In order to properly care for our contact lens patients, we have to take responsibility for the changes that are occurring in the tear film under the lens.
I’m a firm believer that contact lenses can enhance my patients’ quality of life. My commitment is to ensure that in offering contact lenses I also remain accountable for the changes induced on the ocular surface by the contact lens. It does no good to offer the patient momentary freedom from glasses at the sacrifice of his long-term ocular comfort. In order to properly care for our contact lens patients, we have to take responsibility for the changes that are occurring in the tear film under the lens.
Related: Fitting ortho-k lenses
Not only will this type of accountability create better outcomes for our patients, it will ultimately benefit our bottom lines. If you have attended any contact lens dinner in the past several years, you have likely heard about the dropout rate. It has been quoted to be 16 percent to 22 percent depending on the study-this number has not decreased over the past 20 years despite advances in technology.
Every study seems to point to discomfort as the main reason patients discontinue lens wear. Specifically, we know that 50 percent of contact wearers have concomitant dry eye disease.1 Moreover, up to 90 percent of contact lens wearers report experiencing dry eye symptoms at some point.2,3
Do you think you have contact lens patients dropping out? Whenever this question is asked, most doctors don’t see it as a significant problem within their practices. However, one easy way to conceptualize this is to ask yourself if your contact lens numbers have been pretty steady since this date from last year and the year before. Most doctors will agree that they are. That may sound like a reassuring thought, but it is actually far from it
We all have new fits on our schedule weekly, even daily in some offices. So how is it that our numbers are flat-lined? It’s because of the “revolving door” within our contact lens practice. While we aren’t usually involved in the exit, it is certainly happening. We constantly search for new marketing and promotional ideas and incur expenses to drive new patients through the door. But logistically we know it’s more cost effective to keep an existing patient than to recruit a new one. If only we could predict which patients are more likely to drop out (without our knowledge).
Maybe we can. Let’s shift our focus to why patients leave and how to better equip them to stay.
Ocular surface and lid function
When the tears of contact lens wearers were tested, there was an upregulation of multiple inflammatory mediators, including IL-6, IL-8, and TNF-a, as well as a significant reduction in both tear volume and tear film break-up time (TBUT).4
More importantly, there is an increased risk for meibomian gland dysfunction (MGD).5-8 It is critical to understand that once meibomian glands are shortened or atrophied, they cannot be restored.
In addition to these compromises to the ocular surface, we have to consider what they might do to the patient’s lid function. In my office, we experimented (with a sample size of one!) by performing LipiView (TearScience) on a staff member over his contact lenses one afternoon. The next morning we repeated LipiView after he had been out of lens wear for about 15 hours. While his lipid layer thickness did increase without contact lenses, it increased by only approximately 16 nm.
Conversely, we were shocked at the change we saw in the both the blink frequency and the partial blink rate. Over his lenses, he had four out of five partial blinks OD and three out of four partial plinks OS.
Without the lenses, he had zero of nine partial blinks OD and zero of seven blinks OS. Of course, this is an isolated case, but it should at least serve to raise awareness that contact lenses are foreign to the eye and can potentially change the ocular surface as well as lid function.
We can start by making our contact lens exam a truly different evaluation as compared to our routine eye exam.
In every exam, but especially with our contact lens patients, we should evaluate tear visual consistency, volume, chemistry, and quality; meibomian gland function and structure; and tissue damage, lid function, and systemic health.
We should prioritize spending time examining the lid for edema, hyperemia, telangiectasia, and meibomian gland stasis. Then use lissamine green and fluorescein to look at possible lid wiper epitheliopathy and the Line of Marx and potential corneal or conjunctival staining.
We should be astutely aware of any appearance of allergy or inflammation, incorporating osmolarity testing when possible. Measuring tear meniscus height or doing a phenol red thread test will help us keep tabs on patients’ tear volume over time.
Check for partial blinks with the aid of LipiView, Keratograph 5M (Oculus), or by slowing down any video you take with an anterior segment camera. If trying to catch the partial blink manually, it helps to use fluorescein and a cobalt blue filter.
Finally, ask the patient how her comfort is in the mornings, and check for lagophthalmos.
Maybe before we even see the clinical signs-but definitely afterward-we should be asking more specific, open-ended questions to our contact lens wearers.
Never ask them, “How are you doing with your contact lenses?” But ask, “On a scale of one to 10, what is your comfort at the end of the day?” or “If you could change one thing about your contact lenses, what would it be?”
Not only does this give us valuable information, it opens the door for us to introduce them to another lens material or wear modality.
Related: Using toricity with scleral lenses
Ideally, at the first clinical sign of any ocular surface concern we convert the patient into daily disposables by creating a sense of value based on ocular health. Too often when a patient is having problems, we immediately jump into changing the lens, occasionally the lens care, and stop there.
While that may be in order and may help short term, we should also be implementing ocular surface treatments to keep them wearing their lenses long term. After all, if we change only the material or lens care and the patient continues to have problems, he is even more likely to drop out of lens wear and even less likely to tell us.
Maybe it’s not as hard as we thought to predict future contact lens intolerance through better assessment of patients’ current clinical presentations. When you see a clinical sign implicating a water or oil insufficiency; or if you see signs of allergy, inflammation, bacteria, or lid function problems, implement treatments immediately.
Sometimes we get so caught up in the contact lens portion of the exam that it can be easy to overlook simple pathology or put off treatment.
There are a handful of treatments I find myself using over and over with my contact lens patients. Plugs, of course, can come in handy to increase the tear volume but only in the absence of inflammation. When there are signs of allergies, I proceed with an allergy drop, even if the patient denies itching.
When there are signs of inflammation, I intervene with Restasis (cyclosporine, Allergan). This can be a good solution to aid in preventing contact lens dropout and secondary tissue damage from inflammation and evaporative stress.
Contact lens wearers are often on board because with its bid dosing they can instill the drops before and after contact lens wear.
I’ve found that Lipiflow can make a big difference in allowing patients with MGD wear their lenses longer and more comfortably. I also discuss the importance of blinking with every contact lens patient, especially those logging in hours of device use.
We know patients drop out of lens wear. We know they drop out because of discomfort.
However, because they don’t need our permission to do so, we don’t always get the opportunity to intervene. If we want to make a difference in the outcome for the patient (and our bottom line), the key is timing.
Practice preventative medicine instead of reactive medicine. Intervene early, as soon as the signs manifest, with or without patient symptoms. Of course, in order to induce patient compliance in the absence of symptoms, you must thoroughly educate the patient.
Use your anterior segment camera, Keratograph 5M, LipiView, Tear Lab Osmolarity System, or whatever you currently have, to spend time helping the patient understand.
If you commit to accountable contact lens fitting, not only will your patients likely stay in contact lenses longer, they’ll likely remain loyal to your practice longer.
1. Doughty MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon KA. A patient questionnaire approach to estimating the prevalence of dry eye symptoms in patients presenting to optometric practices across Canada. Optom Vis Sci. 1997 Aug;74(8):624-31.
2. Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self-reported dry eye disease across refractive modalities. Invest Ophthalmol Vis Sci 2005 Jun;46(6):1911-4.
3. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007 Feb;26(2):168-74.
4. Glasson MJ, Stapleton F, Keay L, Sweeney D, Willcox MD. Differences in clinical parameters and tear film of tolerant and intolerant contact lens wearers. Invest Ophthalmol Vis Sci. 2003 Dec;44(12):5116-24..
5. Arita R, Itoh K, Inoue K, Kuchiba A, Yamaguchi T, Amano S. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology. 2009 Mar;116(3):379-84.
6. Ong BL. Relation between contact lens wear and meibomian gland dysfunction. Optom Vis Sci. 1996 Mar;73(3):208-10.
7. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc. 1980 Mar;51(3):243-51.
8. Paugh JR, Knapp LL, Martinson JR, Hom MM. Meibomian therapy in problematic contact lens wear. Optom Vis Sci. 1990 Nov;67(11):803-6.