In the early days of contact lenses, practitioners sought the “Holy Grail” of a comfortable fit for all patients, while accepting that it was simply not possible with then-current technology.

In the late 1880s, the glass scleral lens was the only option, and it was uncomfortable. Barely tolerable, it could only be worn for short periods of time.

Fortunately, comfort has improved with material and design advances over time. Ironically, we’re even fitting scleral lenses more frequently, and patients are actually comfortable for many hours of wear with these lenses.

Unfortunately, lens discomfort remains the main reason patients discontinue lens wear today; up to half of all lens wearers experience discomfort with significant frequency.¹

It’s surprising that, after many decades, comfort remains the main impediment to sustained contact lens wear. Recent advances (i.e., disposable lens options, water gradient technology) have helped, but patients continue to abandon contact lenses with dismaying frequency.

The commonly quoted rate of 10% is likely a gross underestimation of the number lost every year.

A recent publication by the Tear Film & Ocular Surface Society (TFOS) in IOVS ( http://www.iovs.org/content/54/11.toc) takes a comprehensive look at this problem.

I would like to provide our readers with a few of the many highlights from the 18-month TFOS International Workshop. The workshop provides current information on a wide range of topics, from an epidemiology review to management of contact lens disinfection.

• A number of factors play a pivotal role in lens-related discomfort. Contact lens material and design factors were examined as modifiable items that may help solve this common dilemma. As clinicians, we try to reduce discomfort by limiting wear time, adding wetting agents, changing lens design and care system, inserting punctal plugs, incorporating dietary supplements, altering blink behavior and attempting to improve the environment.

In the TFOS review, only two level-one factors were identified: (1) dietary supplementation (omega 6-primrose oil) and (2) altering lens design.^1,2 A fascinating area of interest is the neuro-biologic aspect of discomfort. Specifically, the lens interacts with some of the most richly innervated regions of the human body.¹ Several areas are targeted for further study: nerve morphology and structural changes, biochemistry of the nervous system, and integration of research from the central and peripheral nervous system.¹

• The conjunctiva and related anatomy appear to be more closely linked to discomfort than any other ocular structure changes in lens wear. Of note, contact lens wear causes alterations in the meibomian glands, bulbar conjunctiva (parallel folds) and palpebral conjunctiva in the “lid wiper” zone.^1,2

• The TFOS review investigated the biochemical and functional changes of the tear film in lens wear. Tear film stability (evaporation) is recognized as a very important factor in lens-related discomfort.¹

• The treatment and management subcommittee identified several topics of interest, but quickly pointed out that discomfort is “relatively non-specific,” as it can result from a multitude of sources other than lenses.² It provided a step-wise approach to managing contact lens discomfort that includes: (1) treating non-lens associated problems and coexisting disease, and (2) a focus on lens design, material and solutions.

Possible additional measures include reducing deposits, fitting steeper base curves, and using larger diameter, thinner lenses.² Tear supplements, oral supplements, punctal occlusion and oral/topical drugs may have a role as well.

The New Standard
This productive workgroup has done an exhaustive review of the literature and posed provocative questions; it deserves our congratulations.

Contact lens discomfort remains a significant clinical challenge, and it’s a sobering fact that most wearers experience some form of discomfort over time. Nonetheless, progress is being made to improve contact lens comfort.

The TFOS work sets the standard for using today’s science to solve the challenging problems compromising comfortable lens wear.

We look forward to the day when the market grows without the exorbitant number of dropouts that have stifled the industry for decades.

1. Nichols JJ, Willcox MD, Bron AJ, et al: The TFOS international workshop on contact lens discomfort: Executive summary. IOVS (suppl). 2013; 54(11):7-13.
2. Papas EB, Ciolino JB, Jacobs D, et al: The TFOS international workshop on contact lens discomfort: Report of management and therapy. IOVS (suppl). 2013; 54(11): 183-203.