December 13, 2016

A 47–year–old contact lens patient presented with a chief complaint of redness and irritation after wearing her lenses in excess of eight hours per day. How can we prevent this patient from dropping out of contact lenses and improve her comfort?

In this instance, the individual presented as a new patient, noting that her two former eye care practitioners (one MD and one OD) both failed to address her contact lens wear complications adequately. Her first eye care provider diagnosed her with blepharitis, and began treatment with lid hygiene agents and topical antibiotics. This seemed to help a little at first—but after four to six weeks, the patient again reported that she was experiencing irritation and decreased wear time.

She then scheduled an appointment with the second eye care provider, who didn’t mention blepharitis but switched her contact lens to a different brand (Bausch + Lomb Ultra for Presbyopia). This too seemed to help for a short time; however, after another six to eight weeks, she began to experience irritation and decreased wear time.

Did both doctors miss the underlying problem?

After conducting a workup at my practice, I informed the patient that both doctors actually had it right… But, because the interventions weren’t performed simultaneously, it may not have been enough. I agreed with the new contact lens option, as well as the diagnosis of blepharitis. In addition, I noted that she exhibited moderate meibomian gland dysfunction (MGD) and dry eye.

I educated her on the benefits of the new contact lens; recommended lid hygiene and the option of in–office BlephEx and/or thermal pulsation (LipiFlow, TearScience); and prescribed a hydrating compress (Bruder) for home use, Zylet (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension, Bausch + Lomb) BID for the inflammation and Soothe XP (Bausch + Lomb) PRN. Thus, we addressed all the primary components of MGD: gland obstruction, inflammation and tear film instability.

Within three weeks, the patient noticed a significant difference and her wear time had increased. At four weeks, we discontinued Zylet use, but maintained her on hydrating compresses, lid hygiene and Soothe XP, as well as added oral omega fatty acid supplementation. At that time, the patient reported "this is the best I can recall feeling in a decade," and that she could now wear her lenses a full 12 to 14 hours per day.

Contact lens dropout rates in North America have essentially remained the same for 20 years. This seems surprising considering the incredible advances we’ve had in contact lens technology and solutions. Could it be that the benefits of advanced contact lens modalities largely have been marginalized by a higher incidence of ocular surface disease secondary to the exponential increase in digital device use? Moreover, is MGD the principal contributor?

Given the patient’s response to treatment, as well as the switch to a more advanced and better wetting contact lens, it appears that MGD was the underlying cause of her lens wear discomfort. The take–home message: Eye care providers must not only prescribe the most advanced contact lens options, but also treat underlying ocular surface disease simultaneously to help patients achieve a lifetime of comfortable wear.

"All problems become smaller if you don't dodge them, but confront them. Touch a thistle timidly, and it pricks you; grasp it boldly, and its spines crumble."
    –Admiral William Halsey


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