Contact Lens Practice Pearls

For Comfortable Lens Wear, Start With the Ocular Surface

BY JASON R. MILLER, OD, MBA, FAAO

When contact lens patients struggle with lens comfort, we often jump to another lens or care solution, or to lecturing patients about compliance. While these may be the quickest options during a busy day, we should first check for any ocular surface complications that may be affecting their success.

Eyelid Margin Disease

Blepharitis is one underlying ocular surface condition that can impact lens wear. Common symptoms include burning, itching, excessive tearing, granular sensation, and scratchiness or foreign-body sensation. Decreased vision or changes in visual clarity may occur due to a poor tear film, eyelids stuck together, and/or eyes being red or crusty upon waking.

Early treatment of blepharitis begins with warm compresses and eyelid hygiene. Commercially available pre-packaged lid scrubs work well for patients who prefer their convenience. Consider an antibiotic ointment or an antibiotic/steroid combination ointment for an acute disease state.

Posterior blepharitis, commonly referred to as meibomian gland dysfunction (MGD), is a chronic inflammation within the meibomian glands, resulting in stagnation of lipid flow and an altered composition of tear quantity and quality. Patients experience more rapid tear evaporation and increased ocular surface irritation.

In addition to gland expression, make sure to inspect the lid margins. Remember to look for irregularities such as telangiectatic blood vessels, notching, and extensive loss of lash follicles. Treat MGD initially with warm compresses, but if that is insufficient, consider prescribing topical and oral agents.

Dry Eye Disease

Many factors can contribute to contact lens discomfort, but dry eyes may be the biggest. Fluorescein dye allows you to evaluate tear film breakup time (TBUT), and you can easily see whether patients have corneal staining or lid wiper epitheliopathy. Conjunctival staining with lissamine green is sometimes the initial sign of dry eye in patients (Sutphin et al, 2006-2007). Using these vital dyes will help paint a clear picture of the dryness symptoms that patients may be experiencing.

The initial treatment of dry eye depends on the severity of the diagnosed condition. First consider whether anything in your patients’ environment, lifestyle, or diet can be modified to improve their symptoms. For example, advise patients to limit computer and ceiling fan use, reduce their caffeine intake, and quit smoking. Certain medications, including antihistamines, antidepressants, antihypertensives, antidiuretics, and anticholinergics, can also cause dryness symptoms. Instruct symptomatic patients to increase their fluid intake, and prescribe omega-3 and omega-6 supplements (Rashid et al, 2008) as well as artificial tears.

The next level of management often includes topical ocular medications, such as Restasis (Allergan), and oral prescriptive products. And don’t underestimate the value of punctal plugs—they may be exactly what a patient needs.

Seasonal Allergic Conjunctivitis

You may be surprised to learn how many of your patients can’t wear their lenses during allergy season. Many options are available for this common condition. Depending on severity, you can choose from combination mast-cell stabilizers/antihistamines to topical steroids. Daily disposable lenses can also help limit allergen buildup on the lenses. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #211.

Dr. Miller is in a partnership private practice in Powell, Ohio, and is an adjunct faculty member for The Ohio State University College of Optometry. He has received honoraria for writing, speaking, acting in an advisory capacity, or research from Alcon, Allergan, CooperVision, and Visioneering Technologies. You can reach him at drmiller@eyecarepowell.com.