Contact Lens Business
Dry Eye and Contact Lenses
Three experts offer suggestions for dealing with contact lens patients who develop this challenging problem.
BY CHRISTOPHER KENT, SENIOR ASSOCIATE EDITOR

Dry eyes and contact lenses are a poor combination. This month, we invited readers to offer suggestions for managing patients with this problem.

BEING PROACTIVE

Zoraida Fiol-Silva, M.D., director of the contact lens department at Wills Eye Hospital in Philadelphia, observes:

"A common mistake made by patients who really do have dry eyes (remember -- patients may report almost anything as 'dry eyes') is that they wait for symptoms to appear instead of using a lubricant regularly. If lubrication is used after the symptoms appear, patients usually report: 'These drops are only good for a couple of minutes, then the symptoms come back.'

"Also, if symptoms worsen with frequent use of a lubricant, the patient may actually be reacting to something in the lubricant. I strongly recommend prescribing a preservative-free lubricant."

THE MEIBOMIAN GLAND FACTOR

"A large percentage of contact lens patients with dry eye symptoms have meibomian gland dysfunction as a component of their dry eye problem," says Michael A. Lemp, M.D., clinical professor of ophthalmology at Georgetown University in Washington, D.C. "This results in increased evaporative tear loss at the surface, adding to the evaporative tear loss caused by contact lenses.

"The key to diagnosing a meibomian gland problem is to express the glands using your fingertip. If the glands are functioning normally, you should find that about two thirds of the glands produce a clear lipid material. (At any given moment, about one third of a patient's meibomian glands will have recently emptied.) If the fluid is turbid, cloudy or coagulated like toothpaste, that's evidence of gland dysfunction.

"To treat meibomian gland dysfunction, use broad-spectrum antibiotics systemically and have the patient apply warm compresses. Monitor the patient until excretion quality improves."

DETERMINING THE BEST APPROACH

Dr. William H. Constad, who practices at Hudson Eye Physicians and Surgeons in Jersey City, N.Y., follows a series of steps to determine the best approach for a given patient.

"If a contact lens patient shows signs of dry eye, I conduct a clinical exam, including the use of a Schirmer II test to evaluate the quantity of tears being produced," he explains. "I check carefully for infection or conjunctivitis. If the patient has no complaint despite evidence of dry eye, and I find no clinical damage, I leave the patient alone.

"I instruct patients with moderate or severe dry eye to use preservative-free drops 5 or 6 times a day for a week. If they're comfortable after a week, they taper by one dose per day each week until symptoms reappear, indicating that they need the previous, higher dose.

"Patients who need drops 5 or 6 times a day are good candidates for punctal plugs. Symptomatic patients who measure less than 10 mm on the Schirmer II test generally do well with a plug in the lower punctum. If this doesn't resolve the problem, you can plug both puncta. If the patient is uncomfortable with the plugs, you can easily remove them and use a canalicular insert or hyfercate the punctum."

IN SEARCH OF . . . THE SOLUTION

Warren G. McDonald, Ph.D., director of contact lens services at the Jacksonville Eye Clinic in Jacksonville, N.C., and adjunct professor at Webster University, shares this story:

"A family doctor I met mentioned that he'd developed a dry eye problem that made it painful to wear his contact lenses. Upon questioning, he said he was using a solution that I knew had recently been reported to have some toxicity. I suggested trying a different solution.

"He e-mailed me a few weeks later to say that this resolved the problem. So, if you find no underlying etiology, try having your patient switch solutions."