Contact Lens Practice Pearls
Become a Dry Eye Practitioner
BY GREGORY J. NIXON, OD, FAAO
The most contemporary summary of dry eye epidemiology data estimates prevalence rates ranging from 5 percent to 35 percent (Smith, 2007). However, dry eye symptoms are reported in up to 50 percent of contact lens wearers (Nichols, 2005). It is commonly accepted that dry eye symptoms are a leading contributor to patients ceasing lens wear. Yet, survey data (Karpecki, 2009) suggests that most practitioners aren’t adequately addressing their dry eye patients’ needs. With such a large unmet need, it is clear that contact lens practitioners need to focus on becoming dry eye practitioners as well.
Identify Your Dry Eye Patients
The first step is to properly identify dry eye sufferers. While most dry eye patients have symptoms, they are not always offered within a chief complaint. Therefore, it is valuable to institute a symptom survey to help identify and categorize the severity of dry eye patients. For a comprehensive look at dry eye questionnaires, consult the International Dye Eye WorkShop (DEWS) report (Smith, 2007). These surveys will give you direct information on patients, increase awareness of the condition and provoke more conversation about their symptoms.
Confirm and Classify
The 2007 DEWS report also revised the definition and classification structure for dry eye diseases. It highlighted the multifactorial nature of the condition and introduced inflammation as a key component of dry eye.
Therefore, dry eye evaluation must also be multifaceted. In addition to assessing tear volume, quality, and stability, it is necessary to interpret staining patterns and complete a full lid evaluation to rule out the presence or co-existence of anterior or posterior blepharitis.
Anterior blepharitis is characterized by redness, scaling, and crusting of the lids secondary to Staphylococcal overgrowth that can manifest as a direct infection or hypersensitive immune reaction.
Posterior blepharitis, including meibomian gland dysfunction (MGD), often displays clogged meibomian glands with thickened lipid secretions and thickened lid margins with telangiectasias and scalloped borders. MGD compromises lipid metabolism resulting in free fatty acid formation on the lid margin and ocular surface. These fatty acids are inflammatory in nature and can induce dry eye symptoms. There is overlap in many symptoms of dry eye disease and blepharitis, so careful clinical evaluation is important.
The survey data reviewed by Karpecki estimated that 72 percent of practitioners offered artificial tears as the only treatment plan to patients complaining of dry eye symptoms. It is clear that more practitioners need broader treatment strategies to appropriately treat the complex spectrum of dry eye and ocular surface disease. Proper assessment is critical to determine contributing factors that chronic infection and inflammation play in dry eye symptoms and to provide the corresponding treatment with appropriate antibiotic, steroid, and immunosuppressive therapy.
Once the disease process is actively managed, artificial tears still play a role as supportive therapy to alleviate symptoms. For contact lens wearers, be sure to recommend nonpreserved products or those with “vanishing” preservatives to limit chemical interactions with lens materials.
Make the Effort
Because dry eye symptoms are a leading contributor to lens dropout, we need to make a concerted effort to identify sufferers and address symptoms. Capitalize on the increased knowledge of dry eye management to alleviate symptoms and facilitate healthy and comfortable lens wear. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #176.
Dr. Nixon is an associate professor of clinical optometry and the extern director at The Ohio University College of Optometry. He is also in a group private practice in Westerville, Ohio. He is on the Allergan Academic Advisory Board and the B+L Advisory Board. You can reach him at firstname.lastname@example.org.