December 2018

COVER FEATURE

Good habits for healthy eyes
Challenges and opportunities abound for contact lens users


by Vanessa Caceres EyeWorld Contributing Writer


Infectious keratitis with extended wear contact lens
Source: Francis Price Jr., MD

Diffuse multifocal corneal subepithelial and anterior stromal infiltrates in soft contact lens wearer using a multipurpose disinfection solution
Source: Terrence O’Brien, MD


Patients love their contacts, until they don’t

Contact lenses provide millions of patients with improved vision. However, dry eye, allergies, and infections, among other causes, continue to affect patients’ ability to comfortably use contacts.
Contact lens users—and the ophthalmologists and optometrists who treat those patients—face a number of challenges and opportunities that affect the lens-wearing experience.

Dry eye

Eye doctors hear it all the time—patients choose to stop wearing contact lenses. What’s going on to make them stop wearing the lenses?
“A study among North American contact lens wearers found that nearly 80% of them reported discomfort, while 77% reported dryness,1” said Terrence P. O’Brien, MD, professor of ophthalmology, and Charlotte Breyer Rodgers Distinguished Chair in Ophthalmology, Bascom Palmer Eye Institute, University of Miami. “Many patients who have had to stop or reduce contact lens wearing time indicate that their quality of life is significantly affected, both in terms of perceived better vision with their contacts as well as personal image based on physical appearance.”
Contact lens intolerability “is often multifactorial and difficult to pinpoint precisely,” said Christopher Starr, MD, associate professor of ophthalmology, and director of the cornea fellowship, refractive surgery, and ophthalmic education, Weill Cornell Medicine Center, New York Presbyterian Hospital, New York. “Typically it’s a combination of sensitivity or allergy to the lens material and/or solutions as well as chronic dry eye disease, often associated with meibomian gland disease.” The risk for the latter increases with time, age, and frequent contact lens wear.
As more dry eye treatments develop, it will be interesting to see if these are able to improve the ability to wear lenses, said Francis Price Jr., MD, Price Vision Group, Indianapolis. “We now have a variety of treatments for that, including supplements, intense pulsed light treatments, and combined heat and compression devices.” A study with a 3-year follow-up from Dr. Price and Marianne Price, PhD, Cornea Research Foundation of America, Indianapolis, found that 14% of the contact lens wearers discontinued use during the study, mostly due to dry eye.2

More reasons for discomfort

Allergies, including giant papillary conjunctivitis (GPC), also play a role in contact lens discomfort, said Francis Mah, MD, director, cornea and external disease, and codirector, refractive surgery, Scripps Clinic, La Jolla, California. Although these patients often are managed by optometrists, the small percentage who don’t improve end up visiting ophthalmologists, he said. However, as trends have shifted to the use of disposable contact lenses, GPC has become less common, Dr. O’Brien said.
Contact lens infection—something often linked to poor lens hygiene—can lead patients out of their lenses. “Microbial keratitis, especially when involving a highly virulent or indolent pathogen such as Pseudomonas, MRSA, fungus, or Acanthamoeba, is among the most feared complications of contact lens wear,” Dr. Starr said.
“[Infections] have been most commonly associated with gram-negative organisms, but gram positive microbes such as Staphylococcus aureus and Streptococcus pneumoniae species can lead to contact lens-associated red eye and other problems limiting use of contact lenses. … Microbial keratitis is the most severe and fortunately the least common microbial-driven adverse response with contact lens wear,” Dr. O’Brien said.
Discussing with patients what increases the risk for ocular infection—such as sleeping in lenses, exposing the lenses to water, and not cleaning and changing the lenses as prescribed—is a crucial part of patient education, Dr. Mah said. However, even though infection occurrences are low, it can be hard to find patients who follow all of the hygiene rules, he added.
Because of the risk for infection, many ophthalmologists are not fans of extended-wear lenses. As Dr. Starr remarked, “While the Food and Drug Administration has approved some lenses for sleeping in, in general I recommend against these. Sleeping with a foreign body in your eye is simply not a good idea, even if the lens is approved for it,” he said. The only time that Dr. Francis Price recommends extended wearing of contact lenses is when the lenses protect the eye from exposure or are used as a bandage for an epithelial defect.
Eye doctors also generally steer patients away from cosmetic color contact lenses, which can be a potential source of infection, Dr. Mah said. Cases of severe microbial keratitis in children and young adults sharing cosmetic contact lenses have been reported, Dr. O’Brien noted.
Age—or more specifically, reaching presbyopic age—can affect a patient’s desire to wear contacts as well. Dr. Mah has patients who choose to stop wearing lenses because they don’t want to use multifocal or monovision contacts. Additionally, difficulty manipulating lenses due to age or arthritis lead a small number of patients to stop using contacts, Dr. Marianne Price said.
Despite discomfort with lenses, getting patients out of their contacts is not always as easy as it sounds. “Often I have patients in tears, asking, ‘How am I supposed to live, work, or drive without my contacts?’” Dr. Mah said. “The problem is abuse of the lenses. They need a contact lens holiday.” Most of these patients may need to use topical steroids and one of the commercially available agents for dry eye. “I tell them they’ll eventually be off everything and back in their contacts, but they won’t stop Restasis [cyclosporine, Allergan, Dublin, Ireland] or Xiidra [lifitegrast, Shire, Lexington, Massachusetts]. The main problem they had was dry eye,” he explained.

Improving lenses

The technology associated with contact lenses continues to improve, potentially improving use and creating new opportunities for lenses and lens users.
“New polymers for contact lenses and new shapes are continually being developed,” Dr. Marianne Price said. Eyes that have more difficult fits now have access to more scleral contact lenses, which can be particularly helpful in keratoconus and post-keratoplasty eyes.
New lens designs have evolved to improve ocular comfort. This includes newer silicone hydrogel materials that are more comfortable to wear and do not sacrifice high oxygen permeability of the silicone material, Dr. O’Brien said. “Contact lens research has endeavored to improve overall comfort by increasing water content, decreasing the modulus, lowering contact angle hysteresis, and adding surface coatings and plasma treatments,” he said.
Dr. O’Brien also cited newer technology such as the development of antimicrobial films to coat contact lenses with material to inhibit microbial colonization, smart contact lens storage cases that could detect a potential case contamination, wearable electronics to help monitor ocular health status, and regenerative technology that could be used in patients previously not suitable for contact lens wear.

LASIK versus contact lenses

If a patient wants to go beyond the use of glasses for better vision and does not have a cataract, what would be better to recommend—contact lenses or LASIK?
In a study of 1,800 patients followed over a 3-year period that compared continued contact lens wear to LASIK,2 97% of those who wore contact lenses before they had LASIK said that they preferred LASIK, according to Dr. Francis Price and Dr. Marianne Price. These same patients had an easier time with night driving post-LASIK and actually had some improvement in dry eye symptoms compared with patients who continued wearing contact lenses.
The risk for contact lens wear is cumulative, particularly with patients who choose to wear the lenses overnight, Dr. O’Brien said. “While laser vision correction with LASIK or PRK as surgical procedures have their own potential risks, complications, and adverse events, studies have shown these to be of statistically low probability for properly selected patients, with the one-time procedural event performed by experienced refractive surgeons,” he explained.

References

1. Begley CG, et al. Characterization of ocular surface symptoms from optometric practices in North America. Cornea. 2001;20:610–8.
2. Price MO, et al. Three-year longitudinal survey comparing visual satisfaction with LASIK and contact lenses. Ophthalmology. 2016;123:1659–66.

Editors’ note: Dr. Mah has financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb (Bridgewater, New Jersey), Johnson & Johnson Vision (Santa Ana, California), Novartis (Basel, Switzerland), and Shire. Dr. O’Brien has financial interests with Alcon, Allergan, and Bausch + Lomb. Dr. Francis Price and Dr. Marianne Price have financial interests with Alcon, Allergan, and Haag-Streit (Koniz, Switzerland). Dr. Starr has financial interests with Allergan, Bausch + Lomb, BlephEx (Franklin, Tennessee), Bruder (Alpharetta, Georgia), Kala (Waltham, Massachusetts), Novartis, Quidel (San Diego), Shire, Sun Pharmaceutical (Mumbai, India), and TearLab (San Diego).

Contact information

Mah
: mah.francis@scrippshealth.org
O’Brien: tobrien@med.miami.edu
Price: fprice@pricevisiongroup.net; mprice@cornea.org
Starr: cestarr@med.cornell.edu

10 practical tips and pearls for contact lens wearers


1. Wash and dry hands before every contact lens manipulation. Minimize contact with tap water.
2. Remove contact lenses nightly before sleep to reduce complications. Avoid wearing them overnight.
3. Clean and disinfect lenses after removal using only sterile contact lens multipurpose disinfection solutions. Rub the contact lens, even if it’s labeled as a “no rub” solution.
4. Maintain a clean contact lens storage case and change it regularly.
5. Avoid moistening contact lenses prior to insertion in the eye with any non-sterile solution (tap water, saliva, or homemade saline solutions).
6. Do not wear contact lenses while swimming, showering, or bathing.
7. Minimize the use of preservative-containing or viscous eye drops during contact lens wear.
8. Replace contact lenses frequently according to recommendation, such as daily, weekly, or biweekly. Do not extend beyond the prescribed wearing time.
9. Have regular ophthalmic examinations.
10. Remove the contact lens immediately if symptoms of ocular discomfort, redness, or pain occur. Seek professional eye care promptly.

Source: Terrence O’Brien, MD

Challenges and opportunities abound for contact lens users Challenges and opportunities abound for contact lens users
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