Follow these tips to increase the likelihood of successful contact lens wear

With an estimated 76 million people suffering from glaucoma worldwide, and that population predicted to reach 111.8 million by 2040, we can expect to diagnose an increasing number of our contact lens patients with this second leading cause of blindness.¹

Here, I provide key considerations to help ensure successful outcomes in managing contact lens wearers who have glaucoma.

LIMIT PRESERVATIVES

It is well established that preservatives in topical ocular medications, such as glaucoma drugs, can create a toxic effect on the ocular surface. Specifically, topical anti-glaucoma medications may cause burning, irritation, itching, tearing, and a decrease in visual acuity within three months of commencing treatment. These symptoms can negatively impact patient compliance with their anti-glaucoma medications, and lead to contact lens dropout.

Prescribing topical hypotensive medications that are preservative-free or contain “softer” preservatives may result in less toxicity than those containing the more commonly used benzalkonium chloride (BAK).² (See “Defy Glaucoma-Related Dry Eye,” p.46.)

We can further limit exposure to preservatives in contact lens-wearing glaucoma patients by fitting daily disposable lenses and prescribing a hydrogen peroxide-based disinfection system for those who must wear reusable lenses. Additionally, we can prescribe unpreserved artificial tears for lubrication and rewetting.

CONSIDER MEDICATION TIMING

Some 47% of non-adherent glaucoma patients cite medication schedule as a barrier to medication adherence.³ Medication timing is also a challenge in our contact lens-wearing glaucoma patients.^1-3 Reducing dosing frequency, number of medications, and accommodating patient routines can promote compliance with therapy.

Specifically, I have found that evening dosing with a single medication after contact lens removal is ideal, as the interaction and effect on drug absorption, adsorption, and release when medication is instilled during lens wear is complex: Factors include contact lens polymer and surface characteristics, the molecular size and charge of the active drug ingredients, and the presence and type of preservative. Limiting dosing to once daily while lenses are worn and prescribing daily disposable lenses reduces exposure to preservatives.

If medication must also be used prior to contact lens insertion, we should instruct the patient to wait 15 minutes to insert their contact lenses to counteract any possible interaction and effect on drug absorption and release. The good news: Most topical drugs have a contact time of five minutes or less on the ocular surface due to tearing, blinking, and nasolacrimal drainage.⁴ Additionally, potential uptake and release of the active medication may not necessarily be a concern, as it may prolong drug bioavailability. In fact, contact lens drug delivery of glaucoma medications is on the horizon.⁵

CONTEMPLATE SURGICAL INTERVENTIONS

When IOP is not well controlled pharmacologically, we should consider discussing surgical alternatives, such as laser procedures, MIGS, incisional surgeries (e.g., trabeculotomy), or tube shunts, which should result in a reduction in necessary topical medication and, therefore, improvements in medication compliance, ocular surface health, and contact lens tolerance.

For patients requiring filtering procedures resulting in a bleb, we should consider a low modulus soft contact lens, a corneal GP lens fit steep to ride low, or a scleral lens that is notched or vaulted. We want to correct any corneal irregularity, while avoiding mechanical insult to the bleb.⁶ We must monitor these patients carefully for bleb leaks or infection.

KEYS TO SUCCESS

With attention to both therapeutic and lifestyle needs, glaucoma patients can successfully wear contact lenses. Limiting preservatives and considering medication timing can lead to a successful outcome. OM

REFERENCES

1. Allison K, Patel D, Alabi O. Epidemiology of Glaucoma: The Past, Present, and Predictions for the Future. Cureus. 2020;12(11):e11686. doi:10.7759/cureus.11686.
2. Zhang X, Vadoothker S, Munir WM, Saeedi O. Surface Disease and Glaucoma Medications: A Clinical Approach. Eye Contact Lens. 2019;45(1):11-18. doi: 10.1097/ICL.0000000000000544
3. Robin AL, Muir KW. Medication adherence in patients with ocular hypertension or glaucoma. Expert Rev Ophthalmol. 2019;14(2):73-87. doi.org/10.1080/17469899.2019.1635456
4. Morrison PWJ, Khutoryanskiy VV. Advances in ophthalmic drug delivery. Ther Deliv. 2014;5(12):1297-1315. doi: 10.4155/tde.14.75.
5. Rykowska I, Nowak I, Nowak R. Soft Contact Lenses as Drug Delivery Systems: A Review. Molecules. 2021;26(18):5577. doi: 10.3390/molecules26185577.
6. Samples JR, Andre M, MacRae SM. Use of gas permeable contact lenses following trabeculectomy. CLAO J. 1990;16(4):282-284.

DR. RESNICK is president and managing partner at Drs. Farkas, Kassalow, Resnick, and Associates, a contact lens and anterior segment specialty practice in New York. She is a diplomate in the Cornea, Contact Lens, and Refractive Technology section of the AAO, a diplomate of the ABO, and a fellow of the Scleral Lens Education Society.