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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