Article Date: 6/1/2011

Three-Tiered Comfort Approach
contact lens management

Three-Tiered Comfort Approach

Consider these surefire techniques to keep your patients in lens wear.

Mile Brujic, O.D.

It's no secret that one of the main reasons for contact lens dropout is discomfort. As a result, eyecare practitioners as well as contact lens and solution manufacturers are constantly looking for ways to overcome this hurdle to successful wear. Through my experience, I've discovered a three-tiered approach to maximize comfort, and, therefore, dissuade patients from contact lens dropout.

Here, I explain this approach.

1. Optimize the ocular surface

Because any compromise in the ocular surface's health will challenge comfortable lens wear, it's essential you're vigilant about both identifying and treating any underlying ocular surface disease both before contact-lens fitting and at subsequent follow-up visits. Personally, I look for signs of ocular surface disease at every exam of both my contact lens wearers and non-contact lens wearers, so that I have a good global sense of the ocular surface's general health. The following has enabled me to detect subtle ocular surface disease:

Apply fluorescein dye to the ocular surface by wetting a fluorescein strip with saline and touching it to the ocular surface. Waiting roughly one minute enables me to determine whether corneal or conjunctival staining indicative of dry eye is present.
Assess tear film break-up time (TBUT) with a cobalt blue light and wratten filter. A TBUT less than eight seconds may represent a compromised tear film.1
Assess the tear prism. You can easily accomplish this with fluorescein dye present, as it highlights the lacrimal lake. A tear meniscus height less than 0.5mm is usually indicative of underlying dry eye.2
Evert the palpebral conjunctiva so the lid wiper area (the small region just posterior to the lash line that rubs along the ocular surface) can be assessed for fluorescein staining. If this area stains, the patient has lid wiper epitheliopathy, which is associated with dry eye and uncomfortable contact lens wear.3,4
During the palpebral conjunctival eversion, evaluate the tarsal plate. The presence of papillae is usually indicative of an immunological response to excessive depositing on the contact lens. This can cause discomfort.
Assess the ocular surface with a traditional white light slit lamp. This will enable you to identify any generalized inflammation of the conjunctiva, cornea and lid margin—all signs of a compromised ocular surface.
Express the meibomian glands to determine the quality of their secretions. Thick oils and stagnant glands are indicative of meibomian gland dysfunction.

With the information gleaned from these steps, you can make a clinical judgment as to whether the ocular surface requires intervention to increase its health. (See “Dry Eye Workshop Recommended Therapeutic Protocol,” below.)

2. Match the lens to the lifestyle

Because a patient's lifestyle affects lens wear, and, therefore, comfort, it's essential you meet patients' individual needs to ensure comfortable wear. You can accomplish this by asking about the patient's work and hobbies.

For example, if a spectacle-wearing early presbyope presented with a desire for contact lens wear during basketball, which they play three times a week, I'd likely recommend a daily disposable contact lens. The reason: Part-time contact lens wearers have a difficult time keeping track of the age of their lenses because they do not wear them every day. Having a fresh lens each time they wear their lenses will maximize comfort each time they wear their lenses, and because they will be playing basketball, they do not require a presbyopic correction for this task.

3. Communicate compliance

We know all too well that patients tend to deviate from our directions, prompting issues of discomfort. I've found the following script—directed at the patient—is highly effective in increasing patient compliance:

“I want you to be able to wear your lenses comfortably and successfully. In order for you to do that, it's crucial you follow the directions I've given you regarding your lenses. I've had patients who've decided to deviate from my directions, and these patients have returned with complaints of discomfort, and in some cases, serious complications. I never want that to be you. So, please follow the specific replacement schedule, use the solution I've prescribed—not one that looks similar—and care for the lenses the way I've described.”

Solution switching has been the culprit for discomfort for several of my contact lens patients. To reduce this problem, I've asked patients to bring their contact lens case and solution with them to their follow-up appointments. Because patients know I'll be checking these items, I find they're more likely to comply with the prescribed solution.

For patients who switch solutions despite my script and course of action, I switch them back to the prescribed solution. Also, I instruct them to use a new lens case so the residual effects of old contact lens cases, such as biofilms that may have formed in their existing cases (which could continue to hinder comfortable contact lens wear) are not a factor. This has reinvigorated patient satisfaction with lens wear.

By consistently applying this three-tiered approach, you'll not only improve patient satisfaction with contact lens wear, but also the revenue stream from the contact lens portion of your practice. I have. OM

Dry Eye Workshop Recommended Protocol 5,6
• Environmental modifications (avoid fans toward face, such as at work, home and ceiling fans while sleeping); artificial tear use; heat and eyelid hygiene if blepharitis component present
• Unpreserved artificial tears (if used more than q.i.d.); consider hydroxypropyl cellulose ophthalmic insert (Lacrisert, Aton Pharma) for people using artificial tears greater than four times per day; consider either a steroid or cyclosporine for immunomodulation; consider nutritional supplements
• Punctal occlusion; consider oral tetracyclines


1) Moore JE, Graham JE, Goodall EA, et al. Concordance between common dry eye diagnostic tests. Br J Ophthalmol. 2009 Jan;93(1):66-72.
2) Catania LJ. Diagnoses of the Cornea. In: Catania LJ. Primary Care of the Anterior Segment. 2nd ed. East Norwalk. Appleton & Lange. 1995: 223.
3) 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.
4) Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005 Jan;31(1):2-8.
5) Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006 Sep;25(8):900-7
6) Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007) Ocul Surf. 2007 Apr;5(2):163-78.


Optometric Management, Issue: June 2011