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 Involvement
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.
To 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.
Next, 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.
Relief for Presbyopes
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 again.
Clarke Newman, OD
Seasonal allergies 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.
If 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.
With 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 you prescribe.
Allergies 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 incompatibility issues.
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 solution.
Don't 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.
As 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.
Giant Papillary Conjunctivitis (GPC)
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 the increased 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 problem.
Don't 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.
Discontinue 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.
After 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.
Use 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.
Dr. Newman 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.