Modern Optometry sat down with Mile Brujic, OD, FAAO, to discuss the management of dry eye in patients who wear contact lenses.
Katie Herman, Modern Optometry: Since the start of the COVID-19 pandemic, and with working from home being the new norm for many, have you seen an increase in dry eye in your contact lens-wearing patients?
Mile Brujic, OD, FAAO: We’ve seen an increase in dry eye, period. We can’t even specify that to contact lens wearers. It’s contact lens wearers, non-contact lens wearers. There are more people in general coming in and discussing dry eye. I think part of it has to do with mask-associated dry eye, which is becoming more of an issue.1
KH: When a patient with dry eye is interested in wearing contact lenses, what do you reach for first? Any advice for what to not reach for?
Dr. Brujic: It depends on the patient. If he or she is already wearing contact lenses and is complaining about comfort issues, I’ll address any ocular surface concerns that may be present and do a thorough workup to make sure that any underlying issues are addressed. Doing that may actually help ameliorate a lot of those symptoms that the patient is experiencing.
We thought we used computers a lot before the pandemic! Now we’re using them even more. Depending on what we see on the patient’s ocular surface, we follow a bifurcated decision tree.
Starting from a more extreme situation, if you have a patient with significant corneal staining and corneal involvement, a specialty lens, including a scleral lens, may be warranted. If the patient has a milder issue, meaning the ocular surface looks good but he or she is simply in front of a computer a lot and thus blinking less and staring more, then punctal plugs to retain the tears on the surface of the eye can work well.
On the other hand, if you have an individual who is really experiencing dryness and constantly using drops, I always go back to compliance. Is the patient doing what he or she is supposed to be doing with his or her lenses? Often these individuals will benefit by transitioning from either a biweekly or a monthly disposable lens into a daily disposable lens.
KH: How do you determine which lens will be best for each patient? Do you match up dry eye severity and lens properties, or do you consider other factors?
Dr. Brujic: Usually the first step is determining the patient’s prescriptive needs. Then it’s looking at the available contact lens options for those prescription needs. Next, we talk about the options to optimize those considerations within the prescription needs that are available.
KH: What are some techniques you use when fitting a patient with dry eye for scleral lenses?
Dr. Brujic: The cool thing about patients with dry eye is you’re not dealing with an ectatic cornea, you’re dealing with a regularly shaped cornea that’s just dry. All you have to do when you’re fitting that patient with a scleral lens is create a moisture chamber. In my mind, fitting patients with dry eye in scleral lenses is, relatively speaking, straightforward because the cornea you’re typically working with has a regular shape, so you’re simply attempting to maintain moisture on the surface of that eye.
[Editor’s note: Read more about the use of scleral lenses for managing patients with dry eye disease at bit.ly/MOD1020DS.]
HELP YOUR PATIENTS HELP THEMSELVES
KH: What tips do you give your lens-wearing patients with dry eye for managing their symptoms?
Dr. Brujic: As crazy as it sounds, we first instruct them to do as we tell them because compliance is a major issue. As long as they’re doing what we ask of them, they’re better off than if they make their own judgment calls.
Next, we have them bring in all of their contact lens solutions and eye drops they are currently using. Sometimes there are things patients are using (eg, over-the-counter redness relievers) that can do more harm than good. The underlying cause ultimately determines what we recommend for each patient.
KH: Do you also prescribe eye drops in addition to contact lenses? Do you find that patients are compliant with using eye drops?
Dr. Brujic: I’m not a huge proponent of artificial tears. I think they have their place in eye care as a supplement, but I think that it’s incumbent upon the eye care practitioner to make sure that they understand the underlying cause of whatever’s causing the patient to require or need those drops.
We do prescribe drops in our practice, but that is down a clinical path of determining what is causing the patient’s dryness and whether he or she would benefit from a product like lifitegrast ophthalmic solution 5% (Xiidra, Novartis) or cyclosporine ophthalmic emulsion 5% (Restasis, Allergan) versus other types of mechanisms that may help their eyes feel and function better. In other words, clinically we have to make a judgment call.
Is this more of a meibomian gland dysfunction issue or an aqueous issue? Which one do we target first? The diagnostic tools that we have don’t limit those to non–contact lens wearers. We’ll actually utilize those diagnostic tests and tools to help our contact lens wearers too. Again, if a contact lens wearer is complaining about dryness or dry eye (Figure), we still run an InflammaDry (Quidel) test on that individual, just like we would a non–contact lens wearer.
Figure. The surface of a contact lens immediately after a blink (A). About 4 seconds after the blink tears can be seen beading up on the lens over the dry surface (B).
KH: Do you see that modifications to diet or environment can have a significant effect on dry eye?
Dr. Brujic: It depends on the patient, but sometimes, yes. To give you a perfect example, we’re in a digital world right now, and I don’t know where this started, but there’s this preconceived notion that a computer screen should be at eye level. In actuality, for a dry eye patient, that’s the worst place for it to be. Ideally, screens should be a little bit below eye level.
Take a picture of yourself when you’re looking up, when you’re looking straight ahead, and when you’re looking down. What you’ll find is that the palpebral fissure—the space between the upper and lower lid—is much less exposed when you’re looking down versus looking up or straight ahead. Making that small change reduces the amount of ocular surface exposure and blink rate. Diet is a massive influence, and it depends on how much or how little the individual is interested in modifying that.
There are lifestyle changes that can change the quality of the tear film. But one thing we know and do, is prescribe a combination of oral omega-3 and omega-6 fatty acids, along with other agents that are known to have antiinflammatory properties on the ocular surface. Changes to diet and the environment can both influence a patient’s dry eye, but it depends on the patient as to how much influence those changes will have.
THREE BASIC GUIDELINES
KH: Do you have any other tips for fitting patients with dry eye in contact lenses?
Dr. Brujic: One, make sure you’re embracing new technologies as they come out to address these issues. Two, pay particularly close attention to contact lens materials that are designed to maintain homeostasis on the surface of the eye. Three, don’t forget to analyze the ocular surface.
Again, if you have a patient who was comfortable in their contact lenses last year and nothing has changed with their lenses, other than the fact that they are now dry, consider it a callout to the fact that their ocular surface may be eroding in terms of its ability to support a contact lens. In order to improve that, optimize the ocular surface and utilize those materials that help promote a homeostatic ocular surface.
- 1. CORE alerts practitioners to mask-associated dry eye (MADE) [press release]. Centre for Ocular Research & Education. August 31, 2020. https://core.uwaterloo.ca/news/core-alerts-practitioners-to-mask-associated-dry-eye-made/. Accessed September 29, 2020.