Imagine an ideal world in which contact lenses are fit only on pristine eyes. These eyes do not have any signs of disease or dryness. After contact lenses are fit, the patients report exceptional vision, deny any discomfort, and contact lens wear continues successfully for the rest of their lives.
In reality, this is not the case. Often, patients experience blurry vision or discomfort, leading to reduced wearing time of contact lenses each day. Contact lenses are then worn less frequently each week. Eventually, contact lens wear is discontinued altogether.
But this sequence of events is not necessarily inevitable, and it is often preventable. This article will discuss some of the factors associated with contact lens discomfort and what steps to take both before and after initiating or resuming lens wear to help ensure wearing success.
A CLOSER LOOK AT CONTACT LENS DISCOMFORT AND DROPOUT
The discontinuation, or dropout, of contact lenses has not changed much over time. According to published studies, contact lens dropout ranges from 15% to 23% of wearers.1 These rates are extremely high, especially with the advancements in contact lens materials and designs currently available. In a study that evaluated the impact of contemporary contact lens materials and designs on contact lens discontinuation, the primary reasons for discontinuation were discomfort and dryness; the secondary reasons were red eyes and expense.2 Of interest, there was no difference in compliance with lens replacement between current contact lens wearers and those who discontinued contact lens wear.2 Silicone hydrogel contact lens wearers had lower dropout rates.
One reason for this dropout rate is that contact lens wear is intrinsically inflammatory, according to a recent analysis of uncomplicated contact lens wear.3 The classical, clinical definition of inflammation includes rubor (redness), calor (heat), tumor (swelling), dolor (pain), and functio laesa (loss of function); the contemporary, subclinical definition of inflammation of cellular and biochemical reactions was examined.3 Hydrogel contact lens wear fulfilled all clinical and subclinical criteria. Most criteria were met with silicone hydrogel lens wear.
Contact lens discomfort is a significant and challenging problem frequently experienced by lens wearers.1 With contact lens discomfort, there are episodes of persistent adverse sensations of the eye related to contact lens wear due to poor compatibility between the contact lens and ocular environment. These episodes may or may not be accompanied by visual disturbance.1
Contact lens discomfort can eventually lead to discontinuation of contact lens wear.4 The frequency of dryness and discomfort has been reported to range from approximately 30% to 70% of contact lens wearers.5
The progression of contact lens dropout has been well defined by the Tear Film and Ocular Surface Society (TFOS).1 First, patients struggle with contact lens wear, are physically aware of contact lenses, and their vision is affected. Next, comfortable wearing time of contact lenses is reduced. Subsequently, total wearing time of contact lenses lessens. Temporary discontinuation of contact lens wear follows, and finally, permanent discontinuation, or dropout, of contact lenses occurs.
ONLY FOOLS RUSH IN
When patients present with an interest in contact lenses, experts who were interviewed encouraged practitioners not to rush into contact lens fitting immediately.6 For contact lenses that are not fit for medical necessity, in which immediate fitting is necessary, it is advised to pause, discuss contact lens options, and evaluate the ocular surface prior to fitting contact lenses. If contact lenses are fit immediately, the ocular surface does not somehow “get better” or “improve” over time.
It is helpful to ask patients whether they have previously worn contact lenses. If so, investigate the positive and negative aspects of their experience with lens wear. If patients discontinued contact lenses, ask why they did so. Was it specifically due to difficulty with vision, comfort, limited wearing time, or all three?
To have a successful contact lens experience, it is critical to treat ocular surface disease and alter contact lens habits. Take, for example, a soft multifocal lens wearer. Instead of changing designs, powers, replacement schedules, or materials, treat the ocular surface first to obtain the best outcome as quickly as possible.
Treating the ocular surface prior to lens fitting helps extend the comfortable wearing time of contact lenses each day.7 It also helps improve the comfortable wearing time of lenses at the end of the replacement period.7
Addressing the ocular surface improves vision in general and especially with contact lens wear, which is especially important for multifocal contact lens wearers. This also speeds up the time to achieve a successful contact lens fit, which reduces chair time, saving time for both practitioner and patient.
DIAGNOSING DRY EYE AND LENS DISCOMFORT
Dry eye is a highly prevalent condition, ranging from approximately 7% to 34%.8 Dry eye disease (DED) is a chronic and common problem, particularly in adults age 50 years and older.8 There are many different intrinsic factors that cause dry eye, including female gender, hormonal changes,8 and autoimmune conditions such as Sjögren’s syndrome, lupus, rheumatoid arthritis, and diabetes. Extrinsic factors that exacerbate dry eye symptoms include hormone replacement therapy, androgen therapy, vitamin A and D deficiency, a diet low in omega-3 fatty acids, refractive surgery, and medications including anticholinergic drugs, antidepressants, antipsychotics, medications for Parkinson’s disease, and antihistamine drugs.8 Environmental factors such as pollen, working on electronic devices such as computers, overhead ceiling fans, and/or contact lens wear can worsen dry eye.9
Contact lens wear is an independent risk factor for DED. The presence of contact lenses on the eye may lead to dryness. A contact lens segregates the tear film into pre- and post-lens layers, with the minority of the bulk of tears behind the lens. Studies have noted a reduced tear meniscus height10 and an increase in tear film evaporation10 with contact lenses.
Now let’s circle back to our patient who is interested in contact lenses. Prior to commencing a contact lens fitting, it is pertinent to first identify and manage ocular surface disease. According to Sullivan et al, there is often a poor correlation between the symptoms and severity of DED.12 In their retrospective analysis that evaluated the signs and symptoms of dry eye, only 57% of patients who had clinical signs of DED were symptomatic. The only correlations between the signs and symptoms were corneal and conjunctival staining.12
It is essential to evaluate the ocular surface, tear film, and meibomian gland structure and function. According to The International Workshop on Meibomian Gland Dysfunction (MGD) report, MGD can lead to an altered tear film, resulting in eye irritation and clinically apparent inflammation and ocular surface disease.13 Lemp et al reported that 86% of patients had some degree of MGD, and the number of patients exhibiting only MGD (n = 79) was more than three times greater than the number of patients exhibiting only aqueous deficient dry eye (n = 23).14 Meibomian glands are important to provide lipids to the tear film. Intact, well-functioning meibomian glands enhance tear film stability, creating a more even tear film and a smooth optical surface for the cornea at the air-lipid interface. This healthy, functional tear film and ocular surface can improve vision and ocular comfort, particularly in contact lens wearers.
Of interest, there is a higher frequency of MGD in contact lens wearers.15 A 2016 study evaluated the effect of long-term contact lens wear on the morphology of meibomian glands using meiboscore and digital analysis.16 This study determined that long-term lens wear of more than three years can cause meibomian gland loss. The authors advised that digital analysis is helpful in the morphologic evaluation of meibomian glands. When evaluating MGD, it is helpful to determine whether eyelid telangiectasia is present, the number of glands present, whether there is any evidence of meibomian gland orifice obstruction, and whether there is decreased quality of meibomian gland secretions. Meibomian gland dropout can be visualized using transillumination or infrared photo imaging (Figure 1).
There are multiple ways to diagnose dry eye disease. Fluorescein, rose bengal, and lissamine green vital dyes can be used to stain the cornea and conjunctivae (Figure 2). Tear film breakup time correlates with aqueous and evaporative tear deficiency. Schirmer’s test and phenol red thread may be used to assess tear production. The components of the tear film may be evaluated by determining tear film osmolarity and matrix metalloproteinase-9 (MMP-9) levels. Tear meniscus height may also be evaluated. Several dry eye questionnaires are available, which are valuable to obtain information prior to the objective examination. It is now possible to utilize novel computerized technology to assess the entire ocular surface, tear film, and meibomian glands.17
When traditional clinical dry eye findings are absent but patient symptoms are present, staining the lid wiper with vital dyes can be beneficial. Korb et al reported a significant difference (P < 0.0001) in the frequency of lid wiper staining between the symptomatic and asymptomatic groups.18 Symptomatic patients had 76% staining of the lid wiper compared to 12% in the asymptomatic group. Both subjective and objective findings provide valuable information about each patient, with the purpose of forming a personalized treatment plan.
PREPARING THE OCULAR SURFACE FOR CONTACT LENS WEAR
Maximum success with contact lenses is achieved by preparing the dry eye for contact lens wear. Patient education is imperative. As dry eye is a chronic condition that affects quality of life, management strategies are used long-term over weeks, months, or years. Explaining the chronic disease state, how it interacts with the ocular surface, how contact lens wear is affected, and management strategies will enable patients to take responsibility and achieve the best results. Explaining management steps in a clear, detailed fashion will lead to the most successful outcome. Additionally, educate patients about why the initial contact lens wear needs to be delayed and the resultant expected benefits.
At subsequent visits, review the progress with patients and encourage continued home care. Explain the expected time frame of treatment before fitting contact lenses successfully, and keep patients informed at each step. Once contact lens wear is initiated or resumed, it is critical to keep the ocular surface healthy with ongoing management.
Children often present with an interest in being fit with contact lenses for the first time. It is easy to overlook dry eye disease in this population. A recent study evaluated children from 3 to 6 years of age for dry eye and found a 97.5% incidence of DED in subjects who had seasonal and/or perennial allergic conjunctivitis compared to a 27.5% incidence in controls.19
There are many therapies for managing dry eye disease. In fact, $3.8 billion is spent each year in the United States on dry eye symptom relief.20 Management options include over-the-counter artificial tears (either nonpreserved or preserved), topical gels, and ointments.
Prescription eye drops can add additional effectiveness in treating DED. Topical cyclosporine 0.05% may be used to increase tear production in patients who have suppressed tear production due to ocular inflammation. Topical lifitegrast 5%, a lymphocyte function-associated antigen intercellular adhesion molecule 1 antagonist, inhibits inflammatory pathways in DED by impeding T-cell activation and the release of inflammatory mediators. In severe cases of ocular surface disease, topical steroids and autologous serum drops can rehabilitate the ocular surface.
Punctal plugs, either collagen (temporary) or silicone (permanent), may help increase the quantity of tears to stay on the eye longer in those who have decreased tear production. If punctal plugs provide relief, punctal laser cauterization can be used to seal the puncta, which is a more permanent treatment option.21,22
Eyelid hygiene, including eyelid scrubs or foams, can be used on a daily basis. Warm compresses with warm wet washcloths, or with a variety of commercial products, are applied for five to 10 minutes daily to heat the eyelids, helping to loosen potentially clogged meibomian glands, enabling a healthy ocular surface. Next, gently moving the compress or cotton pad across the eyelid margins five to 10 times serves to scrub the eyelid and therefore remove any debris that may be blocking the meibomian glands. Additionally, removing eye makeup results in clean eyelids and helps create a healthy tear film.
Review the inflammatory role of allergies and dry eye as well as the importance of treating all conditions. Diagnosing and managing allergic eye disease is crucial for successful contact lens wear. Mast cell stabilizer/antihistamine eye drops, cool compresses, refrigerated artificial tears, wearing sunglasses when outdoors, leaving shoes outside, and bathing after exposure to allergens can all prevent ocular inflammation due to allergies.
Dietary supplements such as omega-3 fatty acids can help improve the quality of the meibum produced by the meibomian glands, thereby improving patient symptoms.23 Specifically, omega-3s that contain gamma-linolenic acid are very effective for MGD.24 Additionally, consider prescribing a topical emollient lubricant or liposomal spray, topical azithromycin, and oral tetracycline derivatives.25,26
There are multiple in-office procedures that employ heat, expression, thermal pulsation, and intense pulse light treatment aimed to improve meibomian gland function. Moisture goggles worn at night, moisture release eyewear worn during the day, and humidifiers are additive strategies for managing ocular surface disease.
Electronic devices alter the blink rate.27 The blink rate is 10 to 15 times per minute in normal individuals and may be up to 60% less when looking at electronic devices.28 Smartphones, which are held closer to the face, may increase digital eye strain. The Vision Council reported that 31% of Americans experience eye strain, 22% experience dry eyes, and 22.1% report blurred vision.29 Advise patients to follow the 20-20-20 rule, taking a 20-second break from digital devices every 20 minutes and looking at something 20 feet away. Additionally, reduce overhead lighting to eliminate screen glare, employ a proper viewing distance of arm’s distance away when looking at a screen, and increase text size on devices to better define the content on the screen.
CONTACT LENS CONSIDERATIONS
The TFOS recommended multiple approaches to manage contact lens discomfort.1 First, it is advised to eliminate the lens care system by changing to a daily replacement modality. Next, it is recommended to change the lens care solution or care system. The frequency of contact lens replacement may be altered. The lens design and/or material may be changed. Tear supplementation may be added, including lubricating drops, wetting drops, lacrimal inserts, and punctal occlusion. Incorporating dietary supplementation, such as evening primrose oil, or topical medications may be of benefit. Finally, the environment of contact lens wearers can be improved.
Using scleral lenses to manage ocular surface disease has been widely reported in the literature for many years.30 Scleral lenses may be used to improve corneal epithelial integrity, vision-related quality of life, and visual acuity in patients who have ocular surface disease.31-33 The post-lens fluid reservoir of scleral lenses protects and lubricates the ocular surface. However, poor wetting of the scleral lens front surface and fogging of the post-lens fluid reservoir are common sources of frustration for both practitioners and patients. Treating the underlying problem of DED will yield the best outcome for lens surface wettability and fogging. Additionally, using surface treatment technology, changing lens care both in regard to disinfection and application solutions, reviewing proper lens handling, replacing applicators, and altering lens design and materials are all options to improve complications related to scleral lenses.
Once contact lens wear is initiated or resumed, it is critical to keep the ocular surface healthy with ongoing management and regular follow-up appointments. At each subsequent visit, review not only contact lens solutions, handling, replacement, and wearing time, but also assess compliance with instructions for managing ocular surface disease. These can include drops, used both with and without contact lens wear; eyelid hygiene; dietary supplementation; and environmental factors.
THE ROAD TO CONTACT LENS SUCCESS
The next time a patient who has dry eye disease is interested in contact lenses, the temptation may be to proceed, hoping that contact lens wear may become more comfortable with time or the eyes will get better and become less dry. Pause, educate your patients, and manage ocular surface disease before proceeding with the contact lens fitting. Managing dry eyes prior to contact lens wear will improve outcomes in the long term, preventing contact lens dropout, which in turn benefits both patients and practitioners. CLS
- Nichols JJ, Willcox MD, Bron AJ, et al. The TFOS International Workshop on Contact Lens Discomfort: executive summary. Invest Ophthalmol Vis Sci. 2013 Oct 18;54:TFOS7-TFOS13.
- Dumbleton K, Woods CA, Jones LW, Fonn D. The impact of contemporary contact lenses on contact lens discontinuation. Eye Contact Lens. 2013 Jan;39:93-99.
- Efron N. Contact lens wear is intrinsically inflammatory. Clin Exp Optom. 2017 Jan;100:3-19.
- Nichols KK, Redfern RL, Jacob JT, et al. The TFOS International Workshop on Contact Lens Discomfort: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2013 Oct 18;54: TFOS14-TFOS19.
- Begley CG, Chalmers RL, Mitchell GL, et al. Characterization of ocular surface symptoms from optometric practices in North America. Cornea. 2001 Aug;20:610-618.
- Townsend W. Dry Eye Dx and Tx: Preparing Dry Eyes for Lenses. Contact Lens Spectrum. 2015 Apr;30:19.
- Fuller, D. Yes, Dry Eye Patients Can Wear Contacts. Review of Optometry. August 15, 2015. Accessible at www.reviewofoptometry.com/article/yes-dry-eye-patients-can-wear-contacts .
- The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5:93-107.
- Kumar N, Feuer W, Lanza NL, Galor A. Seasonal Variation in Dry Eye. Ophthalmology. 2015 Aug;122:1727-1729.
- Nagahara Y, Koh S, Maeda N, et al. Prominent Decrease of Tear Meniscus Height With Contact Lens Wear and Efficacy of Eye Drop Instillation. Eye Contact Lens. 2015 Sep;41:318-322.
- Guillon M, Maissa C. Contact lens wear affects tear film evaporation. Eye Contact Lens. 2008 Nov;34:326-330.
- Sullivan BD, Crews LA, Messmer EM, et al. Correlations between commonly used objective signs and symptoms for the diagnosis of dry eye disease: clinical implications. Acta Ophthalmol. 2014 Mar;92:161-166.
- Nichols KK, Foulks GN, Bron AJ, Foulks GN, Sullivan BD. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52:1922-1929.
- Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31:472-478.
- Machalińska A, Zakrzewska A, Adamek B, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea. 2015 Sep;34:1098-104
- Tang Y, Wu Y, Rong B, et al. The effect of long-term contact lens wear on the morphology of meibomian glands. Zhonghua Yan Ke Za Zhi. 2016 Aug;52:604-609.
- Baek J, Doh SH, Chung SK. Comparison of tear meniscus height measurements obtained with the Keratograph and Fourier Domain optical coherence tomography in dry eye. Cornea. 2015 Oct;34:1209-1213.
- Korb DR, Herman JP, Greiner JV, et al. Lid Wiper Epitheliopathy and Dry Eye Symptoms. Eye Contact Lens. 2005 Jan;31:2-8.
- Chen L, Pi L, Fang J, et al. High incidence of dry eye in young children with allergic conjunctivitis in Southwest China. Acta Ophthalmol. 2016 Dec;94:e727-e730.
- Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye disease in the United States: a decision tree analysis. Cornea. 2011 Apr;30:379-387.
- Willis RM, Folberg R, Krachmer JH, Holland EJ. The treatment of aqueous-deficient dry eye with removable punctal plugs. A clinical anti impression-cytologic study. Ophthalmology. 1987 May;94:514-518.
- Liu D, Sadhan Y. Surgical punctal occlusion: a retrospective study. Br J Ophthalmol. 2002 Sep;86: 1031-1034.
- Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Effect of re-esterified omega 3 nutritional supplementation on dry eyes. Cornea. 2016 Sep;35:1185-1191.
- Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linoleic acid on meibomian gland dysfunction. Cornea. 2007 Apr;26:260-264.
- Yoo SE, Lee DC, Chang MH. The effect of low-dose doxycycline therapy in chronic meibomian gland dysfunction. Korean J Ophthalmol. 2005 Dec;19:258-263.
- Kashkouli MB, Fazel AJ, Kiavash V, et al. Oral azithromycin versus doxycycline in meibomian gland dysfunction: a randomised double-masked open-label clinical trial. Br J Ophthalmol. 2015 Feb;99:199-204.
- Blehm C, Vishnu S, Khattak A. Computer vision syndrome: a review. Surv Ophthalmol. 2005 May-Jun;50:253-262.
- Acosta MC, Gallar J, Belmonte C. The influence of eye solutions on blinking and ocular comfort at rest and during work at video display terminals. Exp Eye Res. 1999 Jun;68:663–669.
- The Vision Council. Digital Eye Strain. Available at https://www.thevisioncouncil.org/content/digital-eye-strain . Accessed on June 5, 2017.
- Klein M. Contact Lens in Cases of Neuroparalytic Keratitis. Br J Ophthalmol. 1943 May;27:221-222.
- Schornack MM, Pyle J, Patel SV. Scleral Lenses in the Management of Ocular Surface Disease. Ophthalmology. 2014 Jul;121:1398-1405.
- Blackmore SJ. The use of contact lenses in the treatment of persistent epithelial defects. Cont Lens Anterior Eye. 2010 Oct;33:239-244.
- Bavinger JC, DeLoss K, Mian SI. Scleral lens use in dry eye syndrome. Curr Opin Ophthalmol. 2015 Jul;26:p.319-324.