CASE FILES: SOLVE THE DRYNESS PROBLEM

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Following tumor resection, this patient required contact lenses for symptom relief and improved acuity.

A 55-year-old female presented with a history of acoustic neuroma on her left side for which she underwent resection. Following the procedure, she experienced lagophthalmos in her left eye, for which she had a gold weight implanted in her left upper eye lid. She also had exposure keratopathy and dry eye in her left eye.

The patient previously had no refractive error and required no vision correction. At this visit, visual acuity was 20/25 in her right eye and 20/100 in her left, limited by the compromised ocular surface. The left eye showed no improvement with refraction. The slit lamp examination revealed a clear cornea in her right eye and grade 3 diffuse punctate keratitis in the left.

How would you treat this patient? Read on for more details.

BANDAGE LENS
I fit this patient with a soft bandage lens using an 8.6mm base curve, 13.8mm diameter and plano prescription. I also placed a punctal plug in her left lower lid.

The patient returned three days later complaining of blurred vision and discomfort in the left eye. The punctate keratitis persisted. We placed an alternate bandage lens using an, 8.6mm base curve, 14mm diameter and +0.50D prescription, but this, too, provided little improvement.

Searching to deliver additional hydration and improve protection of the ocular surface, I fit her with a semi-scleral gas permeable contact lens using a 7.7mm base curve, 15.0mm diameter and -2.87D prescription. This brought her visual acuity to 20/30 and relieved her symptoms during the daytime hours. However, she remained uncomfortable following removal of the lens at bedtime and throughout the night.

TWO-LENS APPROACH
Eventually, I recommended that she wear TruForm’s DigiForm N1 semi-scleral gas permeable lens during waking hours and switch to CooperVision’s Biofinity lens at bedtime. That way, her cornea would always be protected.
The patient still struggled with poor wettability of the anterior surface of the gas permeable lens. I added a plug to her upper lid as well. This provided a solution to the wettability issue for the next two years.

As contact lens technology continued to evolve, I refit her into a Zenlens Prolate from Alden Optical using a 7.8mm base curve, 17mm diameter and +1.50D sphere, which brought her visual acuity to 20/25. I also switched her nighttime lens to Alcon’s DAILIES TOTAL 1 Water Gradient Contact lens, 8.5mm base curve, 14.1mm diameter and -0.50D sphere. This combination resolved her keratopathy and resulted in improved comfort, wettability and visual acuity.

The patient eventually developed a dense posterior subcapsular cataract in the left eye. She underwent cataract extraction with an intraocular lens implant, which brought her visual acuity to 20/30.

TWOFOLD ISSUE
This case demonstrates the need to think outside the proverbial box. The combination of a semi-scleral gas permeable lens during waking hours and a soft contact lens overnight provided adequate relief and surface integrity. She continues to experience relief today with improved visual function and no evidence of hypoxia.

Consider how patients might benefit from the particular surface characteristics of different polymers and perhaps employ them in off-label applications where indicated. For example, the DAILIES Total 1 lens is not approved or designed for overnight wear or as bandage lens therapy. But its surface characteristics satisfied the challenges presented in this case. Without this solution, the patient would likely be debilitated and perhaps a candidate for tarsorrhaphy.

PREVENTING DROPOUTS
Though you may not see cases as severe as this patient’s was, you will likely encounter patients who experience contact lens-related dryness—one of the principle reasons patients discontinue contact lens wear. Treatment may determine whether these patients continue wearing their lenses.

When you encounter a contact lens patient with dry eye, your first priority is to evaluate the etiology which, in turn, will determine how you manage the patient. Some considerations:

  • Is the patient’s condition limited to contact lens wear, or do symptoms occur even when the patient is not wearing lenses?
  • Does the patient have blepharitis or meibomian gland dysfunction?
  • Is this simply a case of tear volume deficiency?
  • Does the patient have an anatomical issue such as ectropion or one of the issues presented by the patient discussed above?

Management will depend on the pathology. For lid disease, start with conventional means, including warm compresses; digital expression; hypochlorous acid lid cleanser; and oral antibiotic, topical steroid or combination drops. You might also consider omega-3 and fish oil supplements.

MATERIAL CHANGE
You can take additional measures if contact lens wear remains limited. One benefit of daily disposables: There’s no need to use disinfecting agents, which may further compromise the dry eye environment. Simply refitting to new technology, daily disposables, often ameliorates the symptoms, affording greater comfort and tolerance, expanding wear schedules and increasing satisfaction.

In recent years, we have seen numerous advances in contact lens materials and designs. For example, CooperVision’s Biofinity Energys combines Aquaform technology—which features high oxygen permeability, low modulus and uniform wettability—with Digital Zone Optics, which helps alleviate symptoms of asthenopia that can often mimic dry eye. (The lens is especially designed for users of digital devices.)

In addition, Bausch + Lomb’s Ultra monthly disposable features MoistureSeal technology which helps maintain moisture for up to 16 hours and allows for a highly wettable surface, as well as a proprietary aspheric design to reduce spherical aberrations. Additional examples include Alcon’s DAILIES TOTAL 1 Water Gradient Contact Lenses, B+L’s Biotrue ONEday, and CooperVision’s MyDay lenses and Johnson & Johnson Vision’s 1-DAY ACUVUE MOIST.

NEXT STEPS
When changes in lens materials fall short of resolving dryness-related issues, consider adjunct agents. My preference is to offer more convenient options. Topical lubricants may address the patient’s needs, but the effect is likely to be limited in duration, requiring frequent application and increased frustration for the patient.

Gel drops, such as Alcon’s SYSTANE Gel Drops and Allergan’s REFRESH LIQUIGEL Lubricant Eye Gel, have proven more efficacious due to their increased residence time on the ocular surface. These are not labeled for use with contact lenses, but I’ve found that they tend to perform well without compromising the contact lens or ocular surface.

My next step: Punctal occlusion. I prefer surface plugs due to their ease of self-monitoring and removal.

If contact lens success remains limited, a consideration would be employing Allergan’s Restasis (cyclosporine 0.05%) or Shire’s Xiidra (lifitegrast 0.5%). With either agent, instruct the patient to use 10 minutes before inserting a contact lens in the morning and after lens removal at the end of the day.

Robert A. Ryan, OD, FAAO, is an associate professor in ophthalmology at Flaum Eye Institute at the University of Rochester Medical Center. He is actively engaged in contact lens specialty practice and clinical research.

WHERE TO FIND IT
Alcon Laboratories
800.451.3937 | Alcon.com

Alden Optical, Inc.
800.253.3669 | AldenOptical.com

Allergan
800.347.4500 | Allergan.com

Bausch + Lomb
800.828.9030 | Bausch.com

CooperVision, Inc.
800.341.2020 | CooperVision.com

Johnson & Johnson Vision
800.843.2020 | ACUVUEProfessional.com

Shire
617.349.0200 | Shire.com

TruForm Optics Inc.
800.792.1095 | TFOptics.com

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