dry eye dx and tx
Managing Dry Eye in Specialty Lens Patients
BY ANN LAURENZI, OD, FAAO
More than a million contact lens wearers drop out of lens wear annually due to end-of-day discomfort issues, many associated with dry eye symptoms. However, some patients don't have the option to drop out because they need contact lenses to achieve functional vision for everyday activities. Examples include keratoconus patients, post-PK patients with anisometropia who can't be corrected in spectacles or post-trauma patients who have irregular astigmatism.
I would like to offer a few clinical pearls that have proven successful for keeping such patients in my specialty contact lens clinic comfortable during lens wear.
Pre-Contact Lens Wear
Many specialty lens patients have underlying conditions such as allergies, mild inflammation or tear film insufficiencies, which produce mucus debris that can accumulate, collect and deposit in the lashes, lid margins and conjunctival fornix. It may help to teach such patients to do a saline rinse before lens application.
Have patients lie down with a towel under their head and stream saline into all four quadrants of the eye. They should look down and, while holding the upper lid, stream the saline to rinse under the upper lid; then look up to rinse the inferior conjunctival fornix and repeat the process for the nasal and temporal quadrants.
Performing a saline rinse can remove debris that could get trapped under the lens and irritate the eye throughout the day.
Advise instilling a lubricating eye drop prior to lens application. Cohen et all (2004) showed that doing so can increase wear time and end-of-day comfort.
|TABLE 1 Ingredients in Contact Lens Rewetting Drops|
|Wetting Agents: Surfactants that act on the surface to wet/clean the lens.|
Demulcents: Agents that protect and lubricate mucous membrane surfaces.
Electrolytes: Help maintain the integrity of the corneal epithelium.
Buffering agents: Maintain the pH of the solution.
Preservatives: Ward off bacterial contamination. Recommend preservative-free drops or those with rapidly metabolized preservatives for patients who use them more than three-to-four times daily to limit toxicity.
During Contact Lens Wear
Advise patients to use lubricating drops during lens wear. Although it's safe to use nonpreserved artificial tears with contact lenses, they only hydrate and do not provide the benefits of drops that are specifically formulated to be used with contact lenses. The ingredients in contact lens rewetting drops are designed to moisturize, clean and lubricate rather than just hydrate the lens (Table 1).
Have patients take out their lenses mid-day to clean and soak them. Removing a soft or GP lens and placing it in solution even for a minimal time of 15 minutes can rehydrate and clean the lens, allowing for more hours of wear and comfort.
Prior to removal, instruct patients to use their rewetting drop to loosen the lens for removal. Lubricating the lens and ocular surface will make removal easier and the eye more comfortable post-lens wear.
Using a lubricating drop after lens wear can restabilize the tear film and quiet the ocular surface. If a lubricating drop isn't enough because the epithelium is disrupted, instruct patients to use a gel or ointment at bedtime to restore the irritated surface. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #153.
Dr. Laurenzi practices at the Cole Eye Institute in Cleveland, Ohio, where she specializes in refractive surgery co-management, contact lenses and clinical research.