private practice in Orange
County, CA, specializing in contact lenses. He serves as president of Orange County
Eyecare Optometry and also as a clinical investigator for contact lens and ocular
pharmaceutical companies. He is a diplomate of the American Academy of Optometry's
Cornea and Contact Lens Section.
Contact Lens Spectrum, Issue: November 2006