Treatment Plan

Comfortable Wear Despite CLDE

BY WILLIAM L. MILLER, OD, MS, PHD, FAAO

Contact lens-induced dry eye (CLDE) is one of the chief causes of decreased wearing time and contact lens dropouts. The dryness may be pathophysiologic or lens- and/or care system-related.

Meibomian gland dysfunction (MGD) is a leading cause of evaporative dry eye. It can create surface dryness, increasing the likelihood for deposition that can affect vision and comfort. The non-wetting contact lens surface can create frictional forces that can lead to lid wiper epitheliopathy (LWE).

LWE has been studied in both non-contact lens wearers and in contact lens wearers (Korb et al, 2010; Yeniad et al, 2010; Pult et al, 2008; McMonnies, 2007). As the condition is provoked by surface dryness, it’s best to address and treat the root causes, including MGD. However, this longterm therapeutic approach may take weeks to offer relief. Other short-term solutions can enhance contact lens surface wettability.

Your therapeutic approach may depend on staging the MGD, with stages 3 and 4 requiring approaches that may include anti-inflammatories or a short respite from contact lens wear. Any topical anti-inflammatory must be applied without contact lenses.

Rewetting Agents

Early treatments may include topical tear supplements and changing the lens material and/or care system. Systemic antibiotics can be used for their anti-inflammatory effects. More immediate solutions to MGD-induced evaporative dry eye include hot compresses, lid massage, improving blink efficiency, and topical drop instillation. Commonly used topical rewetting agents compatible with contact lens wear include Aquify Long-Lasting Comfort Drops (Alcon), Blink Contacts (Abbott Medical Optics), Clerz Plus (Alcon), Opti-Free PureMoist Rewetting Drops (Alcon), Opti-Free Replenish Rewetting Drops (Alcon), Refresh Contacts (Allergan), and ReNu Rewetting Drops (Bausch + Lomb). I recommend planned and targeted instillation rather than having patients wait until the contact lenses are dry or uncomfortable. Dosing options may be b.i.d., t.i.d., or q.i.d., depending on the severity of your patient’s complaints.

Lens Care Solutions

Newer multipurpose disinfection systems may be useful in increasing the wettability of the contact lens surface. Many utilize novel wetting agents that can promote a longer-lasting wettable surface. Biotrue (hyaluronan, B+L), Opti-Free PureMoist (polyoxyethylene-polyoxybutylene, Alcon), and Opti-Free Replenish (tetronic 1304 and C9ED3A, Alcon) are examples.

Contact Lens Materials

You may also consider changes in contact lens material or modality. Some silicone hydrogel lenses are more prone to lipid deposition compared to hydrogel lenses. This can reduce wettability and creates a vicious cycle that includes lipid buildup as the surface dries, inducing friction that irritates the eyelid margin—a perfect scenario for LWE and the increased evaporation of the tear film aqueous due to the alteration of the superficial lipid layer.

It may be necessary to change to a lens material with a lower wetting angle such as a hydrogel or hydrogel-like soft contact lens. Or switch your patient to a daily disposable contact lens, decreasing possible protein or lipid deposition.

Enhancing Comfort

Rewetting agents, multipurpose care systems, and contact lens material and modality choices can all promote a longer-lasting and more lubricious contact lens surface. They help improve the evaporative cascade and lessen friction for the excursion of the eyelid. CLS

To obtain references for this article, please visit http://www.clspectrum. com/references.asp and click on document #212.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a consultant or advisor to Alcon and Vistakon and has received research funding from Alcon and CooperVision and lecture or authorship honoraria from Alcon and B+L. You can reach him at wmiller@uh.edu.