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Have you ever given a second opinion to a patient who has been advised by previous doctors that she is “not a contact lens candidate”? Have you ever fit a patient for contacts and found out he had dry eye disease (DED) after the fact?
If you answered “yes” to one of these questions, this article can help you streamline your contact lens thinking for the future, lessen chair time, reduce patient frustration, and increase your patients’ trust and patience with you as their eye doctor.
Most optometric and ophthalmic practices charge a fitting fee or refit fee for contact lens evaluation and new contact lens fits. Because these services are usually paid out of pocket by most patients, their expectation is that the service will be a pleasant experience that will not take weeks to months to accomplish. Most patients are busy and seek an efficient contact lens fitting process. No one, including the doctor, wants to work backward, fixing problems after the contact lens fitting process has started.
The number one reason for contact lens dropout is DED.1 If DED is diagnosed and treated prior to or during the contact lens fitting process, both doctor and patient benefit. The patient has a more fluid experience and greater respect for the process. The doctor benefits with less chair time, happier patients, and more referrals. And patients often recommend a doctor who managed to find a problem that no one else could!
The best thing to do to avoid these problems is to screen patients for DED (see DED Screening Checklist) before or during the contact lens fitting process. If patients are returning for a contact lens refit or coming to you for a second opinion, it is best to have a high level of suspicion for DED (see Questions for Contact Lens Refit or Second Opinion).
POPULATIONS AT RISK
Leading populations at risk for DED include peri- or postmenopausal women and those taking medications such as antihistamines and antidepressants. Rosacea and meibomian gland disease (MGD) can also be significant factors, as well as thyroid disease and other inflammatory diseases such as rheumatoid arthritis. The ever-increasing time spent on digital displays (computers, tablets, phones) increases risk for DED. And finally, previous contact lens dropout is a red flag for potential DED (see Red Flags for DED).2
A simple explanation of dry eye and its effect on contact lens wear is imperative from the start. I tell patients that contact lenses are made mostly of water, and the osmolarity theory tells us that water attracts water; so if you have a water-deficient eye, a contact lens will attract the tears that you already have too little of.
Treatments may include artificial tears, warm compresses, increased water consumption, use of a humidifier, increasing consumption of omega-3 fatty acids, decreasing consumption of caffeine, prescription of Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and/or Xiidra (lifitegrast ophthalmic solution 5%, Shire), and insertion of punctal plugs. Patients will respect the decision to proactively treat problems before they become symptomatic.
Depending on the severity of DED, doctors can perform a contact lens fitting on the day of the initial visit and treat the DED concurrently while fitting proceeds. If DED is severe and the patient presents with symptoms, it is optimal to treat, delay the fitting for a few weeks, have the patient return for a follow-up visit, and then perform contact lens fitting if the DED treatment was successful.
PERI- OR POSTMENOPAUSAL WOMEN
This population is at a natural disadvantage. Lack of estrogen contributes directly to dryness in all mucus membranes, including the tear film. When patients have a decreased tear breakup time, a contact lens is not going to feel as comfortable as if they had well-lubricated eyes.
I educate this population about the mucus membrane dryness and bluntly state, “The contact lens will feel like a hockey puck if we don’t treat the dry eye first.” Most patients in this demographic are in tune with their hormonal changes already and can easily relate to this message. They also appreciate the candor and the physician’s foresight in treating their eyes proactively.
MEDICATION SIDE EFFECTS
In my practice I find the main offenders in DED are antihistamines and antidepressants. These drying medications can affect patients young or old, men or women. Make sure to prescreen for all systemic medications, and always look at the patient’s list of medications used thoroughly prior to the examination. Sometimes it is helpful to give a list of these drying medications to your technician or scribe so they can highlight these on the patient’s form and you will not overlook them.
Patients with thyroid disease will usually at some point have signs or symptoms of DED. Most thyroid patients are aware of this; however, if they are not, it is the duty of the eye care physician to educate them about the eye manifestations of thyroid eye disease, especially when fitting contact lenses. A patient with thyroid disease may not have DED symptoms without contacts, but just adding the contact lens to the equation may cause the symptoms to arise.
Patients with rheumatoid arthritis may also be included in this group. As we now know, from the 2007 Dry Eye Workshop, DED is an inflammatory condition: When the body is inflamed, the eye can be inflamed.3 DED and contact lens wear can be contraindicated in these patients initially, but treatment before and during contact lens wear can minimize comfort problems.
When introducing myself, I always pay attention to the patient’s physical health. I especially examine the face. Rosacea can be easily diagnosed by looking for spidery veins in the cheek and nose area. Often patients with rosacea will have some form of blepharitis or MGD on slit-lamp examination.
These patients often have English, Irish, or Scottish heritage. I simply educate these patients that they are missing some of the oil component of their tear film, and this is what is keeping their tears from sticking to the cornea.
DIGITAL EYE STRAIN
With the increasing use of digital displays, the amount of time patients spend staring is higher than ever.4 It is not uncommon for most of our patients to use a digital device more than 5 hours a day. This complicates DED factors. With the decrease in blink rate that accompanies staring at a screen, the cornea is not sufficiently hydrated, and this leads to DED. Determining how much digital device work a patient does can indicate the need to evaluate for DED.
Although it may not seem ideal for patients who seek a quick and easy contact lens fitting process, over time patients come to appreciate the comfortable and uncomplicated experience that comes from identifying DED before or during contact lens fitting. Spending the extra time initially to uncover DED problems saves time backpedaling to treat disease after the process has begun.
A contact lens fitting is more than the selection of base curve, power, and diameter. Ocular health plays a significant role in the process. As I tell patients, “Your contact will only work as well as the eye under it.” Patients expect a smooth contact lens fitting process, especially when they are paying out of pocket. The referrals from these satisfied patients will prove the value of proactive identification of DED.
1. Nichols JJ, Sinnott LT. Tear film, contact lens, and patient-related factors associatedwith contact lens-related dry eye. Invest Opthalmol Vis Sci. 2006;47(4):1319-1328.
2. Uchino M, Schaumberg DA. Dry eye disease: impact on quality of life and vision. Curr Ophthalmol Rep. 2013:1(2):51-57.
3. 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.
4. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit on blink rate and tear stability. Optom Vis Sci. 1991:68(11):888-892.
Michelene Todd, OD
• Private practice, specializing in contact lenses and dry eye disease, in Southbury, Connecticut
• Financial interest: none acknowledged