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C O N TA C T L E N S M O N T H LY
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
▲
DRYNESS AND discomfort
FIGURE 1. Biomicroscope
appearance of contact lens
with contact lenses are extremely
wearer. Can you see symptoms of
common, affecting nearly half of
contact lens related dryness?
all soft lens wearers. The large
number of sufferers, estimated at
nearly one million in the UK alone,
symptoms. Figure 2 shows a
should be strong motivation for eye
sample symptom question. The
care practitioners to re-examine and
frequency of each symptom
retune their approach to diagnosing
is first established and, if that
and treating the problems of their
symptom is reported at all, the
symptomatic contact lens patients
intensity at the beginning and
(Figure 1).
end of the day is gathered. At
Contact lens patients who are
the end of the survey we asked
experiencing a less than optimum
patients whether they had a
lens wearing experience not only
practitioner or self-diagnosis of
have a negative experience, but
dry eye as a global indicator of
are at higher risk of limiting their
their condition. The power of
wearing time and abandoning lens wear 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 have been analysed to show that practipatients who discontinue contact lens dryness in the population overall, as well tioners often under-estimate the patients’
wear were in their mid-20s when they as establishing normal symptoms reported perception of the dry eye condition in
began lens wear and stopped within the by patients who do not suffer from dry both contact lens wearers and non-wearers
first two years of wear.1
alike.3 Nearly 40 per cent more contact
The investment of
lens wearers self-described themselves as
chair time with a patient
having dry eye (17.7 per cent) compared to
who soon discontinues Top five reasons for discontinuation of lens wear
the number who had been told they had
lens wear is lost if their Reason
dry eye by their practitioner.2 Patients
Per cent important
who self-diagnose but aren’t given a
comfort problems are
or very important
practitioner diagnosis represent patients
ignored or glossed My eyes felt dry
42.5 per cent
whose needs are not being met by their
over. Through the past The lenses were uncomfortable late in the day 40.3 per cent
eye care providers.
decade the authors have The lenses felt scratchy and irritating
37.6 per cent
Among the 1,054 subjects surveyed
been researching the Wearing contact lenses was too much trouble 35.9 per cent
30.4 per cent
were 367 current contact lens wearers
measurement of ocular The lenses were uncomfortable all day
and 181 former contact lens wearers (26
surface symptoms and
per cent of those who were not currently
developing methods to
specifically elicit them in dry eye patients eyes. These symptom norms can then be wearing lenses). When asked their reasons
and contact lens wearers alike. A number compared to symptoms among groups of for discontinuation of lens wear, the
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 see if their symptoms alone can distin- and discomfort late in the day as their top
approach mild to moderate dry eye and guish them from patients without dry eye two reasons. As shown in Table 1, four
CL-related dryness with a new level of 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 surface sensations rather than inconvenience, cost or other reasons
findings that support reasons to better the contact lens wearers
unrelated to lens comfort.
diagnose contact lens related dryness and as a distinct group to
These results are in
compare with non-lens
point to effective strategies for treatment.
Factors in CL-related dryness
agreement with researchers
In 1998 the authors, along with a collab- wearers.
from the University of
T h e D E Q a n d ◆ Coffee and alcohol
orative research team, studied over 1,000
Waterloo, Ontario, Canada,
unselected clinical patients presenting CLDEQ question- ◆ Age
who found that 50 per cent
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
We distributed the newly developed Dry query a number of ◆ Gender
of the patients cited discomEye Questionnaire and Contact Lens habitual ocular surface ◆ Lids
fort or dryness as the reason
Dry Eye Questionnaires (DEQ and symptoms, contact ◆ Lens type
for discontinuation. They
CLDEQ) to these patients presenting for lens wearing history ◆ Computer use
also reported that patients
all types of eye care in order to establish and habits, along with ◆ Climate
who discontinued lens wear
population norms for ocular surface other lifestyle factors ◆ Smog and smoke
had a reduced wearing time
symptoms. Surveying patients who were that were suspected ◆ Driving
compared to successful
not selected for their dry eye diagnosis is to influence dryness
wearers. 4 A more recent
C O N TA C T L E N S M O N T H LY
strategy. Alternatively, rewetting drops
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.
There is definitely room for improvement in terms of treatment effectiveness
for contact lens related dryness.
How can a clinician predict or avoid
contact lens related dryness in their
contact lens patients? First we must
understand the varied factors that can
influence or cause sensations of dryness
on the ocular surface, with or without
contact lenses.
FIGURE 2. Sample symptom question (CLDEQ, Indiana University)
5 Questions about EYE DRYNESS:
a) During a typical day in the past week, how often did your eyes
feel dry while wearing your lenses?
❏
❏
❏
❏
❏
Never (please skip to question 6)
Infrequently
Frequently
Constantly
Not Sure
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
Very
intense
intense
1
2
3
4
5
Not
sure
0
c) At the end of your wearing time?
Not at all
Very
intense
intense
1
2
3
4
5
Not
sure
0
study conducted in the UK concurred,
finding that 51 per cent of the subjects
cited discomfort as the principal reason for
giving up lens wear.5
HOW PATIENTS COPE WITH
DRYNESS SYMPTOMS
Symptom frequency for lens wearers
and non-wearers
Symptom intensity for lens wearers and
non-wearers
% with frequent to constant
% with moderate to intense
4). Fifty-five percent of the contact lens
wearers also reported symptoms that were
triggered by environmental factors of
smoke, smog, air conditioning or central
heating, much higher than among the
non-wearers. Contact lens wearers avoid
these environments if their lenses exacerbate their dryness.
Thus, the clinical picture for CLrelated dryness comprises a vast majority
of patients whose eyes are fairly free of
symptoms without lenses that become
quite symptomatic during contact lens
wear. As shown in Figure 5, the typical
contact lens wearer manages their dryness
symptoms primarily by removing their
lenses (55.8 per cent), use of contact lens
rewetting drops (47.1 per cent) or artificial tears (14.8 per cent). Patients who
reported that they remove lenses cited
dryness as the most common reason for
lens removal. Removing lenses did work
to relieve symptoms; it was reported to
be completely effective by 47.4 per cent
of patients who practised this coping
Contact lens wearers in the new millennium lead lives that include many
work or lifestyle factors that may
negatively impact their comfort with
contact lenses. As a group, contact lens
wearers are growing older, wear lenses
for long wearing days, may live or work
in challenging arid environments, and
use more over the counter medications
with drying side effects than in previous
decades. Most likely they commute longer
distances to work, drink more coffee and
other caffeinated beverages, fly more
frequently and spend many more hours
in front of computer screens for work and
recreational purposes than patients in
the 1980s and 1990s (Table 2). All these
factors may drive dryness sensations
in contact lens wearers. As outdoor air
becomes more polluted, indoor air quality
deteriorates even though it is more highly
conditioned. Patients’ eyes are being
bombarded with factors that may make
their ocular surface less than ideal for
contact lens wear.
The self-reported use of medications
among contact lens wearers that have
drying side effects from our 1998 study
is shown in Table 3.2 Since that time, a
number of widely used drugs have come
on the prescription or over-the-counter
100
Non-wearers
CL wearers
80
60
40
20
0
Dryness
Discomfort
80
60
Non-wearers
CL wearers
40
20
0
AM dryness PM dryness AM discomfort PM discomfort
▲
Our study of unselected patients showed
that, compared to non-wearers, the
contact lens wearers reported significantly
more frequent and intense symptoms,
particularly discomfort and dryness late
in the day as shown in Figures 3a and
3b. In another section of the questionnaire we asked about symptoms when
contact lens wearers were not wearing
their lenses and found that these patients’
symptoms were greatly relieved by
removal of their lenses: no surprise to
the clinicians on the team. Frequent to
constant dryness was reported by 26.8
per cent of subjects while wearing lenses
and only 6.2 per cent without their lenses
in place, a significant reduction (Figure
FACTORS THAT INFLUENCE
CL-RELATED DRYNESS
C O N TA C T L E N S M O N T H LY
market, including loratidine (eg Claritin) for the
self-prescribed treatment of
Self-reported medication use by contact lens wearers
allergies. Over-the-counter
Medication
Per cent of CL wearers
antihistamines and similar
Oral
antihistamine
35.6
per cent
compounds are known to have
Oral
contraceptives
1
5.2
per
cent (of females)
drying effects on the ocular
Depression medication
6.4 per cent
surface that are the cause of
Thyroid medication
3.9 per cent
increased symptoms. These
drugs are use by millions of
patients and represented a global market
of over £2.9bn in 2000 according to IMS
Health’s World Review. Very often the
Key points in contact lens-related
patient has no choice but to seasonally
dryness
use oral antihistamines while wearing
◆ Examine patients with contact lens
lenses if they choose to be a full-time
related dryness primarily with your ears!
wearer even though they may exacerbate
◆ Patients who have symptoms but no
symptoms of dryness. The use of antitreatment represent an unmet need
depression medications is also on the rise
◆ Ask patients about the number of hours
among adults. The IMS Health’s World
of comfortable lens wear vs total hours
Review states that anti-depression medica◆ Fifty-five per cent of CL wearers have
tions account for the third largest class of
symptoms triggered by smoke, central
medications sold, amounting to £7bn, with
heating or A/C
a growth of 18 per cent over the previous
◆ Fifty-six per cent of CL wearers relieve
year. In addition, older contact lens
dryness symptoms by removing lenses
wearers, many of whom are now well past
◆ Lens wearers are older, more
their 40s but still dedicated to continued
medicated, spend more time with
use of their contact lenses, are more
computers than in the past. New
likely to use a plethora of pharmaceudemands require new treatments!
tical agents to treat conditions related to
advancing age, such as hormone replacement medications in women, diuretics or
of Economic Cooperation and Develophypertension treatment in men.
ment statistics. Time spent on recreational
The amount of time contact lens
computer use likely rose proportionally.
patients spend using computer screens
has also increased dramatically over the
PRACTITIONERS’ BEST STRATEGY
past few years. Use of computer screens
Because of changes in these lifestyle
reduces the blink rate, resulting in
factors that may reduce a person’s chance
surface drying of lenses and the discomof success with contact lenses, we propose
fort sequelae that follow. In our study of
that practitioners begin a more active,
unselected patients, we found that 26.4
probing discussion about ocular surface
per cent of contact lens wearers used a
symptoms as part of their routine case
computer for more than six hours per day
history for new and current contact lens
while at work in addition to their recreawearers. To illustrate how to conduct a
tional computer use. The penetration of
more problem-oriented, revealing case
home computers, mobile personal data
history, let us examine an analogous
devices and cell phones with input or
problem in vision care; presbyopia. If a
text screens has grown exponentially in
40-year-old emmetropic patient presents
the past few years in the UK market. For
for examination without any vision
example, the proportion of UK households
complaints, how many practitioners
with a home computer rose from 38.0 to
would miss the opportunity to counsel
65.3 per cent in the time period from 2000
the patient on the impending change
to 2004, according to recent Organization
Proportion with frequent to constant symptoms
with and without lens wear
6%
27%
94%
73%
While wearing lenses
HOW TO EXAMINE PATIENTS
WITH CL-RELATED DRYNESS?
WITH YOUR EARS!
Paradoxically, contact lens wearers who
report frequent or intense symptoms of
dryness do not look like patients with
pathological dry eye. Very often they
do not even have a rapidly drying lens
surface between blinks as measured
by non-invasive tear break-up times. A
thorough, routine contact lens examination will reveal that most symptomatic
contact lens patients have an adequate
supply of tears, no frank inflammation and
don’t exhibit significant signs of ocular
surface damage that would be present in
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 fluorescein 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
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,
▲
Reporting symptoms
No symptoms
Without lens
in the person’s near vision?
The answer is that very few of
us would miss the opportunity.
Because the practitioner is wellequipped with both knowledge
of the process of presbyopia and
tools with which to treat it (even
if there is no treatment required
at the moment), the practitioner
will usually discuss the condition
because the patient will benefit from
knowing what is about to happen to their
vision in the near future. Knowledge on
the part of the patient will reduce worry
and stimulate them to seek treatment
when their declining near vision does
become bothersome.
Similarly, if practitioners have familiarised themselves with knowledge about
contact lens-related dryness and are
familiar with effective options with which
to treat those contact lens wearers (ie more
lubricious lens materials, non-toxic care
systems, tear replacements) they will very
likely be more willing to initiate a guided
discussion about dryness symptoms with
their contact lens patients. Nowadays
there are soft lens materials on or coming
to market that have been designed with
physical properties that relieve or reduce
symptoms of dryness in many contact
lens wearers. Symptoms that may have
posed a stubborn, intransient problem in
the past may now be effectively treated,
reinforcing the value of routine eye
care to the patient. Now is the time for
practitioners to revamp their diagnostic
skills with regard to contact lens-related
dryness.
C O N TA C T L E N S M O N T H LY
% Who use treatment
symptoms that exceed the
CONCLUSIONS
Relief reported by lens wearers who manage
norm must be considered the
dryness symptoms by self-treatment
The key points in contact lens
‘sign’ of contact lens related
related dryness are summarised
dryness.
in Table 4. Many symptomatic
Researchers who have
contact lens patients present
studied the most often used
100
for eye care with eyes that
‘tests’ for diagnosing dry eye
Less than complete relief
appear normal but are causing
found that the case history was
Complete relief
80
symptoms of discomfort and
most often used by experts in
dryness, especially late in the
the dry eye field and by practi60
day. Bothersome symptoms
tioners in a variety of health
affect approximately half of
care settings. 7,8 The case
history to elicit symptoms as
soft lens wearers and can be
40
carried out in these settings,
treated with lenses designed
however, wasn’t standardised or
to reduce symptoms of
20
easily quantified as to whether
dryness and careful choices of
the symptoms were normal
lens care. With new thinking
0
or abnormal, which compliand a few simple questions,
Remove
CL rewetting
Artificial
cates the diagnostic effort. We
practitioners can begin to tune
lens
drops
tears
propose using a short series of
their contact lens exams and
Self-treatment for dryness
questions to open the discusproduct recommendations to
sion about contact lens related
be able to make use all the
dryness. Answers to these
tools available to them to help
questions will help determine whether hours lenses are actually worn each their patients with contact lens related
patients could benefit from a treatment day. A disagreement of more than two dryness symptoms.
plan directed at the reduction of dryness hours (total hours worn minus comfortThe patient will certainly notice the
able hours worn) indicate a patient extra care given and is likely to remain as
symptoms as a priority in their treatment.
Figure 6 shows recommended who is struggling to wear lenses toward a lens wearer for a much longer period of
questions that will assist in identi- the end of the wearing day. We also time.
fying patients who could benefit from suggest probing on late day symptom
treatments directed at solving their intensity since these were often reported Acknowledgement
contact lens-related dryness problems. by patients who globally described This article is an educational initiative sponsored
These questions include querying the themselves as having dry eyes, even by Johnson & Johnson Vision Care
typical number of hours of comfort- though their practitioners did not
References
able lens wear compared to the number of diagnose them as having dry eyes.
Screening questions for contact lens-related dryness
1) How many hours per day do you wear your lenses? ____ hrs
2) How many hours are your lenses comfortable per day? ____ hrs
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?
Never ❏
Seldom ❏
Frequently
❏
Almost every day ❏
4) Questions about EYE DRYNESS:
a) During a typical day in the past week, how often did your eyes feel dry while wearing your
lenses?
Never (please skip to question 4) ❏
Infrequently ❏
Frequently ❏
Constantly ❏
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
Intense
1
2
Very
Intense
5
Not
Sure
0
c) At the end of your wearing time?
Not at All
Very
Intense
Intense
1
2
3
4
5
Not
Sure
0
3
4
5) Have you been told you have dry eyes?
Yes ❏
No ❏
6) Do you think you have dry eyes?
Yes ❏
No ❏
Scoring Responses:
Responses that may indicate contact lens related dryness are listed below.
Q1+2:
Hrs of Wear – Hrs of Comfortable Wear <2 hrs
Q3:
Frequently or Almost Every Day
Q4a:
Frequently or Constantly
Q4b,c:
4 or 5
Q5 or 6
Yes
1 In the News: Ciba Vision study on soft contact
lens dropouts. Optom Vis Sci, 2004;81(11)814.
2 Begley CG, Chalmers RL, Mitchell GL, Nichols
KK, Caffery BA, Simpson T, DuToit R, Portello
J, Davis L. Characterization of ocular surface
symptoms from optometric practices in North
America. Cornea, 2001;20(6):610-8.
3 Chalmers RL, Begley CG, Edrington T,
Caffery B, Nelson JD, Snyder C, Simpson T.
The Agreement between Self-Assessment and
Clinician Assessment of Dry Eye Severity. Cornea,
In Press 2005.
4 Pritchard N, Fonn D, Brazeau D. Discontinuation of contact lens wear. Int Contact Lens Clin,
1999;26:157-61
5 Young G, Veys J, Pritchard N, Coleman S. A
multi-centre study of lapsed contact lens wearers.
Ophthal Physiol Opt, 2002;22:516-27.
6 Begley, CG, Chalmers RL, Abetz L, Venkataraman K, et al. The Relationship Between
Habitual Patient-Reported Symptoms and
Clinical Signs Among Patients with Dry Eye of
Varying Severity. Invest Ophthalmol Vis Sci, 2003;44:
11;4753-61.
7 Korb DR. Survey of preferred tests for diagnosis of
the tear film and dry eye. Cornea, 2000;19(4):483-6.
8 Nichols KK, Nichols JJ, Zadnik K. Frequency
of dry eye diagnostic test procedures used in various
modes of ophthalmic practice. Cornea, 2000;19(4):
477-482.
◆ Dr Robin Chalmers is a clinical trial
consultant and Dr Carolyn Begley is a
professor at Indiana University School of
Optometry in Bloomington, USA