Combatting dry eye during contact lens wear

Figures 1 and 2. Redness seen with contact lens discomfort. (Photos courtesy of Milton M. Hom, OD, FAAO)

This article was updated on May 13, 2022

Dry eye disease is a major issue for contact lens (CL) wearers. The statistics are impressive, with 50% of all CL wearers reporting discomfort at the end of the day and more than 25% stopping CL altogether,¹ according to Milton M. Hom, OD, FAAO, who in practice at Canyon City Eyecare in Azusa, California. He shared his pearls for managing CL patients.

The important points for optometrists to confirm during the all-important history taking are the lens type, lens care products used, replacement schedule, environmental conditions, symptom onset, systemic and ocular diseases/conditions, and drop/oral medication use.

Milton M. Hom, OD, FAAO

Environment is everything

Outdoor air pollution is a primary culprit, followed by digital device usage, which can cause ocular redness, itching, and scratchiness. These symptoms increase in CL wearers working on electronic devices when exposed to air-conditioning and heating units.

CL wearers who use electronic devices longer than 4 hours daily² show an increased bulbar, limbal, and lid redness and lid roughness, with reduced tear breakup time (TBUT) and Schirmer test results (see Figures 1 and 2).

Underlying disorders

Diabetes, high blood pressure, glaucoma, autoimmune disease, headache, allergy, and asthma all contribute to CL discomfort.

Diabetes is perhaps the worst offender, with 52.8% of patients reporting dry eye symptoms compared with 9.3% of controls.

In line with this, the higher the glycated hemoglobin A1c, the higher the rate of dry eye.³

Diabetes also causes decreased corneal sensitivity and affects the nerve architecture, increasing the potential for development of corneal ulcers.⁴ The adverse effects of diabetes on the cornea set off a cascade of tissue disruption that can ultimately lead to abrasions.⁵

Use of steroids can stimulate glucose production that is sufficiently high to impede the production of extra compensatory insulin, resulting in steroid diabetes, and interference with glycemic control, Hom said.

Important tools

Hom advises using questionnaires to ferret out the soft CL wearers who might benefit from clinical attention to the CL-related symptoms. Use of the Contact Lens Dry Eye Questionnaire is one such way to identify these patients. By using questionnaires, patients can grade their scores to best represent their discomfort levels.

Another avenue to symptom relief may be achieved with use of daily disposable CLs, which have been found to provide significant and stable reduction in soft CL-related symptoms.⁶

Examples of available disposable CLs include Dailies Total1 contact lenses (Alcon) with 33% water in the design, Precision1 contact lenses (Alcon) with 51% water, and Infuse (Bausch + Lomb) with moisturizers.

Rewetting drops can be used with CLs to moisturize the corneal surface before and immediately after inserting the CLs. Many rewetting drops are versions of multipurpose solutions.

Hom prefers using the more modern types of rewetters that are based on artificial tears. Such rewetting drops include sodium hyaluronate, which is a natural moisturizer contained in Blink eye drops (Johnson & Johnson Vision), Biotrue (Bausch + Lomb), and Refresh Relieva (Allergan).

CL materials and solutions

Newer CL materials are being introduced to increase patient comfort. Bausch + Lomb offers its monthly Ultra CL, with a silicone hydrogel that is 46% water. The Alcon Total30 monthly lens is made from lehfilcon A and is 55% water.

Hom also advises that optometrists not overlook a change in CL solutions. Peroxide products such as Clear Care (Alcon) and PeroxiClear (Bausch + Lomb) did not differ in subjective ratings of comfort, dryness, or vision, but peroxide was reported to provide longer periods of comfort when used with hydrogel lenses.⁷

Therapies

Another factor that affects comfort is that CL wearers may have underlying ocular conditions that do not respond to a change in CL material or solutions.

A favorite contact lens therapy of Hom’s is antihistamine drops. OTC ketotifen (Zaditor; Alcon) may be useful to relieve ocular itching associated with allergy for up to 12 hours. In addition, oral omega-3 essential fatty acids have been used to reduce CL discomfort by addressing ocular inflammation, with various formulations attempted.

Of note: TBUT, ocular limbal and bulbar redness, blepharitis, tear production, and staining did not respond significantly to alleviating dry eye symptoms. However, oral and topical applications to address CL discomfort did have a positive effect and reduced proinflammatory cytokines.⁸

Other factors that can cause CL discomfort among CL wearers include the presence of Demodex, a mite that thrives in the eyelashes. Meibomian gland discomfort is also very common, and frequently used therapies include warm compresses and moist heat compresses to reduce gland blockage.

A debate has raged about whether CL wear causes the meibomian glands to atrophy; however, the jury remains out about that topic, as well as the ability of meibography to predict meibomian gland function.

This article was adapted from Hom’s presentation at the SECO 2022 annual meeting held March 9-13, 2022, in New Orleans, Louisiana. Hom is in private practice in Azusa, California, and is a consultant to numerous manufacturers of contact lens and related products. He can be reached at eyemage@mminternet.com.

References

1. Jones L. Coping with contact lens discomfort. Review of Cornea & Contact Lenses. February 15, 2018. Accessed March 14, 2022. https://www.reviewofcontactlenses.com/article/rccl0218-coping-with-contact-lens-discomfort

2. Tauste A, Ronda E, Baste V, Bråtveit M, Moen BE, Seguí Crespo MD. Ocular surface and tear film status among contact lens wearers and non-wearers who use VDT at work: comparing three different lens types. Int Arch Occup Environ Health. 2018;91(3):327-335. doi:10.1007/s00420-017-1283-2

3. Seifart U, Strempel I. [The dry eye and diabetes mellitus]. Ophthalmologe. 1994;91(2):235-239.

4. Hom MM. Diabetes and dry eye: the forgotten connection. Rev Optom. 2010;147(9):94-105.

5. Rosenberg ME, Tervo TM, Immonen IJ, Müller LJ, Grönhagen-Riska C, Vesaluoma MH. Corneal structure and sensitivity in type 1 diabetes mellitus. Invest Ophthalmol Vis Sci. 2000;41(10):2915-2921.

6. Chalmers RL, Keay L, Hickson-Curran SD, Gleason WJ. Cutoff score and responsiveness of the 8-item Contact lens Dry Eye Questionnaire (CLDEQ-8) in a large daily disposable contact lens registry. Cont Lens Anterior Eye. 2016;39(5):342-352. doi:10.1016/j.clae.2016.04.005

7. Keir N, Woods CA, Dumbleton, Jones L. Clinical performance of different care systems with silicone hydrogel contact lenses. Cont Lens Anterior Eye. 2010;33(4):189-195. doi:10.1016/j.clae.2010.01.006

8. Downie LE, Gad A, Wong CY, et al. Modulating contact lens discomfort with anti-inflammatory approaches: a randomized controlled trial. Invest Ophthalmol Vis Sci. 2018;59(8):3755-3766.