cultivating compliance

When is it a Compliance Issue?

BY GLORIA B. CHIU, OD, & TIMOTHY B. EDRINGTON, OD, MS

It is inevitable that you'll encounter corneal staining, especially on the inferior third of the cornea (Figure 1). But how often is the etiology of this staining clearly understood? Patient compliance may be the culprit, but let's also explore a few other possibilities.

Figure 1. Inferior corneal staining.

Compliance Issues: Patient Education Indicated

1. Prolonged lens wear. Regardless of the material, a lens that stays on the eye for too long may induce corneal desiccation and staining. Frequent lubrication with artificial tears and decreased wearing time may help.

2. Improper lens removal technique. Ideally, a soft lens should be gently decentered onto the bulbar conjunctiva before removal to avoid irritation from pinching the lens off the cornea. Consider observing patients removing a contact lens in-office so that you can review proper technique if necessary.

3. Eye rubbing. Forceful pressure from fingers or knuckles may chafe the cornea. If the rubbing is allergy-related, consider daily disposable lenses or a topical antihistamine/mast cell stabilizer.

While it's important to properly educate patients regarding lens compliance issues, it's equally important to ensure that patients understand why it's necessary to follow specific guidelines. If patients realize that their actions may result in compromised corneal health, vision and comfort, they may be more willing to comply with specific recommendations.

Not Compliance Issues: Practitioner Action Required

1. Inadequate lens fit. A lens that is too steep or flat may not drape the cornea properly, which may disrupt the tear film and contribute to staining. Over-keratometry can show changes in the projected mire images between blinks on a soft lens wearer. If the mire images blur immediately after a blink and then slowly become clear, the lens is likely too flat. If the mire images are clear immediately after a blink and then slowly distort, the lens is too steep or the patient's tear film is compromised. Consider a different base curve, diameter or design with a thinner profile to improve the draping characteristics.

2. Solution toxicity. Certain combinations of soft lenses and multipurpose solutions may contribute to increased corneal staining. If the patient is compliant with lens care and wear time, a change to another care regimen with a different preservative may do the trick. Inquire about the patient's care systems during an examination so that potential lens/solution incompatibilities may be identified and resolved.

3. Lagophthalmos and partial blinking. Incomplete closure of the eyelids hinders adequate tear flow over the ocular surface. Frequent use of artificial lubricants, an ointment at night after lens removal and eye exercises designed to improve blinking efficiency may help reduce exposure of the inferior cornea.

4. Blepharitis and meibomitis. Inflammation of the eyelids and meibomian glands results in a decreased quality of mucus and lipids and an increase of proteins in the tear film. This debris may exacerbate corneal staining by disrupting tear flow and lens hydration, as the accumulated material generally settles along the lower lid margin. Prescribe lid hygiene including a warm compress, lid massage and lid scrubs daily before lens application to promote clean eyelids and a smooth tear film. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #157.

Dr. Chiu received her optometry degree from the University of California, Berkeley. She is currently the cornea and contact lens resident at the Southern California College of Optometry. Dr. Edrington is a professor at the Southern California College of Optometry. Email him at tedrington@scco.edu.