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According to oft-cited data from the 2007 International Dry Eye Workshop, 50% of contact lens patients experience ocular irritation.1 This equates to approximately 17 million Americans. Contact lens discomfort (CLD) and dry eye disease (DED) can lead to contact lens dropout. As DED is on the rise, so are the numbers of contact lens–intolerant patients who will present to our practices.
Appropriate evaluation and management strategies for this patient population are crucial in any contact lens practice, whether general or specialty, to achieve success and ultimately improve quality of life for these patients. What do we do when a patient presents to our practice complaining of symptoms of dryness, irritation, reduced wear time, or blurred vision associated with contact lens wear? Often our first approach is to switch lens materials, change replacement schedule, or change care products at the initial visit. Should we instead perform an ocular surface evaluation and treat the underlying condition before attempting refitting?
The Tear Film & Ocular Surface Society’s International Workshop on Contact Lens Discomfort defined CLD as a condition characterized by “episodic or persistent adverse ocular sensations related to lens wear, either with or without visual disturbance, resulting from reduced compatibility between the contact lens and the ocular environment, which can lead to decreased wearing time and discontinuation of contact lens wear.”2
In order to properly manage the CLD patient, every practice needs a plan. Clinical evaluation of the patient experiencing CLD is outlined in this article.
In this era of managed care and vision care plans, practices that desire to manage DED and CLD must develop solid business and economic strategies to provide the best quality of care for these often frustrated patients. Effective and intelligent scheduling is important to preserve the office schedule flow and the practice’s bottom line.
If a patient is being referred specifically for a dry eye evaluation, it is easy for the staff to schedule the time and educate the patient on the type of testing necessary and what his or her expectations should be. In reality, however, often these patients present for routine examination wanting to utilize their vision care plan. History taking then reveals previous contact lens dropout or suggests underlying disease.
In the case of the dropout patient, most experts would agree that it is prudent to evaluate the ocular surface and treat the underlying condition first before proceeding with contact lens refitting. The eye care professional must educate the patient on the need to perform a medical evaluation first for best success and care, bill the examination and testing medically, and hold off on billing their vision care plan for a future examination once stability of the ocular surface is achieved. This strategy may help to reduce chair time that would otherwise ensue due to multiple CLD problem visits.
Evaluation of the patient with CLD can employ everything from basic tools to advanced point-of-care testing. The initial task is to evaluate symptoms by use of questionnaires. My office employs the Ocular Surface Disease Index (OSDI) questionnaire, as it is included in the Keratograph 5M (Oculus) testing. We also have the Dry Eye OSDI Questionnaire app loaded on iPads for the staff to easily administer.
Another questionnaire, the Standard Patient Evaluation of Eye Dryness (SPEED), has become popular in offices due to its valid, repeatable, and efficient assessment of symptoms. Comparison studies have shown both the OSDI and SPEED questionnaires to be reliable.3,4 The SPEED score has been shown to correlate well with meibomian gland function.5
Gross observation of the patient is critical. A basic exam includes a slit-lamp examination of the lids, the meibomian glands and their degree of expression, the lid wiper area, and measurement of the tear meniscus height. Schirmer 1 testing should be considered. Staining of the cornea and conjunctiva with fluorescein and lissamine green (LG) vital dyes is essential. Corneal staining is more indicative of late disease, and LG conjunctival staining indicates early disease. It has been reported that LG is used by only about 5% to 10% of eye care providers.6,7 LG conjunctival staining and reduced Schirmer 1 testing have also been shown to correlate with positive Sjögren syndrome serology and lip biopsy results.8
Several point-of-care testing modalities for DED are available. The TearLab Osmolarity Test (TearLab) is helpful, as DED is highly correlated with hyperosmolarity. The InflammaDry immunoassay (Rapid Pathogen Screening) evaluates the level in the tears of the inflammatory marker matrix metalloproteinase 9, which is elevated in DED.
The Oculus Keratograph 5M and the LipiScan and LipiView devices (latter two from TearScience), among others, are sophisticated instruments capable of performing meibography.
The following case presentation illustrates the importance of fully evaluating the CLD patient.
A 56-year-old white woman presented with a chief complaint of chronic xerophthalmia and blurred vision. The patient reported that she was no longer able to wear her soft hydrogel multifocal monthly contact lenses. Her main goal was to return to lens wear. She had seen numerous providers with no success. Current therapy included topical preserved artificial tear supplements. Her medical history was significant for an inconclusive diagnosis of systemic lupus erythematous (SLE) many years earlier. She reported mild xerostomia. No seasonal or known medical allergies were reported.
Given the extent of her history, we decided to proceed with a complete ocular surface evaluation. She completed the OSDI questionnaire with a score indicating moderately severe ocular surface disease (Figure 1). Gross observation of the patient did not reveal rosacea facies, rash, or joint abnormalities. Slit-lamp examination revealed thickened lid margins with inspissation in both eyes. Meibomian gland expression was difficult OU. Tear meniscus height was normal OU.
TearLab testing revealed normal osmolarity, and InflammaDry assay was negative OU. Meibography revealed inferior truncation and ductal dilation (Figures 2 and 3). Evaluation of tear film stability with fluorescein dye revealed a rapid tear breakup time. Inferior fluorescein corneal staining was present OU. Evaluation of the bulbar conjunctiva with LG vital stain revealed bilateral nasal staining (Figure 4) and lid wiper epitheliopathy OU.
Our initial diagnosis was bilateral meibomian gland dysfunction, but given her xerostomia and previous history of inconclusive SLE, we referred the patient for a rheumatologic consultation to rule out SLE and Sjögren syndrome. Avise CTD (Exagen Diagnostics) connective tissue disease diagnostic testing was positive for markers (ds-DNA, ANA, and EC4d/BC4d) associated with SLE. SS-A and SS-B serology testing was negative. Given that SS-A and SS-B testing can be inconclusive, the rheumatologist ordered a labial salivary gland biopsy, which was also negative, thus ruling out Sjögren syndrome.
Systemic and ocular therapy subsequently led to improved ocular surface health for this patient. She was successfully refit into daily disposable multifocal contact lenses. This case illustrates how an initial ocular surface evaluation led to a diagnosis of ocular and systemic disease and, ultimately, a happy patient.
CLD may be the presenting sign of ocular or systemic disease. Proper evaluation and management can improve quality of life for patients with CLD. Evaluation and treatment of ocular surface disease before refitting these patients may lead to contact lens success and reduced chair time. Consider performing this type of evaluation before changing lens materials, modalities, or care products.
1. [No authors listed]. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):93-107.
2. Nichols JJ, Willcox MDP, Bron AJ, et al. The TFOS International Workshop on Contact Lens Discomfort: Executive Summary. Invest Ophthalmol Vis Sci. 2013;54:TFOS7–TFOS13.
3. Finis D, Pischel N, Konig C, et al. Comparison of the OSDI and SPEED questionnaires for the evaluation of dry eye disease in clinical routine. Ophthalmologe. 2014;111(11):1050-1056.
4. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Cornea. 2013;32(9):1204-1210.
5. Keir N, Ngo W, Situ P, et al. Evaluation of the Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire. Invest Ophthalmol Vis Sci. 2013; 54:6028.
6. Nichols KK, Nichols JJ, Zadnik K. Frequency of dry eye diagnostic test procedures used in various modes of ophthalmic practice. Cornea. 2000;19(4):477-482.
7. Korb DR. Survey of preferred tests for diagnosis of the tear film and dry eye. Cornea. 2000;19(4):483-486.
8. Bunya VY, Bhosai SJ, Heidenreich AM, et al; Sjögren’s International Collaborative Clinical Alliance (SICCA) Study Group. Association of dry eye tests with extra-ocular signs among 3514 participants in the Sjogren’s Syndrome International Registry. Am J Ophthalmol. 2016;172:87-93.
Casey L. Hogan, OD, FAAO
• Diplomate, American Board of Optometry
• Principal with Advanced Eye Care Professionals, Oak Lawn, Illinois
• Adjunct faculty, Illinois College of Optometry
• (708) 229-2200; firstname.lastname@example.org; Twitter: @EyeDocAEP
• Financial interest: none acknowledged