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At Issue: Contact lenses and dry eye
At Issue posed the following question to a panel of experts: "Which contact lens would you recommend for patients with dry eye?"
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No specific lens
Prof. Dr. med. Thomas F. Neuhann: In my experience, there is no specific contact lens material that is clearly and reproducibly superior to others in patients with dry eyes. To date I have not been able to clearly confirm claims made by some manufacturers with respect to their materials.
If anything, I recommend monthly replacement of contact lenses, use of soft contact lenses and meticulous cleaning with either hard or soft contact lenses in order to assure the best possible surface quality with no deposits. This, in combination with generous use of artificial tears, is all I really recommend in this respect.
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Non-ionic lenses
Walter L. Choate, OD, FAAO: Without question, one of the greatest challenges facing today’s contact lens practitioner is the patient who presents with various stages of ocular surface disease. When faced with this type of patient, we strive to treat the medical conditions present prior to proceeding with any type of contact lens evaluation.
Fitting the dry eye patient with hydrogel contact lenses can be made somewhat easier if one remembers the dynamics involved with ocular surface-tear interaction and the contact lens itself. Hydrogel lenses differ from rigid gas permeable lenses in the following areas: water content, surface charge, surface deposition and on-eye dehydration effects. Surface water is loosely bound by weak hydrogen bounds to the lens material, which are easily displaced by lysozyme, creating a cascade of surface spoilage. Furthermore, the lens matrix loses moisture from osmotic gradients, squeezing from the lids during blinking and wicking from the tear film.
Non-ionic lenses, which are available in low and high water polymers, minimize surface deposition and dehydration effects. Two good examples of older materials that do a good job in this area are the CooperVision Preference (tetrafilcon A) and the Wesley Jessen Gentle Touch (netrafilcon A). Biocompatibles also offers the PC Compatibles product (omafilcon A) which incorporates synthetic phosphoryl choline to help bind water into the matrix of the lens and resist protein and lipid deposition and on-eye dehydration. Benz Research and Development produces the hioxifilcon A 59% Extreme H20 lens, which has many of the same performance characteristics as the PC Compatibles product. Finally, the newer generation silicone hydrogels such as the Bausch & Lomb PureVision and the CIBA Vision Focus Night and Day products, seem to work well with a variety of tear chemistries.
The challenge for the future for the contact lens practitioner seeking to improve success with the dry eye patient will be to match these high-performing non-ionic materials with the right care system for a patient’s individual tear chemistry.
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More like a process
Patricia M. Keech, OD: Years ago, I asked my mother for her recipe for stuffing a turkey. Her response was, it isn’t really a recipe, it’s a process. The same could be said when one approaches a contact lens patient with dry eye symptoms.
First, I try to elicit and understand the patient’s symptoms, which will certainly affect my recommendations. Ask about the age, sex, working environment, situations that exacerbate the dry eye, how long the situation has occurred, whether it is getting worse, what type of contact lens the patient is already wearing, what solutions they use and what medications they take?
Signs will also indicate how severe the situation is. Is there redness, corneal involvement or lid pathology? If we can address any underlying problems such as dehydration, medication side effects, overuse of caffeine, excessive or improper use of makeup or environmental issues, we do that first.
Second, evaluate the lenses the patient is currently wearing. Are they being replaced at appropriate intervals? Are they soiling quickly? What is the nature of the deposits? Are solutions being used properly? Sometimes changing the care system or reducing the replacement interval will solve the problem. In other cases, a material or modality change is necessary to provide relief. Most dry eye patients need more than a multipurpose care system. Usually, an enzyme cleaner and a surfactant cleaner are both necessary to maintain good eye health and comfort. If daily lubrication is necessary, preservative free products generally increase comfort.
Next decide if soft or rigid lenses are most likely to aid the patient. That’s right, some dry eye patients do better in rigid gas permeable lenses. If many soft lens materials have been unsuccessful, or if rigid lenses would provide additional acuity, rigid lenses may be the answer, especially if the issue is not tear volume but tear quality. Rigid lenses can actually stimulate tear production in some cases. Rigid lens materials do not dehydrate or coat as quickly as soft lenses. If a rigid material is contemplated, use one with permeability and wettability. Compare two different materials side by side during diagnostic fitting. Observations under the biomicroscope and the patient’s response help decide which material is better.
Soft lenses can be fit the same way. I always compare at least two materials at the initial fitting to see which performs better for the patient. Information is obtained very quickly as to which is more comfortable, gives better vision and which wets better in the short term. The patient may even wear two different lens materials for the first week or so, to decide which lens design and material performs better for that patient.
How do I choose a material? My favorite dry eye soft lenses have proven to be (in no particular order) Preference (CooperVision), Pro-clear Compatibles (Biocompatibles), FreshLook (CIBA Vision), Frequency 55 (CooperVision), PureVision (Bausch & Lomb), Focus and Focus Dailies (CIBA Vision). Generally, thicker, lower water, deposit-resistant lenses do better. The Focus material may appear to be an anomaly as it is ionic, but it can work very well. Just don’t use a liquid enzyme cleaner with it, unless you like to see allergic corneal infiltrates. Remember, more frequent replacement is better for dry eyes.
Patients with severe dry eyes should not wear contact lenses at all, due to increased exposure to infection. That evaluation lies with the clinical judgement of the practitioner. Dry eyes can progress and need to be evaluated more frequently than the average patient.
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Every case individual
Kelly Kinney Nichols, OD, MPH: In fitting (or refitting) contact lenses in the dry eye patient, there is not one perfect lens for every person. Every case is individual, including the tests that are performed, the lenses that are fitted, the wearing time and any additional treatment that might be warranted. The Proclear soft hydrophilic lens (Bio- compatibles) is currently FDA approved for wear in dry eye patients. A similar lens, the Extreme H20 lens (Benz), is also prescribed often as a dry eye lens. It is though that these lenses have less surface drying, and therefore reduce patient symptoms of dry eye. Low water content lenses, such as the Biomedics 38 lens (American Hydron), have been often used in dry eye patients; however, research on which type of contact lens works best for dry eye patients is limited.
Often, dry eye symptoms occur only when patients are wearing contact lenses. In these cases of contact lens-related dry eye, changing lens materials may help. It is also possible that the patient may be experiencing sensitivity to contact lens solutions, which should be ruled out. In these patients, daily disposable lenses can eliminate the need for solutions. In addition, if the patient is a part-time contact lens wearer, daily disposables are cost-effective and convenient.
In my experiences with dry eye and contact lenses, I like to have a “tool box” of different lens types to offer to my patients as we work through their fitting and dry eye treatment together. Anterior segment disorders that masquerade or compound dry eye symptoms, such as blepharitis, need to be diagnosed and treated. Punctal plugs can be considered. In my experience, these can reduce symptoms effectively in patients with aqueous deficiency. Finally, I recommend that re-wetting drops be instilled before the eyes feel dry and irritated. Hopefully, through careful attention to a patient’s symptoms and a little extra chair time, a successful (and realistic) contact lens fit can be reached.
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RGP recommended
Kensaku Miyake, MD: We recommend rigid gas permeable contact lenses with use of preservative-free artificial tear solutions. With dry eye, disposable contact lenses are often prescribed, so one must avoid creating serious complications since patients are not in close contact with their ophthalmologist.
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Soft lenses after LASIK
Carmen Barraquer, MD: Throughout the years, only 3 times have I had to recommend the use of a soft contact lens for a short period of time for any of my LASIK patients. Two of these patients had undergone cosmetic lid surgery. In every case we used a soft bandage lens with 72% permeability and 15.5 mm diameter.
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Not recommended
Emanuel Rosen, FCOphth: I would amply say that it is not our practice to use contact lenses in this situation, indeed just the reverse. We would avoid use of contact lenses in this situation.
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