Article

PRESCRIBING FOR PRESBYOPIA

PROACTIVELY MANAGE CONTACT LENS DRY EYE

A dreary, overcast April morning was brightened considerably when a youthful 52-year-old woman with short salt-and-pepper hair greeted me with a warm, engaging smile. New to our practice, she laughingly introduced herself as a “trailing spouse” whose husband had recently taken a job at the local university. Originally from northern Wisconsin, she and her husband recently became empty-nesters. With no children at home and a new community to explore, she dove in head-first. All of this gave birth to her new passion: tennis.

A tennis buddy suggested that she consider contact lenses, and she was “here to see what you think.” I told her that many patients enjoy the benefits of contact lens wear, particularly for sports. We proceeded with the examination to assess her viability as a candidate.

The patient’s general health history was significant for menopause, which she stated was managed effectively. She reported to otherwise be quite healthy. She described occasional use of artificial tears for allergies but had no significant complaints of eye dryness or redness. In the past, she wore her glasses primarily for reading but in recent years has found them also quite helpful when performing distance tasks such as driving, watching movies, and, of course, playing tennis.

Refractive findings were OD +1.50DS, +2.25D add, 20/20 and OS +1.75 –0.25 x 095, +2.25D add, 20/20. Keratometry was 42.75 @ 180; 42.50 @ 090 OD and OS.

External examination showed healthy-appearing eyelids but mild, diffuse bulbar injection OD and OS. Slit lamp examination revealed what appeared to be clear eyelid margins and a clear cornea OD and OS. The tear prism was normal OD and OS. Eversion of the eyelids revealed little to no injection or follicular changes of the palpebral conjunctiva, which I found surprising in light of the patient’s reported “allergies.”

Itching for An Answer

Intrigued by the lack of signs of allergy, I asked the patient when her eyes itched. She responded with a vague “every now and then.” Then the light bulb went on; I asked “Is it your eye or your eyelid that itches?” She responded “I guess I mean the eyelid. Right here.” She pointed to her eyelashes.

I proceeded to evaluate her meibomian glands, which expressed easily but carried moderately heavy particulate matter. The patient had meibomian gland dysfunction.

I told the patient that she was an excellent candidate for contact lens wear, but my examination revealed a common, chronic condition. I explained that the glands in her eyelids were not adequately producing oil into the tear film. Without the oil, the tears dry up too quickly, which would reduce comfort with contact lens wear.

I instructed the patient to clean her eyelids at the lash line twice a day for two weeks, then daily thereafter. I also prescribed a heat mask and instructed her to apply it at least daily for a minimum of 10 minutes. I shared with her that many of my patients found it most convenient to do this at bedtime. Following heat application, I encouraged her to “milk” the eyelid glands by rolling her clean fingers across her eyelids toward the lid margins.

After two weeks of eyelid therapy, there was improvement in gland expression. So, I proceeded to fit the patient with daily disposable multifocal soft lenses. She returned one week later with good results. We ordered an annual supply of the lenses and released the patient for one year.

The New Paradigm

No longer should we jump into contact lens fitting only to back-track when problems arise. By exploring the health of both the eyelids and the ocular surface and by proactively instituting treatment, we were able to satisfy this patient from the very start.

And she continues to do quite well. About a month after fitting this patient, we crossed paths in the local grocery store. She reported not only good success with her lens wear, her eyes felt better in general. Sounds like we scored an ace. CLS