It is estimated that around 17 million individuals in the United States have contact lens related dry eyes.1 While not typically responsible for permanent loss of vision, dry eyes can impose a significant amount of distress to those who are affected. Symptoms of dryness are often cited as the primary reason patients drop out of contact lens wear.

The condition of discomfort to the eyes due to dryness has been given many names: dry eye syndrome, ocular surface disease and dysfunctional tear syndrome, among others. It is generally accepted that there is an inflammatory component to a dry eye disorder, which indicates that your body is responding (or failing to respond) to the irritants and distresses of daily life (e.g. pollution, allergens, dust, etc). The publication of findings at the International Dry Eye Workshop Group (DEWS) has provided the definition currently guiding the field.

People with dry eye are significantly more likely to report problems with everyday activities such as reading, office work, using a computer, watching television and driving. Overall, individuals with dry eyes are about three times more likely to report problems with their vision than those without dry eyes.

Many individuals have little to no trouble with their eyes or vision until they attempt to wear contact lenses. Dry eye is associated with contact lens discomfort and is believed to be one of the foremost reasons that some people give up wearing contact lenses. This phenomenon is known as contact lens induced dry eye (CLIDE).

Since dry eye of mild severity can have few objective clinical signs in the presence of subjective symptoms, the appearance of symptoms due to contact lens wear is said to induce the dry eye. It could also be possible that some of these patients have sub-clinical dry eye disease before contact lens wear. Contact lens wearers are more than 10 times more likely than emmetropes and five times more likely than patients wearing spectacles to complain of dry eye symptoms.2

Diagnosing Dry Eye
Accurate diagnosis of dry eye disease begins with a case history. The prudent practitioner will ask about general symptoms of ocular discomfort. The answers are not likely to lock them into a particular diagnosis, but serve the purpose of determining that there is discomfort that needs relief.

Begin by asking whether your patient is experiencing any burning, stinging, itching or dryness. The answer to this question will provide an adequate net to catch all those suffering from dry eye, lid disease, tear film dysfunction, allergies or some combination of the above. Follow up with more specific questions about grittiness, scratchiness or a sandy feeling.

•  Next, determine whether you are dealing with an acute or chronic condition by establishing a timeline of the symptoms. While an acute allergic or infectious response to an exogenous stimulus will be encountered, the appearance, symptomatology and appropriate treatment will rarely confuse the astute practitioner. Instead, give more attention to the differentiation of symptoms related to lid disease, tear film dysfunction and chronic/seasonal ocular allergies.

Remember that toxins, desiccation and the allergic cascade will all be exacerbated with contact lens wear and will be reported by the suffering patient using similar vernacular. However, when a patient presents with a symptom like itching, you can start with a working diagnosis of either lid disease (blepharitis or meibomian gland dysfunction) or allergies. The next step is to ask where the itching occurs: from the skin of the eyelid or the eye itself.

Find out when the symptoms occur. Details such as the time of day, duration of lens wear or extraneous irritants (ceiling fans, driving, wind, animals, etc.) are especially valuable. Similarly, a history of previous styes would also be significant. For example, mucopurulent discharge leads us toward infectious etiology, but reports of tearing or watering deserve strong consideration as being allergic in nature. Knowing whether the watering comes from the eye nasally (over-production) or temporally (poor lid function) can be even more helpful.

Take time to compile a detailed contact lens history. Symptoms of dryness should be cataloged. Do they occur upon awakening, with immediate lens application, after a specific duration of lens wear, only in certain locations or when performing certain tasks? Also, find out if there is a variation in dry eye symptoms depending on lens age. A tendency for overwear or under-cleaning should be noted, as should the use of older generation or generic multiple-purpose solutions. Objective assessment begins with external observation. Any erythema, swelling or weeping appearance to the eyelids, along with pointing of the lashes, is significant. A gross observation of the amount of ocular redness, its location and its asymmetry is also pertinent.

Biomiscropic evaluation begins with the eyelid skin, lids and lashes. Pay particular attention to the quality and quantity of the lacrimal lake along the lid margin (tear meniscus height), as well as the patency of the meibomian gland orifices. This last observation, along with digital expression of the glands and evaluation of the expressed contents is perhaps the most often overlooked test in the evaluation of patients with ocular discomfort.

Use both fluorescein and lissamine green to evaluate the cornea, conjunctiva and tear film. Pre-lens tear film thinning time has been described as the finding most strongly associated with dry eye in contact lens patients. This finding correlates well with lipid layer thickness and stability, again emphasizing careful tear film assessment of the contact lens candidate or wearer. The presence of any corneal staining will confirm either lid or tear dysfunction; ocular allergic response rarely demonstrates staining.

Evaluation of the upper palpebral conjunctiva is important, but while the lid is everted, pay particular attention to the lid wiper—looking for breakdown and irregularity (staining with lissamine green). Of particular interest is the heaviness, or redundancy, of the bulbar conjunctiva. It may take a practitioner some time to become familiar with normal bulbar conjunctival tension in order to properly identify edema (chemosis) and redundancy (conjunctivalchalasis). This latter condition is particularly noticeable in our older contact lens wearers and may require surgical correction.

Creative Management of CLIDE
Management can be a creative concoction, depending on the individual presentation. Here are some of the most useful treatments and recommendations in our arsenal:

Supplements and Nutrition. There have been countless articles describing the role of inflammation in dry eye, and the suggested use of various supplements, diet and lifestyle changes. Researchers routinely suggest increased omega-3 essential fatty acids. Eye care practitioners should definitely make a careful study of the role of diet (oily fish), fish oil supplements (both OTC and Rx) and flaxseed oil supplements. In my opinion, any contact lens patient experiencing any type of ocular discomfort should be educated about the benefits of introducing more omega-3 into their system.

Hygiene. We should consistently recommend eyelid cleansing utilizing a commercially prepared product intended for that purpose. It is inexcusable to ignore a mild to moderate presentation of lid disease, but then suddenly become attentive when the lids are markedly indurated, erythematous and painful.

Most patients with ocular irritation will benefit from regular cleansing. It has been our observation that men, more than women, need this attention. Presumably, this is related to the lack of nightly eyelid makeup removal and/or the concern about getting soap in the eyes. It should be our message that a little soap—of the right composition—around the eyes is a good idea.

Lubrication. It is a worthwhile endeavor for the practitioner to become aware and involved in the delicate differences between formulations. We have found most patients do best with an emulsion that attempts to mimic the lipid layer (e.g. Systane Balance or Soothe XP). However, these products are neither approved for lens wear, nor particularly formulated for their use. There is a controversy over whether practitioners should utilize such products “off-label,” taking the appropriate precautions and educational efforts, or only stick to approved contact lens rewetting drops. I personally believe that the aggressive use of new sophisticated lubrication products off-label is preferred to remaining at the mercy of pharmaceutical companies for approved versions of these helpful agents.   

Hyperosmotic. While salt-based ointments were our only option until a few years ago, there has been a new place for the use of hyperosomotic therapy with the introduction of Fresh Kote. This novel medication provides wonderful relief for patients who have an irregular, poorly healing corneal epithelium. The patients who benefit from it most usually have concurrent lid disease and are also treated with an antibiotic with anti-inflammatory activities.

I use Fresh Kote to promote corneal healing and then taper off of the medication once healing has occurred. Because of its use in primarily therapeutic situations, it is rarely prescribed concurrent with contact lens wear. However, when necessary, such as in the case of recurrent corneal erosions, cautious use and close monitoring could be attempted (again, off label).

Antibiotics. The use of both AzaSite (azithromycin 1% opthahlmic solution, Inspire Pharmaceuticals) and doxycycline for treating lid disease has been discussed extensively. Azasite works well as an off-label topical lid medication. We have the patient rub the drop into the lower lid and then rest the eyes closed for two to three minutes.

The use of an oral medication has its risks and benefits that should be considered carefully. Two unique formulations of doxycycline that I believe are well suited to lid disease management are Oracea (Galderma Pharmaceuticals) and Periostat (CollaGenex Pharmaceuticals). The first is a 40mg capsule with 30mg of immediate activity and 10mg of delayed release granules. The second is 20mg, a lower dose which can be more easily tolerated in those who have experienced difficulty from a reduction in normal bacterial flora, either intestinal or vaginal.

Wear Schedule. With patients experiencing CLIDE, the goal is to eliminate all symptoms when wearing the lenses and provide that comfort for as many daily wear hours as possible; overnight wear should be avoided in patients with anything short of a pristine ocular surface.
When assessing the situation, you should set incremental goals with the patient. For example, if they are currently comfortable with their lenses for two to three hours, bump that up to five or six hours. I have found that being able to hit the work day expectation of nine to 10 hours of comfortable lens wear is deemed a success by the patient. If the patient is going out later that evening, a one to two hour soak in solution can often give them an evening of comfortable lens wear.

Lens Material. Before we had silicone hydrogel materials, a practitioner could count on particular lenses behaving a certain way based on their thick/thin profile, water content and ionic characteristics—the four categories of hydrogel lenses. Nowadays, with the proprietary component to silicone hydrogel innovation and production, practitioners must test for themselves which material characteristics will be best tolerated on patients experiencing CLIDE.

While it is generally agreed that water content is not as important to lens hydration as once believed, there is increasing discussion about the role of friction between the eyelid and the lens surface.3,4 Lenses that can accommodate a pre-lens tear film similar to the healthy tears are most likely to provide successful lens wear. While manufacturers do point out the benefits of their particular silicone hydrogel lens, I’ve found that each patient needs a unique assessment with various lenses.

When supreme oxygen transmission can be compromised, standard hydrogel lenses with unique surface treatments can bring maximum wearing time to patients experiencing dryness. The Proclear family of lenses continues to be a strong performing lens in our practice, many times out-performing the silicone hydrogel lenses when faced with symptoms of dryness.

Replacement Schedule. Reducing wear time and increasing replacement frequency are two ways to help alleviate acute symptoms. Patients who experience no symptoms the first few days of a two-week or monthly replacement lens do very well when switched to a daily disposable lens. There are now numerous daily disposable lenses with varying material compositions, surface treatments and lubricity enhancements. When a particular prescription is not available in a daily disposable—or a two-week or monthly lens performs well for a shorter-than-advertised number of days—do not be too timid to prescribe a more frequent replacement schedule such as every week for the two-week lens or every two weeks for the monthly lens.

Care Systems. In cases when the daily disposable modality is not feasible, it is important to stress the importance of the care system. Peroxide based systems, such as Clear Care (Alcon), can be used as an alternative to multipurpose solutions. The general observation is that peroxide patients are less likely to move down the row and select an inferior generic product. However, a recent study showed that a multipurpose solution containing Aldox and Polyquad was superior at removing lipid depositions on silicone hydrogel lenses compared to peroxide.5

Practitioners who do choose to prescribe (not recommend or suggest) a particular new formulation of a multipurpose solution should make it absolutely clear that generic products are not equivalent. You need to remain vigilant to ensure that your patients are using the best combination of products.

Oral Antihistamines. Patients suffering from ocular allergies often also have systemic allergy symptoms, and are taking systemic allergy medications. These drugs, both over-the-counter and prescription, have been shown to increase dryness of the ocular surface. Topical agents should be the primary prescription written by eye care practitioners as they deliver high concentration of medication to the ocular surface with fewer side effects than oral medications. Remember to work with the patient’s allergist or primary care physician before suggesting a switch from oral antihistamines to other topical agents (e.g. nasal sprays).

• Topical Antihistamines. When allergic conjunctivitis is thought to be a compounding factor with CLIDE, the use of a topical antihistamine/mast-cell stabilizer combination should be considered. A once-a-day instillation of these agents either before lens insertion or after contact lens removal at night can often bring great relief from the environmental irritants that are being held on the surface of the lens due dry eye.

Topical Anti-Inflammatories. Topical corticosteroids can successfully reduce the inflammation typical of dry eye, but should be reserved for cases that are acute, moderate to severe in intensity or cases of atopic, vernal and contact lens papillary conjunctivitis.

Remember that corticosteroids are not generally regarded as a reasonable long-term treatment option for successful contact lens wear in dry eye patients. In addition to the ocular side effects of prolonged use, including increased intraocular pressure and risk of cataract formation, the constant presence of a steroid during contact lens wear could create trouble if microbial keratitis occurred. However, a management course of “soft” steroids to normalize a patient prior to contact lens fitting can be very useful.

Cyclosprin A (Restasis) has been a wonderful adjunct in the management of CLIDE, making it possible for many patients to wear their lenses comfortably for longer periods before experiencing dry eye symptoms. Remember that it may take some time for the tear film to improve and increase with cyclosporine use, so you will need to educate the patient about this delay. I have found b.i.d. use of cyclosporine concurrent with lens wear—instillation before lenses are applied and after they are removed—to be very well tolerated.

Symptoms of ocular irritation are under-reported by patients. Therefore, it is the responsibility of the astute contact lens practitioner to initiate conversation about discomfort. Thorough evaluation, proper diagnosis and timely treatment and management are essential to the success of our dry eye contact lens patients. 

Dr. Krohn has no current pertinent financial disclosures.

Dr. Jeffrey Krohn is a partner at Fig Garden Optometry in Fresno, Calif. Recently certified by the American Board of Optometry, he serves as an administrator for the Vision Source network of practices. He is a Fellow in the American Academy of Optometry, and a Diplomate in the Cornea, Contact Lenses and Refractive Technology section.

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2. Nichols JJ, Ziegler C, Mitchell Gl, Nichols KK. Self-reported dry eye disease across refractive modalities. Invest Ophthalmol Vis Sci. 2005 Jun;46:1911-4
3. Ngai V, Medley JB, Jones L, et al. Friction of contact lenses: Silicone hydrogel versus conventional hydrogel. Tribology and interface engineering series. 2005;48;371-9.
4. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers. CLAO J. 2002 Oct;28(4):211-6.
5. Heynen M, Lorentz H, Srinivasan S, Jones L. Quantification of non-polar lipid deposits on Senofilcon-A contact lenses. Optom Vis Sci. 2011 Oct;88(10);1172-9.