A Preemptive Strike

Astonishingly, there are at least 34 million Americans that currently wear contact lenses regardless of their ocular condition. From presbyopia to astigmatism, lens technology has evolved to address the needs of a wide range of patients with varying ocular issues. However, the contact lens dropout rate remains a persistent concern for practices, especially with patients suffering from dry eye.

A recent study found that 52.7% of contact lens wearers, compared to an estimated 14% to 33% of the general population, suffer from dry eye.Scaffidi RC, Korb DR. Comparison of the efficacy of two lipid emulsion eyedrops in increasing tear film lipid layer thickness. Eye Contact Lens. 2007 Jan;33(1):38-44. In a 2010 global survey conducted by John Rumpakis, O.D., M.B.A., the primary reason patients discontinue use of their lenses is discomfort associated with dry eye (50%), followed by a preference for glasses (15.9%) and fi nally, expense (12.3%).Rumpakis J. New data on contact lens dropouts: an international perspective. Rev Optom. 2010 Jan;147(1):37-42. As eye care practitioners, we struggle to work with fi nancial constraints and our patients’ personal preferences. However, we can take steps to prevent a contact lens user from discontinuing use solely due to dry eye.

In this column, we’ll look at the patient profi le of a contact lens user with dry eye, describe ways to screen for the disease and examine the many treatment options currently available.

The Dry Eye Dilemma

Dry eye is both a medical concern as well as a refractive issue, and should be treated before the initial prescription and/or continuation of lenses. By treating the eye fi rst, you can then focus on equipping your patient with the most appropriate lens choice.

Ocular dryness and the use of contact lenses presents a considerable challenge: Contact lenses may exacerbate pre-existing dry eye, and can also induce dry eye in patients who may have previously never had any symptoms. This type of dry eye is a condition known as contact lens-induced dry eye (CLIDE). When a contact lens is placed on the precorneal tear fi lm, the normal tear fi lm is disrupted, which leads to more rapid tear fi lm break-up and evaporation.Ousler GW 3rd, Anderson RT, Osborn KE. The effect of senofilcon A contact lenses compared to habitual contact lenses on ocular discomfort during exposure to a controlled adverse environment. Curr Med Res Opin. 2008 Feb;24(2):335-41. Contact lens wear also can decrease corneal sensitivity and disrupt the normal tear secretion that is needed to preserve the ocular surface.Foulks G. What is dry eye and what does it mean to the contact lens wearer? Eye Contact Lens. 2003;29:96-100.

Keep in mind that losing contact lens patients can signifi cantly impact your practice’s income. In fact, each contact lens dropout costs an optometric practice an average of $21,695 over the lifetime value of that patient. These losses can be avoided if a patient’s dry eye is appropriately managed fi rst.

Recognize Patient Behavior

It should be noted that a comprehensive dry eye exam is different from a regular check-up of a patient’s overall ocular health. Before fi tting your patient in contact lenses, conduct a thorough eye exam. Ask basic questions, such as whether your patient is experiencing any common signs of dry eye, including burning, stinging or grittiness. Upon clinical presentation, it is important to clearly differentiate between symptoms related to lid disease (blepharitis or meibomian gland dysfunction) and symptoms of allergy. For example, an allergic eye itches, while a dry eye burns and produces a gritty sensation.

Next, follow up with more detailed questions to gain some insight into your patient’s daily habits. Note non-compliant tendencies among your patients, such as sleeping in lenses or skipping cleaning regimens. Learn about your patient’s individual lens needs, such as how many hours of continuous lens wear is expected, to establish the most customized approach to their lens care. Consider switching your patient to a daily disposable lens, which may help alleviate many symptoms and improve compliance.

Diagnostic tests like staining reveal a dry eye patient’s symptoms such as inceased tear film break-up. Being fully aware of your patient’s dry eye is crucial before outfitting them in lenses.

While collecting a personal history, fi nd out about your patient’s home and work environments. Symptoms of ocular discomfort are higher among contact lens users who spend signifi cant time in areas controlled by air conditioners and/ or heating units, and those who are exposed to windborne and airborne pollutants.Gonzalez-Meijome JM, Parafita MA, Yebra-Pimentel E, Almeida JB. Symptoms in a population of contact lens and noncontact lens wearers under different environmental conditions. Optom Vis Sci. 2007 Apr;84(4):296-302.

Visually taxing activities, such as reading, watching television or using a computer, can exacerbate dry eye symptoms. Suggest that your patients avoid these stressors for an extended period of time. These subtle changes in lifestyle can often have a signifi cant impact on dry eye patients’ quality of life. Finally, find out at what time of the day the symptoms are at their worst. Studies have shown that subjects with dry eye display impaired visual function in the evening rather than in the morning.Walker PM, Lane KJ, Ousler GW 3rd, Abelson MB. Diurnal variation of visual function and the signs and symptoms of dry eye. Cornea. 2010 Jun;29(6):607-12.

Clinical Examination

There are several techniques used to diagnose dry eye.

The Treatment Options

Advances in contact lens technology have broken the barrier between dry eye sufferers and contact lenses. Soft contact lens materials, including omalfi con A and etafi lcon A, have higher oxygen permeability than previousgeneration lenses, allowing the eye to “breathe” easily and the tear fi lm to replenish more readily. One study showed that senofi lcon A (Acuvue Oasys, Johnson & Johnson) is particularly effective in improving comfort over time in habitual lens wearers who are exposed to adverse environmental conditions.

These lenses were also shown to enhance wettability and improve comfort, which can eventually lead to fewer dropouts.

Rewetting drops can also be used. Proactively selecting the optimal care products for your patient’s particular lenses can enhance performance and the overall wear experience, which ultimately can reduce dropouts.

Despite the number of treatment options available today, nothing is as successful as establishing a management strategy with your patients that works best for their individual needs. Emphasize frequent check-ups and maintain a clear line of communication for long-term contact lens-wearing success. Pre-emptively treat dry eye fi rst and then follow with a contact lens prescription that works best for a patient’s condition. This will help minimize dropouts at your practice and make your patients much more comfortable in their lenses.