By: Paul M. Karpecki, OD, FAAO
Clinical Director – PECAA
A 37-year-old contact lens patient presented with a chief complaint of redness and irritation after wearing her lenses in excess of six to eight hours per day. How can we prevent this patient from dropping out of contact lenses and improve her comfort?
In this instance, the individual presented as a new patient, noting that her two former eye care practitioners (one MD and one OD) both failed to address her contact lens wear complications adequately. Her first eye care provider diagnosed her with blepharitis, and began treatment with lid hygiene agents and topical antibiotics. This seemed to help a little at first—but after four to six weeks, the patient again reported that she was experiencing irritation and decreased wear time.
She then scheduled an appointment with the second optometrist, who didn’t mention blepharitis but switched her contact lens to a different brand (Bausch + Lomb Ultra for Presbyopia). This too seemed to help for a short time; however, after another six to eight weeks, she began to experience irritation and decreased wear time.
Did both doctors miss the underlying problem?
After conducting a workup at my practice, I informed the patient that both doctors actually had it right… But, because the interventions weren’t performed simultaneously, it may not have been enough. I agreed with the new contact lens option, as well as the diagnosis of blepharitis. In addition, I noted that she exhibited moderate meibomian gland dysfunction (MGD) and dry eye.
I educated her on the benefits of the new contact lens; recommended lid hygiene and the option of in-office BlephEx, thermal pulsation (LipiFlow); and prescribed a hydrating compress for home use such as the Bruder Hydrating Compress. This compress is the only commercial com-press that has scientific research supporting it can maintain temperatures between 104 and 114 degrees or the optimal 40 degrees C on the inner eyelid for 10 minutes. Zylet (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension, Bausch + Lomb) BID for the inflammation. Loteprednol is 10x more lipophilic than Tobradex and all B+L pharmaceutical products are pay no more than $35 for patients with commercial insurance and $65 for Medicare and cash pay patients through Walgreens now (some like Bepreve are only $10). For artificial tears consider Soothe XP (Bausch + Lomb) PRN or RetaineMGD. Thus, we addressed all the primary components of MGD: gland obstruction, inflammation, biofilm removal and tear film instability.
Within three weeks, the patient noticed a significant difference and her wear time had increased.
At four weeks, we discontinued Zylet use, but maintained her on hydrating compresses, lid hygiene (OcuSoft Lid Scrub plus or SteriLid as examples) and Soothe XP, as well as added oral omega fatty acid supplementation (HydroEye from Science Based Health). At that time, the patient reported “this is the best I can recall feeling in a decade,” and that she could now wear her lenses a full 12 to 14 hours per day.
Contact lens dropout rates in North America have essentially remained the same for over 20 years. This seems surprising considering the incredible advances we’ve had in contact lens technology and solutions. Could it be that the benefits of advanced contact lens modalities largely have been marginalized by a higher incidence of ocular surface disease secondary to the exponential in-crease in digital device use? Moreover, is MGD the principal contributor?
Given the patient’s response to treatment, as well as the switch to a more advanced and better wetting contact lens, it appears that MGD was the underlying cause of her lens wear discomfort. The take-home message: Eye care providers must not only prescribe the most advanced contact lens options, but also treat underlying ocular surface disease simultaneously to help patients achieve a lifetime of comfortable wear.
Summary for Treating MGD:
• Obstruction: Daily hydrating compress (e.g. Bruder mask) and/or Thermal Pulsation and/or eyelid debridement
• Inflammation: Zylet or Loteprednol or Xiidra or Restasis & Omega fatty acids or oral doxycycline/azithromycin
• Biofilm: Daily lid hygiene (lid scrubs surfactant or hypochlorus acid) and/or Blephex
• Tearfilm: Artificial tears or rewetting drops (e.g. Blink contacts)