DISCLOSURE CONTACT LENSES AND DRY EYE Cause or remedy? Dr Langis Michaud O.D. M.Sc. FAAO (Dipl) FSLS FBCLA Professor Speaker Fees /Consultant fees / Travel Grants / Research Funding Valeant (Bausch & Lomb) Cooper Vision Johnson & Johnson Vision care Ciba/Alcon Blanchard Labs Synergeyes Allergan CASE NO.1 CASE NO. 2 M.H. Afro-American male of 24 years old Consults for contact lens discomfort bougth his last supply through internet Is wearing bi-weekly disposable lenses on a monthly basis, overnight wear a few times /month Smokes Non compliant with lens care, switch solutions all the time (cost issue) S.Y., Caucasian female of 34 y.o. Is working on computer 8h00 /week Fitted in contact lenses 4 years ago- went well until the last 6 months Recurrent episodes of c.l. intolerance, eye redness lasting x 1 week Self-medicated with OTC topical antibiotics Fitted with senofilcon A lenses, is using polyquad-based solution Slit lamp: multiple corneal infiltrates CASE NO 3 CASE NO.4 P.T. Caucasian female of 63 years old Fitted in RGP lenses for > 25 years Consult for reflex tearing and ocular discomfort lasting for a few years Tried many comfort drops, tear substitutes (drops +gels) with no lasting success Tried omega 3s but did not see any improvement. Background of severe arthritis S.P. Latino male of 39 years old Had Lasik surgery 10 years ago Resume contact lens wear 1 year ago to improve intermediate and near vision Can t tolerate them for more than 4h00 per day Complaints of reduced vision at night and eye dryness under certain circumstances Very sensitive eyes during allergy seasons. Can t tolerate lenses at all 1
CASE NO. 5 WHAT DO THEY HAVE IN COMMON? Caucasian female of 48 y.o. Known for irregular corneas Salzman s nodular dystrophy Fitted with soft MF lenses monthly replacement Can t see well at far and at near Ocular dryness felt with and without contact lenses Contact lenses: cause or remedy? Contact lens wear : different modalities Environmental conditions: differs Age : differs Ethnical origins: differs BUT : Sustained intolerance to contact lens wear : CLD Symptoms of eye dryness : DED Contact lenses: Cause or remedy?? CONTACT LENS INDUCED DISCOMFORT (CLD) Fist reported in. 1960! PREVALENCE Prevalence: >50% contact lens wearers (Dumbleton. Cafferey- TFOS 2013) Is characterized by episodic or persistent adverse ocular sensations related to lens wear, either with or without visual disturbance, resulting from reduced compatibility between the contact lens and the ocular environment, which can lead to decreased wearing time and discontinuation of contact lens wear (Nichols, Wilcox TFOS workshop 2013) No.1 reason to drop-out < 40 y.o. / No.2 reason, after vision, >40 17% per year Cost: 7.5K /year / OD (440 pts in average) 1 Wearers report 13h00 of wear but 8h00 of comfortable wear in average No. 1 reason for contact lens drop-out 1- Rumpakis, J. New Data on Contact Lens Dropouts: An International Perspective. Review of Optometry, Jan 2010. http://www.revoptom.com/content/d/contact_lenses and solutions/c/18929/ DRY EYE DISEASE (DED) CONTACT LENSES: CAUSE Is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. (DEWS- 2007) Contact lenses can be a cause to induce dryness symptoms in marginal DED patients Disturb tear film Influence microflora Side effects of chemicals Friction / irritation /inflammation Prevalence: 7.8 to 29% of the population (CJO- National DED Guidelines for Canadian Optometrists) No.1 reason for consultation in primary care optometry (AOA status of the profession 2013) Action 1) Ocular surface restoration (including appropriate medication) 2) Look for materials with high biocompatibility (friction, deposits, pathogens attraction, etc) 3) Reduce /eliminate chemicals 4) Long-term ocular surface management 2
CONTACT LENSES REMEDY? CLINICAL STEPS Contact lenses can be a remedy Help to restore/ protect the ocular surface Reduce exposure to allergens and other environmental factors UV protection Fluid/Tear reservoir 1. Be pro-active to identify risk factors/symptoms 2. Screen ocular surface prior/after to contact lens fitting Track ocular rosacea ACTION 1) Treat the ocular surface first address most of the risk factors 2) Soft (daily disposable) or RGP (sclerals) 3) Contribution of topical meds / omegas 3. TREAT /RESTORE THE OCULAR SURFACE based on your findings 4. Manage contact lens designs /fits to improve patient s outcomes. 1. CASE HISTORY Oriented case history before contact lens fitting and at follow-up Simple key questions : what, when, evolution pattern, contributing factors, systemic symptoms 1. SCREENING EXAMINATION Evaluate face, eyelids, lashes, blink and lid closure 2. Evaluate tear film (TBUT using fluorescein strips) 3. Fluorescein corneal staining (after determining TBUT) Validated questionnaires (OSDI, etc.) Define your patients based on their symptoms (Episodic, chronic, recalcitrant) 16 ORDER OF TESTING DURING THE DE WORK-UP Testing must be done in a systematic manner and specific order, because the sequence of testing can affect results Suggested Order of Testing 1. Case history and DE questionnaire 2. Osmolarity (if available) 3.Tear quantity and volume Either: Schirmer 1 (without anesthesia) or Phenol red thread test/cotton thread test 4. Anterior segment evaluation with white light (focus on lid margin) 5.Tear break-up time 6. Ocular surface integrity (with appropriate dyes and filters) 7. Meibomian gland expression and assessment 17 ESSENTIAL TO TEST MEIBOMIAN GLAND EXPRESSION ESSENTIAL part of any screening assessment Grade Meibum appearance (clear-turbidsolid) and the expression (easy- difficulthard) 18 3
ROSACEA DID YOU KNOW? ROSACEA A CHRONIC INFLAMMATORY DISORDER President CLINTON Prince HARRY CAMERON DIAZ LADY DIANA AFFECTED AREAS CLASSIFICATION (4 subtypes) Primarily Evaporative DE DIAGNOSIS OF DE Primarily Acqueous Deficient DE TREAT/PRE-TREAT THE OCULAR SURFACE Episodic Chronic Recalcitrant Episodic Chronic Recalcitrant 21 Propovitch, L. Dry eye guidlines, CJO 2014 MANAGE CONTACT LENSES CLD TREATMENT STRATEGIES TO IMPROVE CONTACT LENS INDUCED DRYNESS WHAT IS REALLY WORKING? Dr Langis Michaud O.D. M.Sc. FAAO (Dipl) FSLS FBCLA Professor Dre Sandrine Malaison-Tremblay O.D. Resident Contact lenses Nichols JJ. TFOS executive summary, IOVS 2013 4
1ST STUDY : EVALUATING 2 STRATEGIES TO IMPROVE CLID Subjects are randomly assigned to Group A (habitual lenses, new pair, switch to Hydrogene Peroxide (HP)) Group B (switch to etafilcon A daily disposable lenses) 1 month of wear Clinical testing V.A. (High and Low contrast); TBUT; slit lamp CLDEQ-8 questionnaire (scale 1-5) / U of M questionnaire on day-to-day activities (1-4) Subjects recruited A: 4 F / 3 M B : 5 F / 2 M A: 24,7 (+ 2,5) ans B: 22,5 (+ 1,9) ans A:OD -3,00 (+ 1,63) B: OD -3,92 (+ 2,46) D OS - 3,32 (+ 1,76) D OS - 4,42 (+ 2,26) D Group A (solutions) RESULTS No statistical difference for visual acuity, TBUT and ocular health No statistical difference for day-to-day visual tasks (reading, computer, driving) CLDEQ Scores HP reduces dryness frequency (3 to 2) not its intensity, and visual blur (2 to 1) Reduced need to remove lenses due to discomfort (2 to 1) RESULTS (SUITE) Groupe B (1 day) CONCLUSION Increased TBUT 6.9 (+2.6) to 9.3 (+ 3.7); p=0.025 Both strategies help to improve dryness frequency Better subjective v.a. (reading, computer, evening) CLDEQ scores : improvement Frequency (3 to 1) and intensity (3 to 2) of eye dryness Frequency (2 to 1) and intensity (2 to 1) of blurred vision Reduced blinking rate (2 to 1) Daily disposable provide better outcome Less deposits More stable tear film Better optics (??) vs older lenses 2 ND STUDY: WHICH OF THE FOLLOWING DAILY DISPOSABLE IS BETTER VS CLID? Multi-sites (University clinic and 3 private practices) Symptomatic patients (64 F / 16 M) Monthly disposable wearers (78%), bi-weekly (22%) Randomly assigned / cross-over design Clinical testing GROUP A: switch to Nelficon A lenses then Delfilcon A lenses ; 1 month each GROUP B: vice versa Visual acuity Ocular health RESULTS Factors not improved Total hours of wear Use of comfort drops Conjunctival hyperemia Factors improved Comfortable hours of wear Blurred vision frequency and intensity Dryness frequency and intensity TBUT Conjunctival and corneal staining Subjective questionnaire CLDEQ 8 questionnaire 5
Overall preference for lenses worn WHICH ONE IS BETTER? University patients were highly symptomatic Both lenses improved their symptoms and clinical signs Delfilcon A was slightly better % of subjects 90 80 70 60 50 40 30 20 10 0 81,6 78,8 76 18,4 13,2 15,8 7,9 7,9 0 PC UC Global Sites Initial Lenses DA DTO Private practice patients showed low to moderate eye dryness Nelficon A lenses failed to improve their symptoms Delfilcon A lenses improved significantly their symptoms 22% increase of comfortable hours of wear (7.6/11.9 to 10.7/12.3) CLDEQ TOTAL score by lens worn CASE NO.1 CASE NO.1 M.H. Afro-American male of 24 years old Consults for contact lens discomfort bougth his last supply through internet Is wearing bi-weekly disposable lenses on a monthly basis, overnight wear a few times /month Smokes Non compliant with lens care, switch solutions all the time (cost issue) CAUSE Interaction between lenses and care regimen Risk factors: overwear / chemicals from solutions / smoking / age (< 25 y.o.)/ gender Management Adapt a lens to the patient not a patient to a lens Work on modifiable risk factors In this case: daily disposable (SiHy for overwear) advise to cease smoking Cost could be an issue Refractive surgery as an option 1-Kislan, 2010; Szczotka-Flynn, 2007b 2-Holden, 2001; Jalbert, 2001; Morgan, 2005b CASE NO. 2 CONTACT LENS-ASSOCIATED INFILTRATIVE KERATITIS (CLAIK) AND MULTIPURPOSE SOLUTIONS S.Y., Caucasian female of 34 y.o. Is working on computer 8h00 /week Fitted in contact lenses 4 years ago- went well until the last 6 months Recurrent episodes of c.l. intolerance, eye redness lasting x 1 week Self-medicated with OTC topical antibiotics Fitted with senofilcon A lenses, is using polyquad-based solution Slit lamp: multiple corneal infiltrates CAUSE Association between SiHy lens materials and infiltrates 1 or other adverse events 2 CLAIK presents as sterile with small, superficial, granular infiltrates and may or may not be accompanied by symptoms 6
Carnt NA et al. Contact Lens-Related Adverse Events and the Silicone Hydrogel Lenses and Daily Wear Care System Used. Arch Ophthalmol. 2009; 127 (12): 1616-1623 1 CLAIK Galyfilcon A = Advance; Senofilcon A = Oasys; Balafilcon A = Purevision; Lotrafilcon B = O2Optix; Lotrafilcon A = Focus Night N Day OPTI FREE RepleniSH MPDS users had on average a 6% incidence per patientmonth of CIEs. A hydrogen peroxide based solution, CLEAR CARE Contact Lens Cleaning and Disinfecting Solution, had the lowest incidence of CIEs. 2012.02.01-CN4615 DDX CASE NO 3 P.T. Caucasian female of 63 years old Fitted in RGP lenses for > 25 years Consult for reflex tearing and ocular discomfort lasting for a few years Tried many comfort drops, tear substitutes (drops +gels) with no lasting success Tried omega 3s but did not see any improvement. Background of severe arthritis REMEDY. With a lens design modification Source: Sacco, A.J. CL Spectrum, Jan 2011 SJÖGREN SYNDROME (SS) Presence of prolonged symptoms, dry mouth, low tear flow and ocular staining raise suspicion of SS Should SS be suspected, refer the patient to a rheumatologist with the results of specific tests for DE and your opinion AMERICAN-EUROPEAN CONSENSUS GROUP CRITERIA FOR THE DIAGNOSIS OF SS I. Ocular symptoms of inadequate tear production x 3 months Persistent dry eyes, gritty sensation, use of tear supplements >3x/day II. Ocular signs of corneal damage due to inadequate tearing Schirmer s test a <5mm/5 min or positive vital dye staining III. Oral symptoms of decreased saliva production 3 months Dry mouth, swollen salivary glands, frequent use of liquids to swallow dry food IV. Salivary gland histology demonstrating foci of lymphocytes (biopsy) V. Tests indicating impaired salivary gland function (sialography) 41 VI. Presence of autoantibodies (anti-ro/ssa and/or anti-la/ssb) 42 a. Schirmer s test without anesthesia Ann Rheum Dis 2002;61:554-8 7
AMERICAN COLLEGE OF RHEUMATOLOGISTS (ACR) CRITERIA FOR THE DIAGNOSIS OF SS A At Least 2 of 3 Criteria Must Be Present: 1. Positive serum anti-ssa and/or anti-ssb antibody testing OR a positive RF and an ANA titer 1:320 2. Ocular staining score 3 b 3. Presence of focal lymphocytic sialadenitis with a focus score 1 focus/4mm 2 in labial salivary gland biopsy samples ANA = antinuclear antibody RF = rheumatoid factor a. Developed by Sjögren s International Collaborative Clinical Alliance (SICCA) b. Assuming the individual is not concurrently using daily eye drops Arthritis Care Res (Hoboken ) 2012;64:475-87 43 OVERVIEW OF MANAGEMENT OF CHRONIC DE* Short Term Long Term Topical corticosteroids Topical cyclosporine Essential fatty acids Supportive SCLERAL LENSES Oral tetracycline or macrolide antibiotics Lacrimal occlusion Meibomian gland expression Sleep masks/lid taping 44 *Treatments for episodic DE are continued during treatment for chronic DE CASE NO.4 CASE NO. 5 S.P. Latino male of 39 years old Had Lasik surgery 10 years ago Resume contact lens wear 1 year ago to improve intermediate and near vision Can t tolerate them for more than 4h00 per day Complaints of reduced vision at night and eye dryness under certain circumstances Very sensitive eyes during allergy seasons. Can t tolerate lenses at all Caucasian female of 48 y.o. Known for irregular corneas Salzman s nodular dystrophy Fitted with soft MF lenses monthly replacement Can t see well at far and at near Ocular dryness felt with and without contact lenses REMEDY Contact lenses: cause or remedy? CAUSE AND REMEDY with lens design changes CASES NO 4 & 5 SUMMARY RGP scleral lenses Case no 4: Oblate design scleral lens Improves visual acuity Contributes to reduces ocular dryness symptoms Minimizes allergen exposure Compatible with aqueous-deficiency DED (cyclosporine and other medications) Case no 5: Multi-focal scleral lenses or Hybrids Lenses very stable on front of the eye Restore irregular corneal surface stabilizes tear film over it In any patients wearing CL or as a candidate to CL wear Evaluate the ocular surface Assess tear film stability Treat proactively any conditions which could contribute to CLD or DED Track ocular rosacea Try to eliminate risk factors Daily disposable: material /patient dependant Hydrogene peroxide Medication / Tear substitute / Omegas 8
SUMMARY (2) Contact lenses can be a cause of dryness symptoms Multifactorial Coefficient of friction Diameter /overall fit Care regimen / compliance langis.michaud@umontreal.ca Consider scleral lenses All of the RGP benefits with the initial and long term comfort Look for regular corneas patients : different approach 9