Not a Dry Eye in the Place
Don't shed tears when dry eye patients desert your contact lens practice. Employ these strategies instead.
By Kelly K. Nichols, OD, MPH, PhD
Can you imagine how many patients you'd keep in contact lenses if you could take better care of their dry eyes? A lot more than you might guess.
That's because too many dry eye symptoms go unnoticed or unreported. If we do a better job of managing these patients before their names disappear from our appointment books, dryness won't be the second leading cause of lens dropouts, right behind discomfort. Here are some ideas that can keep you from crying the blues over lost patients.
When Interviewing Patients
So much of our success is rooted in how we communicate with patients. First, make sure you schedule dry eye suspects for evaluations in the afternoon, when they'll be able to report end-of-day symptoms more accurately. And when patients have to be refit, or if they come to you asking for better contact lenses, pay attention. You may be close to losing them.
At the same time, keep in mind that you can't totally rely on what patients tell you at one visit. In a recent study,1 many patients changed their self-reported dry eye classifications from dry eye to healthy and vice versa between their first and
second visits. "Dry" is a relative term and a variable condition; patients may be responding to how they feel on one particular day. Be sure to ask patients about symptoms on multiple occasions.
When patients report dry eye symptoms, they often summarize how their eyes have felt over a period of time. So it's very important to ask your patients to describe how their eyes feel at specific times of the day, especially the end of the day, so you can record the information and compare it to what they report later.
Also pay attention to what patients say about their contact lens solutions. A red flag should go up if they tell you they buy whatever solution is on the shelf or whatever is on sale.
Find out how many hours they can wear their contact lenses in what they consider total comfort, or without feeling the lenses on their eyes. Record that number and then monitor it for progress during future visits or after treatments.
Some contact lens dry eye patients will use rewetting drops quite frequently. They may need to be watched carefully so you can catch problems before they occur.
Clinical Findings to Consider
Most contact lens dry eye patients report that they don't have dry eye symptoms while wearing their spectacles. Also, when you look at clinical signs, you'll find that they range from normal to moderately abnormal.
At The Ohio State University, we've been evaluating the pre-lens tear film and how it looks after a blink. We've found that seconds after a blink, you start to see dewetting on some areas of the lens.
We're also investigating the meibomian glands and lipids. We need to know more about components of lipids and how they change with contact lens wear. When expressing the glands, we need to standardize how much pressure to apply, the size of the droplet, and how much volume should be expressed. Nonetheless, it's important to express the glands to evaluate lipid production.
Another important issue for postmenopausal women and bifocal patients is the appearance of the meibomian gland orifices and whether there's been meibomian gland dropout.
Most dry eye experts agree an abnormal tear breakup time is less than or equal to 6 to 7 seconds, timed with a stopwatch. If you use a small quantity of fluorescein enough to see but not so much that it's running over the edge your readings between visits will be more reliable.
We don't agree, however, on how long after instillation we should measure breakup. We also don't agree on how long after removing a contact lens we should wait before measuring fluorescein tear breakup. We need standardization in these areas as well.
Some tests, although available, are not usually used in clinical practice. One such test is the fluorophotometer, which can look at dye disappearance at the front of the eye. You can do that yourself by putting fluorescein in the eye and measuring how long it takes to drain off the surface. If it lasts approximately 10 minutes or more, the patient likely has dry eye.
Some experimental tests measure evaporation from the tear surface. We've been looking at interference patterns; and some clinicians are working with wavefront and topography to understand the visual component of dry eye or dry eye with contact lenses.
We've found that lissamine green is very valuable for evaluating contact lens dry eye. Often, you'll see a ring around the conjunctiva just outside where the contact lens sits. Waiting at least 1 minute after instillation is helpful in seeing lissamine green staining.
Is Medical Management Appropriate?
Some patients don't want to wear their contact lenses if their dry eye needs medical management. But patients who do want to continue wearing their lenses can use Systane lubricant eye drops and cyclosporine ophthalmic emulsion 0.05% (Restasis).
Systane helps prelubricate the ocular surface before lens application. Patients can instill a drop in the morning approximately 15 minutes before lens application, apply their lenses, wear them all day then remove their lenses and instill a drop at the end of the day. This approach has demonstrated a more comfortable daily lens wearing experience and may be just as effective as medical management in mild to moderate dry eye.
Remember the Subtle Signs
When you monitor your contact lens dry eye patients, record the subtle clues that make a difference. Be specific, writing down the worst symptoms, when patients experience them, how often, how often they wear their lenses and for how many hours. Remember to look carefully at what you see on the front surface of the eye and record that as well. If you do all of this, you stand your best chance of keeping your patients happy.
Dr. Nichols is an associate professor at The Ohio State University College of Optometry.
1. Nichols JJ, Mitchell GL, Nichols KK. An assessment of self-reported disease classification in epidemiological studies of dry eye. Invest Ophthalmol Vis Sci. 2004 Oct;45(10):3453-7.