dry eye dx and tx
An Often Overlooked Source of Lens-Related Dryness
BY ANN LAURENZI, OD, FAAO
We are all aware of our contact lens patients' complaints of dry eye and the associated lens discomfort, compromised vision and decreased wear time. And we're acutely aware of the large number of patients who drop out of contact lens wear altogether.
Time and again I've seen patients who have undergone cleaning solution, wear schedule and lens material changes only to still have the same dry eye and contact lens problems. Thus, are we assessing patients fully to solve these dry eye issues?
Inspect the Lids
Dry eye issues may be exacerbated by contact lens wear, but many times the lenses are not the underlying etiology of the problems. An often overlooked condition that can cause dry eye and seemingly unsolvable contact lens intolerance is meibomitis. Even mild cases can compromise the tear film and create lid inflammation, which may decrease wear time, comfort and visual acuity in lens wearers.
Lid disease has a reported association in 67-to-75 percent of dry eye patients. Meibomian gland dysfunction commonly results from epithelial plugs or changes in the glands' secretions (hyperviscosity), causing gland obstruction and therefore reduced lipid secretion into the tear film. The lack of adequate lipids in the tear film can result in evaporative dry eye even if aqueous production is normal.
Bacteria growing on the eyelid margin may also break down meibomian gland secretions, resulting in irritation. Changes in meibomian gland secretions can also support bacterial growth, allowing for debris accumulation and crusting on the lashes. The poor quality and quantity of the tear film and associated inflammation is cause for decreased vision and overall irritation in any patient and definitely can produce complaints in contact lens wearers.
Treatment for meibomitis may include mechanical, systemic and localized therapy. Start with heat to melt the sebum and improve circulation. Follow this with lid hygiene and massage to open the glands and remove bacteria on the lids. Systemic anti-inflammatory therapy with omega-3 fatty acid supplementation (flax or fish oil) and/or antibiotic therapy tetra-, doxy- or minocycline) can break down congested oils in the glands. Localized therapy may include topical antibiotic ointments erythromycin or bacitracin) and immunomodulation with cortical steroids or cyclosporine drops.
Another emerging therapy is treating with azithromycin antibiotic (ophthalmic solution 1%) drops twice daily for two days, then once daily for 28 days. It's recommended to instill drops in the evening and then massage the lids to get maximum tissue penetration and effect.
When All Else Fails
So if your contact lens fit looks good, you've tried changing the care systems and materials or if you have fit a patient in daily disposable contact lenses and he's still complaining of dry eye, visual fluctuation and lens irritation, then assess the lids for meibomitis. You may just save another dropout! CLS
To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #151.
Dr. Laurenzi practices at the Cole Eye Institute in Cleveland, Ohio, where she specializes in refractive surgery co-management, contact lenses and clinical research.