LENS CARE

Communicating the Importance of Lens Care

Two theoretical cases illustrate common lens-wearing issues and how a systematic approach—including some old-fashioned detective work—can help resolve them.

By Bruce W. Anderson, OD, FAAO

Vision care for the contact lens wearer doesn't end with dispensing the optimal lens with the proper fit and power. It begins there. Ongoing communication with the patient is essential to ensure a positive, long-term contact lens-wearing experience.

When patients encounter problems with their lenses, asking carefully crafted questions aimed at uncovering the cause of the issue is an essential problem-solving step. A detailed case history will provide the clues you need. I call this "playing detective." The types of questions I ask may include: What are your symptoms? How long have you had this problem? When do you experience the problem? How often do you replace your lenses? What is your wearing schedule? Are there any other issues with lens wear?

After a thorough eye examination and lens evaluation, I continue my discussion with the patient to identify the most likely cause for his symptoms. I inquire about vision needs and habits at work, especially in terms of computer use. I also ask about physical activity and leisure time pursuits. Taking into consideration the lens type being worn, I try to determine the level of adherence to the prescribed replacement schedule. Then I review the lens care regimen, including which products the patient uses and how closely he follows the manufacturer's instructions. Educating patients about the importance of adherence can help them make the connection between correct use of the lens care solution and greater satisfaction with their lenses.

The following are two theoretical cases that are representative of my approach to solving contact lens problems. They illustrate how questioning and counseling patients can help identify concerns, which can lead to successful resolution of contact lens wear issues.

Case 1: Discomfort Upon Lens Application

In this example, a new contact lens wearer returns to the office two months after starting monthly replacement lenses. He says the lenses sting when he applies them in the morning.

Patient's Case History First, I ask the patient when the problem started. Is the stinging upon lens application or after a period of time? If the stinging is not immediate, when does it begin? Is the patient using the care products I recommended and as indicated? Does the problem exist when new lenses are applied? Does the problem progress as the lenses are worn during the month? Is the patient taking any new medications? Have there been any changes in health or routines that may affect his eyes?

Patient's Responses The patient says the stinging started about a month ago. He feels it shortly after applying his lenses, usually within seconds to several minutes. He is using a generic multipurpose solution (MPS) that he bought on sale instead of the product I recommended. He does not rub the lenses, per the instructions on the solution bottle. He also uses saline solution for occasional soaking because it was cheaper than the generic MPS and did not seem to sting as much. The patient does not experience the stinging on the first day he wears a new pair of lenses. The problem does not worsen during the month's use. There have been no changes in his medications, general health or routines.

Lens Use The patient applies his lenses after he showers in the morning and removes them just before going to bed at night. He does not sleep in the lenses, per my original recommendations. To date, he has followed the manufacturer's recommendations for lens disposal and has discarded the first two pairs of lenses after one month of wear. The patient started wearing the third pair of lenses a few days before coming to see me.

Examination Next, I conduct a thorough ocular health examination to rule out serious problems, such as infection or abrasion. I also look for subtle signs, such as injection, staining, microcysts or other corneal changes. In this scenario, the patient's eyes are healthy with no obvious ocular signs or changes on the cornea.

Possible Reasons for Discomfort This patient's discomfort is probably not related to the brand of contact lenses he is wearing, because he reports no problems on the first day of new lens wear. Because the problem occurs upon lens application as opposed to later in the day, it is more likely a care solution problem. The amount of contact lens care solution is at its highest concentration on the lens surface and absorbed in the lens immediately upon removal from the case. As the lens is worn, tears flush out and replace the absorbed solution. Therefore, the stinging is most likely related to one or more of the following:

• Sensitivity to ingredients in the MPS
• The pH of the care solution
• Transfer of soap oils or cosmetic agents from hands to lens.

Of these possibilities, the first two may be more likely, given that the patient adheres to the recommended lens disposal regimen and reports feeling the same degree of discomfort throughout the month. The third option, although less likely, should be addressed as a precautionary measure.

Intervention Once I have identified the most likely cause of discomfort, which in this case is the MPS, I counsel the patient on how we can best resolve this problem. I recommend a different MPS and emphasize the need for greater adherence to the recommended lens care regimen.

Choice of Care Solution Because the patient prefers the convenience of an MPS, I recommend a trial of a different brand. As clinicians, we need to be knowledgeable about the physical makeup of the various contact lens care products—the pH, preservatives and other ingredients—so that we can make educated choices when trying to resolve solution-related problems. For example, if the pH of a patient's current MPS is different from the normal human ocular environment, it may be helpful to try a formulation with a compatible pH or a composition closer to natural tears. Similarly, knowing the preservative(s) used in specific care solutions enables us to switch to a different formulation when necessary.

I also remind the patient not to switch from the recommended contact lens care solution. If he has to change to a generic lens care product for personal reasons, then I will counsel him on which ones may be best for his needs. I also advise him to stop using saline as an overnight soak and recommend a specific lens care routine (See, "Lens Care Best Practices," below).

Like many contact lens wearers, this patient seems unaware of the increased risk of an infection from not soaking his lenses in a product that disinfects them. He was only concerned about solving the stinging problem. To encourage adherence to good lens care, I remind patients that properly cleaned and disinfected lenses will not only reduce their risk for eye infections but may also be more comfortable to wear.

If Stinging Persists If adherence to best lens care practices and a change in MPS fail to resolve the patient's symptoms, I will recommend a peroxide care regimen along with a preservative-free saline rinse to eliminate all possibility that the preservative or another MPS ingredient is the problem.

If the symptoms persist after the patient switches to the preservative-free regimen, I will recommend changing to a different brand of contact lens. In this scenario, the patient's symptoms do not seem to occur on the first day he uses a new lens. Nevertheless, there could be an underlying sensitivity to the lens material, and switching to a different lens, possibly one that is discarded more frequently, such as a daily disposable, could resolve the stinging issue.

Follow-up Visit In this case, the stinging stopped after a change in care solution and with better adherence to the recommended lens care regimen, which included rubbing and rinsing the lenses as part of the cleaning routine.

Case 2: Contact Lens-induced Dry Eye

About 50 percent of contact lens wearers in the United States have contact lens-related dry eye (International Dry Eye Workshop, 2007a; Chalmers, 2005; Nichols, 2005). Contact lens use is associated with low lacrimal tear flow and tear film instability, as well as increased tear evaporation, particularly when lens wettability is poor (International Dry Eye Workshop 2007b; Guillon, 2008). Environmental factors, such as air quality and low humidity, can also induce symptoms of dry eye (Chalmers, 2005; Guillon, 2008).

In this case, a patient who has worn biweekly lenses for many years comes to the office for advice about a new problem with lens discomfort. Her eyes have been feeling dry, gritty and itchy for the past month, particularly toward the end of the day.

Patient's Case History As always, a comprehensive evaluation starts with a complete and thorough history. I ask the patient about the onset, duration, frequency, and intensity of these symptoms. I also ask her about lens use and care, and any changes in the her circumstances that might account for her discomfort.

Lens Use The patient always removes her lenses at night and does not sleep in them. In fact, because of the recent dryness symptoms, she has begun removing her lenses soon after dinner and wearing her eyeglasses until bedtime. She discards her lenses every two weeks as indicated.

Patient's Responses The patient is consistently compliant with contact lens care but admits she does not rub her lenses on nights when she feels very tired. She is uncertain how frequently she replaces the lens case, responding "every now and then." I ask if she can remember the last time she discarded the old case, and she responds, "Maybe two or three months ago."

When I ask about any recent changes in her usual work and home routines, the patient says she recently started a new job that requires longer hours working on a computer than her previous position required. Upon further questioning, the patient notes the air conditioning in her new office is kept on high all day.

Examination The patient's eyes are slightly red but with no obvious signs noted upon slit-lamp examination. I evaluate tear quality to quantify possible tear deficiencies. I evaluate fluorescein staining, tear breakup time and other signs of tear abnormalities. In this case, no tear film abnormalities are noted.

Possible Reasons for Discomfort As with any new problem or symptom, it is important to determine a time line. Determine when the problem started and when the symptom is most noted, ask about any changes in routine or environment, then relate this back to the onset of the symptom and look for patterns. Possible reasons for a new problem with lens discomfort could relate to medication use, such as antihistamines, which could have a drying effect. Are there any current problems with seasonal allergies? What is the condition of the contact lenses? Are there excessive deposits that may be causing an increase in symptoms? Does the problem occur every day or just on work days vs. weekends? This question will help isolate an environmental pattern.

As noted in the patient's responses, there had been a change in her work environment, which coincided with the onset of symptoms. However, a careful history will help determine if there is more than one possible reason for any new problem. If no changes have occurred other than the work environment, then determine what is different in the new environment and what may be recommended to provide relief.

Intervention I reinforce the need for proper lens care, explaining that lack of cleaning can lead to lens deposits, which may affect the wettability of the contact lenses and lead to discomfort. As for the high level of air conditioning at her new office, which may be drying her eyes, I recommend that if adjusting the thermostat is not an option, she move her workstation so that it is not near an air vent.

Given the recent change in the patient's work-related computer use, I advise her to blink frequently to lubricate her eyes and reduce her risk for dry eye. I also recommend that she take short visual breaks from her computer screen every 20 minutes, looking off into the distance for 20 seconds to minimize the risk of eye strain.

Lens Care Best Practices This patient generally follows contact lens care best practices, but I emphasize the importance of rubbing and rinsing her lenses every time they are cleaned and replacing the lens case monthly. The contact lens case should be rinsed daily with care solution, not tap water, which is not sterile and can contain Acanthamoeba and other microbes (Shoff et al, 2008), Even with proper daily rinsing, monthly replacement of the contact lens case should be part of the lens care routine. Studies have shown that within 1 month, between 68 percent and 100 percent of contact lens cases become contaminated with bacteria and other microorganisms (Lakkis, 2006; Vincent, 2007).

Contact Lens Care Solution This patient may also benefit from a change to a lens care solution that contains a humectant, such as hyaluronan. Using rewetting drops on an as-needed basis can also provide extra lubrication during the day.

If Symptoms of Dryness Persist In this case, clinical signs were fairly normal, with the exception of slight redness; however, if these changes in the patient's routine do not improve her symptoms, I would consider prescribing a different contact lens, such as a silicone hydrogel lens (if she is currently wearing a hydrogel lens) or a Proclear lens (CooperVision), as these lenses dehydrate less than other types/brands (Schorner, 2010). I would also recommend a full workup for dry eye disease.

Validated questionnaires are available to assess dry eye symptoms, (International Dry Eye Workshop, 2007c) and complete descriptions of available diagnostic tests and questionnaires are included in the 2007 report by the International Dry Eye WorkShop (DEWS), which is available through the Tear Film and Ocular Society website (www.tearfilm.org/dewsreport/).

Follow-up Visit In this hypothetical scenario, the patient's symptoms resolved after she resumed proper lens care procedures, including rubbing and rinsing lenses before storage each night. The use of a multipurpose lens care solution containing a natural wetting agent and rewetting drops on an as-needed basis have also helped to alleviate discomfort.

At work, the patient takes periodic breaks from looking at the computer screen, and although she feels awkward stopping work, she notices that her eyes seem less strained. The patient agrees to begin discarding lens cases every month.

Ophthalmic Products

Comfort is a common issue with contact lens wear because of the effect of the lenses on the tear film and also because of patients' reactions to contact lens care solutions, which can vary from patient to patient. It is imperative that we stay up to date on the latest developments for these products so we can formulate effective treatment plans to address each patient's needs.

A growing trend in contact lens care and lens use is the development of products based on the composition of ocular structures. Both hyaluronan (HA; an endogenous lubricant found in eyes and other parts of the body) and a pH range between 7.3 and 7.7 help maintain a healthy environment in the human eye. Recent ophthalmic products have incorporated these features in an effort to not only provide some of the benefits of natural tears, but to do so in a manner that is not foreign to the eye. These features were viewed as effective in a study of 392 contact lens patients who switched to a bio-inspired MPS (Merchea et al, 2010).

Impact of Lens Care on Comfort

In my experience, many patients see their contact lens care solutions as only storage solutions. As eyecare practitioners, we can help patients increase their success with contact lens wear by educating them on the other benefits of proper lens care. The fact that clean lenses are more comfortable at lens application and at the end of the day can be a strong motivation for adhering to lens care best practices.

To summarize, if contact lens wearers are experiencing discomfort, the first step toward determining the cause of the irritation is to discuss the patient's symptoms, lens care routine and daily vision needs. Possible strategies for resolving the problem may include reminding patients of the value of adhering to the prescribed lens care regimen and addressing any obstacles that prevent adherence. Switching to a different lens care product and possibly adding lubricating drops to the lens-wearing routine may be beneficial.

Providing the best vision possible is just the first step toward a positive lens-wearing experience. Making specific recommendations for care products and providing education about lens cleaning routines will help ensure long-term satisfaction. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #193.

Dr. Anderson is in private practice in Tampa, Fla., and he is director of the Contact Lens Clinic at the Department of Ophthalmology, University of South Florida College of Medicine. He is a Fellow in the American Academy of Optometry and a Diplomate in Cornea and Contact Lenses He has worked as an advisor or consultant to Bausch +Lomb and Ciba Vision. Editorial and content assistance for this article were provided by BioScience Communications.