IS THIS THE NEW NORM?

IS PROACTIVE PRESCRIBING FOR DISCOMFORT THE NEW NORMAL?

MILE BRUJIC, OD, & DAVID L. KADING, OD

Seventy-three percent of patients report at least one symptom of ocular discomfort or dryness, and 35% of current contact lens wearers report dissatisfaction with their lens wear (Richdale et al, 2007). As clinicians, how should we take these numbers? Do we keep going the way we have always gone and only fix a problem when it presents itself?

These were the questions that the two of us asked ourselves three years ago when we realized that, given the statistics, our methods of problem solving were not solving our patients’ problems. We wanted to look at other methods of interacting with our patients. As such, we asked whether proactive prescribing is the new normal for our contact lens patients?

What’s Your Approach?

We encounter patients who are everywhere on the discomfort spectrum in our clinics. Some patients report that their lenses are amazing and that we have changed their lives by prescribing them. Others report that their lenses are “fine,” and we stop the questioning there for fear of what they will say if we ask them what “fine” means. Other patients are downright in pain and are ready to give up on lens wear.

For some clinicians, diagnosis and treatment are based on the combination of standard clinical observations and how they relate to symptom severity. But studies show that there are rarely correlations between the symptoms and signs (Nichols K. et al, 2004; Nichols J. et al, 2004). As such, the two of us have elected to take a new approach. We now place far more emphasis on the change to symptoms over time in combination with advanced diagnostic testing. We have elected to perform at least one additional measure, whether it be a symptoms questionnaire, osmolarity testing, matrix metalloproteinase-9 testing, or lipid layer thickness testing.

Because we assume that we left patients the previous year in the best possible state, if any of our testing reveals a less-than-optimal outcome, we conclude that the ocular surface has been negatively affected by lens wear and is causing a cyclical state of dryness that usually, in our experience, is not completely fixed with a lens change alone.

Our treatment methods for these patients will certainly be based on our comprehensive diagnosis, but generally they include the use of cyclosporine, lifitegrast, and/or heat and thermal pulsation. Additional treatments may be used in addition to these, depending on severity.

Since taking this proactive approach, we can clinically report that our contact lens wearing outcomes have improved. We still have patients who experience contact lens discomfort, but the number of patients who report back ready to drop out of lens wear has decreased.

The Verdict

If 73% of patients have symptoms of dryness at some level in a normal contact lens practice, we certainly do not want to be normal. Instead, we choose to be not normal and to proactively prescribe for our patients. Won’t you join us? CLS

For references, please visit www.clspectrum.com/references and click on document #253.

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, B+L, Bruder, Optovue, RPS, SpecialEyes, and VMax Vision and has received research funding from Optovue and SpecialEyes.
Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Mile Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon Laboratories, Allergan, Bausch + Lomb, CooperVision, Johnson & Johnson Vision Care, Oculus, OptoVue, RPS Detectors, Paragon Vision Sciences, TearScience, Valeant Pharmaceuticals, Valley Contax, VSP, ZeaVision, and Zeiss. Follow him on Twitter @davekading.