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C O N T A C T L E N S M O N T H L Y
Use your ears (not your eyes)
to identify CL-related dryness
Dr Robin Chalmers and Dr Carolyn Begley describe their questionnaire-based
assessment of dry eye symptoms among contact lens wearers
FIGURE 1. Biomicroscope
appearance of contact lens
wearer. Can you see symptoms of
contact lens related dryness?
number of sufferers, estimated at nearly one million in the UK alone, the best method to determine the breadth practitioner and self-assessment of dry eye altogether. It has been reported that most and seriousness of the problem of ocular dryness in the population overall, as well tioners often under-estimate the patients’ as establishing normal symptoms reported both contact lens wearers and non-wearers lens wearers self-described themselves as having dry eye (17.7 per cent) compared to who soon discontinues Top five reasons for discontinuation of lens wear
dry eye by their practitioner.2 Patients Per cent important
or very important
practitioner diagnosis represent patients over. Through the past The lenses were uncomfortable late in the day 40.3 per cent been researching the Wearing contact lenses was too much trouble 35.9 per cent measurement of ocular The lenses were uncomfortable all day per cent of those who were not currently specifically elicit them in dry eye patients wearing lenses). When asked their reasons and contact lens wearers alike. A number of our research experiences have reshaped patients with various types of dry eye to former contact lens wearers cited dryness our thinking on how practitioners should and discomfort late in the day as their top guish them from patients without dry eye diagnoses. Although they are not a group of the top five reasons related to ocular forethought. This article will outline some with a dry eye diagnosis, per se, we studied diagnose contact lens related dryness and point to effective strategies for treatment.
Factors in CL-related dryness
In 1998 the authors, along with a collab- orative research team, studied over 1,000 in six clinical centres in North America.2 n a i r e s t h o r o u g h l y ◆ Medication all types of eye care in order to establish other lifestyle factors ◆ Smog and smoke not selected for their dry eye diagnosis is C O N T A C T L E N S M O N T H L Y
strategy. Alternatively, rewetting drops FIGURE 2. Sample symptom question (CLDEQ, Indiana University)
were rated as giving complete relief by 22.3 per cent and artificial tears by a paltry 4.9 per cent of those who used them. 5 Questions about EYE DRYNESS:
There is definitely room for improve-ment in terms of treatment effectiveness a) During a typical day in the past week, how often did your eyes feel dry while wearing your lenses? influence or cause sensations of dryness on the ocular surface, with or without When your eyes felt dry, how intense was this feeling of dryness
while wearing your lenses…
b) Within the first two hours of putting in your lenses?
Not at all
FACTORS THAT INFLUENCE
CL-RELATED DRYNESS
c) At the end of your wearing time? Not at all
negatively impact their comfort with contact lenses. As a group, contact lens wearers are growing older, wear lenses 4). Fifty-five percent of the contact lens finding that 51 per cent of the subjects wearers also reported symptoms that were cited discomfort as the principal reason for smoke, smog, air conditioning or central with drying side effects than in previous decades. Most likely they commute longer distances to work, drink more coffee and HOW PATIENTS COPE WITH
these environments if their lenses exacer- DRYNESS SYMPTOMS
in front of computer screens for work and related dryness comprises a vast majority contact lens wearers reported significantly of patients whose eyes are fairly free of the 1980s and 1990s (Table 2). All these particularly discomfort and dryness late becomes more polluted, indoor air quality contact lens wearer manages their dryness deteriorates even though it is more highly lenses (55.8 per cent), use of contact lens their lenses and found that these patients’ rewetting drops (47.1 per cent) or artifi- their ocular surface less than ideal for cial tears (14.8 per cent). Patients who per cent of subjects while wearing lenses is shown in Table 3.2 Since that time, a and only 6.2 per cent without their lenses be completely effective by 47.4 per cent number of widely used drugs have come ▲ in place, a significant reduction (Figure Symptom frequency for lens wearers
Symptom intensity for lens wearers and
and non-wearers
non-wearers
% with moderate to intense
% with frequent to constant
AM dryness PM dryness AM discomfort PM discomfort C O N T A C T L E N S M O N T H L Y
Self-reported medication use by contact lens wearers
Medication
Per cent of CL wearers
patients and represented a global market of over £2.9bn in 2000 according to IMS knowing what is about to happen to their Health’s World Review. Very often the Key points in contact lens-related
the part of the patient will reduce worry related dryness primarily with your ears! Similarly, if practitioners have familiar- depression medications is also on the rise ◆ Ask patients about the number of hours among adults. The IMS Health’s World Review states that anti-depression medica- familiar with effective options with which ◆ Fifty-five per cent of CL wearers have tions account for the third largest class of to treat those contact lens wearers (ie more medications sold, amounting to £7bn, with lubricious lens materials, non-toxic care a growth of 18 per cent over the previous systems, tear replacements) they will very ◆ Fifty-six per cent of CL wearers relieve likely be more willing to initiate a guided their 40s but still dedicated to continued there are soft lens materials on or coming tical agents to treat conditions related to physical properties that relieve or reduce ment statistics. Time spent on recreational posed a stubborn, intransient problem in computer use likely rose proportionally. the past may now be effectively treated, has also increased dramatically over the care to the patient. Now is the time for PRACTITIONERS’ BEST STRATEGY
practitioners to revamp their diagnostic skills with regard to contact lens-related factors that may reduce a person’s chance fort sequelae that follow. In our study of of success with contact lenses, we propose HOW TO EXAMINE PATIENTS
WITH CL-RELATED DRYNESS?
computer for more than six hours per day WITH YOUR EARS!
while at work in addition to their recrea- history for new and current contact lens problem in vision care; presbyopia. If a the past few years in the UK market. For example, the proportion of UK households 65.3 per cent in the time period from 2000 to 2004, according to recent Organization tion will reveal that most symptomatic contact lens patients have an adequate supply of tears, no frank inflammation and Proportion with frequent to constant symptoms
don’t exhibit significant signs of ocular with and without lens wear
even moderate dry eye patients who do not wear lenses. Standard clinical tests that are used to diagnose pathological dry eye such as the Schirmer test, tear prism height, or the degree of corneal fluores-cein staining don’t correlate very well with symptoms in dry eye sufferers.6 Because contact lens-related dryness is a problem with few clinical signs, the clinician must While wearing lenses
Without lens
query and listen for, rather than look for, contact lens-associated dryness among their existing contact lens wearers. When ▲ clinical signs are within normal limits, C O N T A C T L E N S M O N T H L Y
CONCLUSIONS
Relief reported by lens wearers who manage
dryness symptoms by self-treatment
ho use treatment
their patients with contact lens related plan directed at the reduction of dryness symptoms as a priority in their treatment.
extra care given and is likely to remain as Figure 6 shows recommended who is struggling to wear lenses toward a lens wearer for a much longer period of intensity since these were often reported Acknowledgement
This article is an educational initiative sponsored References
1 In the News: Ciba Vision study on soft contact
Screening questions for contact lens-related dryness
lens dropouts. Optom Vis Sci, 2004;81(11)814.
2 Begley CG, Chalmers RL, Mitchell GL, Nichols 1) How many hours per day do you wear your lenses? ____ hrs KK, Caffery BA, Simpson T, DuToit R, Portello 2) How many hours are your lenses comfortable per day? ____ hrs J, Davis L. Characterization of ocular surface 3) In a typical week, how often do you feel the need to remove your lenses before it is convenient due to a feeling of dryness? symptoms from optometric practices in North America. Cornea, 2001;20(6):610-8.
4) Questions about EYE DRYNESS:
Caffery B, Nelson JD, Snyder C, Simpson T. a) During a typical day in the past week, how often did your eyes feel dry while wearing your The Agreement between Self-Assessment and Clinician Assessment of Dry Eye Severity. Cornea, 4 Pritchard N, Fonn D, Brazeau D. Discontinu-ation of contact lens wear. Int Contact Lens Clin, When your eyes felt dry, how intense was this feeling of dryness while wearing your lenses… b) Within the first two hours of putting in your lenses? 5 Young G, Veys J, Pritchard N, Coleman S. A Not at All
multi-centre study of lapsed contact lens wearers. Ophthal Physiol Opt, 2002;22:516-27.
6 Begley, CG, Chalmers RL, Abetz L, Venkata- raman K, et al. The Relationship Between Not at All
Clinical Signs Among Patients with Dry Eye of Varying Severity. Invest Ophthalmol Vis Sci, 2003;44: 5) Have you been told you have dry eyes? 11;4753-61. 7 Korb DR. Survey of preferred tests for diagnosis of 6) Do you think you have dry eyes? the tear film and dry eye. Cornea, 2000;19(4):483-6.
8 Nichols KK, Nichols JJ, Zadnik K. Frequency Scoring Responses:
Responses that may indicate contact lens related dryness are listed below.
of dry eye diagnostic test procedures used in various Hrs of Wear – Hrs of Comfortable Wear <2 hrs modes of ophthalmic practice. Cornea, 2000;19(4): ◆ Dr Robin Chalmers is a clinical trial consultant and Dr Carolyn Begley is a professor at Indiana University School of Optometry in Bloomington, USA

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