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Many patients find it difficult to wear contact lenses due to dry eye disease (DED). It is estimated that 10% to 30% of patients drop out of contact lens wear each year. Several studies have shown that dry eye and/or lens discomfort is the leading cause of contact lens dropout.1-3
Moreover, 50% of contact lens wearers report experiencing symptoms of DED at least occasionally. Given that there are about 35 million contact lens wearers in the United States, this means as many as 17 million contact lens wearers experience DED symptoms.4
Helping patients stay comfortable in their contact lenses can have a significant impact on the financial health of your practice. Assuming an office has 3,000 patients annually, each of whom generates $300 in sales, eliminating a 10% dropout rate would save $90,000 in yearly sales.
DIAGNOSE AND TREAT DED EARLY
The surest way to reduce the contact lens dropout rate is to diagnose and treat patients with DED early. A thorough review of your patients’ systemic health and medications may lead you to suspect DED, as many conditions are commonly associated with the condition.
Diabetes affects more than 11% of Americans, and several studies indicate that 20% to 53% of patients with diabetes report clinically significant DED.2,3 Other studies show that patients with proliferative diabetic retinopathy exhibit significantly less tear film function than those who have nonproliferative disease.5
These findings support a protocol of providing a DED assessment as an integral part of every diabetic eye examination. Given the inflammatory process involved in diabetic DED, prescribing antioxidants, nutritional supplements, and antiinflammatory agents, including topical corticosteroids, is often advantageous.
Rosacea affects about 14 million Americans,6 and as many as 60% of these patients experience associated ocular complications.7
DED associated with rosacea stems from meibomian gland dysfunction and resulting evaporative loss. Researchers have found elevated interleukin-1 alpha concentrations in the tears of rosacea patients as well as greater matrix metalloproteinase activity.8 Tetracycline has an inhibitory effect on both these factors and often works well as the first line of defense.8
The management of ocular surface disease should include educating patients with ocular rosacea to avoid trigger foods such as chocolate, tomatoes, citrus fruits, hot spices, alcohol, and heated beverages. Avoiding direct exposure to sunlight and the appropriate use of sunscreen can also be beneficial.
About 20% of people with HIV/AIDS develop damaged lacrimal glands that lead to ocular dryness.9
Hormone Replacement Therapy
Hormone replacement therapy is used by an estimated 38% of postmenopausal women in the United States.10 One study of 25,665 postmenopausal women found that each 3-year increase in the length of time that hormone replacement therapy was used was associated with a 15% elevation in the risk of clinically diagnosed DED or severe symptoms.11
Sjögren syndrome. This systemic condition is classically affiliated with DED. Dry eyes in Sjögren are caused by decreased aqueous production, as inflammatory changes in the lacrimal gland lead to reduced function.
Rheumatoid arthritis. More than 90% of people with rheumatoid arthritis have DED, and 50% present with moderate to severe forms of the disease.13,14
Systemic lupus erythematosus. The most common ocular manifestation of systemic lupus erythematosus is keratoconjunctivitis sicca, and the majority of patients report at least one symptom of DED.15 Additionally, ocular symptoms may persist while the systemic disease is in remission.
Thyroid eye disease. This is commonly associated with DED due to exophthalmos-related corneal exposure.16
Common medications associated with DED include anticholinergics, antihypertensives, antidepressants, cardiac antiarrhythmics, oral contraceptives, and oral antihistamines. Smoking and alcohol consumption will also worsen symptoms.
THE DED EXAMINATION
After addressing any underlying systemic condition and reducing or eliminating contributing medications, perform a complete DED workup, including:
- evaluating tear meniscus height
- tear film breakup testing both with and without sodium fluorescein
- sodium fluorescein staining of the cornea and conjunctiva
- lissamine green staining of the cornea and conjunctiva and to look for damage to the upper eyelid edge (lid wiper epitheliopathy) from repeated blinking over a poor tear film
- Schirmer or phenol red thread testing
- tear film osmolarity testing or lactoferrin microassay evaluation
- gauge meibomian gland function and deploy treatment needed (see Treatment for Ocular Surface Disease)
Patients who complain of symptoms that develop 2 to 3 hours into lens wear may be suffering from solution toxicity. Certainly, it should not be surprising that continually using a solution that contains chemicals such as a preservative for disinfection and/or a surfactant for cleaning may lead to altered ocular biology. Examine the corneal surface carefully for the presence of diffuse solution-induced corneal staining. Switching to a preservative-free hydrogen peroxide disinfection system is often beneficial. Patients may not see any immediate relief, however, as it can take up to 2 weeks to eradicate the residual effects from previous lens care products. Dispensing a new pair of lenses when changing solution systems may speed recovery. You might also consider refitting your patient in a daily disposable lens and thereby avoid the solutions conundrum entirely.
ARTIFICIAL TEARS/ REWETTING DROPS
For many contact lens patients with DED, their problem becomes worse later in the day as their lens dehydrates (most likely due to evaporation). Many use artificial tears and rewetting drops to rehydrate their soft contact lenses. This often offers only temporary relief and can become costly, especially if patients (as recommended) use preservative-free artificial tears. Approximately 90% of the drop is lost in each application, meaning that rewetting drops have to be reinstilled frequently throughout the day to provide effective comfort.17
Another option is to instruct patients to remove their lenses for a brief immersion in saline to allow their lenses to fully rehydrate while also rehydrating their eyes using nonpreserved artificial tears. Many patients report this rehydration process provides significantly longer relief than rewetting drops or artificial tears alone.
The dehydration of soft lenses can affect the fit of the lens by altering the lens parameters and ocular health by lowering the oxygen transmissibility. Proclear (CooperVision) lenses use a unique material containing molecules of phosphorylcholine, a substance found naturally in human cell membranes, to help sustain lens hydration. Proclear contact lenses are the only lenses to receive FDA clearance that enables the product to claim “may provide improved comfort for contact lens wearers who experience mild discomfort or symptoms relating to dryness during lens wear.”
Silicone hydrogel contact lenses such as Acuvue Oasys (Johnson & Johnson Vision Care), Air Optix Aqua (Alcon), Biofinity (CooperVision), and PureVision2 (Bausch + Lomb) offer low-water content and high permeability, resulting in less evaporation and dehydration than with conventional hydrogels. Silicone hydrogel lenses now account for the majority of contact lens fittings performed in the United States due in part to the reduced risk of hypoxic changes in the cornea over time and less sensitivity to low tear volumes. The combination of low water content and high Dk/t may result in improved comfort for patients who had previously experienced dryness in thin, high-water-content conventional hydrogel lenses.
DED in contact lens wearers is often complicated and multifactorial. Managing these patients effectively may require anything from educating them on contact lens care to managing their ocular surface and lid disease to changing solutions or refitting them in a different lens material or modality. Patients who appreciate better comfort with their lenses tend to be more loyal, and more loyal patients leads to a more successful and profitable practice.
Mark Ventocilla, OD, is a clinical professor at the Michigan College of Optometry in Big Rapids. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Ventocilla may be reached at firstname.lastname@example.org.
- Rumpakis J. New data on contact lens dropouts: an international perspective. January 15, 2010. Rev Optom. http://www.revoptom.com/content/d/contact_lenses_and_solutions/c/18929/. Accessed May 7, 2014.
- Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007;26(2):168-174.
- Young G, Veys J, Pritchard N, Coleman S. A multicentre study of lapsed contact lens wearers. Ophthalmic Physiol Opt. 2002;22(6):516-527.
- McMahon TT, Zadnik K. Twenty-five years of contact lenses: the impact on the cornea and ophthalmic practice. Cornea. 2000;19:730-740.
- Yu L, Chen X, Qin G, et al. Tear film function in type 2 diabetic patients with retinopathy. Ophthalmologica. 2008;222(4):284-91.
- National Rosacea Society. Information for Physicians: Patient Education Materials. http://www.rosacea.org. Accessed May 7, 2014.
- Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. 1997;104(11):1863-1867.
- Afonso AA, Sobrin L, Monroy DC, et al. Tear fluid gelatinase B activity correlates with IL-1alpha concentration and fluorescein clearance in ocular rosacea. Invest Ophthalmol Vis Sci. 1999;40(11):2506-2512.
- Beyda N, Cluck D,Taba KE,Middlebrooks M.Ocular manifestations of systemic diseases. US Pharm. 2010;35(4):HS- 2-HS-8.
- Keating NL, Cleary PD, Rossi AS, et al. Use of hormone replacement therapy by postmenopausal women in the United States. Ann Intern Med. 1999;130:545-553.
- Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone replacement therapy and dry eye syndrome. JAMA. 2001;286(17):2114-2119.
- Wolfe F, Michaud K. Prevalence, risk, and risk factors for oral and ocular dryness with particular emphasis on rheumatoid arthritis. J Rheumatol. 2008;35(6):1023-1030.
- Lemp MA. Dry eye (keratoconjunctivitis sicca), rheumatoid arthritis, and Sjogren’s syndrome. Am J Ophthalmol. 2005;140(5):898-899.
- Fujita M, Igarashi T, Kurai T,et al. Correlation between dry eye and rheumatoid arthritis activity. Am J Ophthalmol. 2005;140(5):808-813.
- Jensen JL, Bergem HO, Gilboe IM. Oral and ocular sicca symptoms and findings are prevalent in systemic lupus erythematosus. J Oral Pathol Med. 1999;28(7):317-322.
- Moss SE, Klein R, Klein BE. Long-term incidence of dry eye in an older population. Optom Vis Sci. 2008;85(8):668-674.
- Tonge S, Tighe B, Franklin V, Bright A. Contact lens care, part 6: comfort drops, artificial tears and dry eye therapies. Optician. 2001;222(5817):27-32.