The last 20 years have provided myriad contact lens innovations, including daily disposal modalities, silicone hydrogel technology and water gradient contact lenses, hyaluronic acid for tear retention and new preservative-free solutions. And yet the contact lens dropout rate has not changed. Many of these patients want to stay in contact lenses, but we’re missing the early signs of ocular surface diseases such as meibomian gland dysfunction (MGD), blepharitis and dry eye disease (DED) that are thwarting comfort.
Digital device use is a significant factor in this equation as well. Considering its growth has paralleled these contact lens innovations, that trend has hampered the contact lens success we should have seen.
Studies show blink rates drop from 20 times per minute to about four to five times per minute while using digital devices.1-3 When the blink rate drops by 75%, surface exposure, insufficient expression of the meibomian glands and cleaning of the lid margins all become issues. With a proper blink, the lower lid moves medially. This is both a meibomian gland pumping mechanism and a cleaning motion. Without that full blink, glands become obstructed and significant biofilm, hyperosmolarity and inflammation develop. These early effects on the tear film impact contact lens wearers first, as these patients require an adequate tear film on the ocular surface and the contact lens surface.
Uncover the Problem
If we could keep patients in their contact lenses for one to two more decades, it would be transformational. And it all starts with diagnosis. But we often wait until the patient is far too advanced and already ready to drop out of contact lenses. By then it’s too difficult to return them to comfortable contact lens wear. Research explains this through adaptive immunology, or the ability for the immune system to remember and quickly return to this state with any subsequent insult.
Clinicians should remember that corneal staining is a late-stage indicator. It’s the equivalent of beginning glaucoma treatment only after you have peripheral visual field loss. The key is to use both diagnostic tests and symptom questionnaires that help identify disease at an early stage. Although osmolarity testing may be the easiest and most predictive of early DED, other options include something as simple as meibomian gland expression, meibography and assessing the blink capacity.
Clinicians must also look closely at the lid margins for early biofilm development because, according to the dry eye blepharitis syndrome theory, early biofilm development may play a key role in both MGD and DED. By the time we see scurf, debris or collarettes on the lashes, we’re at advanced stages.
Open the Toolbox
With a formal diagnosis in hand, hopefully early when the patient just begins to notice mild contact lens issues such as decreased wearing time or end-of-day discomfort, clinicians can turn to any number of treatments. Hydrating compresses, lid debridement and in-office expression treatments are all good options, as are lid scrubs and in-office blepharoexfoliation for biofilm development. Inflammation at the early stages can be addressed with Xiidra (lifitegrast, Shire) or Restasis (cyclosporine, Allergan), as well as supplementation with GLA/EPA/DHA-based omega fatty acids.
Solve the Puzzle
When you combine these treatments with newer contact lens materials and modalities, you can achieve improvements quickly, keep patients in contact lenses longer and advance your practice. You’ll be serving patients better—and patient word-of-mouth recommendations spread quickly these days.
Optometry, more than any other profession, has one particular item that can help identify dry eye disease early: contact lens wear. Everyone benefits when you care for your contact lens patients carefully and identify their issues early. In doing so, you beat dry eye and keep patients in successful contact lens wear.
1. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68(11):888-92,
2. Cardona G, García C, Serés C, et al. Blink rate, blink amplitude, and tear film integrity during dynamic visual display terminal tasks. Curr Eye Res. 2011;36(3):190-7.
3. Tsubota K, Nakamori K. Dry eyes and video display terminals. N Engl J Med. 1993:328(8):584.