Contact lens dropout rates have changed very little in the past 20 years. Despite advances in contact lens materials, about 20% to 25% of patients stop wearing their lenses, most often citing discomfort as the reason.¹ Too often, practitioners try to resolve discomfort by switching patients to a different contact lens, but this strategy is not likely to be successful without addressing underlying ocular surface problems, particularly meibomian gland dysfunction (MGD).

The majority of people who have dry eye, which is about 86%, have MGD as at least one component.² MGD is evident in about 60% of contact lens wearers, who are more likely to have abnormal meibum, hyperemia, lid margin telangiectasia, and plugged meibomian orifices compared with age-matched controls.³ A number of studies have reported associations between MGD and contact lens discomfort or dropout.^4-6

Digital device use is exacerbating this problem. Compared to 10 or 20 years ago, we all spend more hours per day viewing some type of electronic screen; this has led to a greater incidence and increased severity of MGD in people of all ages, including young adults and even children.⁷ When we use a digital device, our blink rate decreases from a normal rate of 15 to 20 blinks per minute to less than four blinks per minute.⁸ Blinking not only coats the ocular surface with a fresh layer of tears, it also stimulates the meibomian glands to produce and secrete oils. When the blink rate decreases, meibum stagnates in the glands.

I’m as excited as the next person about new and better contact lenses. However, I believe that the answer to dropout lies in more aggressively diagnosing and treating ocular surface disease (OSD).

RAMP UP YOUR DIAGNOSTIC EFFORTS

The easiest screening tool to implement during a contact lens examination is active listening: simply listen to what patients say about their vision. If patients say that their vision gets blurry when looking at a computer screen or at highway signs and then clears up when they blink, you can be fairly confident that they have OSD. Fluctuating vision was the number one predictor of dry eye in the Progression of Ocular Findings (PROOF) study, with 83% of dry eye patients experiencing intermittent blurred vision at least some of the time, compared with 15% of patients who did not have dry eye.⁹ By the time that a patient reports fluctuating vision, he or she already has level 2 (of 4) dry eye disease.¹⁰

Fluctuating vision is cause for scheduling a separate appointment for a full ocular surface workup. There isn’t enough time during an annual examination to perform all of the necessary ocular surface testing, nor should this be considered part of a standard vision examination when it is more appropriately billed to medical insurance. I hold a patient’s eyeglasses or contact lens prescription until after a dry eye workup and initial treatment, because pretreatment refractions are likely to be inaccurate in patients who have OSD.

In my practice, an ocular surface examination includes testing for tear osmolarity and for the inflammatory tear biomarker matrix metalloproteinase-9 (MMP-9). Together, these two tests provide important information about the presence of inflammation. They are also helpful metrics to determine whether your treatment strategy is working over time and whether a patient is compliant with treatment.

I use two vital dyes to stain the cornea. Lissamine green is an important indicator of tear film health, as it stains dead and devitalized cells, particularly the goblet cells in the mucin layer. Fluorescein stains epithelial defects on the cornea and is useful for evaluating tear breakup time. I understand that some practitioners have stopped performing the Schirmer’s test, but I find that a very low Schirmer’s score helps identify patients who warrant further testing for Sjögren’s, a systemic autoimmune disease that is associated with other serious health conditions and complications, including lymphoma.¹¹

Imaging is also critical for evaluating meibomian gland health, which will significantly influence treatment choices. Although meibography can be accomplished in fairly low-tech ways (i.e., pulling down the lower lid and using a transilluminator to view the glands), the commercially available meibography devices serve as both diagnostic and patient education tools.

When I diagnose OSD, I typically evaluate patients every three months until the tear film is stable. After that, I see patients annually for an ocular surface examination, typically six months before the vision examination.

TREAT FOR CONTACT LENS SUCCESS

I rely on a wide variety of treatments to help patients improve their chance of success with contact lenses. When osmolarity is elevated and the MMP-9 test is positive, I prescribe topical cyclosporine or lifitegrast along with a short course of a topical steroid. I prefer loteprednol gel with submicron technology to achieve good penetration of the steroid with lower levels of preservatives. One bottle, used twice a day until the bottle is empty, helps patients feel better faster as they wait for the longer-acting immunomodulators to take effect at 8-to-10 weeks. In a retrospective study that I conducted, patients experiencing contact lens discomfort who were treated with topical cyclosporine were able to increase their lens-wearing time by 3.5 hours per day.¹²

For punctal occlusion, I prefer dissolvable plugs that last about three-to-four months. These should be inserted only after surface inflammation has been treated.

Topical treatment may suffice for patients who have healthy meibomian glands, but if there is evidence of eyelid disease, patients need MGD-specific treatment. For early MGD, I may prescribe a high-quality, triglyceride-form omega-3 supplement. If I observe gland atrophy or gland dropout on meibography, I also recommend an in-office thermal pulsation treatment and/or intense pulsed light (IPL). Thermal pulsation heats and massages the meibomian glands to unblock them and get healthy meibum flowing. IPL won’t unblock inspissated meibomian glands, but it is a helpful adjunct for patients who have ocular rosacea or telangiectasia, because the laser treatment reduces the tiny blood vessels that carry inflammatory mediators.

By restoring the lipid layer, MGD therapy can prevent evaporation of the tear film to provide a better tear film “cushion” for a contact lens. In a prospective, multicenter trial, thermal pulsation therapy was shown to increase mean comfortable contact lens-wearing time by approximately four hours per day.¹³ Some patients will need an annual thermal pulsation treatment, while others may need treatment only once every three years or even less frequently.

THE LENS IS THE LAST STEP

After all ocular surface issues have been addressed, only then should you consider a change in contact lens material or modality to improve comfort.

Daily disposable lenses are an excellent option for patients who want a healthy way to wear contact lenses. For those prone to dry eye, the daily disposable modality has the added benefits of avoiding solution interactions and not allowing debris to accumulate on the lens and irritate the ocular surface. For patients who wear frequent replacement lenses, I prefer a peroxide-based cleaning system to keep the lenses as pristine as possible.

BUILD LOYALTY

Two of my recent patients illustrate how managing ocular surface problems in contact lens wearers adds value to the practice. The first was a 17-year-old field hockey player, a –7.00D myope, who was struggling with contact lens discomfort. She had already seen two other eyecare professionals, each of whom switched her into different lenses that provided no relief. In addition to abnormal osmolarity and a positive MMP-9 test, this patient had such severe MGD that I initially thought the technician had given me a different patient’s meibography file (Figure 1).

I treated the patient with loteprednol and cyclosporine as well as with high-quality artificial tears and omega-3 supplements. Her meibomian glands were so involved that we performed thermal pulsation therapy immediately. I kept her in the daily disposable contact lenses prescribed by the last practitioner she had seen, and I dissuaded her from starting isotretinoin for acne, a medication known to have damaging side effects to the meibomian glands even after completing the drug course.

The patient is now able to wear her contact lenses for school and after-school sports and is much happier. Since treating her initially, I have also seen both of her parents, two siblings, and her grandmother as new patients in our practice.

The second patient is a 55-year-old bank executive who spends all day at the computer. She wore monthly multifocal contact lenses, and her chief concern was discomfort. She saw an ophthalmologist who inserted punctal plugs, which worsened her discomfort because they were holding tears that contained inflammatory mediators on the cornea.

Upon examination, I found that the patient had high osmolarity, was MMP-9 positive, and had significant corneal staining. The meibomian glands in this case were minimally involved. I removed the punctal plugs and prescribed topical lifitegrast, loteprednol, and oral omega-3 supplements.

About 10 weeks later, I inserted extended-duration dissolvable punctal plugs and fitted the patient with daily disposable multifocal contact lenses. Now able to tolerate her lenses through the entire work day, she loves the daily disposables. In addition to the contact lenses, she purchased a new pair of eyeglasses as well as high-end sunglasses for mountain biking.

LONG-TERM PRACTICE REWARDS

Diagnosing and managing OSD does take extra time and requires that we file a claim with patients’ medical insurance. Nevertheless, it is quite rewarding in terms of patient loyalty, long-term success in contact lenses, referrals, and total value to the practice. CLS

REFERENCES

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12. Kislan T. A retrospective study of contact lens patients with/without cyclosporine. Presented at: American Academy of Ophthalmology Annual Meeting; November 2015; Las Vegas.
13. Blackie CA, Coleman CA, Nichols KK, et al. A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day. Clin Ophthalmol. 2018 Jan;12:169-183.