Dry Eye and GP Lens Wear
BY EDWARD S. BENNETT, OD, MSED
Dry eye and contact lens wear is a popular topic with what appears to be an increasing number of patients. Jeff Sonsino, OD, recently sent me a case to review and discuss, and I sent it to several other members of the GP Lens Institute Advisory Committee who provided valuable insights into the management of this patient and the large number of others who suffer from dry eye.
Dr. Sonsino's patient had undergone LASIK and had been using Restasis (Allergan) for the past three months. Her vision was poor out of her bifocal GP lenses (20/40 OD with ghosting, 20/25 OS). Figure 1 shows the concurrent poor surface wettability with the right lens. She had plugged meibomian glands, trace frothing of the tears, 2+ conjunctival staining, and 3+ superficial punctate keratitis (SPK) OD and OS. She had tear breakup times of five seconds OD and four seconds OS. Her Ocular Surface Disease Index value was 69 out of 100, indicating moderately severe symptomatology.
Figure 1. Poor surface wettability on patient's right GP lens.
Dr. Sonsino aggressively managed her with hot compresses as well as a topical steroid. When minimal improvement was evident in one month, the SteriLid Eyelid Cleanser (Advanced Vision Research) daily eyelid hygiene system was added to her regimen. When she returned one month later, her SPK was greatly reduced and she was successfully fitted into a GP monovision correction with resulting vision of J3 OD and 20/20 (distance) OS.
What Else Could Be Done?
Dr. Sonsino asked the same question anyone else would: what else could be done in cases such as these? It is evident that meibomian gland dysfunction (MGD) needs to be treated before considering new lenses. As dry eye is a greater problem with post-LASIK patients, it is possible that MGD may be part of the formula for dryness in many of these individuals.
The recommendations provided by the advisory committee members included the following:
- Treat the MGD first and aggressively. The use of lid hygiene as noted along with digital expression can be complemented by the use of oral doxycycline and topical steroid therapy.
- Prescribe an omega-3 formulation. It may take several months before there is a significant effect, but such formulations are quite beneficial from an antiinflammatory standpoint
- Prescribe Soothe XP (Bausch & Lomb) or Restasis. Both formulations have emulsion vehicles. The difference, according to one GPLI Advisory Committee member, is that Soothe XP has more than two times the amount of oil and has the longest residence time of any tear formulation he has tested. Certain patients will need to discontinue these drops due to non-wetting as the oil load from the emulsion collects on the lens' front surface.
- Prescribe Azasite (Inspire Pharmaceuticals). This antibiotic that should soon be approved for treating blepharitis has great potential for MGD. One Committee member recommends using it as a pre-lens application drop in all contact lens patients for a quick lavage of the lids.
Another option if a patient remains symptomatic would be punctal plugs.
In December, I will discuss optimizing contact lens success in this and similar cases. CLS
Dr. Bennett acknowledges Drs. Ray Brill, Mile Brujic, Art Epstein, Steve Harney, Milton Hom, Jason Jedlicka, Dave Kading, Pat Keech, Neil Pence, Clarke Newman, Renee Reeder, and Christine Sindt.
Dr. Bennett is an associate professor of optometry at the University of Missouri-St. Louis and is executive director of the GP Lens Institute.