It is important not to overlook the role of the eyelids in successful contact lens wear. Lid position, as well as blink and tear film dynamics, are a critical part of the fitting relationship.

Patients with malpositioned lids or conditions such as blepharoptosis, chalazia, trichiasis, entropion, meibomian gland dysfunction, and ectropion must be diagnosed and managed effectively to ensure a healthy ocular surface and optimal contact lens-wearing experience. Common eyelid conditions can have resulting contact lens interactions that optometrists need to consider in managing contact lens patients.

LUMPS AND BUMPS

Lid lesions are often of great concern to patients and are a common reason for seeking prompt attention.¹ Fortunately, 80% of lumps and bumps are benign.² Lesions affecting the lid margins may interfere with normal function of the lids and quality of the tear film. Chalazia and hordeola, especially when present in the upper lid, should be managed before initiating fitting of a new wearer and should prompt temporary discontinuation of contact lens use in a current wearer.

These conditions not only cause patients aesthetic “distress,” but may also affect vision due to pseudoptosis. Vision may likewise be compromised in cases in which lesions extending to the tarsal surface induce temporary changes in corneal toricity.³

Complications in contact lens wear secondary to lumps and bumps will vary depending on the type and location of the structural alteration. Those present on the lid margin may affect meibomian gland function, altering tear film quality and proper distribution of the tear film over the contact lens surface.

Lid margin lesions may also cause variability in movement and position of both rigid and soft lenses. For example, an internal hordeolum of the upper lid may cause displacement or even dislodging of a rigid contact lens or decentering of a soft lens. An active meibomian gland infection in the lower lid may alter the quality of the lipid layer, and/or increase tear film debris from lesion drainage.

Management of lumps and bumps will vary depending upon the type of lesion, the chronicity, the location, and the level of suspicion for neoplasm. Early hordeola respond well to conservative treatment with heat and oral antibiotics, and if needed, drainage. Chronic chalazia may require intralesional steroid injection or curettage and excision. All excised lesions should undergo tissue analysis for dysplasia and neoplasm.

CONSIDERATIONS IN LID POSITION

Evaluation of lid position is an important component in the contact lens fitting process. Measuring the interpalpebral aperture, documenting interocular asymmetry, and noting the height of upper and lower lids help guide modality selection and lens design. For example, when fitting rigid GP lenses, a lid attachment fit may not be achievable in patients whose upper lids are at or above the upper limbus.

Likewise, the position of the lower lids is important when considering presbyopic lens options for GP lens wearers. It’s best to avoid translating designs in those patients whose lids do not lie parallel to the lower lid margin.

BLEPHAROPTOSIS IN THE CONTACT LENS PATIENT

Blepharoptosis, or ptosis, refers to a low-lying or drooping upper eyelid margin when the eye is in primary gaze. The condition’s severity depends upon the degree of the droop; it can be unilateral or bilateral, congenital, or acquired.⁴ When left untreated, the condition affects both visual function and the patient’s appearance.^4-6 Congenital ptosis is typically a result of developmental myopathy of the levator muscle or innervation abnormality; however, the acquired form appears later in life, with the most common etiology being aponeurogenic.⁷

Mild to moderate ptosis is common, affecting about 12% of the population older than 50 years of age.^8,9 Prolonged contact lens wear is a known cause of acquired ptosis, primarily among rigid lens wearers.

The pathogenesis of contact lens-induced ptosis is like the involutional changes seen in normal aging, characterized by levator dehiscence or disinsertion. One study showed that hard contact lens wearers had a 20 times increased risk of ptosis (odds ratio: 19.9; 95% confidence interval: 6.32-62.9) compared with the nonwearing subjects.⁷ Patients undergoing surgical ptosis repair should be refit into soft lenses postoperatively.

Moderate to advanced ptosis can have significant impact on both cosmesis and visual functioning, negating the most common reasons patients choose to wear contact lenses. For example, a margin reflex distance or MRD-1 of 2mm not only may be aesthetically concerning but can impair the visual field by 24% to 30%.⁶

Traditionally, surgery has been among the few options for patients with unilateral or bilateral ptosis. An invasive procedure is not appropriate for all patients, however, and it can be associated with risks such as infection and under- or overcorrection. The recent introduction of FDA-approved oxymetazoline hydrochloride 0.1% is a practical alternative for patients who must, or wish to, avoid or postpone surgery (Figure 1).

SEEING WELL, LOOKING YOUNGER

In my experience, a youthful appearance and freedom from spectacle lens wear are primary drivers of contact lens wear. Successful contact lens fitting and management requires a thorough workup and examination that includes careful attention to the lids and blink in addition to the health of the ocular surface (Figure 2). Mispositioned lids or lid-related disease can affect contact lens performance, comfort, and ocular health, and should be addressed to prevent short-term adverse effects and/or contact lens dropout. CLS

REFERENCES

1. Bragg KJ, Le PH, Le JK. Hordeolum. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
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3. Jin KW, Shin YJ, Hyon JY. Effects of chalazia on corneal astigmatism: Large-sized chalazia in middle upper eyelids compress the cornea and induce the corneal astigmatism. BMC Ophthalmol. 2017 Mar 31;17:36.
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5. Ho SF, Morawski A, Sampath R, Burns J. Modified visual field test for ptosis surgery (Leicester Peripheral Field Test). Eye (Lond). 2011 Mar;25:365-369.
6. Cahill KV, Burns JA, Weber PA. The effect of blepharoptosis on the field of vision. Ophthal Plast Reconstr Surg. 1987;3(3):121-125.
7. Kitazawa T. Hard contact lens wear and the risk of acquired blepharoptosis: a case-control study. Eplasty. 2013 Jun 19;13:e30.
8. Sridharan GV, Tallis RC, Leatherbarrow B, Forman WM. A community survey of ptosis of the eyelid and pupil size of elderly people. Age Ageing. 1995 Jan;24:21-24.
9. Kim MH, Cho J, Zhao D, Woo KI, Kim YD, Kim S, Wang SW. Prevalence and associated factors of blepharoptosis in Korean adult population: The Korea National Health and Nutrition Examination Survey 2008–2011. Eye (Lond). 2017 Jun;31:940-946.