Managing Contact Lens Intolerance

Contact lens intolerance (CLI) remains one of the most common barriers to long-term success in contact lens wear. Despite remarkable advances in materials, designs, and care systems, a substantial number of contact lens wearers discontinue lens use within the first year. Research found a 26% dropout rate at 1 year, most commonly due to discomfort or dry eyes.¹ For optometrists, this represents not only a clinical challenge, but also a lost opportunity for patient retention and trust.

Fortunately, advances in diagnostic technologies and an expanding portfolio of contact lens materials have transformed how we identify, manage, and potentially prevent CLI. This article describes a systematic approach that may allow us to uncover the root causes of CLI and deliver solutions that restore our patients’ comfort and confidence.

UNDERSTANDING THE PROBLEM

CLI is multifactorial and typically develops gradually. Patients often report dryness, fluctuating vision, redness, and foreign body sensation, symptoms that generally intensify toward the end of the day. Recognizing CLI as a symptom rather than a diagnosis reframes our evaluation.

Underlying causes for CLI generally fall into four categories:

• Ocular surface disease (OSD): Dry eye disease, meibomian gland dysfunction (MGD), and allergic conjunctivitis are frequent culprits of CLI.²
• Lens-related issues: Low oxygen permeability, surface deposits, and poor lens fit can lead to localized hypoxia or mechanical irritation.
• Environmental factors: Digital device use, air conditioning, reduced blink rate, and other aspects of the patient’s home or workspace can all exacerbate OSD and/or CLI.
• Patient behavior: Lens overwear, noncompliance with replacement schedules, and use of improper care solutions can also trigger or amplify CLI.

A STEPWISE DIAGNOSTIC FRAMEWORK

Step 1. History of Symptoms

I begin with a thorough case history, in which I ask open-ended questions about symptom onset, daily wear time, environmental factors, etc. I also use validated questionnaires, such as the Ocular Surface Disease Index, to help quantify symptom burden and track progress.

Key questions I typically ask my patients during this step include:

• How much time do you spend on digital devices?
• At what point during the day do your symptoms begin or start to worsen?
• What is your contact lens replacement routine?
• Have lubricating drops or other interventions helped in the past?

Step 2. Ocular Surface Examination

Because OSD is often the primary driver of intolerance, I evaluate tear film stability, meibomian gland health, and corneal or conjunctival staining. Point-of-care testing such as matrix metallopeptidase-9, osmolarity, and noninvasive tear breakup time (TBUT) can also add valuable information, if available in your clinic.

I have found that treating inflammation and improving meibomian gland function before or alongside lens refitting often restores comfort. Of course, other modern tools such as thermal pulsation, intense pulsed light (IPL) therapy, and low-level light therapy can be excellent adjunct therapies, especially in persistent cases.

Step 3. Lens Fit and Material Evaluation

At this point, I assess the lens fit, including centration and movement, at the slit lamp. If I identify issues related to fit, I consider refitting into a different design or upgrading to a lens material that promotes surface moisture and oxygen transmission.

Step 4. Environmental and Behavioral Factors

Lastly, I discuss environmental factors, such as screen-time habits, hydration, and indoor airflow or ventilation. I reinforce regular blinking and adherence to care and hygiene recommendations, especially for 2-week lens wearers, as they exhibit the highest noncompliance rates.³

MANAGEMENT STRATEGIES

There are various potential solutions we can explore with our patients before resorting to discontinuation of contact lens wear.

Daily Disposable Lenses

In my practice, daily disposable contact lenses remain the most effective upgrade for comfort and hygiene. I have found that reducing deposit buildup and eliminating the need for multipurpose solutions noticeably decreases irritation. Also, patients who wear daily disposable lenses consistently report fewer comfort-related complaints than those using frequent replacement modalities.⁴

Water Gradient and Surface Technologies

The latest generation of silicone hydrogel lenses uses wetting agents, surface treatments, or water-gradient designs to improve wettability and maintain hydration throughout the day. This is critical in a world that is becoming increasingly reliant on digital device use. Consider having your patient switch to a lens product that integrates these technologies.

Advanced Multifocal and Toric Designs

Beyond comfort, discontinuation of lens wear among patients with presbyopia and astigmatism often stems from visual compromise. Fortunately, modern lens designs with precision optics and enhanced rotational stability can now provide reliable vision and comfort across varying visual demands.

Specialty Lenses

Patients with severe dryness, irregular corneas, or post-surgical changes may benefit from scleral designs that vault over the cornea and create a protective tear reservoir. Advances in material permeability, surface coatings, and simplified fitting guides have made scleral lens wear more accessible and comfortable.

Adjunct Ocular Surface Therapies

Lastly, combining CLI management with proactive OSD therapy tends to yield synergistic benefits. The following are a few options to consider:

• prescription antiinflammatory ocular agents
• omega-3 fatty acid supplementation to enhance meibum quality thermal pulsation or IPL therapy for MGD
• nonpreserved lubricating eye drops before and after lens wear

COMMUNICATION AND PATIENT EDUCATION

I have found it helps to frame the conversation about CLI not as a lens rejection, but as an adaptive signal from the ocular surface. A useful message might be: “Your eyes aren’t rejecting the contact lenses; they’re telling us they need something better suited to your current lifestyle.” In addition, visual analogies (ie, comparing blocked meibomian glands with a clogged bottle of toothpaste) can help make clinical explanations more relatable. Of course, providing handouts or digital resources can also help reinforce compliance.

CASE EXAMPLE

To drive home this point, consider the following case example: A 32-year-old man who worked as a software engineer had been a daily lens wearer since college but began experiencing end-of-day dryness and redness, which had been worsening over the past year. Examination revealed a TBUT of 4 seconds and mild gland inspissation. His daily disposable hydrogel lenses offered poor surface wettability for his needs.

To manage his CLI, the patient initiated IPL therapy and switched to a silicone hydrogel daily disposable lens with surface-moisture technology. I also recommended he use preservative-free artificial tears. Using these strategies, comfortable 12-hour lens wear was restored, the redness resolved after a few IPL treatments, and he was satisfied with his lenses.

THE FUTURE OF LENS COMFORT

The future of contact lens wear is exciting. Emerging innovations point toward biomimetic surfaces, sustained-release wetting agents, and smart coatings that respond dynamically to their ocular environment. When paired with individualized diagnostics, such as real-time tear film imaging and digital blink analysis, these developments will allow optometrists to deliver even more personalized care.

CLI may be common, but it’s no longer inevitable. By employing a structured diagnostic process, appropriately managing OSD, leveraging innovative materials, and educating patients on all their options, optometrists can convert frustrated wearers into loyal patients.