The Bruder Eye Hydrating Mask utilizes moist heat to stimulate meibomian oil gland production.
Allergan’s Restasis is prescribed as a long-term solution for patients with dry eye.
Oasis TEARS lubricant drops can be used throughout the day to help reduce dry eye symptoms.

Here’s how to treat two of the most common conditions that lead to CL dropout so you won’t lose out on CL profits.

No matter their mode of practice, optometrists encounter presbyopia perhaps more than any other ailment. This is one diagnosis no human beyond a certain age can escape. While certainly an affliction the young OD building a practice embraces, to the maturing OD it becomes a lesson in empathy as we inevitably must admit that we too will not escape the decline of our precious accommodation and the challenges of losing clarity. And just to prove that misery loves company, this decade of life brings with it our second most common diagnosis, dry eye syndrome (DES). This combination often leads to contact lens dropout.

Never before have we had such a vast selection of vision correction choices to offer our presbyopes who wear contact lenses. Also, thanks to our increasing life span, there has never been as many people with “short-arm syndrome.” The American Optometric Association states that there are well over 100 million of us presbyopes. Like it or not, many of these patients let us know that we will have to pry away their contacts from “my cold, dead fingers.” The progressive OD (pardon the pun) accepts the challenge daily.

While a consensus regarding the ideal type of contact lens correction for presbyopia will never be agreed upon, we can certainly agree that the comorbidity of DES adds a degree of difficulty in getting this patient population to 20/happy.

Whether your preferred treatment choice is over-the-counter readers or mini-scleral center-near rigid gas permeables, DES will contribute to the degree of difficulty in treatment. As many as 50% of our CL patients experience occasional DES symptoms, and between 10% and 30% will become dropouts. Some suggest that untreated DES is the most common reason our patients leave our practice and seek care elsewhere. As profitability today becomes more and more challenging, losing these valuable customers is not an option. (See sidebar on page 18 for financial impact to the practice) So, how do we prevent our presbyopic patients who wear contact lenses from becoming dropouts? I suggest that once we have chosen the appropriate lens type and solutions, we should prescribe treatments according to the severity of the dry eye condition. I love the Dry Eye OSDI Questionnaire app. It calculates the Ocular Surface Disease Index score for a quantitative level of the patient’s symptoms.

Level I
It is important to address symptoms early to avoid problems. For patients with mild symptoms, conservative treatments include warm compresses to stimulate meibomian oil gland production and limit excess evaporation. The Bruder mask (see page 17) offers ease of use and sustained heat. Also, many patients do well with a few artificial tear drops, such as Oasis Tears (top right), as needed daily. This glycerin-based product contains the non-active ingredient sodium hyaluronate, a long-lasting visco-elastic which adheres to the ocular surface without causing blurred vision. Oasis Plus is slightly more viscous.

Supplements to fight the inflammatory process are important as well. We have seen improvements in patients who take EyePromise EZ Tears from ZeaVision, LLC.

Revenue for fitting presbyopes in your practice
Annual exam fee $100
Contact lens profesional fitting fee $125
Annual supply daily disposable multifocal lenses $550
Plano polarized sunglasses $175
Back-up spectacles $600
Medical office visits DES (2) $130
Amounts above are for illustration purposes only and not suggested charges

Level II
For long-term resolution of symptoms, Allergan’s Restasis is extremely beneficial for these patients. The topical immunomodulator increases tear production in patients with ocular inflammation due to keratoconjunctivitis sicca. Many ODs are implementing this topical therapy sooner rather than later as they see patients feeling better and achieving more comfort at the end of the day. I recommend Restasis twice daily before lens insertion (waiting at least 15 minutes before inserting lenses) and at bedtime (after removing lenses).

Level III
Although patients with significant ocular surface disease may find better results with spectacle correction, some patients, such as those with keratoconus and extremely severe refractive errors simply don’t have that option. For these patients we must be creative.

Many corneal specialists actually treat severe corneal diseases using semi-scleral lenses combined with preservative-free solutions and artificial tears to literally bathe the cornea in an ideal solution. Additionally, even though the use of oral pilocarpine (Salagen) is rarely discussed, ophthalmologist Jeffery Hinson, MD, from Macon, GA, is having success. “My patients are very happy using 5 mg tablets once or twice per day for dry eye symptoms. They don’t experience the side effects of those using the recommended dose of three to four per day.” Unfortunately, I have found the drug to be rather expensive and rarely covered by insurance due to lack of prescribing.

Finally, my favorite treatment for severe DES is autologous serum eye drops made from the patient’s own blood by a compounding pharmacy. Serum contains many components found in healthy tears and mimics the tears’ pH and salinity. Patients love how they feel.

We may not always be excited to see a 48-year-old female contact lens patient with hyperopia, astigmatism and dry eye syndrome who is also a computer programmer. We choose to smile and let them know that we love a good challenge. But we can reap the rewards both personally and professionally if we put forth the effort to prevent these patients from dropping out of contact lenses. A happy patient for life makes it all worth it.

Matt Dixon, OD, is in private practice in Perry, GA.


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