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Proper lid hygiene can help reduce number of contact lens dropouts

Issue: February 1997

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CLOVIS, Calif. — Because many contact lens patients discontinue lens wear due to dryness and discomfort, optometrists should be aware that lid disease is a major cause of uncomfortable dry eye symptoms. Patients with lid disease can be treated with a simple regimen and can also be prepared beforehand to avoid such problems.

"The number one reason people discontinue contact lens wear is discomfort and, specifically, dryness," said Cristina M. Schnider, OD, director of Professional Relations and Clinical Affairs for Menicon USA Inc. Schnider said many of these complaints actually stem from lid disease.

To help keep her patients in their contact lenses, Schnider has begun discussing lid hygiene with all of her patients, "particularly contact lens patients," she said, "because my experience in the past few years has been that lid hygiene solves more dry eye problems than other therapies: lenses, solutions or punctum plugs."

Five types of lid disease

When patients develop dry eye symptoms Schnider checks for signs of lid disease. She separates different types of disease based on classifications developed by Shine and McColley:

1. staphylococcal,
2. simple seborrheic,
3. meibomian seborrhea,
4. seborrheic with secondary meibomianitis and
5. primary meibomianitis.

"The five types are lumped together in what people call blepharitis," Schnider said, "but they have slightly different etiologies and manifestations. All of them have slightly different clinical appearances, so classifying them makes it a lot easier in terms of treatment. There's usually one sign you can associate with each of them."

Similar treatment for five forms

Schnider said the basic treatment is similar for all forms of lid disease: hot compresses, lid massage, lid scrubs and therapeutics. Because different manifestations of lid disease require emphasis on different parts of the regimen, "It is a lot more clear when you divide the treatments into individual classifications rather than just trying to do a blanket therapy," she said.

Therapy starts with hot compresses, which soften the tissues and open the pores and the glands. Schnider then tells patients to massage the area in the following manner: place a finger flat across the eye at the brow ridge and roll the finger down to "milk" the meibomian glands: down over the upper lid, up over the lower lid.

The next step is a thorough lid scrub to clear away debris and to mechanically clear bacteria or flakes. Schnider said she does not recommend any particular cleaning agent and often tells patients that a clean washcloth is fine.

Final step: therapeutic agent

The final step is the use of a therapeutic agent, "almost always an oral agent," she said. Schnider primarily recommends tetracycline; in cases of tetracycline allergy she prescribes erythromycin. The usual prescribing regimen is a 2- to 4-week course of 1,000 mg a day, tapered.

Schnider said tetracycline works well for these cases because it is not only antibacterial, but it also reduces the enzymes elaborated by bacteria that change lipids into more irritating soap-like forms. "It reduces the fatty acids in the sebum," Schnider said. "Tetracycline helps balance the biochemical activity."

In some severe cases, Schnider said she adds topicals. However, "I've found very few cases that can't be managed to a significant degree using these four steps," she said. "I rarely use topical drugs anymore."

Vitamins, good hygiene important

Despite the lack of hard data, Schnider believes antioxidant vitamins may also help people who have dry eye conditions related to lid abnormalities. "The use of different vitamins may help normalize the secretions," she said.

Schnider pointed out that patients can avoid many lid problems by observing good hygiene practices. "I recommend that patients add lid hygiene to their normal routine, such as brushing their teeth."

She gives this advice because, "Patients should take responsibility for their own bodies. You can try many different lens types, but if the patients aren't doing the basic lens maintenance, it won't matter."

Research has shown that many patients who discontinue lenses and try a second time often drop out again, Schnider said. Bausch & Lomb's Trends in Lens Care 1996 showed that the discomfort that caused many wearers to drop out of contact lenses "may have stemmed from poor care instruction at the onset of contact lens wear."

According to Trends, only half of all recipients of care kits recall having received lens care instructions. Thirty-three percent said they received no lens care explanation at all.

"Again, the number one reason for discontinuing lens wear is discomfort," she said. "Changing the lens will not solve the problem in many cases, and patients will just discontinue wear again if you don't solve the underlying problem."

For Your Information:

• Cristina M. Schnider, OD, is a member of the Primary Care Optometry News Editorial Advisory Board. She can be reached at Menicon USA Inc., 333 West Pontiac Way, Clovis, CA 93612-5613; (209) 292-2020; fax: (209) 292-2021.

Identifying and Treating Lid Disease