readers' forum
Four-Point Plan to Achieve Comfortable Contact Lens Wear
BY BEZALEL SCHENDOWICH, OD, FIACLE

Our climate in Israel, much like southwestern United States, is generally very warm and very dry. In addition, our air conditioning systems (both for heating and cooling) do not humidify.  Add to this the nearly universal use of computer monitors with their inherent static charge that dries the ocular surface while viewing, and you have built the extreme test environment for contact lens comfort.

On a daily basis, we encounter patients who complain of dryness, burning and gritty sensations in their eyes. We see various patterns of injection and superficial punctate keratopathy. We try to understand the causes but end up in many cases treating only the symptoms. Our motivation is to improve our patients' general ocular condition and reduce the foreign body sensation in situ.

Wouldn't it be nice, if not unconventional, to treat the causes of our patients' aggravations and not merely their symptoms?

Table 1 lists common complaints from our contact lens patients. We can attribute all of these symptoms to an inadequate tear film with exposure interaction. Inadequate tear coverage can result from poor tears or poor tear usage. Poor tears result from insufficient quality or quantity of the tears, while tear usage implies a problem with the blink mechanism.

In the case of insufficient tear production, we have two basic options to help our patients: tear supplements and punctal plugs. Tear supplements temporarily add to the tear layer. Drops which primarily build up the aqueous component of the tears run the risk of causing rapid dissipation of the lipid layer, which accelerates evaporation and surface desiccation. Plugs allow tears to remain on the ocular surface longer, but might inadvertently cause a biofeedback-mediated reduction in production.

If, on the other hand, we find that tear quantity is sufficient, we must investigate tear quality and the blink mechanism. By systematically evaluating the meibomian gland orifices of all my patients, I have found that the vast majority of my patients show some degree of plugging. In a highly evaporative climate such as ours, a poor tear lipid layer is an invitation for discomfort with or without contact lenses.

The four steps of my plan for achieving comfortable contact lens wear are warm lid massages, efficient blinking, the saline rinse and weekly protein removal.

Warm Lid Massages

The treatment for sluggish or blocked meibomian glands is both remedial and preventative. If patients perform it as described, the treatment will cure the immediate problem and provide greater ocular comfort with or without contact lenses. It will also help prevent the future occurrence of blepharitis, which otherwise would have been likely. You must place these patients onto an active program of warm lid massages done at least twice a day for five to 10 minutes.

Instruct patients to lay a very warm, wet cloth over their closed lids. After a minute or so of the warm compress, the patient should gently massage his lids through the cloth in the direction of his aperture (upper lids downward, lower lids upward). The warmth liquifies the hardened tear matter while the massage both cleans the lids and expresses the meibum from the glands. As meibum is expressed, the gland should begin to produce more. After about a month of this treatment, most patients begin to feel improvement that lasts throughout the day.

Efficient Blinking

Adding a treatment to a patient's daily agenda creates the problem of "finding the time." You can remedy this by urging the sufferer to "make the time."

On the other hand, it is difficult to change the way a person performs a subconscious or reflex action, such as blinking. The trick in blink modification therapy is to recognize the partial blink. The ideal way to do this would be to zoom-video the faulty blink in action and replay it for the patient. You can emphasize the need for a more perfect blink by carefully explaining that the horizontal red lines, yellow masses, filmy or foggy vision and crusty contact lenses all result from a blink that ends at the top edge of the lens.

Blinking in a particular way and at a particular frequency ensures the renewal and revitalization of the corneal epithelium and the conjunctiva. Blinking cleans the ocular surface of debris (cellular, dried tears and airborne particles) and flushes fresh tears over the ocular surface. This brings nutrients and mucins to the surface structures and keeps them healthy. Blinking also helps prevent infection and clears and brightens the image received by the retina. It wets the outer eye and, in the case of the contact lens wearer, replenishes the tear layer upon which the contact lens floats.

The only sure way to build a new habit, like proper blinking, is to practice. Patients can simply consciously blink, or they can try blink exercises. Table 2 describes my program of blink modification therapy.

The Saline Rinse

Patients should perform this stage before the massage both morning and evening (and, perhaps, whenever they remove the lenses during the day). The goal of flushing the ocular surface with sterile, unidose or preserved, saline is to remove irritants and contaminants from the environment under the lid. These moieties inevitably build up during the day (mostly under the contact lens) and during the night (under the closed lid) and may cause itching that can lead to compulsive and occasionally violent eye rubbing. A thorough flushing with saline will refresh the eyes and reduce the tendency for potentially dangerous ocular self-abuse.

Protein Removal

Finally, I believe that every contact lens used for more than one week before disposal requires a protein removal treatment at the end of each week's usage. Rubbing the lenses with a cleaning solutions removes much surface debris, but the protein load continues to build during wear. The unremoved protein gradually denatures and may initiate inflammatory reactions of the palpebral conjunctiva. Nothing is sadder than a contact lens-dependent patient who ignores instructions to return for check-ups, neglects his lens care and develops florid GPC. You can help him ­ slowly, and at some not insignificant expense ­ but wouldn't it have been easier to prevent the CLPC?

Patient Motivation and Compliance

I believe the average patient compliance to just about any medical instruction is about 30 percent. I suspect that your success with the four-point plan I have described here will increase if you properly describe the steps and clearly explain their rationale at the beginning of the treatment, with periodic reinforcement sessions at follow-up visits.

Once a patient completes a first month of assiduous rinsing, massaging, blinking and protein removal, he will voluntarily report improved comfort. By encouraging compliance with clear explanations, a self-reinforcing motivation spiral will come into play. In simple words ­ the patient will want to continue treatment.

Dr. Schendowich is a preceptor in the Optometry Clinic at the Hadassah Academic College in Jerusalem, Israel and Adjunct Assistant Clinical Professor of Optometry of SUNY ­ Optometry based in the Optometry Clinic at the Sha'are Zedek Medical Center, Jerusalem, Israel.