January 23, 2020
3 min read

Diagnose dry eye to ensure successful contact lens wear

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Stacy Zubkousky, OD, FSLS
Stacy Zubkousky

by Stacy Zubkousky, OD, FSLS

Incorporating dry eye diagnostic testing is vital for a successful contact lens practice. Evaluating the type and severity of dry eye is crucial in determining the ideal contact lens choice and dry eye treatment that will facilitate ultimate success for that lens.

Working in a specialty contact lens practice, I see on a daily basis patients who struggle to continue to wear contact lenses or who have altogether dropped out of contact lens wear due to dry eye symptoms. Often these patients will remark that contact lenses are not for them, but they do not really understand why and are typically unaware of the many treatment options that could result in successful contact lens wear. While some modifications in contact lens modality, material and solution can help with tolerability, treating the patient’s underlying dry eye disease is essential for a positive contact lens experience.

Diagnostic imaging

Meibomian gland imaging or meibography is a diagnostic tool that has given doctors great insight into the prevalence of evaporative dry eye disease. About 85% of dry eye is evaporative in nature and stems from meibomian gland dysfunction (Findlay et al.). When presented with this overwhelming statistic, it makes sense for an eye care practitioner to start here, at the root of the problem.

Meibomian gland imaging devices on the market today include: LipiScan (Johnson & Johnson), LipiView II Ocular Surface Interferometer (Johnson & Johnson), Oculus Keratograph 5M and Meibox and MX2 (Box Medical Solutions). Thanks to these devices, we can now image the patient’s oil glands and view the amount of atrophy, which can help in determining the level of dry eye treatment and the contact lens choice, ranging from daily disposable lenses to scleral lenses.

Having a profile of the robustness and posture of an individual patient’s meibomian glands helps twofold: the image provides the patient with a direct visualization of their individual glands, motivating them to pursue intervention prior to onset of symptoms; and it enables practitioners to better treat patients by suggesting personalized therapies, contact lens materials and modalities that best serve them.

Although doctors have traditionally thought of dry eye syndrome as a condition exacerbated by inflammation and advancing age, a recent study showed that the majority of asymptomatic children 4 to 17 years old had at least mild meibomian gland atrophy (Blackie et al.).


Little research has been done on this demographic. Atrophy is a lifelong process that begins earlier than we once thought and it is certainly expedited by the unprecedented use of digital devices. As we gain valuable insight into the natural course of meibomian gland atrophy and the impacts of the environment and lifestyle, early intervention in patients who may or may not have become symptomatic becomes essential to extend contact lens tolerability.

Additional diagnostic tools

A toolbox of diagnostic dry eye tools is important for any contact lens practice.

InflammaDry (Quidel) is another tool that is useful for a complete dry eye work-up or when considering placing a patient on topical treatment of steroids or immunomodulatory agents such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Xiidra (lifitegrast ophthalmic solution 5%, Novartis) or Cequa (topical cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical).

InflammaDry is an in-office test that detects elevated levels of matrix metalloproteinase-9 (MMP-9), an enzyme implicated in the propagation of inflammatory dry eye disease. This test is particularly useful in contact lens patients with little to no clinical signs of dry eye who are symptomatic for dry eye with contact lens wear.

Not all diagnostic testing requires significant monetary investment on the part of the practitioner. Schirmer test is an inexpensive method of assessing tear production involving the placement of a filter paper strip into the lower fornix of the eye for several minutes. If the tear production is under 10 mm, it is considered abnormal and suggests aqueous deficient dry eye. Schirmer testing is performed on my patients during a complete dry eye evaluation. This test is particularly useful when I suspect Sjogren’s syndrome.

Another effective diagnostic assessment that does not require additional equipment is the tear break-up time (TBUT). This is measured by instilling sodium fluorescein dye into the patient's eye and observing the tear film evaporation under cobalt blue light. The patient is asked not to blink, and the tear stability is documented by the number of seconds that the tear film coats the cornea before the onset of desiccation. A result under 10 seconds suggests evaporative dry eye.

When a patient wears contact lenses, the tears are separated into pre- and post-tear film (Markoulli et al.). Evaluating the overall tear film quality and stability can further help understand why a patient may be having dry eye with their contact lenses.

The LipiView II can measure lipid layer, and the Oculus Keratograph 5M takes a noninvasive TBUT without the need for dye.


Finlay Q, et al. Aust Prescr. 2018;doi:10.18773/austprescr.2018.048.

Blackie C, et al. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S153297.

Markoulli M, et al. Clinical Optometry. 2017;doi:10.2147/OPTO.S111130.

For more information:

Stacy Zubkousky, OD, FSLS, practices at the Weston Contact Lens Institute in Weston, Fla. She can be reached at: drz@westoncontactlens.com.

Disclosure: Zubkousky reports no relevant financial disclosures.

Editor's note: This article was updated to correct information regarding the Xiidra manufacturer.