Preventing CL dropouts can be a challenge with patients suffering from CLIDE. A number of factors, including the patient’s overall general health, the type of contact lens worn and solution interaction, among others, can influence the condition. Predicting which CL patients are more likely to develop dry eye helps you tailor management to the individual patient needs and set realistic patient goals for successful lens wear.
Over three-quarters of our patients will discontinue contact lens (CL) wear at one time or another due to discomfort.1 We’ve known for a long time that CLs may cause or aggravate dry eye.2 Patients with CL-related dry eye (CLIDE) may complain of dryness, discomfort, grittiness, irritation, burning or foreign body sensation.3 Up to 50% of soft CL wearers complain of dryness.4 There are about 35 million CL wearers in the United States, which suggests that as many as 17 million CL wearers experience significant dry eye symptoms.5 We know our CL patients report more ocular symptoms than do our patients who don’t wear CLs, and their complaints of dryness often increase with wearing time.
How do we keep our CL patients who suffer from dry eye comfortable in their CLs? First, be proactive. Diagnose and treat dry eye before attempting CL wear. Start by gathering the patient’s medicalÃ¢€¨history to understand Ã¢€¨general systemic health andÃ¢€¨ medical therapies. Medications that causeÃ¢€¨ocular surface dryness (e.g., oral antihistamines, anticholinergics,Ã¢€¨ antihypertensives, cardiac antiarrhythmics,Ã¢€¨antidepressants and oral contraceptives)Ã¢€¨should be minimized. Advise your patient thatÃ¢€¨alcohol and smoking will worsen dry eyeÃ¢€¨symptoms.6
Perform a complete dry eye work-up. Include:
• Sodium fluorescein staining of the cornea and conjunctiva
• Tear film break-up testing
• Lissamine green staining of the cornea and conjunctiva
• Schirmer’s or phenol red thread testing
• Tear meniscus height evaluation
• Tear film osmolarity testing or lactoferrin microassay evaluation
Assess meibomian gland function-meibomian gland disease (MGD) is the most common cause of contact lens intolerance.7 Look for conjunctival parallel folds and lid wiper epitheliopathy because they appear to be the most predictive of dry eye.8 Lid wiper epitheliopathy is damage at the upper eyelid edge from repeated blinking over a poor tear film, seen when stained with lissamine green.9 Lid parallel conjunctival folds are small folds in the lower quadrant of the bulbar conjunctiva parallel to the lower lid margin.10
Once a diagnosis of dry eye has been made, treat the dry eye before attempting CLs. Absent a stable precorneal tear film, the patient attempting CL wear is doomed to failure. Concomitant lid disease needs to be addressed as well.
Inflammation is a critical component in dry eye, and short-term topical corticosteroids will provide immediate relief as well as address the underlying cause. The patient may need to begin lid scrubs and warm compresses to treat plugged meibomian glands and blepharitis. Omega-3 fatty acids interact with the fatty acid metabolism of the meibomian glands and enhance their secretions.11 This helps stabilize the lipid layer and the pre-corneal tear film.
The use of 0.5% cyclosporine A (Restasis, Allergan) in CL patients before applying CLs and after lens removal can also significantly increase comfortable wearing time.12 A study by Hom showed a significant reduction in CL intolerance with the use of Restasis when the medication was used before and after CL wear.13 Oral doxycycline may be of benefit in the treatment of dry eye. Doxycycline modifies the fatty acid metabolism within the meibomian glands and enhances the lipid layer of the tear film. Topical azithromycin is another option. Both drugs are commonly used in the treatment of MGD, although their use is off label.
All soft CLs dehydrate on the eye, most likely through evaporation. Use of artificial tears and rewetting drops are the mainstay of treatment. Rewetting drops are a temporary solution, although they do offer some relief. Instruct your patient remove her lenses about halfway through the day and place them in a case with fresh saline for half an hour while also rehydrating her eyes using non-preserved artificial tears. This step allows the lens to rehydrate and can extend the wearing time of patients with more severe dry eye.14
Consider refitting your patients into silicone hydrogel CLs. They are low water content, high oxygen permeable lenses for which evaporation and dehydration appear to be significantly less of a problem than for their conventional hydrogel counterparts.15 Remember that an improper lens fit can cause symptoms that can be misdiagnosed as a dry eye. Allow the lenses to settle on the eye, then carefully evaluate the fit, centration, and movement of the lenses on the eye.
An easy way to avoid lens care solution interaction in CLIDE is to eliminate care solutions. Changing the patient to a daily disposable lens may be your best alternative. For those patients for whom this isn't an option, changing the care regimen to a preservative-free hydrogen peroxide disinfection system is another choice. Let the patient know he may not see any immediate relief because it can take up to two weeks to purge the residual effects from previous lens care products.ODT
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