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When contact lens patients complain of decreased wear time, discomfort, or reduced or fluctuating vision, often the first response of the eye care practitioner is to suggest a change. Perhaps a different brand of contact lens, a different brand of solution, or a change of modality, for instance from monthly to daily disposable, could help to relieve patients’ symptoms. Practitioners should remember, however, that ocular surface disease (OSD), including dry eye disease (DED), is common among contact lens wearers. If an unhealthy ocular surface is the cause of the patient’s complaints, perhaps the better approach would be to treat the underlying medical condition—DED—rather than to immediately start discussing changes in brand or modality.
At my practice, my colleagues and I conducted a study to assess whether treatment of DED with cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan) could increase wear time and improve ocular health in contact lens wearers.1 We retrospectively analyzed 102 patients who presented either for a yearly examination or pathology visit with complaints of ocular discomfort or vision issues, who were diagnosed at that visit with mild to moderate DED, and who underwent 6 months of cyclosporine (Restasis; Allergan) therapy while continuing to use their contact lenses.
In patients diagnosed with mild to moderate DED, the variables we analyzed included BCVA, corneal and conjunctival staining, tear breakup time, Schirmer score, and tear osmolarity. Patients were seen at baseline, 2 months, and 6 months. Among the patients, all of whom were white, 75 had presenting BCVA of at least 20/20 and 27 had BCVA worse than 20/20. Median age was 44.9 years, and 68 patients were women. Patients wore a variety of contact lens brands, and all used Clear Care solution (Alcon).
DED grading in these 102 patients (204 eyes), based on the International Task Force scale,2 was as follows: level 1 (lissamine green staining of conjunctiva), 34 eyes; level 2 (fluctuating vision, corneal staining not central), 107 eyes; level 3(central corneal stain, filamentary keratitis), 63 eyes. Patients with level 4 disease (recurrent erosion, neurotrophic ulcer) were not included. The most common chief complaints were decreased wear time (100 patients), fluctuating vision (84 patients), burning (15 patients) and dryness (14 patients).
At baseline, eyes with BCVA less than 20/20 had significantly worse (P < .05) contact lens wear time, corneal staining, conjunctival staining, and osmolarity than eyes with 20/20 BCVA. There was no difference in these measures between the two groups at 6 months. Patients with BCVA less than 20/20 had a significant improvement in BCVA at 6 months (P < .0001; Table).
The mean improvement in contact lens wear time from baseline to 6 months was significant for the entire study population and for those with BCVA less than 20/20. Wear time increased in the general population from 10.50 to 12.25 hours (P < .05), an improvement of 1.75 hours. In those with BCVA less than 20/20, wear time improved from 7.25 to 10.50 hours (P < .005), an improvement of 3.25 hours. Statistically significant improvements were also seen in conjunctival staining, corneal staining, tear breakup time, osmolarity, and Schirmer score.
The improvements in clinical variables seen after 6 months of cyclosporine treatment in patients continuing to wear their contact lenses indicates that cyclosporine treatment is beneficial in improving ocular surface health in these patients. Improvements in subjective variables, such as contact lens wear time, suggests that cyclosporine treatment can help to increase comfort and tolerability in these patients.
When contact lens wearers complain of discomfort or decreased wear time, it makes sense to consider performing a complete ocular surface health assessment. If DED or OSD is diagnosed, treatment with cyclosporine may be a better option than changing lens or solution brands or modalities.
It is important to remember that OSD can be a progressive condition. If the first response to a patient’s discomfort is to change brands or routines, this may bring temporary relief or improvement, but if the underlying medical condition (ie, DED or OSD) is not treated, the relief will not be permanent.
Treating the OSD with cyclosporine, on the other hand, will lead to better ocular surface health and allow patients to continue wearing their contact lenses with greater comfort and longer wear times. By avoiding a return of patients’ symptoms, this may prevent patient frustration and dissatisfaction and hopefully avoid subsequent contact lens dropout.
Although patients’ ocular health is the main concern, it is worth noting that diagnosing and treating OSD or DED can also be remunerative to the practice, and preventing contact lens dropouts means more future contact lens sales for the practice. n
1. Kislan T, Debello M. A retrospective analysis of cyclosporine 0.05% benefits in dry eye contact lens patients. Poster to be presented at: American Academy of Optometry Annual Meeting; November 9-12, 2016; Anaheim, CA.
2. [no authors listed]. The definition and classification of dry eye disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92.
Thomas P. Kislan, OD
• Medical Director, Hazleton Eye Specialists, Stroudsburg Eye Specialists, and the Dry Eye Center of Northeastern Pennsylvania
• Financial disclosure: consultant to Allergan