Reduce dropout in patients with dry eye

December 13, 2016

Article

When contact lens patients complain of decreased wear time, discomfort, or reduced or fluctuating vision, the eyecare practitioner’s response is often to suggest a change.

Perhaps a different brand of contact lens, a different brand of solution, or a change of modality, for instance from monthly to daily disposable, could help to relieve the patient’s symptoms.

Practitioners should remember, however, that ocular surface disease (OSD), including dry eye disease (DED), is common among contact lens wearers.

If an unhealthy ocular surface is the cause of the patient’s complaints, perhaps the better approach would be to treat the underlying medical condition-the DED-rather than to immediately start discussing changes in brand or modality. A change in brand, modality or solution will usually provide only a temporary improvement because OSD is a progressive disease.

Related: Dry eye and contact lens wear

Dry eye and lens wear

We conducted a study to assess whether treatment of DED with cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan) could increase wear time and improve ocular health in contact lens wearers.¹

We retrospectively analyzed 102 patients who presented for a yearly examination or pathology visit with complaints of ocular discomfort or vision concerns who were diagnosed at that visit with mild to moderate DED, and who underwent six months of cyclosporine therapy while continuing to use their contact lenses.

In patients diagnosed with mild to moderate DED, the variables we analyzed included best-corrected visual acuity (BCVA), corneal and conjunctival staining, tear break-up time (TBUT), Schirmer score, and tear osmolarity.

Patients were seen at baseline, two months, and six months.

Among the patients, all of whom were white, 75 had presenting BCVA of at least 20/20, and 27 had BCVA worse than 20/20.

Median age was 44.9 years, and 68 patients were women.

Patients wore a variety of contact lens brands, and all used Clear Care lens care solution (Alcon).

DED grading in these 102 patients (204 eyes), based on the International Task Force scale,² was as follows:

• Level 1 (lissamine green staining of conjunctiva), 34 eyes
• Level 2 (fluctuating vision, corneal staining not central), 107 eyes
• Level 3(central corneal stain, filamentary keratitis), 63 eyes

Patients with level 4 disease (recurrent erosion, neurotrophic ulcer) were not included.

The most common chief complaints were decreased wear time (100 patients), fluctuating vision (84 patients), burning (15 patients), and dryness (14 patients).

Improvement

At baseline, eyes with BCVA less than 20/20 had significantly worse (P <0.05) contact lens wear time, corneal staining, conjunctival staining, and osmolarity? than eyes with 20/20 BCVA. There was no difference in these measures between the two groups at six months.

Patients with BCVA less than 20/20 had a significant improvement in BCVA at six months (P <0 .0001).

The mean improvement in contact lens wear time from baseline to six months was significant for the entire study population and for those with BCVA less than 20/20. Wear time increased in the general population from 10.50 to 12.25 hours (P < 0.05), an improvement of 1.75 hours.

In those with BCVA less than 20/20, wear time improved from 7.25 to 10.50 hours (P < 0.005), an improvement of 3.25 hours.

Statistically significant improvements were also seen in conjunctival staining, corneal staining, TBUT, osmolarity, and Schirmer score.

Related: First-class dry eye treatment

Discussion

The improvements in clinical variables seen after six months of cyclosporine treatment in patients continuing to wear their contact lenses indicates that cyclosporine treatment is beneficial in improving ocular surface health in these patients. Improvements in subjective variables, such as contact lens wear time, suggests that cyclosporine treatment can help to increase comfort and tolerability in these patients.

When contact lens wearers complain of discomfort or decreased wear time, it makes sense to consider performing a complete ocular surface health assessment. If DED or OSD is diagnosed, treatment with cyclosporine may be a better option than changing lens or solution brands or modalities.

It is important to remember that OSD can be a progressive condition. If the first response to a patient’s discomfort is to change brands or routines, this may bring temporary relief or improvement. If the underlying medical condition (such as DED or OSD) is not treated, the relief will be temporary and ultimately may lead to contact lens drop out and eventual lost revenue to the practice.

Treating the OSD with cyclosporine, on the other hand, will address ocular surface health and allow patients to continue wearing their contact lenses with greater comfort and longer wear times. By avoiding a return of patients’ symptoms, this may prevent patient frustration and dissatisfaction and may avoid subsequent contact lens dropout.

References:

1. Kislan T, Debello M. A retrospective analysis of cyclosporine 0.05% benefits in dry eye contact lens patients. Poster presented at: American Academy of Optometry Annual Meeting. Anaheim, CA. November 8-11, 2016.

2. The definition and classification of dry eye disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007 Apr;5(2):75-92.