DRY EYE DISEASE (DED) affects millions of people worldwide and can significantly impact quality of life.1 This has created a challenge for eyecare practitioners as conventional therapies, such as artificial tears and topical prescription medications, prove to be unsuccessful for many patients.
DED is multifactorial, and the symptoms associated with it can range from mild discomfort and visual disturbance to severe pain and significant impairment in quality of life and daily functioning.2 This does not exclude contact lens wearers. In fact, contact lens wear may exacerbate symptoms in some cases, leading to potentially permanent discontinuation of their wear.3 This happens because the contact lens itself creates a physical interruption in an already unstable tear film
Discomfort is the top reason for contact lens dropout.4 Contact lenses are foreign bodies introduced to the ocular surface for the purposes of correcting refractive error, improving self-perception, and managing myopia in children and young teens.5 But some lenses can also be used to neutralize corneal irregularities and even to protect the ocular surface from mechanical damage or aid in healing the ocular surface.6,7 Despite the utility of some of these lenses as therapeutic options, for it to perform and thrive on a vulnerable eye the ocular surface must be optimized and DED must be effectively managed.
Successful daily contact lens wear is defined as wear that allows a patient to comfortably wear contact lenses for an average of 12 hours a day for at least 6 days a week and see at least as well as they do with spectacles.8 The combination of treating DED and prescribing the most appropriate contact lens modality leads to lens wear success. This article will delve into how to treat DED and then explore how to refine selection and design of various contact lens modalities for patients who have ocular surface disease.
Impact on the Ocular Surface
The precorneal tear film is composed of important components including mucins, aqueous humor, proteins, and lipids.9 These components have different functions, including antimicrobial defense, hydration and lubrication, and ocular clarity. Contact lenses physically disrupt the tear film and divide it into pre- and post-lens layers. This promotes instability and evaporation of the tears.10
In an eye in which tear film instability already exists, a contact lens could exacerbate this instability, increasing inflammation and symptoms of DED. Contact lenses also alter the lid-ocular surface interface, especially toward the upper lid margin, where continuous blinking causes shear stress.11 Lid wiper epitheliopathy (LWE), observed in 80% of symptomatic contact lens wearers, is a clinical indicator of increased friction. It can be detected using vital dyes, such as lissamine green, and strongly correlates with symptoms including burning and foreign body sensation.
Additionally, contact lens use increases tear evaporation, especially in those who have underlying meibomian gland dysfunction (MGD). The meibomian glands produce the meibum that ultimately forms the lipid layer of the tear film, which reduces evaporation of the tears. Extended contact lens wear can alter the lipid composition of the glands and reduce lipid expression.12 This accelerates tear film thinning and evaporation and raises osmolar stress. Even short-term contact lens use has been shown to affect meibomian gland architecture.10
A Modern Definition of Dry Eye
According to the Tear Film & Ocular Surface Society Dry Eye Workshop III (TFOS DEWS III) report, DED is defined as a loss of tear film homeostasis, accompanied by ocular symptoms caused by one or more of four key factors: tear film instability, hyperosmolality, inflammation and damage to the ocular surface, and neurosensory dysfunction.1 DED is not a static condition; it can evolve in response to hormonal fluctuations, systemic medications, aging, environmental humidity, or insult to the ocular surface. Therefore, the goal of treatment is both acute relief and long-term prevention and improvement.
Just as with any disease, early detection of DED can prevent progression, and identifying early signs of tear film instability can prevent permanent structural damage from occurring. Point-of-care metrics, such as tear film breakup time (TBUT), ocular surface staining, tear osmolarity, meibomian gland imaging, and inflammatory markers such as matrix metalloproteinase-9 (MMP-9), can help recognize subclinical disease and identify patients at risk of contact lens intolerance.1
Evaporative DED occurs in those who have tear film instability, which leads to excessive evaporation that may present as a short TBUT. Symptoms include end-of-day fatigue and dryness, especially during prolonged screen use or when in air-conditioned areas or cold climates with dry indoor heating.10 Aqueous-deficient DED, although less common in contact lens wearers, is characterized by reduced tear volume secondary to impaired lacrimal gland function. Patients may display lower Schirmer scores and reduced tear meniscus height.1
Despite the different etiologies, evaporative DED and aqueous-deficient DED may not exhibit a clear clinical presentation that fits neatly into either category. Mixed-mechanism DED is particularly challenging and combines these causes for DED. These patients often present with severe symptoms and management must be multifaceted, addressing poor tear film quality while restoring aqueous support. Regardless of type, the severity of DED can increase in patients taking antihistamines, antidepressants, or systemic isotretinoin or in those who have autoimmune conditions.1
Treatment and Management of DED
Achieving successful contact lens wear requires treating DED prior to contact lens fitting, but concurrent treatment can make a significant difference as well. For mild to moderate cases, intervention begins with in-office patient education and environmental changes. Some early strategies can include improving indoor humidity, reducing direct airflow (air conditioning, fans, and vents) to the eyes during the day and while sleeping, and taking regular breaks from digital screen use. Blink training, including becoming conscious of deliberate and complete blinking during screen use, can be effective in improving lipid distribution and delaying tear breakup.11
Artificial tears (or rewetting drops) remain the first-line therapy and can be selected based on the type of tear film deficiency. Lipid-enhanced tears are beneficial to patients who have MGD, while aqueous-based formulations are preferable for patients who have low tear volume. All formulations should be preservative free to avoid adverse reactions associated with agents such as benzalkonium chloride, which can further destabilize the tear film.1 Additionally, punctal occlusion can help increase tear volume.
Eyelid hygiene, when consistent, can significantly reduce bacterial biofilm, improve comfort, and help stabilize the lipid layer. Demodex blepharitis is an often-overlooked contributor to lid margin inflammation and DED. Demodex folliculorum and Demodex brevis infest the lash follicles and meibomian glands, respectively, where they trigger mechanical, chemical, and inflammatory reactions, disrupt gland function, and increase symptoms. The diagnosis is made clinically with the observation of collarettes, a characteristic finding. Treatment options include tea tree oil-based cleansers, in-office procedures, and, most effectively, prescription lotilaner ophthalmic solution.1
Tear film instability, whether alone or exacerbated by contact lens wear, can lead to the release of inflammatory mediators that increase cytokine expression and surface inflammation.13 Targeting this inflammatory activity can help improve symptoms and signs associated with DED.
Topical immunomodulators, such as cyclosporin A (0.05%, 0.09%, and 0.01%) and lifitegrast (5%), are well established compounds that suppress T-cell-mediated inflammation, enhance tear production, and promote the recovery of goblet cells.14 Clinical improvement can be observed within 6 to 12 weeks, but prolonged use is usually necessary to maintain the therapeutic effect.1
Topical corticosteroids may be used as short-term therapy to mitigate acute inflammation. Low-potency agents such as loteprednol etabonate and fluorometholone have lower side-effect profiles. However, due to the risk of complications, the use of these agents should be limited.
Biologic drops such as autologous serum or platelet-rich plasma can be used in more severe cases. These treatments supply growth factors and anti-inflammatory proteins to the ocular surface, which promote healing of the ocular surface and prevent epithelial breakdown.1 Other therapies include neuromodulation such as varenicline nasal spray, which stimulates natural tear secretion via trigeminal activation, and acoltremon, a TRPM8 receptor agonist that enhances basal tear secretion.15 These agents may improve both quality and quantity of tears.15
Oral treatments such as doxycycline or azithromycin can be used in moderate to severe MGD.16 These antibiotics have both antimicrobial and anti-inflammatory effects that can improve the quality of meibum and reduce lid margin inflammation. Evidence also supports the use of nutritional supplementation with re-esterified omega-3 fatty acids in improving tear film stability, reducing inflammation and alleviating dry eye symptoms.1
In cases of MGD, in-office thermal expression can provide symptom relief and help with the functional and structural improvement of meibomian glands.17 Radiofrequency provides thermal energy, facilitating gland expression, but can also stimulate collagen regeneration and lid laxity.18 Intense pulsed light (IPL) is increasing in popularity, especially for MGD associated with ocular rosacea and vascularized lid margins. IPL reduces periocular inflammation, coagulates telangiectatic vessels, and improves the quality of the meibum.19 Several sessions are required, with periodic maintenance for continued benefit.
Preventing Soft Contact Lens Dropout
Lens material can also impact success with soft lens wear. Hydrogel polymers are classified as ionic or nonionic. Nonionic, lower water content materials experience less dehydration and accumulate fewer deposits and provide better comfort and longer wearing time.20
In the early 2000s, silicone hydrogel lenses were introduced. The goal of the breathable silicone core was to increase oxygen permeability and reduce the risk of infection. Though the rate of infections with these lenses is not lower, they have lower water content and higher oxygen transmissibility, which results in reduced lens dehydration.21
These designs enhance surface wettability and reduce lid-lens friction, which are the 2 most common mechanical contributors to dryness and discomfort.22 They also reduce the induced hypoxic and hypercapnic stress.23 In comparative studies, users reported less discomfort and overall higher satisfaction than those wearing hydrogel lenses.24
Daily disposable lens wear is recommended as a practical and preventative strategy for patients with DED. These lenses eliminate the need for preservative-containing lens solutions and are associated with the lowest risk of infections and inflammatory complications.25 For any reusable lenses, rubbing with solution is recommended as part of the daily cleaning regimen.26
Unfortunately, daily disposable contact lenses are not available for all prescriptions, nor can these lenses provide comfortable wear for all patients with DED. For patients who have MGD or ocular surface inflammation, changing the lens material and/or the replacement schedule may not be sufficient to address the underlying pathology. Tear film instability, goblet cell loss, and lid margin disease require prior or concurrent medical treatment. Prescribing daily lenses should be part of a broader strategy that involves the treatment of underlying DED.
Patients who have DED may benefit from finding a lens material that improves symptoms of discomfort. The wettability of a contact lens can be affected by the contact angle of the lens material. The lower the contact angle of the material, the more readily liquid can spread over the surface of the lens and improve lid-lens interaction and comfort.27
The modulus of the lens material can also play a role in contact lens wear. Silicone hydrogel lenses have a more rigid modulus than hydrogel lenses, making them easier to handle and less adherent to the ocular surface. For patients who remain symptomatic with standard soft lenses, it’s possible to select a more customizable design with diameter, base curve, and edge profiles that can be personalized, allowing for decreased lid-lens friction and improved centration, stability, and comfort of the lens.
Improving Comfort of Scleral Lenses and Corneal GPs for DED Patients
The use of a scleral lens (SL) as a therapeutic option to treat DED has been established.1,28 The SL vaults over the cornea and limbus and gently lands on the conjunctiva. The post-lens fluid reservoir protects the ocular surface from friction and provides a hydrating bandage that promotes healing.
Therefore, these lenses are used not only to correct refractive error or neutralize irregular corneal surfaces but also to provide symptomatic relief and protection, heal epithelial defects, and as a vehicle for drug delivery to the ocular surface.29 Despite the benefits of SLs for DED, patients may still have reduced comfort and fluctuating vision without an adequate pre-lens tear film and proper lens surface wettability.30
Finding an ideal GP lens material for each patient may improve comfort for SL and corneal GP lens wearers. Much attention is given to the fact that GP materials are available with high oxygen transmissibility, but there are other important factors to consider when selecting a material.
As with soft lenses, a lower contact angle enhances lens wettability. Materials with a higher Dk tend to have larger wetting angles and poorer surface wettability, which may contribute to dryness and discomfort for the wearer.31 Higher-Dk lenses are also less resistant to scratches and deposits.
Lens treatments can also improve the wettability of contact lenses. Plasma treatment, which consists of bombarding the lens with ionized oxygen, can improve wettability by up to 40% by creating a hydrophilic surface and lowering the wetting angle.32,33 A covalently bonded polyethylene glycol-based lens surface treatment was designed to enhance overall contact lens comfort by improving lens wettability, deposit resistance, and TBUT.34
Conclusion
Many DED patients assume that they are no longer candidates for contact lens wear; however, this is not the case. With the right approach, even patients who have severe signs and symptoms of DED can be successful contact lens wearers. Identifying the appropriate lens modality and material, whether soft daily disposable, corneal GP, SL, or custom soft lenses, is just a part of the solution. By optimizing the ocular surface through environmental adjustments, healthy habits, and targeted treatments of the underlying cause of DED, patients can achieve comfort and visual clarity and thrive in contact lenses once again.
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