Dry Eye 2016

SPECIAL FEATURE: DRY EYE
Contact lenses and dry eye
Dry eye is one of the most common
conditions seen by eye care practitioners
around the world. It is estimated that
25% of patients will report symptoms of dry
eye¹. For our contact lens (CL) patients this
frequency is likely higher due to the effects that
an in situ contact lens can have on the tear film
and ocular tissue. Reported rates of contact lens
discontinuation internationally vary from 15%
to 31%². Consistently, discomfort and dryness
are rated as the top reasons for this dropout 3 4 5,6 .
However, certain types of contact lenses can also
be an important management option for patients
with mild to severe dry eye. This article will briefly
explore why contact lenses cause dry eye, explain
what can be done to reduce the incidence of dry
eye symptoms in contact lens wearers and describe
some of the contact lens options available to
patients with existing dry eye disease.
Why do CLs cause dryness?
In 2013 the Tear Film and Ocular Surface Society
(TFOS) international workshop on contact lens
discomfort carried out a robust investigation into
this question. Helmed by our very own Associate
Professor Jennifer Craig, the TFOS report on tear
film stability in contact lens wearers suggested
that contact lens induced dryness stems from the
alteration of the tear film into pre- and post-lens
layers (Fig 1.) 7 . The resulting pre-lens tear film has
reduced lipid layer thickness, reduced tear volume
and an increased evaporation rate compared
to the normal tear film 8 . As a result of this
compromised tear film, previously asymptomatic
patients may begin to experience discomfort and
dry eye symptoms 9 . Another school of thought
suggests decreased corneal sensation from contact
lens wear leads to a ‘neurotrophic state’, which
promotes inflammation and compromises the
signal for tear production 10 .
Lid wiper epitheliopathy (LWE) is a clinical sign that
is gaining in popularity amongst practitioners when
describing dry eye. LWE refers to disruption of the lid
margin that ‘wipes’ across the anterior eye surface or
contact lens during blinking (Fig 2.). Studies suggest
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that the presence of LWE is highly associated with
discomfort in contact lens wearers, occurring in
80% of symptomatic contact lens patients versus
13% for asymptomatic wearers 11 . LWE is a sign of
increased friction with each blink; expected in a
dry eye or with the use of a poorly wetting contact
lens. Efron et al.’s recent comprehensive review
of LWE states there is consistent evidence of a
relation between contact lens surface friction and
wearing comfort 12 .
Improving dry eye symptoms in CL
patients?
The presence of LWE in CL patients has
highlighted the importance of having a slippery
lens surface to decrease friction and discomfort.
Coles and Brenan showed that contact lenses
with a higher lubricity tend to be more
comfortable 13 . CL companies have been quick to
release a number of excellent products that serve
to increase the lubricity of patient’s lenses. These
include Alcon’s Dailies Total1 water gradient
lens and Bausch and Lomb’s “MoistureSeal”
technology, incorporated in their Ultra range
of lenses. We should not forget, however, that
silicone hydrogels are naturally more hydrophobic
than hydrogels due to their siloxane components,
and may lead to decreased wettability, and
therefore lubricity in certain wearers 14 . In
these instances, hydrogel materials such as
B+L’s Biotrue ONEday daily and Coopervision’s
Proclear family (incorporating zwitterionic PC
technology; still the only FDA material approved
for patients that experience dryness with contact
lens wear) may be useful. Alcon have also recently
incorporated ‘Hydraglyde moisture matrix’,
a hydrophilic compound that embeds onto a
lens and decreases friction, into their hydrogen
peroxide cleaning solution, AOSept, as well as their
PureMoist multi-purpose disinfecting solution.
Rigid lenses too can benefit from technologies
to improve wettability. This includes the use of
materials such as Optimum Extra with its very
low wetting angles, and plasma-treatment of
rigid lenses to decrease the hydrophobicity of
4UP TO
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the surface 15 . We should
not forget to encourage all
CL patients to use artificial
tear drops as needed for an
immediate improvement
in lens lubricity, especially
after longer-wear time.
To avoid exacerbating any
inflammatory aspects of
dry eye, non-preserved
formulations should be
recommended.
Options if the patient
still cannot wear CLs
comfortably?
Despite advances in
technology some patients,
especially as they age and
their tear volume naturally
decreases, will continue
to experience discomfort
with soft contact lens wear.
In this case sometimes no
lens is better than any lens.
Orthokeratology can be an
excellent modality for patients
who experience regular
contact lens discomfort
but otherwise only show
mild signs of dry eye. One
study showed that patients
refitted from SiHy lenses
into orthokeratology wear
had a statistically significant
increase in goblet cell density
and improvement in dry eye
symptoms after one month 16 .
Anecdotally I have looked after
a number of very satisfied
orthokeratology patients that
were previously unhappy with
their SCL comfort.
Scleral CLs
A report on dry eye and
contact lenses would not be
complete without discussing
scleral contact lenses. Sclerals
are mainly reserved for
patients with severe dry eye,
such as Sjogren’s syndrome
and graft-vs-host disease
(GvHD), that do not find
relief with other treatments.
They are effective as the lens
shields the eye and allows
the post-lens fluid reservoir
to bathe the compromised
ocular surface during wear. Scleral lenses,
including the PROSE lens (Prosthetic Replacement
of the Ocular Surface Ecosystem; an impressive
sounding scleral lens treatment that really just
refers to onsite custom fitting at the B+L contact
lens laboratory), have been shown to improve the
visual function in patients with ocular surface
disease over a five-year period 17 .
A colleague of mine from the States, Dr
Nate Schramm, a scleral lens expert from Fort
Lauderdale, shared this relevant case with me
recently: a 21-year-old man presented to his
practice with severe dry eye symptoms. He has
psoriasis and low testosterone and due to his
programming occupation spent 75% of his day in
front of a computer screen. He had been treated
with meibomian gland probing and punctal
cautery three months before and given a course
of topical cyclosporin, however his symptoms did
not improve. Examination showed instantaneous
tear breakup, stagnant meibomian glands and
Fig 1. Tear film structure with a soft contact lens
Fig 2. Moderate lid-wiper epitheliopathy present on an everted upper lid margin, stained with
lissamine green. Courtesy of OSL
Fig 3. Central corneal OCT scan of the scleral lens fit for the dry eye patient case described
Another SCL patient of mine with punctate epitheliopathy due to mild dry eye. I refitted her into
hyperopic orthokeratology lenses and after a month her epitheliopathy had resolved and daytime
comfort was much improved. Note the lack of corneal staining
scattered corneal epitheliopathy. MGD treatments
were initiated, including Lipiflow, and a scleral lens
was fitted in conjunction with autologous-serum
drops in the lens bowl during insertion (Fig 3).
Despite initial difficulties with handling, this
patient noticed immediate improvement in
comfort when wearing his sclerals. After a year’s
treatment the patient commented the only
treatment that decidedly helped his dry eye were
his scleral lenses.
In summary, technologies for managing dry
eye are improving each year, with contact lens
advancements helping our patients achieve
freedom from spectacle wear in an increasingly
comfortable and safe manner. It should not be
forgotten that certain contact lens modalities
provide important dry eye therapies and should be
considered in recalcitrant cases.
CONTINUED ON P7
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Always read the label. Use only as directed. If symptoms persist, see your healthcare professional. †When wearing make-up, it is recommended to apply from 20cm. *Due to disturbed lipid layer of the tear fi lm. References:
1. Lee S et al. Klin Monatsbl Augenheilkd 2004; 221:1–12. 2. Khaireddin R, Schmidt KG. Klin Monatsbl Augenheilkd. 2010; 227: 128-134. 3. Pult H et al. Contact Lens Anterior Eye 2012, 35:203-207. Reckitt Benckiser, Auckland. TAPS DA1541
FDA and Oculeve
Allergan has filed a de novo application with the US Food and Drug Administration (FDA) for its
Oculeve Intranasal Tear Neurostimulator Device. The de novo classification process is a rapid
regulatory pathway for novel, low- to-moderate-risk medical devices that are deemed to be
first-of-a-kind.
The neurostimulator was acquired by Allergan last year, when it bought Oculeve for US$125
million cash. Allergan has openly stated that dry eye is a priority area. “The Oculeve Intranasal Tear
Neurostimulator is an exciting potential option for patients suffering from dry eye disease, and we
are pleased to have filed the de novo application with FDA that will allow patients to gain access to
this novel medical device,” said David Nicholson, Allergon’s chief R&D officer in a statement.
The device is a non-invasive nasal neurostimulation that stimulates tear production. An element
is inserted into the mucous membrane of the nasal cavity and another under the skin below the
eyebrow, allowing the patient to manually adjust the rate of tear delivery using a wireless controller.
Just prior to filing the application, Allergan announced two pivotal trials (one of which involved the
University of Auckland’s OSL team) of the neurostimulator each met their effectiveness endpoints.
6 NEW ZEALAND OPTICS October 2016