How to relieve systemic dry eye before fitting new contact lenses
Actionable tips to improve comfort and fit.
Image credit: AdobeStock/Seventyfour
When patients reduce or stop wearing contact lenses due to discomfort, we should first assess the ocular surface before switching to a different lens. Today’s lenses are so advanced that, in my experience, patients’ discomfort is rarely caused by the wrong lens. It’s a symptom of dry eye disease (DED), and even mild DED can cause contact lens intolerance. Some patients are aware that DED is the problem: Nearly half of eyeglass wearers say that they’re interested in contact lenses, but 1 in 4 point to DED as the roadblock to wearing them.1
I see this situation every day in my practice, which is based in Boston’s financial district where nearly all my patients have very high screen time. Many of them wear contact lenses and experience some degree of DED. I’ve built up my diagnostic and treatment capabilities to help these patients work and live comfortably, even if they want to wear contacts for long hours.
When patients tell me that they’ve tried multiple lenses without success, I suspect their exam will show evidence of DED. I show my patients photos of their dryness and explain this is the reason their contacts are not working. If their eye is dry without contacts, it will certainly be dry with contacts. I explain that to be successful with contacts, we need to clean up the ocular surface first.
Fix the ocular surface first
Patients with a hydrated ocular surface and good tear film anatomy can add a high-quality contact lens to the ocular surface with minimal disruption. But if a patient has an unstable tear film, any foreign body, contact lens included, will only add to the disruption. Someone with meibomian gland dysfunction (MGD), for example, has rapid evaporation that upsets the tear film’s balance and causes hyperosmotic tears that can damage the cornea. Adding a contact lens will only worsen an already-unstable situation.
Before I prescribe a contact lens, I make sure the ocular surface is ready for it.
Figure 1. OD. With meibography, providers can better visualize atrophied meibomian glands. Image courtesy of Jaclyn Garlich, OD, FAAO
Figure 1. OS. With meibography, providers can better visualize atrophied meibomian glands. Image courtesy of Jaclyn Garlich, OD, FAAO
To get patient buy-in for this process, I find it helps to relate the patient’s problem with contacts directly to one of their signs or symptoms using images. For example, I do meibography and show patients their truncated or atrophied meibomian glands compared with normal glands (Figure 1). I also have a slit-lamp camera, so I can show patients their blepharitis, ocular rosacea, or keratitis. I can even take video as I express their meibomian glands and explain to patients, “This should look like olive oil, but what I’m seeing is thick like toothpaste” (Figure 2).
Figure 2. Slit-lamp video of meibomian gland expression helps patients understand that their meibum has become thick and hard to express. Images courtesy of Jaclyn Garlich, OD, FAAO
The images speak volumes. I explain that if I gave them a new contact lens right away, it wouldn’t be comfortable. They appreciate that we’re taking steps to get it right, starting with a moist, healthy ocular surface.
DED treatments for contact lens comfort
When it comes to getting patients into contact lenses, my first step is to find out their goals (for example, to wear them for social occasions or to go from 3 hours a day to all-day comfort). Developing a treatment plan to meet their goals requires a collaborative approach to ensure that the treatment I recommend is realistic for the patient to incorporate into their daily routine.
Patients are often surprised to learn that we can make significant improvements with some affordable at-home therapies and environmental changes. Many of my patients with DED use a polyunsaturated fatty acid nutraceutical (HydroEye; ScienceBased Health) to improve their meibum from the inside, enhancing the tear film’s lipid component to prevent excessive evaporation. In addition, a preservative-free artificial tear for use at prescribed intervals or as needed, depending on the case, can provide lasting comfort. I’ve been having patients use iVIZIA (Thea Pharma) because I like that the povidone formulation includes trehalose and hyaluronic acid, which are shown to stabilize the tear film and improve DED symptoms.2 It also comes in a multidose bottle that patients like.
To address environmental factors, I give patients a handout that covers common agents that can exacerbate DED (makeup ingredients, makeup removers, blowing fans at work or during sleep, screen use, allergies, etc) with recommendations on how they can alleviate those triggers.
In addition to these core therapies and environmental changes, I often recommend warm compresses with gentle massage to help express the meibomian glands. If a patient has already tried that or has moderate or severe MGD, in-office treatment with thermal expression (TearCare; Sight Sciences, Inc) and/or intense pulsed light (IPL) has proven effective for my patients. In cases where inflammation is not adequately controlled, an immunomodulator or short-term steroid can help improve symptoms. I offer a full range of DED treatments in my practice (punctal plugs, IPL, amniotic membranes, etc), and the therapy I reach for depends on the severity of the disease.
Case study: Screen use and nights out
One of my patients, a woman in her mid-30s with a career that required long hours on the computer, had symptoms common to her work lifestyle: dry, gritty, uncomfortable eyes; eye fatigue; and fluctuating vision. She ended up wearing her contact lenses only a couple of hours per day for social events and then dropped out entirely.
During her exam, her point-of-care testing showed a mild positive matrix metalloproteinase 9 (MMP-9). She had good meibomian gland anatomy, but the meibum expressed from the glands was very thick. Her tear breakup time was 3 seconds OU, and she had 1+ superficial punctate keratitis OU. Given this clinical appearance, any lens she put on this dry base would feel uncomfortable.
When I asked about her goals for contact lenses, she told me she didn’t mind wearing eyeglasses to work, but she’d like to be able to wear contacts comfortably when she goes out with her friends. We came up with a plan to meet her goal. I recommended iVIZIA preservative-free artificial tears twice a day and as needed. To help the MGD, I recommended a HydroEye supplement. For patients with mild MGD, I also recommend warm compresses and massage, but she had already tried this without success, so I did TearCare to remove gland obstruction. I had her add a humidifier to her workstation and turn the fan away from her at night.
When the patient came back 1 month later, she was much happier. Her MMP-9 and keratitis had improved, and there was far less obstruction in her meibomian glands. The consistency of her meibum continues to improve as well. I was able to fit her into a high-quality daily disposable contact lens, which she inserts after putting a drop of iVIZIA in the bowl. She’s very happy now wearing her contact lenses for social events and evenings out.
Most patients can meet their goals for contact lenses—even demanding, all-day wear—if we make sure the ocular surface is healthy first and continue to manage DED so their lenses stay comfortable.
References:
Delaney-Gesing A. New Contact Lens Institute research reveals untapped contact lens demand. Glance by Eyes on Eyecare. March 14, 2024. Accessed July 22, 2024. https://glance.eyesoneyecare.com/stories/2024-03-14/new-contact-len-institute-research-reveals-untapped-contact-lens-demand/
Chiambaretta F, Doan S, Labetoulle M, et al; HA-trehalose Study Group. A randomized, controlled study of the efficacy and safety of a new eyedrop formulation for moderate to severe dry eye syndrome. Eur J Ophthalmol. 2017;27(1):1-9. doi:10.5301/ejo.5000836
