Round Table: Managing Contact Lens Wear in Patients With Diabetes

Experts discuss special considerations for this patient population.

For years, the prevalence of diabetes has been on the rise. In 2012, according to the American Diabetes Association, 29.1 million Americans—9.3% of the population—had diabetes, and the incidence was 1.7 million newly diagnosed cases per year. In addition, 86 million Americans age 20 years and older had prediabetes, and many of those people will be diagnosed with type 2 diabetes within the next decade.1

Perhaps more alarming is the steady increase in the number of children diagnosed with type 2 diabetes due to the obesity epidemic. The estimate is that by 2050, the prevalence of type 2 diabetes in people under the age of 20 years will quadruple. Interestingly, the prevalence of type 1 diabetes is also climbing; experts estimate that the number of people with type 1 diabetes will triple within that same time frame.1

With these kinds of numbers, it is critically important for eye care practitioners to understand how to manage patients with diabetes, particularly those who wish to wear contact lenses. In the past, it was a common belief that diabetes and contact lenses did not mix. In reality, contact lenses are safe for patients with diabetes. March et al found that patients with diabetes showed no increased complications over patients without diabetes for daily soft contact lens wear.2

Although contact lens wear is indeed viable for people with diabetes, there are extra considerations eye care practitioners must acknowledge and discuss with these patients. To find out more, a panel of eye care practitioners was convened to discuss the management of contact lens wear in patients with diabetes.

ABOUT THE PARTICIPANTS

Gary Orsborn, OD, MS, (comoderator) is senior director of global professional affairs at CooperVision.

A. Paul Chous, OD, MA, (comoderator) has a practice specializing in diabetes eye care and education in Tacoma, Washington.

Kerry Gelb, OD, is in private practice in Woodbridge, New Jersey, and other locations in New Jersey and New York.

Milton M. Hom, OD, is in private practice in Azusa, California.

Brittany Mitchell, OD, is in private practice in Birmingham, Alabama, with a focus on contact lenses.

Mark Ventocilla, OD, is adjunct clinical professor at the Michigan College of Optometry in Big Rapids and has private practices in Muskegon, Michigan, and Escondido, California.


Gary Orsborn, OD, MS: Given the statistics cited in the introduction, eye care practitioners will be seeing more and more patients with diabetes, and people with diabetes desire contact lenses as much as any other subpopulation. What are the unique considerations for people with diabetes with respect to contact lens wear?

Kerry Gelb, OD: My approach to fitting contact lenses in patients with type 1 or type 2 diabetes is simple. I fit them with daily disposable contact lenses—which is what I do with most of my patients, regardless of whether they have diabetes or not. Studies have shown that contact lenses are safe for patients with diabetes, with the exception of extended wear contact lenses. Daily disposable lenses are the best option and present the lowest risk for patients with diabetes.

Brittany Mitchell, OD: My approach is much the same as with any patient. Even in patients without diabetes, I am pretty strict about contact lens compliance. Diabetic or not, every patient needs to be compliant by replacing their contacts when they are supposed to, removing them before sleeping, and practicing proper hygiene and lens care.

A. Paul Chous, OD, MA: Patients with diabetes are more prone to having corneal abrasions because high glucose levels in the aqueous humor form advanced glycation end products at the level of the hemidesmosomes, making the overlying epithelium much more fragile than normal. Like Dr. Gelb, I find myself turning to daily disposables more and more because we are not introducing chemical agents that might adversely affect the epithelium, and the lens remains much more pliable because it is replaced so regularly. I think it is important to keep handling of the contact lens to a minimum and to choose a lens that is very pliable and made of a material that is highly oxygen transmissible.

Dr. Orsborn: Is the approach any different if you are fitting contact lenses for a child with diabetes?

Mark Ventocilla, OD: You have to base the decision to fit a child with diabetes on each individual child, just as you have to with adults. You need to evaluate how responsible they are. Is he doing well in school? Does she keep her room clean? I ask a series of questions to kind of delve into the life of each patient, which helps me determine how the child will actually care for the contacts. Parents are helpful in gauging their level of responsibility as well.

Dr. Mitchell: I do not fit many children in rigid gas permeable lenses unless there is an issue. Soft lenses, especially for those with lower modulus (eg, CooperVision Proclear 1-day), are preferred. I do fit a large number of specialty lenses, but in anyone under age 18, I always fit daily disposables.

Dr. Orsborn: Is there a glycemic threshold above which you will not fit a patient with contact lenses? There does not seem to be a clearly established number above which it is considered unsafe.

Milton M. Hom, OD: No, I have no target glycemic level. I rely on comanaging patients with their endocrinologist or primary care physician, and leave it to them to decide whether a patient with diabetes is under control so that he or she is a good candidate for contact lenses.

Beyond that, my main focus is always on the patient’s ocular surface. Research shows that, as A1C levels increase, there is an increase in ocular surface problems. The tear film of a patient with diabetes can actually change. So a lot of the considerations from my point of view are about that ocular surface and how it is altered in a patient with diabetes. We calculate the Ocular Surface Disease Index (OSDI)3 and look at fluorescein staining, tear meniscus height and meibomian gland function on all patients, whether they have diabetes or not. The theme song is vigilance when talking about dry eye disease and its connection to diabetes, contact lenses, and the ocular surface.

Dr. Chous: Dr. Hom is right that individualizing each patient’s A1C goals is the new standard, but I differ slightly in my recommendations precisely because the risk of infection and recurrent erosion is higher as the A1C level goes up. As a practical matter, I will not fit a patient with contact lenses unless the A1C is less than 7.5%. It is interesting, though, because sometimes, a patient’s ocular surface looks healthy, and they have a normal tear film, but their A1C is 10%. Although this is not typical, I have seen patients like this, whose ocular surface looks relatively normal even with severely inadequate blood glucose control.

Dr. Mitchell: I definitely would not fit somebody with an A1C of 10%, either. I like the A1C to be at least in the 7 to 8% range or lower. Anything higher, I would look at closely.

DISEASE PREVENTION, MANAGEMENT

Dr. Orsborn: How can we better treat patients with diabetes? Is there an opportunity for eye care practitioners to help with diabetes prevention?

Dr. Gelb: Overall, we try to take a holistic approach. I have a nutritionist in my practice, and we talk to patients about diabetes prevention. We have developed a 10-point plan for preventing diabetes and actually reversing it, as we know that diabetes is 90% lifestyle. By taking the time to sit with patients and go over the plan, we see great results. Patients lose weight, and then we are able to fit them with contact lenses.

Some people think the responsibility falls to the internist, but I feel that we are certainly within our rights because diabetes is the leading cause of blindness in people under the age of 55. My job is about more than drugs, surgery, contact lenses, and glasses. I believe we need to expand our toolbox to include lifestyle medicine.

Dr. Ventocilla: A key part of treating patients with diabetes is getting them to recognize what is going on with their eyes and by extension their whole body. One tool that I use for every patient is a retinal photo of diabetic retinopathy that I keep as a background on my computer. I take time to explain the changes in the photo to these patients because it is so amorphous; this way, they understand how lifestyle decisions can put their eyes and health at risk. Typically, patients who are newly diagnosed and are not managing their diabetes well do not feel anything wrong. I show them the picture and say, “This is why you are in my office today. It’s not for glasses. It’s not just to help you see better. It’s to keep you from going blind.” I realize blind is a strong word, but I want them to understand the importance of coming back every year. I think it is our role to intervene and help them recognize that they have a chance to live a longer and healthier life if they change their lifestyle.

Dr. Orsborn: Do you communicate with primary care doctors or endocrinologists about contact lens wear in patients with diabetes?

Dr. Chous: I developed type 1 diabetes at age 5. I recently saw my endocrinologist and was talking with him about contact lenses and diabetes. I asked him if he would want to know if I am fitting a mutual patient who has diabetes with contact lenses. His answer kind of surprised me: He said yes.

He said he would want to know because it gives him more leverage in talking to his pediatric patients about achieving better glucose control. You want to wear contacts? You need to do a better job of controlling your diabetes. I was pleasantly surprised because this aligned with my own strategy when counseling patients. I think optometrists and other eye care providers have the opportunity to influence that behavior change as well as internists and endocrinologists.

Dr. Hom: It is important for us to work closely with the endocrinologist or primary care doctor with whom we are comanaging. We should make sure to tell them that their patient is wearing contact lenses. The tear film and cornea are altered. They have dry eye, but a different type of dry eye. Because of the different nature, there are higher risk factors for contact lens patients. They just need to be more carefully monitored.

ONGOING CARE

Dr. Orsborn: For patients with diabetes who are not wearing daily disposables, do you have preferences for a certain disinfection protocol?

Dr. Mitchell: Recently, we have been going back to recommending the original hydrogen peroxide. I think that works best right now.

Dr. Ventocilla: I agree with Dr. Mitchell. I tend to use primarily the hydrogen peroxide-based systems as well, just because I think that, with diabetic patients, there is already a greater risk of complications. Hydrogen peroxide helps prevent further problems. With children, I often start them on multipurpose solutions until I feel they are progressing, then switch them to hydrogen peroxide.

Dr. Orsborn: Are you more stringent in your follow-up care for patients with diabetes?

Dr. Chous: Patients with diabetes need constant reinforcement and education to help prevent the development and progression of potentially blinding eye disease. I think contact lens wear in patients with diabetes is another way for us to make sure that we are getting these patients to our offices on a more regular basis to effectively manage their condition and care.

Dr. Ventocilla: To fit them with contacts in the first place, I need to be comfortable doing so. If I am not comfortable to begin with, I will not fit them at all. My patient base is primarily low income, so follow-up can be problematic. If they have retinopathy then I will not fit them with contacts. Once I have established that the fit looks good and they are wearing and caring for the lenses appropriately, I see them on a yearly basis.

Dr. Gelb: It depends on the disease severity. If I am following a patient for retinopathy—to look for any kind of retinal changes while wearing contact lenses—then certainly, I will see him or her more frequently, about every 4 to 6 months. For new diabetics, I will see them every 6 months to examine them with the RHA instrument from Annidis and look for microaneurysms.

Dr. Hom: Most patients with diabetes also have ocular surface disease. You have to follow-up for that every 3 months, and for retinopathy every 6 months. Also, 40% to 60% of these patients have allergies, so there are two ocular surface issues—not only dry eye, but allergy as well. These patients need a lot of care. This is actually a great practice opportunity if incorporated with the medical model.

PATIENT EDUCATION

Dr. Orsborn: What can we do differently to better educate patients about contact lens wear and diabetes?

Dr. Mitchell: I think everybody could use more education on contact lenses in general, to be honest—both patients and their doctors. It is helpful to have educational materials. In our office, we have a video in the waiting room, and one segment covers contact lenses. I have had patients come in and ask me about things that they have seen on the video, so that has been useful in starting conversations.

Dr. Chous: Speaking as a patient now, not so much as a provider, a lot of patients with diabetes—especially type 1—resent being identified as their diagnosis and being grouped together with every other person who happens to share that diagnosis. As a kid with diabetes, more than anything, I wanted to fit in. Anything that made me feel like I was different was hurtful in a way, and I know a lot of patients who also feel that way.

I think patients with diabetes, just like other patients, would love to hear more about how they can wear contacts. A lot of Americans have diabetes now, and many of them want to wear contact lenses. Sure, there are extra considerations to bear in mind, but it is certainly an option. That said, it makes good sense to have educational materials—for both patients and providers—that are specifically focused on patients with diabetes. We have the opportunity to educate patients about contact lenses and make them a reality for these patients. n

1. Statistics About Diabetes. American Diabetes Association. http://www.diabetes.org/diabetes-basics/statistics/. Accessed October 31, 2014.

2. March W, Long B, Hofmann W, et al. Safety of contact lenses in patients with diabetes. Diabetes Technol Ther. 2004;6(1):49-52.

3. Schiffman RM, Christianson MD, Jacobsen G, et al. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000;118(5):615-621.