Patients are asking more of their eyes than they ever have before. At increasingly younger ages, the population as a whole is spending large amounts of time staring at computer monitors, tablets, phones, and other digital devices. With that intense demand, blink quantity and quality decrease. Consequently, blinks often occur after the tear film breaks up, exposing the eye to the potential for corneal staining or damage to the corneal or conjunctival epithelium. Additionally, we see the meibum in meibomian glands stagnating, which ultimately leads to meibomian gland atrophy. Putting a contact lens on such an eye challenges the ocular surface and will only exacerbate any dry eye issues already present.
Despite an industry that spends millions of dollars in an attempt to make contact lenses more comfortable for patients, dropout rates have not decreased much over the last 20 years. In fact, contact lens discontinuation rates due to discomfort have been reported by various studies as ranging between 12% to 51%.1-5 While dry eye disease historically tended to be more prevalent in post-menopausal women,6 our society’s dependence on devices means that dry eye symptoms now encompass a wide range of patients.
Treating the ocular surface through a variety of methods will not only restore health to the eye but should also reduce contact lens dropout rates by relieving patients’ discomfort.
TREATMENT PARADIGM—WHAT WORKS AND WHAT DOES NOT
In the past, if I had a patient who presented with contact lens discomfort, my first response was to try a different contact lens material, care solution, or modality. I was, in effect, a brand and modality chaser, and I would try different options until we found something that worked. While this method may temporarily relieve symptoms, it does not address the underlying cause of those symptoms.
I have since taken the opposite approach, and I now treat the eye first. The state of the ocular surface is a significant factor. And, in most instances, if patients have well-hydrated eyes, contact lenses will work well without discomfort. On the other hand, if you have a borderline dry eye patient and try to fit that patient with a contact lens, this will ultimately result in a contact lens failure or dropout.
Dry eye is multifactorial, and it is crucial to understand all of the factors at play to successfully treat each patient. To that end, the majority of my patients, including those in a younger age bracket, complete a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. I have seen 10-year-old patients who have gland damage and 20-year-olds who have glands that appear decades older. The challenges to the ocular surface are greater than ever, and you cannot assume that patients will not have issues based on their age.
Multiple diagnostic tests are then conducted. We measure tear osmolarity in addition to the level of the inflammatory biomarker matrix metalloproteinase-9 (MMP-9), both of which are known to be elevated in patients who have dry eye. I also use lissamine green for conjunctival staining, and I look along the lid wiper region for any signs of extended lid wiper damage or a waxy buildup.
If the dry eye is inflammatory, I factor in the age of the patient prior to deciding upon the next step of treatment. For patients under 18 years of age, I do not typically move right to medications such as cyclosporine or lifitegrast, as I believe younger patients have enough of an immune reserve that their condition will not result in a chronic inflammation loop. Rather, they suffer from an acute response that is manageable. I typically treat these patients with blink exercises, taking breaks from devices, artificial tears, and nutritional supplements.
If the meibum is thickened, I prescribe warm compresses. It is not uncommon in children to have meibomian gland atrophy even though the meibum looks good. During periods of evaporative stress due a severely depressed blink rate, the need to constantly replace lost cells may lead to gland “burn out,” resulting in atrophy. This differs from obstructive meibomian gland dysfunction in which the meibum thickens and the glands die as a result of obstruction.
In older patients, if inflammation is detected, I begin them on cyclosporine or lifitegrast. If the meibum is thickened, we will discuss thermal pulsation treatments. Depending on the patient’s lifestyle, I may also recommend artificial tears. For those who spend a great deal of time on a computer or device, blink rates will inevitably be low. I do not want to rely on one medication such as cyclosporine or lifitegrast as a cover-all treatment. Adding an artificial tear several times a day helps to extend the tear film breakup time and gives the eye a little added protection. Artificial tears are osmoprotective as well and will aid in keeping the osmolarity in check so that it does not develop into an inflammatory trigger.
In general, if a patient’s test results are positive for MMP-9—and he or she is placed on cyclosporine or lifitegrast, and the follow-up exam shows no sign of elevated MMP-9 or inflammation but low tear volume—I utilize extended duration punctal plugs. These plugs can preserve a better-quality tear while the medicine works to return homeostasis to the lacrimal functional unit. I also look for any signs of blepharitis. Essentially, I want to clean up the surface of the eye, starting with the lashes and lids and working back to the cornea. I address and treat each problem that is discovered.
While dry eye is often inflammatory, this is not always the case. It is possible to catch the disease before it turns inflammatory, which is another reason why I screen such young patients. Keep in mind the multifactorial nature of this disease and the prevalence of outside components that may exacerbate dry eye. Many patients in their teens and 20s are heavy computer and electronic device users and are often taking antihistamines, oral contraceptives, or allergy medications, which are all substances that can cause dryness. If the disease is detected early enough, it is possible to stop inflammation before it starts and then simply treat with artificial tears.
THE BENEFITS OF NUTRITIONAL SUPPLEMENTS
The adjunct to any therapy that I advocate always includes nutritional supplements. To support a healthy ocular surface, treatment can also occur from the inside out. Combining nutritional supplements with blink exercises, warm compresses, immunomodulators, artificial tears (if necessary), and any other therapies that are appropriate ensures that patients receive a well-rounded treatment regimen to combat dry eye.
While there are several good nutraceuticals on the market, it is important to pay attention to the ingredients and scientific evidence. I prefer a patented formulation that includes the anti-inflammatory omega-6 fatty acid gamma-linolenic acid (GLA) along with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), the fatty acids found in fish oil. Unlike EPA and DHA, GLA is plant-based and has been shown to be very effective in relieving dry eye symptoms.7,8 The combination of EPA with GLA both suppresses pro-inflammatory mediators and stimulates anti-inflammatory activity, making it exceptionally beneficial for dry eye.9-13
Patients are well known to struggle with compliance. Consequently, there are certain steps that I take to help encourage cooperation. For example, nearly everything that I recommend for my patients is sold in the clinic as a method of driving compliance. Artificial tears, warm compresses, and nutritional supplements are all offered to both provide patients with an affordable, convenient location to purchase everything that they need and to ensure that patients are getting the correct products that will produce the results we want. Each patient’s file contains a list of his or her prescribed therapies, and a member of my staff will sit down with our patients and go over everything with them to ensure that they understand their management plan.
Sending patients home with written material to study at their convenience is also critical. The information flow during the office visit might be overwhelming for patients. Having that material in hand gives them an information source to which they can refer when needed.
Compliance does, to some degree, depend upon how much a patient wants relief from his or her symptoms. A patient who has a SPEED score of 13 (out of a possible 28), for example, will most likely be very compliant, while an asymptomatic patient who has a score of 2 might be more difficult to convince. Ensuring that patients are truly asymptomatic by asking the right questions with the SPEED questionnaire, and having the conviction that the treatment regimen chosen for each patient is the best course of action, can help with these patients.
From there, test results are tremendously helpful. Patients rarely argue with a positive test result. Being able to demonstrate the dynamic of how their tear film affects their vision is also immensely helpful in driving compliance. To do this, I ask patients to hold their eyes open after a blink as long as possible while looking at the 20/30 line, then blink to clear their vision. Being able to “see” why a hydrated eye is so essential typically convinces most patients of the importance of compliance. The most expensive glasses or contact lenses with the best optics in the world will not help if a patient’s tear film breaks up after 2 seconds.
Educating patients on the importance of ocular surface health is key to ensuring compliance. Not everyone will comply; however, as their eyecare practitioner, I lay out my best recommendations and do my best to assist in their therapy. My end goal is a pristine ocular surface, because a well-hydrated eye is a quiet, happy eye. CLS
- 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.
- Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26:168-174.
- Young G, Veys J, Pritchard N, Coleman S. A multi-centre study of lapsed contact lens wearers. Ophthalmic Physiol Opt. 2002 Nov;22:516-527.
- Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. Int Contact Lens Clin. 1999 Nov;26:157-162.
- Weed K, Fonn D, Potvin R. Discontinuation of contact lens wear. Optom Vis Sci. 1993;70(12s):140.
- Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003 Aug;136:318-326.
- Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008 Jun;31:141-146.
- Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003 Mar;22:97-101.
- Creuzot C, Passemard M, Viau S, et al. [Improvement of dry eye symptoms with polyunsaturated fatty acids] [in French]. J Fr Ophtalmol. 2006 Oct;29:868-873.
- Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011 Nov;89:e591-e597.
- Barham JB, Edens MB, Fonteh AN, Johnson MM, Easter L, Chilton FH. Addition of eicosapentaenoic acid to gamma-linolenic acid-supplemented diets prevents serum arachidonic acid accumulation in humans. J Nutr. 2000 Aug;130:1925-1931.
- Viau S, Leclère L, Buteau B, et al. Polyunsaturated fatty acids induce modification in the lipid composition and the prostaglandin production of the conjunctival epithelium cells. Graefes Arch Clin Exp Ophthalmol. 2012 Feb;250:211-222.
- Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013 Oct;32:1297-1304.