Patients often prefer contact lenses to eyeglasses because contact lenses can correct their vision without changing their appearance. The growing number of indications for contact lenses include refractive correction, myopia control, therapeutic applications, and presbyopia.^1-3 A primary reason why patients drop out of contact lens wear is discomfort related to dryness, although among current successful lens wearers, more than 50% also report symptoms of dryness.^4,5Contact lens wearers are five times more likely compared to spectacle wearers to report dry eye symptoms. However, dry eye disease and dryness symptoms are not caused only by contact lens wear, they are also caused by other factors such as the general aging process, environmental conditions, medications, extended computer work or reading, or corneal surgery.⁶

We published our last biennial dry eye report in 2018. Since that time, a new U.S. Food and Drug Administration (FDA)-approved ophthalmic medication to treat dry eye disease and a new device to treat the signs and symptoms of dry eye disease have entered the market. This article reports current dry eye diagnostic and treatment practice trends of eyecare practitioners.

The survey for this dry eye report was conducted online in April and May 2020; it was completed by 132 eyecare practitioners currently practicing in the United States. The survey questions asked practitioners to estimate the frequency of dry eye in both non-lens and contact lens wearers as well as what diagnostic tools and treatments they commonly implemented in practice. The following sections will analyze the survey results in detail and will compare this year’s results to those from previous years.

DRY EYE FREQUENCY, SEVERITY, AND ETIOLOGY (NON-LENS WEARERS)

Dry eye disease was redefined in 2017 by the Tear Film & Ocular Surface Society’s Dry Eye Workshop II (DEWS II); loss of hemostasis of the tear film, neurosensory abnormalities, and symptoms were added to the 2007 definition.⁷ In addition to pain or discomfort, dry eye can cause dryness, burning, stinging, redness, or blurry vision. Associated signs include loss of corneal sensitivity, increased tear film osmolarity, trigeminal de-innervation, pre-lens tear film thinning (particularly of the lipid layer), and shortened blink intervals.⁸ Depending on how investigators define lens “dropout” due to discomfort, a large range (12% to 51%) has been reported. Dropout can be defined to include reduced wearing time, intermittent wear time, temporary discontinuation of wear over varying periods, or even permanent discontinuation of contact lens wear.⁹

Some reports indicate that one in five patients present with self-reported symptomatic dry eye, although it is estimated that nearly one in three patients present to clinics with both signs and symptoms of dry eye disease.¹⁰ These frequency estimates are similar to those from 2009 to 2014; however, this year’s respondents reported that on average, 43% of their non-contact lens wearers have some form of dry eye. Similar reports from 2018 (42%) and 2016 (39%) may indicate an increased awareness of dry eye disease.

Dry eye disease has historically been subdivided into the two main categories of aqueous deficient and evaporative. The DEWS II report updated this classification to indicate that dry eye exists more on a continuum scale.⁸ Because of this, a “mixed” response was added to the classes of dry eye for this year’s survey. Our respondents estimated that 44% of their non-lens-wearing patients have evaporative dry eye, 34% have mixed, and 24% have aqueous deficient (Figure 1).

As discussed previously, the updated definition of dry eye includes terminology to account for a broader range of symptoms; it also divides presenting patients into symptomatic and asymptomatic in the clinical diagnosis schematic.⁸ In the 2020 survey, respondents reported that their preferred methods for making a dry eye diagnosis in non-lens wearers were symptom assessment (19%) and the tear breakup test (19%); in 2018, symptom assessment was preferred by 33% of respondents (Figure 2). A similar number of respondents on average indicated that they express meibomian glands in “most” of their non-lens-wearing dry eye patients (35%) compared to 2018 (35%), but this percentage was less than that of 2016 (41%) (Figure 3). Osmolarity testing continued this year as an infrequently preferred method for diagnosing dry eye in non-lens wearers (3%), and only 1% of respondents preferred matrix metalloproteinase-9 (MMP-9) testing, which is an indicator of inflammatory status on the ocular surface.¹¹ Both of these percentages remained unchanged from the 2018 results.

The DEWS II report recommends diagnostic testing to assess symptomatology as well as either tear breakup time, tear osmolarity, or ocular surface staining as preferred methods.¹² These tests represent the minimum recommendation; clinicians should perform additional testing to identify dysfunctional aspects of the ocular surface to guide their diagnoses and treatment plans.

Symptom assessment continues to play a vital role in diagnosing dry eye; 66% of this year’s respondents indicated that symptom assessment is “very important” in making their diagnosis (Figure 4). Fifteen percent of respondents reported that they make a diagnosis only if a patient has symptoms, which was slightly higher compared to the 2018 results (14%).

MANAGING DRY EYE IN NON-LENS WEARERS

Understanding the etiology behind aqueous deficient, evaporative, and mixed dry eye classes can be essential to developing successful treatment plans to both alleviate symptoms and restore ocular homeostasis. This year, a lower number of respondents reported using artificial tears/lubricants (53%) most frequently for treating aqueous deficient dry eye in non-lens wearers, compared to 62% in 2018. When treating evaporative dry eye, respondents continue to recommend warm compresses/lid hygiene most frequently (31%), followed by artificial tears/lubricants (30%) and lipid-based tear supplements (19%) (Figure 5).

CONTACT LENS DRY EYE FREQUENCY, SEVERITY, ETIOLOGY, AND PROGNOSIS

The integrity of the tear film is essential to the success of contact lens wear. A contact lens separates the tear film into pre- and post-lens tear layers, so any dysfunction related to the tears increases the possibility of complications and discomfort. The pre-lens tear film coats the outer surface of the contact lens as a thinned lipid layer with some of the aqueous-mucin components, whereas the post-lens tear film is a thinner aqueous-mucin layer through which oxygen is transmitted to the cornea.¹⁴There is a high rate of tear evaporation among soft contact lens wearers, even those who are asymptomatic.¹⁵ Because of this, patients who previously did not experience symptoms may develop symptoms of discomfort and dryness.¹⁶

For 2020, our survey respondents reported a similar frequency of dry eye among their contact lens wearers (48%) as in 2016 (44%) and in 2018 (43%); this is also similar with our respondents’ dry eye frequency estimates for non-lens wearers in 2020 (43%). In addition, our 2020 respondents reported that 44% of their contact lens dry eye patients have evaporative dry eye (Figure 1, Table 2), which is lower than that reported in 2016 (66%) and in 2018 (65%). This is believed to result from the addition of a mixed classification to the answer choices this year.

It’s interesting that the perceived classifications of dry eye for both non-lens and lens wearers were the same for this year’s survey responses. Similarly, this year’s respondents believe that 53% of their contact lens dry eye patients have meibomian gland disease, compared to 56% in 2016 and 55% in 2018 (Table 1).

Respondents to this year’s survey indicated that 18% of their contact lens wearers permanently discontinue lens wear each year because of dryness and discomfort, which is a slightly higher percentage than that reported in 2016 (15%) and in 2014 (14%) but is the same as that from 2018 (18%). However, differences in methodology, location, and year in which the study was conducted affect the dropout rates reported by clinical studies, and the literature typically reports higher rates compared to those of our current survey respondents. Dumbleton et al reported a 23% permanent dropout rate, primarily because of discomfort and dryness.¹⁷ A more recent study reported a 26% dropout rate in the first year of lens wear, citing poor vision and discomfort as contributing factors.¹⁸

Virtually unchanged over the past four years of our survey is that 60% of contact lens-wearing dry eye patients have a mild form of the disease, compared to 12% who have a severe form (Figure 6). Also, 32% of this year’s respondents prefer symptom assessment in diagnosing dry eye in lens wearers (Figure 7), which, as previously discussed, is also the preferred method for non-lens wearers. While slightly lower from what was reported in 2016 (37%) and in 2018 (37%), this still indicates that symptoms play a significant role in determining whether a contact lens wearer has dry eye.

The tear film breakup test and meibomian gland assessment were each preferred by 14% of this year’s respondents; in addition, corneal staining was preferred by 18% (Figure 7), which was a higher percentage compared to 2016 (16%) and to 2018 (9%).

As far as the importance of symptoms when diagnosing dry eye in lens wearers, 72% of this year’s respondents rated symptom assessment as “very important,” and 16% believe that it is “essential–diagnosis only if symptoms present” (Figure 4).

The area of the palpebral conjunctiva that touches the ocular surface during blinking is known as the lid wiper, and when this area stains with lissamine green, it is known as lid wiper epitheliopathy (LWE).¹⁹ This sign more frequently occurs in symptomatic contact lens wearers as well as in symptomatic dry eye patients.^20-23 However, Stahl et al failed to find an association between LWE and contact lens discomfort in 20 subjects.²⁴ In our 2020 survey, 46% of respondents indicated that they actively check for lid margin staining in “most patients” compared to 39% in 2016 and to 35% in 2018 (Figure 8). However, only 13% actively check in “most contact lens patients,” and 8% do not actively assess for lid margin staining.

MANAGING LENS-RELATED DRY EYE

Practitioners should educate patients about their options given the wide assortment of available contact lens materials and designs. In addition, determining the underlying cause of the dryness or discomfort symptoms will guide the selection of a treatment option that will help ensure contact lens wear continuation.

This year’s respondents indicated that the one treatment option that they use most frequently for contact lens patients who have dry eye disease is to refit into a lens that has a more frequent replacement schedule (50%); which is similar to 2016 (49%) and to 2018 (52%) (Figure 9).

Refitting into a daily disposable contact lens is a trend that has continued to increase since 2014 and may even be a first-line recommendation because of perceived better comfort. In fact, 62% of the 2020 respondents indicated that daily disposable silicone hydrogel contact lenses are the most efficacious at reducing dryness and discomfort (Figure 10); this was similar to the reported percentage from 2018 (64%) and was increased from 2016 (57%) and from 2014 (45%), as was the number of daily disposable silicone hydrogel lenses available in spherical, toric, and multifocal designs on the market.

Among other treatment options, changing care solution, use of rewetting drops, and refitting into a different contact lens material with the same replacement schedule were reported by 7%, 13%, and 15% of respondents, respectively (Figure 9). Also, 4% of this year’s respondents reported prescribing topical lifitegrast for treating contact lens dry eye.

CONCLUDING THOUGHTS

The clinical uses of contact lenses are continuing to expand beyond refractive correction to include other purposes such as myopia control and delivery of therapeutics.^25,26 With this in mind and the continued relatively high frequency estimates of dry eye disease in both non-lens wearers (43%) and in lens wearers (48%), eye-care practitioners need to be prepared with treatments to help alleviate discomfort symptoms that may develop from contact lens wear.

It is also crucial for practitioners to continually inquire about symptoms and to assess the eyelids, meibomian glands, and tear film stability to determine whether any intervention is needed. CLS

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