Review of Cornea & Contact 


A War on Two Fronts: Combat Dry Eye and Allergy in Contact Lens Wearers

Preventing contact lens dropout in patients with multiple complications can be challenging, but these tips and tricks can help.

By Harry M. Green, OD, PhD

Release Date:

May 15, 2017

Expiration Date:

May 1, 2020

Goal Statement:

Preventing contact lens dropout consumes much of an optometrist's time, and there are many methods for ensuring contact lens wearers remain happy in their lenses. Two of the most common culprits for contact lens discomfort, and thus dropout, are dry eye disease and ocular allergy. Although treating one of these issues is challenging enough, patients often present with both dry eye and allergy, further complicating their management. This article will help optometrists understand the conditions, how to treat them and what to do when both are present.

Faculty/Editorial Board:

Harry M. Green, OD, PhD

Credit Statement:

This course is COPE approved for 1 hour of continuing education credit. Course ID is 53489-CL. Check with your state licensing board to see if this counts toward your CE requirements for relicensure.

Joint-Sponsorship Statement:

This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.

Disclosure Statement:

The authors, reviewers and editorial staff have no relationships to disclose.

As optometrists, we spend a great deal of our time trying to keep our contact lens wearers happy and comfortable. No matter how much effort we put into this, preventing dropout is often a struggle. While there are many reasons for dropout, two of the most common are dry eye and allergic eye disease.1 When both are present, it creates a significant clinical challenge.

Identifying the Problem
To keep contact lens patients comfortable, practitioners should consider potential dry eye and allergic eye diseases at the beginning of the fitting process. While this may seem trite, many clinicians approach soft contact lens fitting by arbitrarily choosing a lens, slapping it on and seeing how the patient does. However, prior to initiating the fitting process, a careful history regarding pre-existing symptomatology and clinical evaluation of the ocular surface are key to increasing your success rate, particularly in dry eye and allergy sufferers.

Although these meibomian glands do not appear inspissated, they are completely obstructed.

Dry Eye
Many practitioners, especially those with an older patient demographic, have taken to including dry eye questionnaires in a patient's intake, and the Dry Eye Ocular Surface Disease Index (OSDI) in particular.2 The OSDI has been validated in clinical studies to assess quality of life in patients as their condition improves.3 Many practitioners, however, feel their patients already have enough paperwork to fill out, and high OSDI patients are likely poor candidates for contact lens wear anyway.

I find that simply asking a patient if they have dry eye symptoms when not wearing lenses is sufficient to indicate that the patient will have excessive dryness with contact lens wear. If the patient reports symptoms on a regular basis in the absence of contact lens wear, I treat the dry eye aggressively to get it under control prior to initiating wear. I ask established lens wearers how many hours of wear it takes before they experience (1) any dryness and (2) sufficient dryness to force them to remove their lenses. If the former is less than six hours and the latter is less than 10 hours, there is likely an underlying etiology that can be identified and addressed.

Many of these patients are on edge of the proverbial dry eye "cliff," and contact lens wear is enough to push them over. To pull them back to safety, I draw on a limited number of dry eye tests that are likely to yield positive results. In particular, I focus on tear film stability and the (nearly) ubiquitously present evaporative component. This means a thorough evaluation for blepharitis, with particular attention to the meibomian glands and their dysfunction.  

Meibomitis is an extremely common condition that presents with a wide variety of symptoms, both in type and severity.4 It is the result of chronic inflammation secondary to Staphylococcal species that are commonly part of the established skin flora. The bacteria slough off exotoxins that incite inflammation within the gland, thereby changing the chemical composition of the meibum. The result is an increase in the melting temperature, which slows the flow of meibum from glands. A very common, and under-recognized, feature of meibomitis is meibomian gland obstruction (MGO), which is characterized by a plug of epithelial cells that physically block the gland opening.5 MGO is not necessarily evident in white light exams; if the gland openings appear normal in a white light exam, it is necessary to physically express the glands gently to determine if they are obstructed.

Tear break-up time should be performed prior to any type of gland expression, as the physical expression itself will influence the result. To determine if the glands are completely obstructed, apply gentle pressure along the lid margin, with opposing pressure against the globe. Normally functioning meibomian glands will express with only slight pressure, and the appearance of the expressed meibum should be clear and flow easily. If it takes more than gentle pressure to get the glands to express, or if they do not express at all, then treatment of the lid disease should significantly reduce symptoms.

Perform your tear break-up time before trying to gently express the meibomian glands.

From an allergy perspective, the review of systems (ROS) on our intake paperwork should provide us with the first clue. However, my experience is that patients with allergies often downplay their significance. Many of my patients report not having allergies and do not list over-the-counter (OTC) allergy medicines on the ROS because their allergies "aren't that bad" and are controlled with the OTC systemic antihistamines. I find that it is more reliable to directly ask current or potential contact lens wearers if they have allergies, regardless of what they report on their ROS. Ask more pointed questions regarding the presence of atopy, and specifically atopic dermatitis of the face or lids. Very often, atopic dermatitis of the lids has palpebral conjunctival involvement as a comorbidity. Remember, allergic eye disease only rarely occurs in isolation. Inquire about other affected organ systems due to allergic rhinitis, asthma and food allergy. 

Identifying ocular allergy on clinical examination can be done by looking for signs of low-level, chronic allergic eye disease on the ocular surface. These include signs of atopic dermatitis on the lids and face, hyperemia of the palpebral conjunctiva, a mixed papillary and follicular response on the tarsal conjunctiva and conjunctivochalasis. 

Lastly, it is absolutely essential to flip the upper lid and examine the upper tarsus of current or potential contact lens wearers. I'm often surprised by what I find, including fibrosis from chronic allergic inflammation with recurrent exacerbations. Many patients with a constellation of these subtle signs will not report allergic symptoms until asked; often, patients will report no symptoms at all, even after a direct inquiry.  

Redundant conjunctiva from chronic bouts of allergic inflammation.

Treating DED
Initial treatment for dry eye disease is usually twice-a-day warm compresses and lid hygiene. I also recommend that the patient begin taking daily omega-3 supplements. Research shows omega-3 fatty acids increase the secretion and quality of the meibum from the meibomian glands in patients that take them on a daily basis for six weeks.6 My general recommendation is a supplement high in EPA and DHA (fish or krill oil-based) because of the increased bioavailability over linoleic acid (flax-seed oil) and dosing at three capsules per day. 

The greatest challenge with treating dry eye patients is compliance. Getting patients to follow recommendations that take 20 to 30 minutes out of their daily routine is a daunting task. However, many commercially available warm compresses not only hold a sufficient amount of heat for the entire session, but also absorb ambient humidity when the compress is not in use, and release water vapor when in use. A plethora of commercially available lid soaps and soap products are formulated to provide effective lid hygiene without causing significant ocular surface discomfort.

Another great option for effective symptomatic relief is the use of rewetting drops. There are many different options available OTC, and they can be very effective when used properly. Clinicians should avoid prescribing them "as needed," as consistent use throughout the patient's normal contact lens wear time is key. Dosing at regular intervals throughout the day often extends wear-time significantly. However, make sure the patient understands that the maximum usage should be four times a day.

Although antibiotics can be useful for some dry eye patients, antibiotic resistance has become a significant concern across the entire health care field, and it is our duty as clinicians to use them as sparingly as possible.7 In addition, other potential side effects of long-term use of systemic antibiotics include the development of severe systemic allergy, pharmacologically-induced intracranial hypertension and the augmentation of gut flora, which can lead to colonization by aggressive bacterial strains, such as Clostridium difficile. In females, there is also the added increased risk of vaginal moniliasis with chronic use of antibiotics.

Demodicosis has been recognized more and more as a significant contributor to dry eye symptomatology, and clinically significant infestations should be treated aggressively to minimize the mite population. Treatment can include in-office procedures such as a 10-minute warm compress followed by cleaning and debridement of the lid margins with a spatula or cotton swab to remove mite-derived debris at the base of the lashes. Tea tree oil ointment 50% or ivermectin cream 1% can then be applied to the lid margins. Be aware, however, that these products are not particularly compatible with the ocular surface and tend to be uncomfortable for the patient. Tea tree oil also has a pungent odor. Much of the work to control this chronic condition needs to be done at home, and clinicians can prescribe the same methodology used for controlling MGD, but specifically using ocular soaps that contain tea tree oil. 

Whitish fibrosis from chronic allergic inflammation on the upper tarsal conjunctiva.

When Allergies Hit
For patients with overt signs and symptoms of simple allergic conjunctivitis, contact lens intolerance can pose a significant clinical challenge. This is particularly true for seasonal allergy sufferers or perennial sufferers with seasonal exacerbations. The latter are the most challenging because their allergies usually stem from multiple sources. These patients tend to do very well with consistent use of topical mast cell stabilizers. Stand-alone mast cell stabilizers, such as cromolyn, are extremely safe and effective with long-term use.8 However, this class of topical medications frequently has QID dosing to reach therapeutic levels in the eye, and dosing over contact lenses should be avoided. Thankfully, multimodal anti-allergy drugs, such as ketotifen, are widely available and have excellent safety records.8 They typically have QD to BID dosing, which allows contact lens wearers to dose prior to insertion and after removal. These drugs have both OTC and prescription options.

Lastly, there are many daily disposable soft contact lens options for both spherical and astigmatic fits. The main advantage for allergy sufferers is that frequent replacement eliminates proteinaceous deposit formation on the surface of the lens and the associated reduced comfort. These deposits can bind exogenous allergens and inflammatory mediators and can exacerbate the allergic inflammation.9 One-day replacement lenses simply do not allow enough time for these deposits to establish themselves. 

Avoid deposits like these by fitting your allergy patients in daily replacement contact lenses.

The Double Whammy
There will invariably be some contact lens wearers who suffer from a combination of ocular allergy and dry eye disease, leading to intolerance and dropout. The clinical problem with this is that warm compresses, the main treatment for evaporative dry eye due to MGD, can worsen an allergic response. 

One of the key pathophysiologic mechanisms in an allergic response is histamine release by mast cell degranulation.8 This causes vasodilation and vascular leakage of serum components, as well as pruritis. The application of heat will increase mast cell degranulation, thus increasing itching symptoms. Heat by itself causes vasodilation and increased vascular permeability, making swelling of the surrounding tissues even worse. In fact, one of the supportive therapies for allergy is cold compress. The decrease in temperature causes vasoconstriction and stabilizes mast cells so that fewer are triggered to degranulate.

I take a step-by-step approach to treating these patients, and always start with getting the allergic eye disease under control first. If necessary, I pulse with a topical steroid to rapidly control the ocular surface inflammation. I concomitantly start the patient on a multimodal anti-allergy drop, because I know that mast cell stabilization will take four to six weeks for to reach maximum therapeutic effect.8 Follow-up timing will depend on the individualized treatment plan, but I generally wait six weeks before instituting dry eye therapy. Often, good allergic control in these patients will create enough symptomatic relief that dry eye therapy does not have to be as aggressive. A good starting point is the use of rewetting drops (preferably refrigerated) throughout the day. This not only keeps the ocular surface moist and comfortable, but also acts as a periodic lavage of the ocular surface, physically flushing out allergens.

No matter how you approach treating these patients, keep in mind that contact lens wear is a luxury that is simply not appropriate for some patients. With good clinical thinking and use of the many treatments at our disposal, most of these patients can achieve comfortable, full-time contact lens wear. But I always warn patients that contact lens wear may have to be limited or abandoned entirely if reasonable therapy is ineffective. 

Dr. Green is an assistant clinical professor at the UC Berkeley School of Optometry and did his PhD work in immunology at the California Institute of Technology. He is currently the director of UC Berkeley Digital and director of Berkeley Optometry Online Education.

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