Troubleshoot contact lens discomfort and prevent complications

February 13, 2019

In the last

In the last contact lens department (seeLook for small signs to prevent contact lens complications), I reviewed complications specific to contact lenses. Another aspect to consider is the underlying conditions that are amplified by the patient’s contact lens wear. Many ocular conditions can occur with or without hyperemia.

“Red eye” is a nonspecific term used to describe an eye that appears red due to illness, injury, or another condition in which the vessels enlarge as a defense mechanism.

When an OD sees a contact lens patient with a red eye, the first thought might be of contact lens-related concerns. But we must keep an open mind to other etiologies, such as these underlying-seemingly unrelated-causes, or even posterior segment problems.

A long list of causes of varying severity can lead to the same symptom of redness. Keep your staff informed to help you triage, especially when you are out of the office.

Patients should always be instructed to remove contact lenses when any degree of redness, discharge, or discomfort is present. Let’s start with the obvious: dry eye disease.

Related: Experts offer advice on fitting, pricing daily disposables

Dry eye disease
Dry eye disease has been documented as four times more prevalent in patients who wear contact lenses,1 with two-thirds of contact lens wearers being female.2

In fact, 50 to 90 percent of contact lens wearers report having symptoms of dry eye.3,4 The average onset of dry eye symptoms is nearly 10 years sooner in contact lens wearers at age 27 compared to age 36 in non-lens wearers.5

Of course, dry eye is an encompassing term. Whether the patient has a lack of water or a lack of oil, the loss is magnified when the tear film is split in two by the contact lens, resulting in a significantly reduced tear breakup time (TBUT) and tear volume for contact lens wearers.6

In fact, 59 percent of contact lens wearers were tested to be hyperosmolar in a 2017 study.7

Typically, when ODs see a low tear meniscus height or obtain a short phenol red thread test or Schirmmer’s test, they assume there is sluggish aqueous function.

An OD can utilize lissamine green to identify staining on the upper lid, indicating lid wiper epitheliopathy. This indicates low tear volume and friction against the ocular surface. 

Excessive staining on the lower lid margin is assessed as the line of Marx and can represent keratinization and meibomian gland disease.8

To note, it is important to use enough lissamine green dye and to tap it along the lower lid margin before asking the patient to blink. If you fail to see a fine line at the mucocutaneous junction, you need additional dye.

Contact lens wearers are more prone to have meibomian gland dysfunction (MGD),9-12 and symptomatic contact lens wearers often show signs of MGD.13 It is critical that ODs carefully screen for this in every contact lens patient in order to promote long-term comfortable contact lens wear.12

Related: Blog: Modern-day techniques for diagnosing dry eye disease

It is also crucial to assess meibomian function by multiple means. Carefully examine the lid margin to look for stagnant meibomian glands, thickening, and scalloping of the lid margin. Express the glands diagnostically to determine the flow and turbidity of the excretion, then use fluorescein to time tear film evaporation.

The challenge is that this will change once the contact lens is applied, and using standard fluorescein over the contact lens is not reasonable. This is unfortunate, considering the evaporation with the contact lenses on the eyes is what likely influences the patient’s comfort and ability to wear lenses long term.

In this case, noninvasive keratograph tear break-up time (NKBUT) proves very useful. I use the Oculus Keratograph 5M to perform interferometry testing over the contact lens, showing me a rainbow prism in the tear film when adequate oil is present.
Ensure your staff is asking pertinent questions such as wear time and comfort at removal. Ask staff to notify you when the patient has to blink multiple times to read the acuity chart.

In addition, inflammation is a key component of dry eye. Inflammatory proteins (including interleukin [IL-6, IL-8,] and tumor necrosis factor [TNF-α]) are upregulated with contact lens wear.6

Inflammation creates a cascade of events leading to greater potential damage to the lacrimal and meibomian glands, thus creating a greater deficit in tear volume.

Discuss dry eye treatments early with your contact lens patients. It is much easier to implement something simple at this stage, often preventing progression and the need for multiple treatments.

Related: How to address the three aspects of dry eye disease

However, ODs may hesitate to have this conversation because the contact lens wearer does not experience symptoms at this stage and may not be receptive to the warning. Regardless, it is an OD’s obligation to screen and identify these early challenges and educate the patient on treatment options.

The most effective way to succeed in convincing patients to begin treatment is sharing images and measurements of the patient’s ocular surface. This saves discussion time and allows the message to be better received through visualization and an understanding of the problem.

Contact lens wearers are some of the best candidates for lifitigrast (Xiidra, Shire) or cyclosporine (Restasis, Allergen; Cequa, Sun) treatment. This patient base often has commercial insurance to help with drug coverage, and these serve as simple treatments for underlying inflammation and to prevent progression of the ocular surface issues.

A 2016 study showed that after initiating cyclosporine therapy, the average wear time of symptomatic wearers (wearing lenses less than eight hours per day) increased by 2.1 ± 1.4 hours at two months and 4.6 ±1.4 hours at six months.14

ODs should also discuss hydration, a diet rich in omega-3 foods, and supplements. For patients who want longer wear time, or who have loss or changes in their meibomian structure, I recommend thermal pulsation (LipiFlow, Johnson & Johnson Vision) or intense pulsed light (IPL) treatment (M22, Lumenis).

These patients are sometimes more amenable to an in-office treatment as opposed to significant at-home maintenance. A single LipiFlow treatment was found to increase wear time of contact lens patients by an average of four hours per day at Month One.15

Advanced warm compress masks, such as Traquileyes (Eye Eco), and a new mechanical treatment called NuLids (NuSight Medical), are among a few of the at-home options that can help maintain oil flow after an in-office treatment has been performed.

Relatd: New cylcosporine therapy joins fight against dry eye disease

Blink function
MGD may be more prevalent in contact lens wearers due to the relativity of the blink to meibomian glands function, and possibility that contact lens wear negatively affects the blink function in these patients.

This population may also spend more time on the computer, which decreases blink frequency and rate of blink completion.16

The contact lens can act as a shield that desensitizes the cornea. The corneal nerves are involved in the feedback loop that stimulates the blink action. As partial blinks leave a portion of the globe exposed, it can cause evaporative stress which leads to additional inflammation. Moreover, meibomian glands are not stimulated to release oil unless the lids close completely. Proper lid closure is also important for ocular hygiene because it plays a role in tear drainage and lid maintenance.

I have conducted an in-office assessment of lipid layer thickness and rate of partial blinks on patients during contact lens wear versus without lenses. Unanimously, the lipid layer thickness was reduced, and the rate of partial blinks was increased in patients without lenses.

Though this was a small sample size, the result was logically due to the relationship between the meibum release and lid closure.

Read more about lid and lashBlepharitis
It is easy to see-if you’re looking-when there is lash debris, wet clumping, or collarettes. But go further to carefully assess the lid margin for migrating makeup or scurf. These can have an even greater influence because of their ability to significantly contaminate the tear film and cause a toxic pool in which the eye is bathed.

Furthermore, such buildup can accumulate in the lacrimal system and conjunctiva over time.17 This can lead to contact lens buildup and intolerance, corneal staining, photophobia, and so on. Unless you have photos and even tear film debris videos to show, this can be a fruitless conversation with the asymptomatic contact lens patient.

Showing patients their tear film debris video is one of the most valuable education tools I have to convert them from wearing reusable lenses to daily disposables, and to motivate behavioral change when it comes to makeup habits. I use my Keratograph’s tear film dynamic function with special lighting to highlight the movement of debris into the tear film.

Lid cleansers
There are many lid cleansers available, including foam soaps (Eye Eco, Ocusoft), gel soaps and saturated pads (Oasis), hypochlorous acids, and even special oils (Purifeyed).

These options are usually low cost to the patient, and research has shown that women who remove their makeup have lower ocular symptoms.18

A hygiene recommendation is a good preventative measure for all contact lens wearers. It may even be advisable for ODs to raise their contact lens exam price by the wholesale cost of one bottle of foam cleanser (~$6.50) and include it as a value add to a patient’s yearly contact lens exam to create healthy habits.

Related: Increase contact lens comfort by paying attention to the lids

Allergy
Too often theallergy component may be overlooked in contact lens patients without itch. Fewer cases of giant papillary conjunctivitis (GPC) are seen today than in the days of longer wear modalities.19

However, I still recommend upper lid eversion to confirm the status of the palpebral conjunctiva. Both the upper and lower palpebral conjunctiva is best assessed with the use of fluorescein.

I always grab an image of this at every contact lens exam and correlate it to the success of the contact lens wear over time.

If there are significant papillae and the presence of a stringy crystalline mucous or a junky tear film, I will initiate treatment with or without the complain of itch. This opens the conversation for daily disposables, flushing the eye before and after contact lens wear, allergy drops, or even allergy testing within my office (AllerFocus).

For patients with intense reactions, I prescribe sublingual immunosuppressive therapy to avoid the drying effect of oral antihistamines. 

As with most ocular surface problems, contact lens wear can make them worse. The more ODs screen for these extremely common underlying concerns, the better long-term care and outcomes they can provide for their patients. Don’t hesitate to have the conversation, even when they are asymptomatic.

Read more by Dr. Brimer

 

References:

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