A Lens Fit for Dry Eye
Here are some clinical pearls to help treat and fit contact lens patients who present with dry eye.
Release Date: March 2013
Expiration Date: March 1, 2016
This article offers some clinical pearls to help treat and fit contact lens patients who present with dry eye.
Lakshman N. Subbaraman, PhD, BSOptom, MSc, and Sruthi Srinivasan, PhD, BSOptom
Dr. Srinivasan is a research assistant professor at the Centre for Contact Lens Research, School of Optometry and Vision Science, University of Waterloo, Canada. She is a fellow of the American Academy of Optometry, member of the Association for Research in Vision & Ophthalmology and the Tear Film & Ocular Surface Society.
Dr. Subbaraman is the head of Biological Sciences at the Centre for Contact Lens Research, School of Optometry and Vision Science, University of Waterloo. He is a two-time recipient of the American Optometric Foundation’s prestigious William Ezell Fellowship, a fellow of the American Academy of Optometry and a member of the Association for Research in Vision & Ophthalmology.
This course is COPE approved for 1 hours of CE credit. COPE ID 37163-CL. Check with your local state licensing board to see if this counts toward your CE requirements for relicensure.
This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.
The authors have no financial relationships to disclose.
Almost 50% to 80% of contact lens wearers experience
symptoms of dry eye.1 Contact lens-related dry eye (CLDE) may
be reported as dryness, discomfort,
gritty sensation, irritation, stinging,
burning or foreign body sensation.2,3 Discontinuations and dropouts from
lens wear are primarily due to symptoms of discomfort and dryness.
CLDE is complex and multifac-torial. Increased tear evaporation,
altered tear osmolarity, poor or
low tear film quality and quantity,
oxygen deprivation, lens deposits,
reactions to lens care solutions and
non-wetting surfaces are some of the
factors that exacerbate dry eye in
contact lens wearers. Environmental
components, allergies and lid disease
can also influence this condition.
This article provides an overview
of the factors that influence CLDE
and outlines some strategies for
Clinicians should start by determining which time of day is most
problematic for the patient who
complains of CLDE. Symptoms that
develop two to three hours into lens
wear are normally indicative of solution toxicity. On the other hand,
end-of-day dryness may be due to
lack of lens surface wetting or other
The FDA classifies commercially
available hydrogel contact lens materials into four groups, depending
upon their charge and water content:
non-ionic, low water content (Group I); non-ionic, high water content
(Group II); ionic, low water content
(Group III); and ionic, high water
content (Group IV). This material
classification seems to be a very
strong predictor of CLDE.
- Deposition. Hydrogel contact
lenses absorb components from the
tear film, particularly proteins, lipids
and mucins.4-7 Deposits are associated with diminished visual acuity,
dryness and discomfort, and lid-related inflammatory changes.8-13
High water content materials have
been associated with significant tear film deposition.9,14-16 In particular,
Group II lenses are prone to lipid
deposition whereas Group IV lenses
have been shown to attract more
protein than lipids.6,17 Further, once
tear proteins (such as lysozyme)
firmly adsorb onto contact lens
materials, the protein undergoes
conformational changes and dena-turation.7,15,18,19 Protein denaturation
is closely linked to inflammatory
conditions, such as papillary conjunctivitis, and can also impact subjective comfort.11-13,20,21
Practitioners should advise their
patients to maintain a clean and
deposit-free lens surface, as well as
review appropriate lens replacement
schedules. Practitioners should also
recommend that their patients rehydrate the lenses with rewetting drops
since proteins exposed to hydrophobic surfaces are more likely to denature, which could potentially result
in reduced comfort. Heavy lipid
depositors should be advised to use a
separate surfactant cleaner.
- Wettability. Deposition of
tear film-derived material reduces
wettability due to denatured protein and increased lipid deposition.17,22,23 This produces areas of
hydrophobicity, resulting in further
deposition and comfort problems.
If patients do exhibit reductions in
wettability, changing to another
lens material will likely have a minimal impact. Such patients are best
managed by switching to lenses
that are replaced more frequently,
such as daily disposable lenses, or
by prescribing rewetting drops that
- Water content and ionicity. Non-ionic, high water content
(Group II) and ionic, high water
content (Group IV) contact lens
wearers have a two to three times
greater likelihood of experiencing
dry eye than individuals wearing
Group I lenses.25 Further, Group II
lens materials are more commonly
associated with dry eye than the
Group IV lens materials.25 This
could be because the polar head
groups associated with the tear film
lipid molecules may be attracted to
higher water content lens materials,
which would leave their non-polar
tails away from the surface of the
lens and potentially lead to evaporation and/or dewetting. Patients
who wore low water content lenses
and maintained their hydration
generally reported that their eyes
"never felt dry" during lens wear.26 Thus, evidence to date suggests that
patients wearing lower water content contact lenses are less likely to
complain of CLDE.
- Dehydration. Dehydration
is influenced by several factors,
including the surrounding environment, water content, water binding
properties, thickness and wearing period.30-38 Dryness symptoms
occur more frequently in soft lens
wearers during open-eye wear, when
conditions are favorable for greater
dehydration.27 Previous studies have
shown that wearing thin, high water
content lenses can result in increased
epithelial staining due to pervaporation. Pervaporation is a process in
which a permeate passes through a
membrane and subsequent evaporation in the vapor phase.28,30 Factors
that explain dehydration-induced
discomfort include increased lid to
lens interaction, changes in lens surface wettability or lens fit, and the
development of epithelial staining
due to pervaporation and subsequent desiccation.28-30
Conventional hydrogel material dehydrates more than silicone
hydrogel lens materials.33,34 Remember, dehydration can affect the fit of
a hydrogel lens by both altering the
lens parameters and lowering the
Clinicians must examine the
patient for corneal staining after lens
removal. The dye of choice in most
clinical practices globally is sodium
fluorescein. This dye aids in highlighting the extent of cellular damage/exposure of epithelial cells by
staining in the form of punctate or
coalescent areas. The use of a yellow
barrier filter, in addition to cobalt
blue excitation filter, is essential to
visualize subtle changes. Examine
the location of staining (i.e., mid-inferior smile staining patterns),
advise proper blinking habits for
patients with incomplete blinks and prescribe artificial tear supplements
- Silicone hydrogel. Several studies have shown that silicone hydro-gel lens wearers reported reduced
dryness and end-of-day discomfort
compared to hydrogel contact lens
patients.40-42 Silicone hydrogel lens
wearers also reported better comfort
after napping or sleeping, and in dry
air or smoky environments because
silicone hydrogel lens materials are
less prone to evaporation (possibly
due to their lower water content)
and absorb fewer airborne pollutants than lenses with higher water
Clinicians should consider refitting the patient with a high-Dk lens
if oxygen deficiency is suspected.
Practitioners should be careful
when using lenses with an increased
modulus of elasticity or poor surface
wettability as they may cause other
conditions, including contact lens-associated papillary conjunctivitis.
In dry and low-humidity environments, such as artificially heated
rooms or during the winter months,
quicker and greater lens dehydration
likely exacerbate dryness in existing
patients or induce symptoms in otherwise asymptomatic patients. Those
who complain of CLDE due to such
environmental conditions would
benefit by rehydrating their lenses
with rewetting drops.
- Solutions. Hydrogen peroxide
solutions are considered the gold
standard for disinfecting contact
lenses. However, when residual peroxide is present on the lenses in sufficiently high concentrations, it can
be toxic to the cornea and can cause
discomfort. When peroxide-based
systems are used at the right concentration, they can provide improved
comfort in contact lens wearers.47,48
Over the last few years, several
novel components have been added
to multipurpose solutions, such as
surfactants or ocular demulcents,
to improve comfort, enhance water
retention and improve surface wetting properties of contact lenses.
Clinicians should examine the
lens and corneal surface carefully,
ensure the appropriate cleaning
solution is being used and check for
patient compliance. Examine corneal
staining to check if solution induced-corneal staining (SICS) is present. If
SICS exists, advise appropriate lens-solution combinations or switch to
- Rewetting drops. Rewetting
(or comfort) drops can be used to
alleviate discomfort that is caused by
dryness. Although they provide temporary relief from these symptoms,
there is currently no rewetting drop
that can provide sustained comfort
and relief from dry eye symptoms
for the length of an entire wearing
day. The drops drain through the
patient's nasolacrimal duct quickly
after instillation, with the remainder
absorbed by the cornea, conjunctiva
and nasal mucosa. With at least
90% loss in each application, rewet-ting drops have to be re-instilled
frequently throughout the day to
provide effective comfort.49
Instilling rewetting drops in the
eye prior to lens wear may increase
the hours of comfortable wear time.
Remember, methylcellulose-containing drops instilled upon lens insertion will neutralize the effects of the
preservative on the ocular surface.50 Preservative-free rewetting drops
will be beneficial for patients with
sensitive eyes. The use of lubricant
drops prior to lens wear and after
lens removal may increase the hours
of comfortable wear time.50
Meibomian gland dysfunction
(MGD) is one of the major causes
of evaporative dry eye and often
is under-diagnosed by clinicians.
Evaluation of the eyelids, meibomian
gland orifices, the ocular surface
and tear film (tear break-up time,
tear meniscus height, debris in tears
and Schirmer test) are necessary to
administer appropriate treatment.
The novel LipiFlow device
(TearScience) is a thermal pulsation system believed to effectively
relieve the meibomian gland blockage. This tool applies a controlled
amount of heat and massage to
the eyelids, treating the upper and
lower lids simultaneously. LipiView
(TearScience) is an interferometer
to evaluate lipid layer thickness. It
is valuable to obtain the lipid layer
thickness using LipiView before and
after the treatment of MGD with the
|A Checklist for Your Patient
- Start by collecting a detailed medical
history to understand the patient’s
general health and corresponding
treatments. Medications that cause
ocular surface dryness (e.g., oral
and oral contraceptives)
should be minimized.
- Confirm that you are not dealing
with a masquerading disease
(e.g., conjunctivochalasis, Sjögren's, etc).
- An inappropriate lens fit may cause
symptoms that can be misinterpreted
as dry eye. Carefully examine the fit,
centration and movement of the lenses.
Measure the iris diameter and check the
lens and lid position. Remember to allow
the lenses to settle on the eye before
judging the fit.
- Finally, advise your patient that
alcohol and smoking will worsen dry eye
symptoms during contact lens wear.
Based on the evaluation,
interventions such as lid hygiene
techniques (lid scrubs and warm
compresses), nutraceuticals (omega-3 fatty acids), rewetting drops/
artificial tears, and topical cyclospo-rine or doxycycline for dry eye and
severe MGD may be required.
Because CLDE cannot easily be
traced to one cause, preventing
contact lens dropouts can be quite
a challenge with patients suffering
from this condition. Several factors,
such as lens material and solutions,
can play a role in exacerbating
or improving dry eye symptoms.
Clinicians should stay abreast of the latest research and developments
to identify underlying causes of this
condition and, ultimately, better treat
Disclosure: Over the past three
years, CCLR has received research
support or honoraria from the following companies: Alcon, Allergan,
AMO, Bausch + Lomb, CIBA Vision,
CooperVision, Essilor, Inspire, Johnson & Johnson, Menicon, OcuSense
and Visioneering. Drs. Subbaraman
and Srinivasan are not paid consultants, do not serve on an advisory
board or own shares in any optometric company.
- Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self-reported dry eye
disease across refractive modalities. Invest Ophthalmol Vis Sci. 2005
- Begley CG, Caffrey B, Nichols KK, Chalmers R. Responses of
contact lens wearers to a dry eye survey. Optom Vis Sci. 2000
- Fonn D, Situ P, Simpson T. Hydrogel lens dehydration and subjective comfort and dryness ratings in symptomatic and asymptomatic
contact lens wearers. Optom Vis Sci. 1999 Oct;76(10):700-4.
- Bontempo AR, Rapp J. Protein and lipid deposition onto hydrophilic
contact lenses in vivo. CLAO J. 2001 Apr;27(2):75-80.
- Castillo EJ, Koenig JL, Anderson JM, Jentoft N. Protein adsorption
on soft contact lenses. III. Mucin. Biomaterials. 1986 Jan;7(1): 9-16. 6.
- Jones L, Evans K, Sariri R, et al. Lipid and protein deposition of
N-vinyl pyrrolidone-containing group II and group IV frequent replacement contact lenses. CLAO J. 1997 Apr;23(2):122-6.
- Sack RA, Jones B, Antignani A, et al. Specificity and biological activity of the protein deposited on the hydrogel surface. Relationship of
polymer structure to biofilm formation. Invest Ophthalmol Vis Sci. 1987
- Gellatly KW, Brennan NA, Efron N. Visual decrement with deposit
accumulation of HEMA contact lenses. Am J Optom Physiol Opt. 1988
- Jones L, Franklin V, Evans K, et al. Spoilation and clinical performance of monthly vs three monthly group II disposable contact lenses.
Optom Vis Sci. 1996 Jan;73(1):16-21.
- Fonn D, Dumbleton K. Dryness and discomfort with silicone hydro-gel contact lenses. Eye Contact Lens. 2003 Jan;29(1 Suppl):S101-4;
discussion S115-8, S192-4.
- Allansmith MR, Korb DR, Greiner JV, et al. Giant papillary
conjunctivitis in contact lens wearers. Am J Ophthalmol. 1977
- Porazinski AD, Donshik PC. Giant papillary conjunctivitis in frequent
replacement contact lens wearers: a retrospective study. CLAO J.
- Skotnitsky CC, Naduvilath TJ, Sweeney DF, Sankaridurg PR. Two presentations of contact lens-induced papillary conjunctivitis
(CLPC) in hydrogel lens wear: Local and general. Optom Vis Sci. 2006 Jan;83(1):27-36.
- Subbaraman LN, Glasier MA, Senchyna M, et al. Kinetics of in vitro
lysozyme deposition on silicone hydrogel, PMMA, and FDA groups I, II,
and IV contact lens materials. Curr Eye Res. 2006 Oct;31(10):787-96.
- Suwala M, Glasier MA, Subbaraman LN, Jones L. Quantity and
conformation of lysozyme deposited on conventional and silicone
hydrogel contact lens materials using an in vitro model. Eye Contact
Lens. 2007 May;33(3):138-43.
- Jones L, Fcoptom, Mann A, et al. An in vivo comparison of
the kinetics of protein and lipid deposition on group II and group
IV frequent-replacement contact lenses. Optom Vis Sci. 2000
- Lorentz H, Jones L. Lipid deposition on hydrogel contact lenses:
how history can help us today. Optom Vis Sci. 2007 Apr;84(4):286- 95.
- Jones L, Senchyna M, Glasier MA, et al. Lysozyme and lipid deposition on silicone hydrogel contact lens materials. Eye Contact Lens.
2003 Jan;29(1 Suppl):S75-9; discussion S83-4, S192-4.
- Senchyna M, Jones L, Louie D, et al. Quantitative and conformational characterization of lysozyme deposited on balafilcon and etafil-con contact lens materials. Curr Eye Res. 2004 Jan;28(1):25-36.
- Skotnitsky C, Sankaridrug PR, Sweeney DF, Holden BA. General
and local contact lens induced papillary conjunctivitis (CLPC). Clin Exp
Optom. 2002 May;85(3):193-7.
- Subbaraman LN, Glasier MA, Varikooty J, et al. Protein deposition
and clinical symptoms in daily wear of etafilcon lenses. Optom Vis Sci.
- Patel S, Thomson A, Raj S. Tear film stability with planned replacement soft lenses. Optician. 1996;212(5558):28-30.
- Lorentz H, Rogers R, Jones L. The impact of lipid on contact angle
wettability. Optom Vis Sci. 2007 Oct;84(10):946-53.
- Subbaraman LN, Bayer S, Glasier MA, et al. Rewetting drops
containing surface active agents improve the clinical performance of
silicone hydrogel contact lenses. Optom Vis Sci. 2006 Mar;83(3):143- 51.
- Ramamoorthy P, Sinnott LT, Nichols JJ. Treatment, material, care,
and patient-related factors in contact lens-related dry eye. Optom Vis
Sci. 2008 Aug;85(8):764-72.
- Efron N, Brennan N. A survey of wearers of low water content
hydrogel contact lenses. Clin Exp Optom. 1988 May;71(3):86-90.
- Efron N, Young G. Dehydration of hydrogel contact lenses in vitro
and in vivo. Ophthal Physiol Opt. 1988;8(3):253-6.
- Holden B, Sweeney D, Seger R. Epithelial erosions caused by thin
high water content lenses. Clin Exp Optom. 1986;69(3):103-7.
- Pritchard N, Fonn D. Dehydration, lens movement and dryness ratings of hydrogel contact lenses. Ophthal Physiol Opt. 1995
- Orsborn GN, Zantos SG. Corneal desiccation staining with thin
high water content contact lenses. CLAO J. 1988 Apr-Jun;14(2):81-5.
- Andrasko G, Schoessler J. The effect of humidity on the dehydration of soft contact lenses on the eye. Int Contact Lens Clin.
- Brennan N, Efron N, Bruce AS, et al. Dehydration of hydrogel
lenses: Environmental influences during normal wear. Am J Optom
Physiol Opt. 1988 Apr;65(4):277-81.
- Jones L, May C, Nazar L, Simpson T. In vitro evaluation of the
dehydration characteristics of silicone hydrogel and conventional
hydrogel contact lens materials. Cont Lens Anterior Eye, 2002
- González-Méijome JM, López-Alemany A, Alemida JB, et al.
Qualitative and quantitative characterization of the in vitro dehydration
process of hydrogel contact lenses. J Biomed Mater Res B Appl Bio-mater, 2007 Nov;83(2):512-26.
- Larsen DW, Huff JW, Holden BA. Proton NMR relaxation in hydro-gel contact lenses: Correlation with in vivo lens dehydration data. Curr
Eye Res. 1990 Jul;9(7):697-706.
- Benz P, Ors J. New materials demand more accurate measurements of performance. CL Spectrum. 1997 Jul;7:40-6.
- Andrasko G. Hydrogel dehydration in various environments. Int
Contact Lens Clin. 1983;10(1):22-8.
- Wechsler S, Prather D, Sosnowski J. In vivo hydration of gel
lenses. Int Contact Lens Clin. 1982;9(3):154-8.
- Efron N, Morgan PB. Hydrogel contact lens dehydration and oxygen transmissibility. CLAO J. 1999 Jul;25(3):148-51.
- Chalmers RL, Hunt C, Hickson-Curran S, Young G. Struggle with
hydrogel CL wear increases with age in young adults. Cont Lens Anterior Eye. 2009 Jun;32(3):113-9.
- Chalmers RL, Dillehay S, Long B, et al. Impact of previous
extended and daily wear schedules on signs and symptoms with high
Dk lotrafilcon A lenses. Optom Vis Sci. 2005 Jun;82(6):549-54.
- Brennan NA, Coles ML, Ang JH. An evaluation of silicone
hydrogel lenses worn on a daily wear basis. Clin Exp Optom. 2006
- Quesnel NM, Giasson CJ. On-eye dehydration of proclear,
resolution 55G and Acuvue contact lenses. Cont Lens Anterior Eye.
- King-Smith PE, Nichols JJ, Nichols KK, et al. Contributions of
evaporation and other mechanisms to tear film thinning and break-up.
Optom Vis Sci. 2008 Aug;85(8):623-30.
- Morgan PB, Efron N. In vivo dehydration of silicone hydrogel contact lenses. Eye Contact Lens. 2003 Jul;29(3):173-6.
- Morgan PB, Efron N. Hydrogel contact lens ageing. CLAO J. 2000
- Dillehay S, McCarter H, T.A.C.C.S. Group. A comparison of multipurpose care systems. CL Spectrum. 2002 Apr;17:30-6.
- Begley C, Edrington T, Chalmers R. Effect of lens care systems on
corneal fluorescein staining and subjective comfort in hydrogel lens
wearers. Int Contact Lens Clin. 1994 Jan/Feb;21(1-2):7-12.
- Tonge S, Tighe B, Franklin V, Bright A. Contact lens care, part
6: comfort drops, artificial tears and dry-eye therapies. Optician.
- Sindt CW, Longmuir RA. Contact lens strategies for the patient
with dry eye. Ocul Surf. 2007 Oct;5(4):294-307.