Article Date: 9/1/2008

Keep Patients Comfortable in Contact Lens Wear
contact lenses

Keep Patients Comfortable in Contact Lens Wear

Here are four common complaints about contact lens wear and the ways in which you can solve them.

GLENDA B. SECOR, O.D., F.A.A.O., Huntington Beach, Calif.

Contact lens patients, like spectacle-wearing and medical patients, stick with practitioners whom they believe they can trust to solve problems and provide the best and most-up-to-date care. (As an aside, typically, contact lens patients purchase plano sunglasses and back-up spectacles from practices to which they become loyal.)

If you want to bind these patients to your practice and encourage word-of-mouth referrals to their family and/or friends who are interested in contact lenses, it's imperative you learn how to keep patients comfortable in lens wear.

The best way to accomplish this is to attempt to prevent potential problems from occurring by using your skills and experience in contact lens fitting and your knowledge of the patient's medical and ocular history (allergies, dry eye, etc.) at the initial fitting. This requires you to:
design any necessary treatment plans.
select a patient-compatible lens material and lens solution.
determine the appropriate powers.
ensure the lens is both physically and physiologically satisfactory.
provide the patient with education on his role in achieving comfortable wear.

This last point is particularly important. The reason: More times than not, both existing and new wearers don't understand the significance of adhering to our recommendations regarding lens replacement, wearing schedule, solution use, storage case replacement and maintaining hygiene (i.e. washing their hands with soap and water when handling lenses, etc.) This, in turn, prompts non-compliant behavior, which often leads to self-inflicted lens discomfort.

By taking the time to explain the consequences of non-compliance to new patients and reinforcing this education to current patients, they'll be more likely to adhere to your recommendations. The bottom line: If you assume they'll blindly follow your directions because you're the doctor, you're in for a great deal of disappointment and unsuccessful patients, who may eventually seek care elsewhere.

Still, despite our best efforts to avert potential problems, 100% of our contact lens patients won't adhere to all our directions. In addition, some patients who do comply can become uncomfortable with lens wear. Keeping these two points in mind, here are four common patient complaints regarding lens wear and the ways in which you can address them to keep these patients satisfied.

1 "My lenses are making my eyes feel dry."

• Solving dryness complaints takes detective work, as there may be several possible causes. Before you can solve this problem, you must first ascertain the specific cause(s) of dryness. To do this, ask the following questions:

What time of day are you experiencing dryness? Patients commonly reply: "At the end of the day," indicating that the culprit may be lens or corneal surface dehydration.

If you deem this to be the case, explain the cause to the patient. Then, prescribe pre-wetting drops and re-wetting drops to be used throughout the day, as needed.

(As an aside, if the patient uses drops often and/or develops a sensitivity to them, prescribe a non-preserved drop. This is because preserved formulations often contain benzalkonium chloride (BAK), which can exacerbate dryness by causing further ocular surface toxicity.)

If lens or corneal surface dehydration is causing dryness, first prescribe re-wetting drops.

If, however, the drops don't provide adequate relief, consider refitting the patient into a dehydration-resistant lens material.

Have you been using the lens care products I prescribed? Unfortunately, many patients answer "no" or "not right now," indicating that the cause of their dryness may be lens-solution incompatibility.

If you determine this is the culprit for the patient's dryness, explain that non-prescribed formulations often cause discomfort and threaten ocular health. Then, explain that compliance with the recommended solution may prevent feelings of dryness and the possible onset of infection.

If the patient answers "yes" to the aforementioned question, ask him how, specifically, he's been using the solution. Often times, patients improperly use products, causing dry eye, among other ocular problems, such as redness.

For instance, some patients don't adequately rub and rinse their lenses. This, in turn, may cause a build up of protein, lipid or microbial organism deposits, which can cause ocular dryness. (Growing evidence supports the finding that digital rubbing reduces the microbial load on the lens).

If you deem misuse to be the cause of the patient's dryness, reinforce to him the proper method of using your prescribed solution. You may even want to have the patient practice once before leaving the exam room.

If lipid deposition continues to be an issue, prescribe a preservative-free, alcohol-based cleaner. The lens solution's alcohol should loosen and remove lens deposits.

Should the patient continue to experience problems, however, consider switching him into a GP lens, as these lenses don't contain water, so deposits from one's tears are less likely to stick to the lens.

Two caveats: GP lenses require a period of adaptation before the patient can achieve comfort, due to edge sensation. In addition, these lenses may cause corneal warpage, which results in "spectacle blur" — a reversible condition, in which one experiences a loss of good spectacle acuity upon lens removal. Be sure and educate the patient about these issues.

If the patient reports using the prescribed solution correctly, his dryness may be due solely to the sensitivity of his ocular surface to the solution's preservative.

In this case, explain the cause, and switch the patient to a preservative-free solution system, such as peroxide. Then, instruct him on the peroxide disinfection process and the importance of properly following your prescribed regimen. You may want to have the patient repeat your instructions before he leaves the exam room.

Should it be evident that the patient deems complying with your prescribed lens solution and methods as a "hassle" or "over his head" (just ask him), recommend he switch to a single-use lens.

Have you been taking any antibiotics, birth control pills, antihistamines, blood pressure drugs or antidepressants since your last visit? This is an important question, as these oral medications have been implicated in causing ocular dryness.

Patients may not be able to discontinue their medications to improve their contact lens comfort, but educating them about medicine interaction certainly puts them at ease, as they now know that they don't have a serious problem.

In these cases, have the patient use pre-wetting drops, re-wetting drops throughout the day, as needed, and an artificial tear or lubricant during non-wearing hours.

Should this not provide the patient with adequate relief, consider switching him into a different silicone hydrogel lens, or perform a dry-eye work-up (i.e. slit lamp exam using fluorescein and lissamine green staining, tear film break-up time assessment, Schirmer test and tear osmolarity measurement). The results of the dry eye workup may prompt you to discuss with him other ways to improve tear film chemistry, such as punctal occlusion.

Has your environment changed at all since your last visit, in terms of air conditioning or heating use? You should ask this question because direct or increased airflow via heating ducts or air conditioning has been shown to cause ocular dryness. Therefore, if the patient says his environment has changed, and you believe this is a contributing factor, educate him about tear evaporation. Then, prescribe pre-wetting drops and re-wetting drops throughout the day, as needed, and during non-lens wear.

Consider switching non-compliant patients into a single-use lens.

Have you recently purchased any new technology, in terms of video games; have you been spending more time using computers? Because the use of technology is rampant, the typical reply to this question is "yes."

If you determine this to be the cause for dryness, explain to the patient that prolonged computer use can contribute to contact lens discomfort because it causes staring at the screens, reducing the blink frequency and therefore causing evaporative tear effects. Then, prescribe pre-wetting drops and re-wetting drops during non-lens wear.

An important caveat: Because other ocular conditions, such as meibomian gland disease, blepharitis and autoimmune conditions, such as rheumatoid arthritis, can cause dry eye, you must perform a dry eye workup to determine whether one or more of these conditions is contributing to the patient's dryness.

If dry eye testing reveals meibomian gland disease or blepharitis, explain these conditions to the patient. Then, prescribe 50mg of oral doxycycline b.i.d. — a broad-spectrum antibiotic that will dampen the inflammation; hot compresses q.i.d. (warm washcloth) to liquefy the thick secretions of the glands; digital lid massage to further express these secretions; and medicated lid scrubs to wash away any remaining debris. (The duration of use of these therapies depends on the clinical presentation.)

For an acute case of non-autoimmune dry eye syndrome (aqueous tear deficiency or evaporative dry eye), prescribe artificial tears, and consider prescribing omega-3 essential fatty acid supplementation, which provides ocular hydration and may therefore preclude lid inflammation and blepharitis. If inflammation appears to be a strong component, prescribe a short-term cycle of a topical corticosteroid. (The amount and duration of these therapies depends on the severity of the patient's condition.)

For chronic dry eye syndrome, consider prescribing cyclosporine 0.05% b.i.d. for use during non-lens wear, as it inhibits the action of T-lymphocytes, reducing ocular surface inflammation, and restores the tears.

2 "I can feel the lenses on my eyes."

• For a majority of lens fitters, silicone hydrogel lenses (SiHy) have become a first lens of choice. Why? SiHy materials offer high-oxygen transmissibility, low water content (reducing lens dehydration), and various companies use proprietary methods to reduce the lens' hydrophobicity and enhance wettability. All these characteristics enable many patients to experience relief from contact-lens induced dryness and decreased wearing time. Also, SiHy lenses reduce the amount of conjunctival injection and corneal neovascularization, increasing overall eye health.

The challenge with SiHy: Some have a greater "stiffness," or modulus, than non-SiHy lenses, causing more subjective lens awareness. While you can successfully minimize this by avoiding fitting a loose lens, some patients still complain.

Explain the cause to these patients, and reassure them that the awareness often subsides within one week. This provides psychological comfort.

Some newly fit SiHy patients, however, simply can't achieve adequate comfort, occasionally developing superior epithelial arcuate lesions (SEALS) or giant papillary conjunctivitis (GPC), due to the stiff lens periphery and edge rubbing on the superior cornea and palpebral conjunctiva.

In such cases, explain the cause of the discomfort, and refit the patient in a SiHy lens that offers additional base curves or provides a lower modulus.

3 "I just can't wear them anymore."

• Some patients simply cannot wear SiHy materials.

Although these patients are in the minority, their incompatibility with the lens may not become apparent for months or years after the initial fitting.

These patients complain of redness, dryness and decreased wearing time. Further, slit lamp exam may reveal signs of punctate staining that may mimic a solution toxicity.

Upon eliminating all other culprits for their complaints, such as severe dry eye, and switching the patient to a preservative-free solution, refit the patient into a HEMA lens, so he can achieve comfort.

If the patient experiences similar problems with a HEMA lens, switch him into a GP lens.

It's rare that no soft lens performs satisfactorily. When this does occur, however, it's not a patient or doctor failure, but a failure of current technology.

I always remind my patients that technology will continue to improve, eventually offering more and possibly better options, and that I'll be keeping my eye out — pun intended — so I can be the first to suggest a new and better product. This provides psychological comfort to patients who fail in silicone hydrogel lenses, among other products, while bonding them to my practice.

4 "I'm no longer comfortable using lens care products."

• Some patients discontinue lens wear because they either no longer have the time needed to properly care for their lenses or they simply don't want to be bothered. Hence, they begin to view lens wear as an "inconvenience."

Meanwhile, other patients express concerns regarding the recent lens solution recalls, or fear of developing fusarium or acanthamoeba eye infections.

Recommend single-use lenses to these patients, as they're a nice alternative for patients who desire wear free of solutions, or who have anxiety regarding lens wear risks.

In a perfect world, using one's skills and experience in fitting and one's knowledge of the patient's medical and ocular history would be enough to keep patients comfortable in contact lens wear. But, this isn't a perfect world, and we're not dealing with perfect patients or perfect products.

As a result, in addition to attempting to prevent potential problems, you must be judicious in educating patients as to their role in comfortable wear, and in providing solutions to common complaints, as has been outlined above. This three-fold approach shows patients that you are genuinely invested in their ocular health and have the expertise to provide them with the best care. Patients become loyal to such practitioners. OM

Dr Secor is in private practice in Huntington Beach, Calif. She is a Fellow of the American Academy of Optometry (AAO) and the immediate past chair of the Section on Cornea & Contact Lenses of the AAO. She was named the California 2006 "Optometrist of the Year." Dr Secor is an experienced clinical investigator and a frequent lecturer on the topic of contact lenses. E-mail her at gbsod@aol.com.


Optometric Management, Issue: September 2008