Reduce contact lens dropout by managing the cause
Contact lenses have improved in function, comfort and design in recent years.
However, between 15% and 20% of patients abandon their use by the end of the first year (Pucker et al). As practitioners, we tend to look at fit, replacement frequency, cleaning solutions or lens material as possible culprits, often switching to a new lens hoping that will increase patient comfort. However, looking beyond the contact lens to the ocular surface may be the answer.
Evaluate ocular surface
To be successful at fitting contact lenses, you must first evaluate and, if needed, manage the ocular surface. During the initial evaluation, we want to look at the possibility of all ocular surface diseases (OSD) including Demodex blepharitis, meibomian gland dysfunction, eyelid ptosis, incomplete blink and incomplete eyelid closure (lagophthalmos).
Taking a multifaceted approach is key to reducing contact lens discomfort and dropout. Eyelid hygiene is the first mediation strategy, including eyelid cleaning. One of my favorite tools is a warm compress that works on the meibomian glands to loosen the oils, which then helps with tear film homeostasis. A contact lens separates the tear film into layers, making homeostasis even more important.
A recent study showed that using a moist, warm compress once a day for 10 minutes can improve contact lens comfort for up to 3 hours (Tichenor et al.).
Patients should also be educated on the environmental factors that contribute to contact lens discomfort. Behavior modification can include a reduction in screen time, alcohol consumption and smoking, increasing water intake and ensuring a better face mask fit to reduce mask-associated dry eye.
LTB4 and inflammation
When trying to understand contact lens comfort and managing the ocular surface, it is important to recognize the role of leukotriene B4 (LTB4) and its association with inflammation.
Inflammatory cytokine imbalance is a key factor in immune-mediated inflammatory diseases including dry eye disease, contact lens-associated red eye, contact lens peripheral ulcers, eyelid hordeolum and infections.
A study testing tears of both symptomatic and asymptomatic contact lens wearers showed that LTB4 was the only inflammatory marker that notably increased both during the day and during contact lens wear with a correlation to discomfort (Masoudi et al.). Additionally, a University of Alabama study also revealed that LTB4 was present in higher levels in contact lens wearers who experienced discomfort vs. normal controls (Panthi).
I like to ask my patients how their contact lenses feel at the beginning of the day and, more importantly, at the end of the day to assess contact lens comfort.
How GLA works
For patients to maintain long-term, comfortable wear of contact lenses, LTB4 production should be inhibited. Gamma linolenic acid (GLA) — which cannot be obtained through diet, fish or flax — reduces inflammation through unique pathways that have dry eye specific effects.
First, GLA is a precursor to 15-HETErE, which is especially potent at inhibiting LTB4. GLA is also a precursor to the anti-inflammatory prostaglandin PGE1. PGE1 is naturally found in tears, lacrimal glands and the conjunctiva and it stimulates lacrimal production and supports mucin production.
Finally, when GLA is combined with eicosapentaenoic acid (EPA), this combination blocks the production of arachidonic acid, the precursor to pro-inflammatory PGE2. Supplementation with GLA has been shown to improve the signs and symptoms of dry eye in many different patient populations, including contact lens wearers, Sjögren’s patients and post-menopausal women (Kokke et al., Sheppard et al., Aragona et al.).
A GLA-containing supplement, HydroEye (ScienceBased Health) has been helpful for my contact lens wearing patients, including those with dry eye disease, often in combination with other treatments such as daily replacement contact lenses, hydrogen peroxide solutions, scleral lenses and immunomodulators.
During this pandemic, I have had to become somewhat creative in the management of eyelid conditions and dry eye via telehealth.
While an in-person visit is ideal for initial examination and diagnosis, I can still ask important questions and determine necessary shifts in maintenance care, including diet and behavior modification with telehealth. I also have focused on ensuring patients can reach me when they have questions or concerns and that we have a follow-up schedule that is appropriate to the recommended management.
It is important to explain to patients that ocular surface disease is a chronic condition and the importance of home care management to improve ocular comfort and potentially vision.
Monitoring of the disease is requisite for long-term success. If we as practitioners can improve the ocular surface, manage tear film homeostasis and reduce ocular inflammation, we will likely increase contact lens satisfaction and retention and prevent contact lens dropout.
Melissa Barnett, OD, FAAO, FSLS, FBCLA, is the principal optometrist at UC Davis Eye Center, Sacramento, Calif. She can be reached at firstname.lastname@example.org.
Aragona P, et al. Invest Ophthalmol Vis Sci. 2005;46:4474-4479.
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Panthi S. Lipid Biomarkers and Pathway Identification for Contact Lens Related Discomfort. Dissertation. The University of Alabama at Birmingham, 2017.
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