contact lens practice pearls
The Importance of the Eyelid
The eyelid is an often overlooked player in contact lens management. An important part of any baseline slit lamp examination should include a thorough examination of the eyelids. This includes both the eyelid margins and the palpebral conjunctiva, particularly the superior tarsal plate. The eyelid margin is a hotbed of metabolic activity. Meibomian glands produce oil into the tear film and onto the ocular surface. cludes both the eyelid margins and the palpebral conjunctiva, particularly the superior tarsal plate.
The eyelid margin is a hotbed of metabolic activity. Meibomian glands produce oil into the tear film and onto the ocular surface. Disorders at the margin can adversely effect these functions.
Poor oil production leads to rapid tear breakup. This predisposes the contact lens wearer to experience dryness and/or rapid lens surface spoilage.
Most eyelid margin pathology results from bacteria feasting on the oil deposits on the lid margin. In addition to compromising oil production, these bacteria produce exotoxins that can lead to corneal complications such as marginal infiltrative keratitis.
Telltale signs to look for are thickened, scalloped lid margins with pouting glands or oil caps at the meibomian gland openings.
Lid scrubs and warm compresses (outside therapy working in) combined with an oral agent such as doxycycline (inside therapy working out) can provide dramatic improvement.
Make Lid Eversion Standard
Eversion of the upper eyelid allows for examination of the superior tarsal plate. Make this procedure standard when examining a patient who's wearing or considering contact lenses. Look for generalized changes suggestive of seasonal allergies. If noted, be proactive and prescribe anti-allergy therapy. More isolated areas of change of the superior conjunctiva is a sign of mechanical irritation from a contact lens edge or from blinking over a soiled lens surface (Figure 1).
Figure 1. Superior tarsal
plate changes resulting
from edge irritation from
a high modulus silicone
Failure to examine the superior tarsal plate can lead to unnecessary and ineffective approaches to solving persistent problems of discomfort and rapid contact lens spoilage. It only takes a moment and can save aggravation and embarrassment. Once discovered, you can effectively manage GPC with temporary lens discontinuation, topical antihistamine/mast cell stabilizers and/or topical steroids and the use of daily disposable lenses.
Upper eyelid position relative to the upper limbus plays a major role in GP lens fitting. An eyelid that covers the upper limbus allows for a lid attachment fit in which the upper lens edge tucks under the eyelid. Because the lid margin doesn't pass over the lens edge with each blink, this approach improves comfort.
Of course, lower lid position is important when fitting a translating GP bifocal. Ideally the lower lid would lie tangential to the lower limbus to support the lens adequately. A lower lid that covers the lower limbus may be acceptable, but you may have to limit the near segment size to fit it between the lower pupil and the lower lid. A bottom lid that lies below the lower limbus precludes translating bifocal use.
Make it your mission to be vigilant about assessing eyelid condition and position when examining a lens candidate or current wearer. This approach will help you avoid potential problems and solve existing complications efficiently and effectively.
Dr. Quinn is in group practice in Athens, Ohio. He is a diplomate of the Cornea and Contact Lens Section of the American Academy of Optometry and an advisor to the GP Lens Institute.