Dry Eye Dx and Tx
Preparing Dry Eyes for Lenses
BY WILLIAM TOWNSEND, OD, FAAO
Our patient presented with an all-too-familiar history. This 38-year-old female began wearing contact lenses in high school and had comfortable, clear vision for many years. In recent years, contact lens wear had become increasingly difficult; she reported lens-related ocular burning, discomfort, and fluctuating vision that worsened during the course of her workday. Extended computer time seemed to make her symptoms worse. She consulted several eyecare practitioners who had changed lens materials, care systems, and/or recommended rewetting drops, but she remained “miserable and frustrated.”
Visual acuities with contact lenses were 20/20 at distance and near. Our evaluation revealed moderately coated, poorly wetting soft lenses; conjunctival fluorescein staining; and moderate-to-severe meibomian gland dysfunction (MGD). Fluorescein breakup time was four to five seconds OD and OS. The patient’s underlying problem was not so much her contact lenses—it was a compromised ocular surface. We explained our findings and told her it was time to take a break from contact lens wear.
Resolving the Real Problem
In virtually every facet of health care, patients are “prepared” for therapy or a procedure. For instance, individuals about to undergo surgery are instructed to discontinue all food and drink for a specified time prior to the procedure. It is also important to “prepare” the eyes for lens wear, particularly when they are dry.
For our patient, after six weeks of spectacle wear during which she underwent treatment for dry eye disease (DED), she resumed lens wear with good comfort and vision. She maintains an ongoing regimen of DED therapy.
As a female, our patient had a significantly higher risk for DED compared to males of the same age. The female-to-male risk factor for developing DED ranges from 17.0% versus 11.1% to 22% versus 12% (Bron et al, 2014). The reasons are multifactorial, but declining androgen levels and inflammation are believed to contribute to these gender differences (Epidemiology Subcommittee of the International Dry Eye WorkShop, 2007).
Regardless of the cause or gender, DED impacts contact lens wear. Dumbleton et al (2013) surveyed 4,207 contact lens wearers and reported a 23% incidence of permanent discontinuation of lens wear. The primary reasons were discomfort and dryness.
How do we as healthcare providers determine when patients should discontinue wear? The answers are complex, and the literature has virtually no information on physician-directed contact lens cessation. Ultimately, the decision depends on one question: What is best for a patient? Conditions that threaten the health of the eye would certainly qualify. Less obvious conditions that could provoke discontinuation include severe MGD, lid wiper epitheliopathy, corneal edema, and obvious evidence of dry eye-related ocular surface damage. Ramamoorthy et al (2008) identified four features suggestive of dry eye as a contributor to lens intolerance: 1) symptoms of dry eye while not wearing contact lenses, 2) reduced overall satisfaction with current contact lenses, 3) reduced daily wear time, and 4) inability to wear lenses as long as desired.
Give Patients a Break
One of the kindest, most productive things that an eyecare provider can do is order discontinuation of lens wear when indicated. Patients may actually be relieved to have “permission” to temporarily stop wearing lenses. It also serves as a starting point for rehabilitation of the ocular surface so that patients can eventually resume contact lens wear with better odds for success. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #233.
Dr. Townsend practices in Canyon, Texas, and is an adjunct professor at the University of Houston College of Optometry. He is president of the Ocular Surface Society of Optometry and conducts research in ocular surface disease, lens care solutions, and medications. He is also a consultant or advisor to Alcon, Allergan, NovaBay, TearScience, TearLab, and Science Based Health. Contact him at firstname.lastname@example.org.