Reader and Industry Forum
Want to Retain Contact Lens Patients? Treat Their Dry Eye
BY MARGUERITE B. McDONALD, MD
Despite the tremendous breakthroughs in contact lens materials and designs, the adoption rate for contact lenses has held steady at about only 20 percent of the U.S. population (allaboutvision.com). For every new contact lens wearer an established one drops out, most often because of discomfort (Richdale et al, 2007). In my experience, untreated external disease—dry eye, blepharitis, or both—is at the root of this high attrition rate.
Dry eyes are a natural consequence of aging, especially for women. This trend is compounded by the long hours that many working adults spend at the computer and by the widespread use of systemic medications that dry out the eyes: heart rate regulators, cholesterol-lowering drugs, antidepressants, antihistamines, and thyroid medications are common culprits taken by millions of Americans. Add contact lenses, and the strain on the ocular surface can be too great for comfort.
As a surgeon, I know that dry eye also makes failed lens wearers poor candidates for laser vision correction. The first step for me—whether I'm trying to help patients stay in contact lenses or get ready for surgery—is to improve their ocular surface health.
Start With the Tears
The very first step for anyone struggling with dryness symptoms is to use an excellent artificial tear frequently throughout the day. Regardless of labeling, I believe that almost any artificial tear can be used up to four times a day with contact lenses. I like to use a high-quality, long-lasting tear designed to spread out quickly on the eye, stabilizing the tear film. Because it is gently preserved, I will recommend Blink Tears (Abbott Medical Optics) as often as eight times a day for contact lens wearers who need frequent lubrication. It is also available in non-preserved and contact lens wetting drop formulations.
Blurred or fluctuating vision, partly due to rapid tear film breakup, is a major complaint of contact lens wearers who are suffering from dry eye. Good artificial tears can bolster the tear film and smooth the optical surface, improving the consistency and quality of vision. Studies have shown, for example, that higherorder aberration (HOA) is affected by dry eye (Wang et al, 2009).
I recently participated in a randomized, prospective study evaluating post-LASIK HOA after instillation of artificial tears (Donnenfeld et al, 2009). The group using Blink Tears demonstrated a reduction in root mean square (RMS) HOA of 0.014μm, while the group using Systane (Alcon), had a slight increase in RMS HOA of 0.011μm (P=0.021). Although these subjects were dealing with post-surgical dry eye rather than specifically with lens-related dryness, the effect of dryness and lubricating drops on HOAs and quality of vision is important to understand.
I like to use Blink Tears because I've found them to be non-blurring in my patients, so using them several times a day doesn't inconvenience patients.
I recommend that patients use a thicker lubricant at night. Gen-Teal Gel (Novartis) is a good choice for contact lens wearers because, unlike bland ointment and other thick ointments, it won't leave a residue on the lenses the next morning.
Treat Dry Eye Early
For many contact lens patients who are near the dropout point, tears may not be enough. My typical regimen also includes cyclosporine 0.05% (Restasis, Allergan) twice daily, omega fatty acid supplements formulated for dry eye, and punctal occlusion in addition to artificial tears during the day and a lubricant at night.
I instruct patients who have blepharitis to use lid scrubs and warm compresses before applying lenses and after removal. For moderate to severe blepharitis cases, I add topical azithromycin (Azasite, Inspire Pharmaceuticals) twice a day for two days, then once a day for 28 days.
I prefer to be aggressive initially in treating dry eye in a contact lens wearer, then back off as the ocular surface begins to heal. That way, patients experiences some relief and can feel optimistic about their contact lens wear.
Some other advice for contact lens wearers who have dry eye:
• Keep the lenses very clean and replace them frequently, perhaps even more frequently than the label suggests. An irritated ocular surface is very sensitive to debris on the lenses.
• Never sleep in your lenses, even if they are approved for continuous wear.
• Remove your lenses for long airplane flights and in extremely low-humidity environments.
• Wear wrap-around sunglasses and a hat outdoors to block wind.
• Direct air conditioning vents away from your face.
Of course, it's also important to be sure that patients are wearing lenses made from silicone hydrogel material whenever possible and using appropriate care systems that are compatible with the lens material.
Reduce Dry Eye, Not Lens Wear
In my experience, there are very few patients who can't successfully wear contact lenses if they adhere to the regimen I've described. Patients are grateful to once again be able to wear their lenses all day, and they become loyal to the practitioner who gets them to that point. We can slow down the contact lens attrition rate by being more proactive in diagnosing and treating dry eye, to the benefit of our patients and our practices. CLS
To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #177.
Dr. McDonald is a clinical professor of ophthalmology at NYU School of Medicine in New York City; she is in private practice with Ophthalmic Consultants of Long Island in Lyn-brook, N.Y. She is also a consultant or advisor to Abbott Medical Optics. Contact her at (516) 593-7778 or firstname.lastname@example.org.