Managing Ocular Surface Irritation in a Busy Specialty Practice
Relieving discomfort for visually compromised specialty lens patients may be easier than you think.
By Jeffrey Dougal, OD, FAAO
A 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 surface.
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 resolution.
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.