When Contact Lenses Cause Dry Eye

Management requires a systematic approach.

BY KENNETH BECKMAN, M.D., F.A.C.S.

Contact lens intolerance poses a significant problem for dry eye patients, particularly with soft contact lens wearers. These patients may present with complaints of dryness, redness, burning, itching, blurred vision, foreign body sensation or inability to keep their contact lenses in for the desired length of time. In fact, according to the National Eye Institute's Visual Function Questionnaire, Impact of Dry Eye on Everyday Life (IDEEL), approximately 34% of patients who wear contact lenses discontinue use at least once, most frequently because of dry eye symptoms.¹ With a systematic approach, management of these patients can be achieved. The following is our practice's approach to addressing this problem.

Patient History First

The importance of obtaining a detailed patient history in the initial stages of treatment cannot be underestimated. In particular, it is necessary to determine the type of lenses currently being worn, such as whether they are daily or extended wear and the frequency with which the lenses are changed. In addition, you need to know what cleaning regimen is being used and what additional drops are being used. A history of exposure, allergy or any other underlying medical problems and medications should be identified, as well.

On examination, careful attention should be paid to the lid margins, conjunctival surface (including the tarsal conjunctiva), tear film and corneal surface. In addition, make sure that the contact lens fits properly. Corneal topography may be needed to rule out keratoconus or other ocular surface irregularities that can compromise the lens fit and lead to intolerance. Once it is determined that the contact lenses fit properly, other potential sources of intolerance can be addressed.

Universal Recommendations

There are a few universal recommendations that we make to eliminate potential sources of contact lens intolerance. First, we recommend using frequently replaced lenses — changing the lenses at least monthly — and suggest that in many cases daily disposable lenses may be beneficial. When patients opt for lenses that are kept in longer than 1 month, we recommend more aggressive cleaning regimens, including weekly enzyme treatments. With frequently replaced lenses, a much simpler regimen of a standard multipurpose cleaner is usually sufficient. This avoids a potential irritation from some of the other cleaning regimens. We also recommend rinsing the lenses with plain saline solution prior to insertion because even multipurpose solutions — which in most cases are sufficient for disinfection — can cause irritation in sensitive eyes.

Ocular Irritation

During the acute stage of contact lens related ocular irritation, lens wear may need to be limited or even temporarily discontinued. Discontinuation of overnight wear is a must at this stage. Frequent lubrication with preservative-free artificial tears can offer significant relief. We usually recommend avoiding contact lens rewetting drops that contain preservatives. Many of these preparations are similar in composition to the multipurpose solutions and therefore can be irritating. We also recommend lid hygiene — warm water lid scrubs typically suffice. Baby shampoo is not usually necessary unless there is crusting or debris on the lid margins that cannot be removed with warm water alone. If baby shampoo must be used, it should be diluted in warm water to avoid further irritation from the shampoo.

The Medical Treatment Plan

A short course of steroids may be helpful as part of the initial treatment regimen. However, given the effects of steroids, they are not a long-term solution and another treatment may be needed for maintenance. For instance, cyclosporine 0.05% (Restasis, Allergan) drops b.i.d. work well.

It is important to instruct patients to wait at least 15 to 20 minutes to insert contact lenses after applying these drops. In some patients, the effect of the drops may not be seen immediately and patients should be counseled to set the foundation for appropriate expectations. While not a frequent occurrence, we do not consider there to be a failure to respond until a full 6 months of treatment has been completed without improvement. Other modalities such as punctal plug placement or oral supplements such as flax seed oil or fish oil tablets can provide added benefit.

Specialty contact lenses designed with the dry eye patient in mind are often helpful, as well. One study by Frank Bucci, M.D., and colleagues at Hazelton Eye Specialists in Pennsylvania showed that specialty contact lenses made of materials that attract and retain water are more comfortable than silicone hydrogel contact lenses in dry eye patients.² A secondary finding showed that the concomitant use of Restasis along with any of the contact lenses used in the study enabled patients who previously could not wear contacts due to ocular surface discomfort secondary to dry eye syndrome to be able to do so successfully.

Acuvue Advance lenses (Johnson & Johnson, New Brunswick, N.J.) made of galyfilcon-A performed better than the lenses patients had been wearing prior to their enrollment in the study. Proclear Biocompatibles (CooperVision, Fairport, NY) made of Omafilcon-A and Extreme H20 Extra's (Benz Research and Development, Sarasota, Fla.) made of Hioxifilcon-A both performed equally well and outperformed the silicone hydrogel Acuvue Advance CLs, across all lens types. Restasis use produced significantly more favorable outcomes by the 1-month follow-up evaluation.²

Allergic Element

Quite often, there is an allergic component to the intolerance. Antihistamine/mast cell stabilizers can be effective at improving the patient's contact lens tolerance and ocular comfort. In patients who do not experience relief with these drops, a short course of steroid drops may be needed. If the patient requires steroids, we recommend that the patient discontinue contact lens wear for the duration of treatment and encourage him not to return to contact lens wear too soon. It is very common for the premature resumption of contact lens wear to actually delay long term tolerance of full time wear.

ITF Recommendations

A treatment plan for contact lens related dry eye can also be based on the International Task Force's (ITF) protocol recommendations. The ITF guidelines are a consensus treatment algorithm for chronic dry eye developed by a Delphi panel of well-known dry eye experts. The general idea of the guidelines is that DTS severity level should be categorized according to the patient's signs and symptoms instead of tests, and that the treatment plan should be based on that severity level.³ The ITF guidelines for moderate to severe DTS (which is level two on the four-level scale) recommend the use of unpreserved tears, gels, ointments, nutritional support such as flax seed and fatty acids, secretagogues, topical steroids and topical cyclosporine A. Level 3 treatment recommendations include tetracyclines and punctal plugs in addition to all interventions suggested for less severe cases of DTS. These recommendations can effectively be applied to contact lens related dry eye depending on the patient's signs and symptoms.

In our practice we find that with careful attention, most dry eye patients can eventually return to contact lens wear. Frequently, this can be done by simply changing the lens regimen and using nonprescription methods. OM

References

1. Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. Int Contact Lens Clin. 1999;26:157-162.
2. Bucci F, Kislan T. Acuvue advance lenses vs extreme H20 and proclear lenses in dry eye patients with and without Restasis use. Poster presented at: Academy 2006 Denver; December 7, 2006; Denver, CO.
3. Behrens A, Doyle JJ, Stern L, Chuck RS, McDonnell PJ and the Dysfunctional Tear Syndrome Study Group. Dysfunctional tear syndrome: A delphi approach to treatment recommendations. Cornea. 2006 in Press.

Kenneth Beckman, M.D., F.A.C.S., is director of corneal services at Columbus Ophthalmology Associates, Columbus, Ohio, and clinical assistant professor of ophthalmology, the Ohio State University. He reports no financial interests.