I HAVE WRITTEN quite a few articles on dry eyes in our presbyopic patients, but never really expected to experience this condition myself. Like many of us, due to myopia, I have had glasses since I was 8 years old. My life was changed with contact lenses at the age of 12—for someone who had glasses, braces, and an acne problem all at the same time.

Now, as a 49-year-old, I can also admit to presbyopia! Additionally, due to the high near work with electronic medical records, I can classify myself as a presbyopic contact lens wearer who has dry eyes! Welcome to the club.

It is crazy how patients age with us and I now have a large population of patients who wear presbyopic contact lenses, and based on my clinical experience I expect 100% of my presbyopic contact lens wearers to have some degree of dry eyes. Practitioners should expect dry eyes, address dry eyes, and fix dry eyes before their patients give up on contact lenses. Dropout is what will happen if this condition is not evaluated, discussed, and treated.

I classify and treat these patients in my clinic by starting with the right questions: At what time does your vision begin to be intermittently blurry when wearing your contact lenses? How much earlier are you taking your contact lenses out now compared to in the past? When do you develop eye fatigue with your contact lenses?

Next, evaluate the patient’s ocular surface and lid wiper area with fluorescein and lissamine green vital dye during your contact lens exam and evaluation. There are many important clinical tests with which you can evaluate the ocular surface behind the slit lamp, but specifically focus on the staining, tear film break-up time, and meibomian gland function. Based on the clinical assessments and classification systems for dry eyes, determine the severity of a patient’s condition and develop a protocol for that patient.

Here are a few ideas to consider for each level of severity (and remember, I expect to label each presbyopic contact lens-wearing patient with one of these levels):

1. Mild Dry Eyes/Presbyopic Contact Lens Wearer  A vast majority of patients will fall into this category. These patients don’t usually complain very much, but they may complain about their vision or comfort at the end of the day. Discuss environmental strategies (taking breaks while on the computer) and basic clinical strategies (drinking more water, heat masks, and even preservative-free lubricants on occasion). If the patient is not wearing daily disposable lenses made of advanced materials, discuss the possibility of switching to that type of lens. Focus on the advantages of improving the ocular surface and improving overall vision with a newly developed and designed lens.
2. Moderate Dry Eyes/Presbyopic Contact Lens Wearer  Many of these patients have already started to limit their contact lens wear by taking them out earlier in the day and maybe wearing them less during certain activities. They have already tried multiple over-the-counter eye drops and are somewhat frustrated with their contact lens-wearing experience. These patients may require some sort of advanced meibomian gland dysfunction treatment and/or prescription product in order to improve and optimize their ocular surface. Again, focus on providing them with a new and improved contact lens option.
3. Severe Dry Eyes/Presbyopic Contact Lens Wearer  These patients have likely already begun to drop out of contact lens wear and become part-time contact lens wearers. They have been fit and refit and “just can’t wear their contact lenses very long without discomfort and poor vision.” They have advanced clinical signs, and advanced clinical treatments are usually needed to optimize their ocular surface. These patients may not ever return to full-time contact lens wear, but practitioners should consider finding ways to help them wear their contact lenses when they would like to wear them the most.

Dry eyes with contact lens wear is an everyday occurrence in a busy eyecare practice. Focus on the visual and comfort needs of your patients and offer them the optimal clinical treatments and contact lenses from the beginning. This will help your contact lens practice continue to attract more presbyopic contact lens wearers. CLS