The right artificial tear simplifies the toughest contact lens cases

As an optometrist with more than 10 years’ experience fitting contact lenses on patients with extreme corneal irregularities, I can get almost any patient into the right lenses comfortably. That goes for traditional contact lens cases as well as patients who need specialty scleral lenses designed to restore vision lost due to ocular surface remodeling (from corneal transplant, keratoconus, surgical disfigurement, severe dry eye disease [DED], corneal scarring, and other problems).

DED often factors into the process of fitting lenses and can exacerbate sensitivities with fit and vision. However, with thoughtful management of DED during the process, I can fit the right lens to achieve vision goals and ready the patient for long-term success.

We have many tools at our disposal to succeed with DED and contact lenses, whether your goal is to fit complex cases, to reduce dropout, or to enable more patients to wear lenses longer. And there is always something new. We do not ever need to give up on finding the right fit and the right management for our patients’ DED.

DED does not rule out contact lenses

When a patient has DED, often our first instinct is to avoid using a contact lens, a plastic device that splits the tear film in two (in front of and behind the lens). This tends to make eyes drier and less comfortable and can induce or exacerbate DED. DED is one of the most common reasons patients stop wearing contact lenses, so why start?

I will divide my answer into 2 main types of patients. Type 1 patients already wear contact lenses and want to stay in them, but irritation and discomfort from DED are affecting their quality of life. Their work is suffering. Without a healthy tear film, their vision can fluctuate. By managing DED, we can help these patients feel comfortable again and stay in their preferred modality, contact lenses.

The second type of patient has never worn contact lenses or has not done so in a long time. These patients might be tired of glasses or are no longer able to get sharp vision in glasses. Some are young persons who do not want to start wearing glasses. In the specialty side of my practice, many of my new contact lens wearers need rigid scleral lenses to regain their vision, so we must make daily contact lens wear comfortable. Before we introduce a lens onto any eye, we want to evaluate the patient for DED and get it under control, both to maintain a healthy ocular surface and to ensure the accuracy of our measurements for fitting.

Tips for evaluation and management

DED is multifactorial, so as I evaluate every contact lens patient for DED, I want to know about every contributing factor. First, I want to know whether they have any underlying systemic conditions like Sjögren syndrome, graft-vs-host disease, and others associated with DED. Next, I do a thorough slit lamp examination, checking meibomian gland secretions, signs of rosacea, inflammation, and Demodex mites (evidenced by collarettes). I check their tear breakup time and do lissamine green staining to check for desiccation of the ocular surface.

Once I understand the patient’s DED, including the type (aqueous deficient or evaporative), I discuss a management plan. Every plan includes artificial tears, as well as warm compresses, and other measures as appropriate. Artificial tear selection is important because I want patients to immediately feel relief and start improving their ocular surface health. To avoid preservatives’ detrimental effects, I only recommend preservative-free artificial tears. Now that they are available in a multidose bottle, all my patients can use them easily. I do not specifically look for tears labeled for contact lenses, but I do check that the tear contains no oil, which can cause contact lenses to blur. When I weigh the different tear compositions, I look for one that contains trehalose, which can have some anti-inflammatory effects.

Once I identify healthy options for artificial tears, I listen to feedback from my many patients with contact lenses and DED, and then I am inclined to prescribe their favorites. Currently, I am recommending iVizia (Théa), a preservative-free povidone/hyaluronic acid/trehalose drop that is very popular with my patients. I have soft contact lens wearers use drops proactively twice a day and any time they need relief.

Patients may employ other therapies if needed. If a patient has meibomian gland dysfunction and ocular rosacea, I often recommend intense pulsed light as an in-office treatment (OptiLight; Lumenis). In some cases, particularly for patients with autoimmune disease, a prescription medication that increases aqueous production can be beneficial (Cequa from Sun Ophthalmics; Restasis from Allergan; Xiidra from Novartis), but often I find that many patients do not need medication if we improve baseline ocular health. In cases with a Demodex component, I recommend a foaming eyelid cleanser with tea tree oil (We Love Eyes Tea Tree Eyelid Foaming Cleanser; We Love Eyes), which has become a staple in my practice because my contact lens patients tell me it makes them more comfortable.

After we make a management plan, patients receive an email with instructions for pre–contact lens health. It details exactly what they will do to treat DED to give themselves the best chance of success with contact lenses.

Case: Exposure keratopathy, DED, and scleral lenses

I treat many patients with exposure keratopathy. Their incomplete lid closure might be due to eyelid trauma, eyelid surgery, or blepharoplasty, among other causes. With a portion of the eye always exposed, these patients suffer from severe DED and, eventually, reconstruction of the ocular surface that causes irregular astigmatism and impaired vision.

Recently, I saw a patient who had damage to her eyelids from radiation, causing exposure keratopathy. After many reconstructive eyelid surgeries, she was referred to me for visual problems and DED. Her best-corrected vision with spectacles was 20/80. Topography showed morphological changes on the ocular surface (Figure).

For patients like her, scleral lenses and artificial tears are essential. Her eyelids will never close all the way, so we need to get a contact lens on the eye to protect the ocular surface, as well as tears to replace those that are continually evaporating. I started the patient on an artificial tear immediately (iVizia) and fit her with a scleral lens. She uses the povidone/hyaluronic acid/trehalose drop over the lens as well as several times a day to nourish the ocular surface.

Contact lenses and artificial tears have transformed this patient’s life. She can see 20/20 with her contact lenses. With routine use of artificial tears and the contact lens covering the exposed area of the eye, she feels dramatically more comfortable. If we can routinely make severely challenged patients like her comfortable in contact lenses, we can do the same with many others. That is why I never give up on treating DED or fitting contact lenses.