Improve contact lens wearing experience with dry eye evaluation
Many of the dry eye patients I see are unaware of the treatment options that could result in their successfully wearing contact lenses.
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.
There are several in-office treatments that I perform on my contact lens patients with meibomian gland disease or more anterior eyelid inflammation known as blepharitis. After performing meibography and a thorough lid evaluation, I determine if an eyelid treatment would be of benefit.
Contact lens patients with a sufficient number of functioning meibomian glands all benefit from lid hygiene and care. Studies have shown that meibomian gland atrophy is accelerated in proportion to the duration of contact lens wear (Michaud et al). Promoting early intervention and maintenance will keep even asymptomatic patients in contact lenses longer (Arita et al.).
Lipiflow (Johnson & Johnson) is a 12-minute in-office thermal pulsation procedure for the eyelids. It combines heat and pressure to open up a patient’s existing oil glands and improve tear film stability. Research conducted on soft contact lens wearers shows that a single treatment significantly reduces dry eye symptoms and increases lens wearing time by up to 4 hours (Blackie et al.). This advanced lid treatment is an excellent addition to any contact lens clinic.
Other in-office treatments for meibomian gland dysfunction are the iLux (Tear Film Innovations), which uses LED light to raise the lid temperature, and TearCare (Sight Sciences), which uses software-controlled, wearable eyelid technology to deliver thermal energy.
In addition to the in-office eyelid therapy implemented by an eye care practitioner, it is critical to educate the patient to perform at-home adjunctive warm compresses and lid massage and to consider nutritional supplementation with re-esterified omega-3 fatty acids.
BlephEx (Scope Ophthalmics) is another in-office procedure I often recommend for my contact lens patients with lid disease. This treatment uses microblepharoexfoliation that allows the doctor to precisely remove biofilm and scurf off the eyelids, which in turn reduces inflammatory toxins in the tear film. This procedure has been shown to be quite successful; in an Australian study of symptomatic contact lens wearers who had BlephEx performed, 58% of the participants became asymptomatic lens wearers after one treatment (Mulder et al.). It is recommended that contact lens wearers repeat the treatment every 4 to 6 months.
Implementing treatment plans
Initially evaluating potential contact lens candidates for dry eye will help avoid troubleshooting later in the fitting process. In mild dry eye cases, I may treat the dry eye concurrently as I begin fitting them in contact lenses. In patients with moderate to severe dry eye, I will treat the disease prior to any contact lens fitting. In cases of severe dry eye from ocular surface disease like Sjögren’s syndrome, Steven Johnson’s syndrome or graft vs. host disease, I may implement the use of custom contact lenses as therapy. In habitual contact lens wearers with dry eye disease, I will often put patients on a contact lens holiday as I get their dry eye under control.
Choosing the right lens
Choosing the right contact lens is critical for a patient with dry eye disease. Opening the conversation with a discussion of the patient’s goals for wear and wear time helps navigate the proper lens selection.
Advantageous choices for a patient with dry eye disease are daily disposable contact lenses and scleral lenses.
As tears evaporate from the ocular surface, residual lipids and proteins accumulate on the front surface of the contact lens. Having the capability to dispose of the lens daily provides the patient with a fresh lens surface with each wear. Further, it eliminates preservative sensitivity to contact lens solution, which can often masquerade as dry eye syndrome.
Material choice is another factor to consider in contact lens selection. Silicone hydrogel lenses provide more comfortable and longer wear times than do hydrogel lenses (Michaud et al.). Due to their lower water content as compared with hydrogels, silicone hydrogels are less likely to desiccate throughout the day.
However, not all dry eye patients benefit from silicone hydrogel material. Patients with inflammatory dry eye and lid disease tend to deposit more lipids on silicone hydrogel lenses. This complication has been overcome with the addition of wetting agents to the lenses. The FDA recently approved a revolutionary polymer coating, Tangible Hydra-PEG (Optimum), for use on a daily disposable silicone hydrogel contact lens.
In addition, silicone hydrogels are contraindicated in patients with silicone allergies. Thus, hydrogel lenses continue to hold a place in the eye care practitioner’s toolbox.
Scleral lenses for dry eye
Scleral lenses were traditionally reserved for patients with corneal ectasias or other medically necessary conditions. However, they have become an increasingly popular choice for patients with normal corneas with dry eye. Scleral lenses are an optimal choice for these patients as they do not touch or irritate the corneal surface and they provide day-long lubrication with their liquid reservoir of preservative-free saline solution. Additional preservative-free lubricating drops can be added to the lens bowl for increased comfort.
The breathable, plastic material does not desiccate with a lack of tears and provides a shield to the cornea from environmental factors, including low humidity and air conditioning. It also protects very sensitive corneas from microtrauma caused by blinking.
Patients with meibomian gland dysfunction and blepharitis can also benefit from scleral lenses. To reduce lipid deposition on the lens, commonly referred to as “front surface fogging,” Tangible Hydra-PEG can now be added to most scleral lenses.
Fitting patients with severe dry eye
There are specific considerations to make when fitting severe dry eye patients in a scleral lens. Larger diameter scleral lenses protect more surface area from the environment, and even a millimeter can make a difference in these patients. Large scleral lenses typically range from 18.1 mm to 24 mm.
Advanced corneoscleral topography has revolutionized scleral lens fitting, and now scleral lens fitters have the capability of precisely vaulting over areas of irregularity, commonly the most irritated areas in patients with dry eye disease. The sMap 3D (Visionary Optics), Eaglet Eye and Pentacam CSP Software (Oculus) all offer this advanced technology.
The EyePrintPro (EyePrint Prosthetics) uses 3D scanning technology to design a scleral lens shell from an impression taken in clinic. This technology allows for immense customization and ocular surface protection even in the most complicated cases.
Evaluating new or current contact lens patients for dry eye is vital for contact lens success. If you come across a patient who thinks that contact lenses are not for them, initiating a dry eye workup with the help of diagnostic tools can help solve the mystery. With the combination of proper dry eye therapy and correct contact lens choice, your patients will see contact lenses in a different light.
- Arita Reiko, et al. Ophthalmol. 2009;doi:10.1016/j.ophtha.2008.10.012.
- Blackie CA, et al. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S153297.
- Mulder D, et al. Invest Ophthalmol Vis Sci. 2015;56(7):4440.
- Michaud L, et al. Cont Lens Anterior Eye. 2015;doi:10.1016/j.clae.2015.11.002.
For more information:
Stacy Zubkousky, OD, FSLS, is an assistant professor and resident education coordinator at Nova Southeastern University in Florida and a contact lens specialist. She can be reached at: firstname.lastname@example.org