Dry eye disease (DED) affects millions of people worldwide (Lemp, 2007). It is such a common clinical problem that approximately one out of every three patients who seeks care from an ophthalmologist reports symptoms (Lemp, 2008). With contact lens dropout rates remaining steady, we obviously want to do what we can to keep all of our patients in their lenses. How can we facilitate comfortable wear, and which lens choices are best for significant DED?
Improve Tear Film Stability and Reduce Inflammation
Treat seasonal allergy, lid wiper epitheliopathy, meibomian gland dysfunction, and blepharitis, no matter how mild. Ensure that patients are using tear supplements correctly, preferably those without preservatives or red-eye reducers, and educate them on environmental contributors, including air vents, smoking, and prolonged use of digital devices.
Patients who have autoimmune disease may have an inflammatory component driving their DED, so good control of their overall disease state combined with topical cyclosporine or lifitegrast may help reduce local inflammation and improve ocular surface health.
Consider Lens Material or Solution Changes
If you’ve addressed the items above and your soft lens patient remains symptomatic, consider more frequent replacement to reduce lens deposits and eliminate irritating preservatives. Although silicone hydrogel lenses are the material of choice for many practitioners, dry eye patients may actually have more difficulty with protein buildup and poor wetting with this material; a hydrogel lens could be a better choice in such cases. If soft lenses are no longer tolerable, GP lenses are a great choice for many dry eye patients. Although these same issues can occur with GPs, they don’t absorb moisture from the eye to stay hydrated; therefore, more tears are available for the ocular surface.
Give Orthokeratology a Try
Although it may seem counterintuitive to put a dry eye sufferer in an overnight lens, orthokeratology (OK) can be a great option, because daytime lens wear is eliminated. Studies have demonstrated improved comfort and dryness scores with OK when compared with silicone hydrogel wear, with one study also demonstrating improved goblet cell density (García-Porta et al, 2016; Carracedo et al, 2016).
I have had excellent personal success with my OK lenses, which were initially fit 8 years ago to help relieve daytime lens discomfort.
When More Is Required
For patients who have severe exposure damage or filamentary keratitis, a well-fitting scleral or mini-scleral lens can dramatically improve the ocular surface. These lenses are filled with nonpreserved, sterile solution that bathes the eye during wear. Severe dry eye patients may have to remove, clean, and refill their lenses at least once during the day due to posterior lens fogging and/or poor surface wetting, but most patients will agree that it’s a small price to pay for significantly improved comfort and eye health.
Scleral lenses are typically worn as a daily wear modality; however, they’ve also been used successfully as extended wear lenses in severe, non-healing cases. However, the risk of microbial keratitis is significantly higher (30%) (Rosenthal et al, 2000; Schornack et al, 2008).
Soft lenses for ophthalmic drug delivery could dramatically change the way we treat our dry eye patients in the future. Drug delivery via a contact lens would increase contact time of the medication with the eye and improve drug bioavailability by as much as 10 to 50 fold (Chauhan and Radke, 2001; Li and Chauhan, 2006). There is much to do to make this modality fully viable, but eliminating a daily drop from a complex, multi-drug regimen could significantly impact quality of life. CLS
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