At A Glance
- Achieving good BCVA and optimum comfort with contact lenses depends on the health of the entire eye and the patient as a whole.
- Contact lens wearers should always be assessed for dry eye disease and ocular surface disease.
- A comprehensive dilated examination should be performed on all contact lens wearers to detect the presence of any disease that could affect VA.
Contact lenses are therapeutic medical devices most commonly used to treat refractive error. Beyond correcting for refractive error, contact lenses can effectively manage many other ocular conditions, including limbal stem cell deficiency and neurotrophic keratitis.1 The manner and quality of the contact lens fit is influenced not only by the ocular surface anatomy but also by the health of the entire eye. Many ocular conditions do not exist in isolation. For example, individuals with high myopia and keratoconus are at heightened risk for glaucoma.2,3
Achieving good BCVA and comfort with contact lenses is, therefore, dependent on optimizing the health of the entire eye, and indeed of the whole patient. For these reasons, it is important not only to monitor the lenses themselves, but also to manage any underlying medical conditions in the presence of these therapeutic devices. By highlighting a few examples, in this article I discuss why having a successful contact lens clinic also requires comprehensive medical care of the entire eye and awareness of your patients’ systemic medical issues.
Ocular Surface Health
The tear film and corneal surface constitute the most anterior refractive surface of the eye. Stability and uniformity of the ocular surface shape play important roles in visual quality, and local variations at this surface can cause an individual to have blurry and fluctuating vision.4 Additionally, at least in soft lenses, the presence of dry eye can contribute to lens dehydration, causing poor vision and discomfort. Thus, contact lens wearers should be assessed for dry eye disease (DED) and consequent ocular surface disease (OSD) (Figure 1).
Figure 1. OSD should be therapeutically treated in order to optimize vision and comfort through contact lenses.
Screening for these conditions can be easily done by administering a dry eye questionnaire. After establishing symptoms, a full DED workup should be performed, including diagnostic tests to ascertain severity. Such tests include tear breakup time (TBUT), osmolarity, and ocular surface staining.5
After disease severity is determined, medical treatment should be tailored to meet the individual’s needs. Prescription topical treatments may include artificial tears and antiinflammatory agents such as lifitegrast ophthalmic solution 5% (Xiidra, Shire), cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), corticosteroids, and/or autologous serum tears.6 At-home lid hygiene and warm compress masks and/or neurostimulation devices can also be dispensed in order to address blepharitis and to increase tear-film volume.7
Tear-film preservation techniques such as punctal occlusion can be performed in the office to help alleviate aqueous deficient DED. Other in-office treatments include manual debridement of the lid margins for management of blepharitis and evacuation of the meibomian glands with controlled heating devices for evaporative DED. Amniotic membrane transplants can also be applied in the office to help heal corneal defects from severe OSD.7
Another medical condition of the cornea that can affect contact lens wear is stromal edema from endothelial disease. Decompensation of the endothelial layer can result from a dystrophy such as Fuchs or can be caused by normal endothelial cell loss after corneal transplant.8 Before fitting such patients, baseline endothelial cell density should be determined using either specular or confocal microscopy.
Internal Ocular Health
Retinal conditions such as glaucoma and macular degeneration can also affect vision through contact lenses. For example, uncontrolled ocular hypertension in glaucoma can cause stress to the corneal endothelium, leading to stromal edema (Figure 2).8 This can result in reduced vision through and decreased wear time in contact lenses.
Macular degeneration causes decreased contrast sensitivity and, with multifocal contact lenses, there could be compounded reduction in contrast sensitivity and decreased visual outcomes.9 A dilated retinal examination should be performed in order to determine whether any retinal disease exists that may affect vision through contact lenses.
Retinal conditions should be managed and followed appropriately through diagnostic testing such as visual fields, fundus photography, and OCT. Referral for surgical treatment should be made when necessary. Educating patients about their retinal health allows them to set appropriate visual expectations for contact lenses.
Systemic medical concerns can also affect eye health and, ultimately, vision and comfort in contact lenses. For instance, autoimmune diseases such as Sjögren syndrome and rheumatoid arthritis are associated with DED and OSD.10,11 For such patients, in addition to topical treatments, therapeutic soft bandage lenses or scleral lenses can be prescribed for healing of the ocular surface and treatment of DED (Figure 3).1
Many patients with autoimmune conditions take oral medications such as hydroxychloroquine (Plaquenil, Sanofi-Aventis) to treat systemic inflammation. These high-risk medications are associated with corneal and retinal side effects that can affect vision.12 Individuals taking these medications should undergo a full ocular evaluation with special attention paid to corneal health when contact lenses are present.
A 32-year-old woman is referred for contact lens management of her keratoconus. She had tried corneal gas permeable lenses but discontinued due to discomfort. Currently, she wears soft toric lenses, which she states are comfortable but do not give her good vision. Besides keratoconus, the patient has an ocular history of corneal crosslinking in the left eye. The right cornea did not receive corneal crosslinking due to significant scarring and thinning. Otherwise, she is healthy and taking no medications.
Manifest refraction is -21.00 -4.00 X 030° OD = 20/70 and -11.25 -3.25 X 135° OS = 20/50. Keratometry shows distorted mires and measurements of 54.87 @ 034 / 61.62 @ 124 OD and 44.12 @ 133 / 48.12 @ 043 OS. Placido-disc topography reveals paracentral inferior corneal steepening in both eyes. Pachymetry shows corneal thickness over the apex of 303 µm OD and 430 µm OS with central corneal thickness of 389 µm OD and 489 µm OS.
Anterior biomicroscopy shows significant apical scarring and thinning of the right cornea and central stromal striae of the left cornea. An external ocular photo is taken in order to monitor progression of the corneal scar. Both eyes show mild bulbar conjunctival hyperemia and papillary conjunctivitis. There is no staining of the cornea or conjunctiva; however, tear meniscus height and TBUT are reduced in both eyes. When questioned, the patient notes that her eyes itch and burn toward end of day and that she has seasonal allergies.
The patient is fitted with scleral contact lenses to increase comfort and provide better quality of vision. The lenses are fitted with the help of anterior OCT imaging. Additionally, she is assured that scleral lenses will offer protection of the ocular surface from environmental allergens. For additional relief, she is prescribed a combined topical mast cell stabilizer and antihistamine for allergies and artificial tears for treatment of DED.
Retinal evaluation reveals optic nerve cup-to-disk ratio of 0.60/0.60 in each eye. The retinal exam is otherwise unremarkable. IOP is 18 mm Hg in each eye. Taking into consideration the corneal thinning from keratoconus, the IOP is likely higher than measured. Thus, the patient is tested for glaucoma. Bilateral fundus photos are taken to monitor for future progression. Gonioscopy reveals open angles in each eye. There are no signs of visual field loss on perimetry testing or thinning of the retinal layers on OCT. The patient is asked to return in 6 months to repeat this testing.
Beyond fitting this patient for contact lenses, a full medical eye evaluation with diagnostic testing is performed. This workup reveals additional eye conditions of allergic conjunctivitis, DED, and ocular hypertension. All of these will be medically managed and treated in order to optimize her eye health for contact lenses. Tables 1 and 2 show the CPT and ICD-10-CM codes, respectively, that could be medically billed in a keratoconic scleral lens patient with a risk of glaucoma from ocular hypertension.
THE BIG PICTURE
Given the linkage between anterior and posterior segment disease and the links between ocular and systemic health, we have every reason to approach contact lens patients medically. Contact lenses are therapeutic medical devices that interact with the ocular surface and thereby potentially affect total ocular health.
Considering contact lenses simply as refractive in nature is as antiquated as thinking of eye examinations as routine. As primary health professionals tasked with maintaining our patients’ ocular health, optometrists must consider contact lens–based therapies medically. A holistic approach to refractive and other medical needs in the presence of contact lenses will best serve our patients by preserving VA and function while simultaneously addressing systemic health and well-being.
- 1. Harthan, JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auckl). 2018;10:65-74.
- 2. Cho, BJ, Shin JY, Yu HG. Complications of pathologic myopia. Eye Contact Lens. 2016;42(1):9-15.
- 3. Loukovitis E, Sfakianaki K, Syrmakesi P, et al. Genetic aspects of keratoconus: A literature review exploring potential genetic contributions and possible genetic relationships with comorbidities. Ophthalmol Ther. 2018;7(2):263-292.
- 4. Herbaut A, Liang H, Denoyer A, Baudouin C, Labbé. Tear film analysis and evaluation of optical quality: A review of the literature. [published online ahead of print January 22, 2019]. J Fr Ophtalmol. 2019;42(2):e21-e35.
- 5. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II diagnostic methodology report. Ocul Surf. 2017;15(3):539-574.
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- 8. Feizi S. Corneal endothelial cell dysfunction: etiologies and management. Ther Adv Ophthalmol. 2018;10:2515841418815802.
- 9. Braga-Mele R, Chang D, Dewey S, et al. J Cataract Refract Surg. 2014;40(2):313-322.
- 10. Akpek EK, Bunya VY, Saldanha IJ. Sjögren’s syndrome: More than just dry eye. Cornea. 2019;38(5):658-661.
- 11. Schargus M, Wolf F, Tony HP, Meyer-Ter-Vehn T, Geerling G. Correlation between tear film osmolarity, dry eye disease, and rheumatoid arthritis. Cornea. 2014;33(12):1257-1261.
- 12. Stelton CR, Connors DB, Walia SS, Walia HS. Hydrochloroquine retinopathy: characteristic presentation with review of screening. Clin Rheumatol. 2013;32(6):895-898.