discovering dry eye
Fitting Tips from the Experts
BY KELLY KINNEY NICHOLS, OD, MS, FAAO
Marginal dry eye or contact lens-related dry eye is often a condition based on symptoms and is usually diagnosed by exclusion. Researchers are taking steps towards understanding the etiology, but until the mysteries of dry eye are unraveled, clinicians must do their best to manage contact lens patients with available tests and contact lenses.
I polled a group of respected contact lens practitioners to determine fitting preferences in response to four patient scenarios.
1. The New Dry Eye Fit
An 18-year-old, athletic non-contact lens wearer with marginal dry eye presents to your office to be fit with contact lenses. How do you proceed?
Most recommended managing any existing lid disease or ocular allergy prior to beginning the fitting process. Lenses mentioned were (in order): low water content lenses (Ocular Sciences' Hydron Biomedics 38), non-ionic lenses (B&L's SofLens66, Biocompatibles' Proclear, Benz Research and Development's Extreme H2O) and daily disposable lenses. Several practitioners suggested considering RGP lenses and avoiding Group IV lenses with thin edges. Re-evaluate dry eye status following the fit, and consider frequent rewetting drops and punctal occlusion as needed.
2. Gradual Onset Irritation Symptoms
A long-term two-week disposable Acuvue contact lens wearer complains of dryness and irritation with lens wear. She uses "whatever solutions are on sale." How do you proceed?
Most practitioners in this situation rule out solution sensitivity first. Following a solution change to CIBA Vision's Quick Care or hydrogen peroxide based systems, the lens material can be changed if needed or punctal occlusion added. Non-preserved artificial tears were recommended, and daily disposable lenses may also be considered to eliminate issues with solutions. One practitioner said, "When it comes to contact lens-related dry eye, the solution is guilty until proven innocent."
3. RGP Patient with Reduced Wear Time
An RGP patient with 1.00D of astigmatism and dry eye problems is experiencing discomfort, reducing his wearing time. How do you proceed?
Most clinicians polled would evaluate the fit and surface of the current lenses and make any lens modifications (adequate tear exchange and edge lift) before switching out of RGP lenses. Surface wetting is important. Fluorosilicone acrylate lens material and Optimum (formerly Lobob) solutions may improve wettability. Following lens modification, many clinicians will consider artificial tears or punctal occlusion. A switch to soft toric lenses is generally recommended when other RGP alternatives fail.
4. Dry Eye and Soft Toric Lenses
A new patient to your office presents wearing soft toric contact lenses (brand unknown) on a yearly replacement basis. She comments that she has been previously diagnosed with dry eye and uses artificial tears b.i.d. to successfully manage dry eye symptoms while wearing lenses. How do you proceed?
A switch to a frequent replacement toric lens and maintenance of artificial tears was the preferred management for this patient. Suggested toric lenses were: B&L's SofLens66 Toric (two-week disposable), CooperVision Preference Toric (three-month replacement), or B&L Optima Toric (three-to-six month replacement).
Almost Anything Goes
Based on the above opinions, there are many approaches in the management of dry eye in contact lens patients. In addition, patient lifestyle is important for the new contact lens patient, and up-front chair time can be beneficial in maintaining patient satisfaction with the lenses and the service. A special thanks to my contact lens colleagues who participated in this e-mail survey.
Dr. Nichols is a graduate research associate at The Ohio State University College of Optometry in the area of dry eye research.