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Presentation

A 25-year-old white male patient reported dryness and irritation with contact lenses in both eyes. He had been wearing contact lenses for 8 years, and over the last 3+ years the lenses had become increasingly uncomfortable. At the time of his visit, he could not wear the lenses for more than 6 to 8 hours before discomfort set in, and his eyes felt dry and therefore uncomfortable for the rest of the wearing day. He had been prescribed a variety of artificial tears (which he used frequently), lubricating ointments, topical cyclosporine, even punctal plugs, but nothing sufficiently helped.

The patient had previously been noted to have a nocturnal lagophthalmos and a history of inferior corneal staining that did not resolve with periodic cessation of lens wear. His job required him to drive 3 to 4 hours every day.

Which of the following could have contributed to this patient’s symptoms of dry and irritated eyes?

 
a. Contact lens wear
Please select again. Yes. Symptoms of dryness and discomfort are prevalent among contact lens wearers and are among the most common causes of contact lens intolerance.1 What else might have contributed to the patient’s symptoms?
  1. Richdale K, Sinnott LT, Skadahl E, et al. Frequency of and factors associated with contact lens dissatisfaction and discontinuation. Cornea. 2007;26:168-74.
 
b. Long driving
Please select again. Yes. It is known that visually or intellectually demanding tasks are associated with reduced blink rate and, in some cases, incomplete blinking.1,2 In this patient’s case, driving for long periods of time could result in less frequent or partial blinking and exposure of the ocular surface to evaporative forces, which could exacerbate dry eye symptoms and signs. What else might have contributed to the patient’s symptoms?
  1. Wong KK, Wan WY, Kaye SB. Blinking and operating: cognition versus vision. Br J Ophthalmol. 2002;86(4):479.
  2. McMonnies CW. Incomplete blinking: exposure keratopathy, lid wiper epitheliopathy, dry eye, refractive surgery, and dry contact lenses. Cont Lens Ant Eye. 2007;30:37-51.
 
c. Lagophthalmos
Please select again. Yes. Proper eyelid closure and a normal blink pattern are essential to preventing excessive drying of the cornea and maintaining a stable tear film. Unable to fully close their eyelids, patients with lagophthalmos commonly complain of dry and irritated eyes. What else might have contributed to the patient’s symptoms?
 
d. All of the above
Yes, multiple factors in the patient’s history could cause or exacerbate his dryness problems. Contact lens wear can profoundly impact the tear film of susceptible patients, inducing symptoms of dryness or exacerbating preexisting dry eye. Driving, which requires intense visual concentration, can lead to reduced blinking, which may exacerbate dry eye symptoms and contribute to the inferior corneal staining. Alternatively, the inferior staining could be a manifestation of exposure keratopathy, which, along with symptoms of ocular dryness and irritation, could be attributable to lagophthalmos.
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Examination

 

The patient’s visual acuity was 20/20 in both eyes, but he had a variable refraction that changed by 0.5 to 0.75 D depending on the visit. Anterior segment evaluation was unremarkable. Fluorescein staining demonstrated inferior punctate epithelial keratopathy bilaterally. The tear film breakup time was less than 6 seconds, and lissamine green demonstrated minimal conjunctival staining.

It could be seen during the slit lamp evaluation with fluorescein that tear volume was reduced. The patient’s tear osmolarity was slightly elevated at 318 mOsm/L in one eye and 315 mOsm/L in the other. Corneal topography showed abnormalities consistent with moderate to severe dry eye. Interferometry demonstrated incomplete blink, and a light test with a transilluminator indicated presence of microlagophthalmos. Meibography and tear MMP levels were unremarkable.

Which of the following steps could I take to establish the patient’s diagnosis?

 
a. Continue with contact lens wear and lubricating eye drops
Please select again. No. The patient’s dry eye symptoms could have been induced by contact lens wear. Continuing lens wear and lubricating eye drops would not help determine the cause of this patient’s problem.
 
b. Reduce lens wear time and use lubricating eye drops more often
Please select again. This would not help with diagnosis. Prior to proceeding with management, the cause of the patient’s dry eye should be determined.
 
c. Discontinue contact lens wear but continue with lubricating eye drops
Please select again. This was not the step I took. Although both symptoms and clinical examination suggest the presence of moderate to severe dry eye in this patient, at this point its cause was not clear. Continuing dry eye treatment with lubricating eye drops may confound the diagnosis of this patient’s problem.
 
d. Discontinue contact lens wear and all eye drops
Yes. The patient’s symptoms and clinical examination strongly suggest that he has moderate to severe dry eye, which would explain why he was unable to wear his contact lenses for a full day. However, the question remains as to whether the primary driver of his condition was contact lens wear or his lid closure problems including incomplete blink and microlagophthalmos. Removal of all the confounding factors including the contact lenses and the lubricating drops can help determine the origin of the patient’s problem.
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Diagnosis

The patient followed my instructions and ceased both lens wear and drop use. When he returned after 2 weeks, he reported no significant improvement in his symptoms. Fluorescein examination found punctate epithelial keratopathy still present in the inferior cornea in both eyes.

Based on all clinical findings, what do you think my diagnosis was?

 
a. Age-related dry eye
Please select again. The patient was simply too young for primary dry eye disease secondary to age-related changes in lacrimal gland secretion or tear dynamics.
 
b. Dry eye secondary to incomplete blink
Yes. That no significant improvement was seen when contact lens wear was stopped suggests that the patient’s condition is of ocular rather than contact lens origin. Indeed, the corneal exposure secondary to incomplete blinking can cause thinning of the tear film and lead to dry eye symptoms and inferior punctate keratopathy.1 Microlagophthalmos may contribute further to the keratopathy through increased tear evaporation and ocular surface exposure at nighttime. While this patient was symptomatic during contact lens wear, his low tear volume, persistent exposure keratopathy, absence of other ocular surface diseases such as meibomian gland dysfunction (MGD), and, above all, lack of improvement following discontinuation of contact lens wear all point to incomplete blink and lid closure as the key basis of his symptoms of dry and irritated eyes.
  1. McMonnies CW. Incomplete blinking: exposure keratopathy, lid wiper epitheliopathy, dry eye, refractive surgery, and dry contact lenses. Cont Lens Ant Eye. 2007;30:37-51.
 
c. Contact lens-related dry eye
Please select again. This was not my diagnosis. Contact lens wear could be eliminated as the primary cause of the patient’s symptoms because discontinuation of contact lens wear resulted in no improvement in his symptoms or signs.
 
d. Dry eye associated with blepharitis
Please select again. This was not my diagnosis. In this case, anterior segment evaluation and meibography have found no prominent blepharitis/meibomian gland dysfunction.
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Treatment Regimen of Tear Supplementation

The patient had been using topical cyclosporine for months when I first saw him. Since he saw no significant improvement, I counseled him to discontinue use of the prescription medicine.

Artificial tears can supplement the tear film and lubricate the ocular surface, but the therapeutic effect is typically brief owing to the solutions’ short retention time on the ocular surface. To relieve this patient’s dry eye symptoms while wearing contact lenses would require artificial tears to be taken at a frequency of at least 4 or 5 times per day.

Given the patient’s age and his desire not to use artificial tears multiple times each day, I considered LACRISERT® (hydroxypropyl cellulose ophthalmic insert) a suitable lubrication therapy for him. In most cases, a single daily application of the ophthalmic insert can protect and lubricate the ocular surface to relieve dry eye symptoms.1 Some patients may require twice daily use for optimal results. The insert’s continuous lubricating effect, in my clinical experience, is beneficial for appropriate contact lens patients with moderate to severe dry eye.

  1. Lacrisert [package insert] Bridgewater, NJ: Valeant Pharmaceuticals International, Inc.; 2014.

I prescribed LACRISERT® (hydroxypropyl cellulose ophthalmic insert), and instructed the patient to apply one insert each morning. What else do you think I recommended to this patient?

 
a. A preservative-free artificial tear
Please select again. Yes. The preservative-free artificial tear can be used both as needed for symptom relief during the day and on top of the LACRISERT® insert to help it dissolve. What else do you think I recommended?
 
b. A thick lubricating ointment
Please select again. Yes. Nighttime use of ointments can help reduce corneal exposure and dryness caused by nocturnal lagophthalmos. What else do you think I recommended?
 
c. Rigid gas permeable lenses
Please select again. This was not my recommendation. The patient was able to obtain acceptable comfort and good vision in soft lenses, so I saw no reason to change them.
 
d. Both a and b
Yes. I routinely recommend applying LACRISERT® with a drop of preservative-free artificial tear on top to help start the dissolving process. The patient can also use the artificial tear as needed during the day for extra ocular comfort. Because this patient had microlagophthalmos, nighttime treatment with an ointment is important to help protect the ocular surface from exposure and drying. For patients with moderate to severe dry eye who do not like using ointments, LACRISERT placed in the eye before bedtime can help provide needed nighttime lubrication and protection. But in this particular case, the patient had no problem using ointments at night.
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Treatment Supportive Care

When the patient returned two weeks later, he reported that his eyes felt better throughout the day. Slit lamp examination showed less inferior corneal staining. The patient then tried several different lens types and was successfully re-fit into the lens that provided the most comfort and best quality of vision.

I instructed the patient to continue his lubricant therapies—LACRISERT® (hydroxypropyl cellulose ophthalmic insert) in the morning with a drop of artificial tear on top, a nonpreserved artificial tear to be used as needed during the day, and a lubricating ointment at night. In addition, I counseled him on strategies to minimize or eliminate factors that have the potential to exacerbate his condition. These strategies included making a conscious effort to blink while driving and turning cooling or heating vents away from his face.

What else do you think I recommended to this patient to help improve his symptoms?

 
a. Omega-3 supplement
Yes. Omega-3 fatty acids have been found to be of benefit to patients with dry eye, potentially through their antiinflammatory activities and effects on tear production.1,2
  1. Wojtowicz JC, Butovich I, Uchiyama E, et al. Pilot, prospective, randomized, double-masked, placebo-controlled clinical trial of an omega-3 supplement for dry eye. Cornea. 2011;30(3):308-14.
  2. Rand AL, Asbell PA. Nutritional supplements for dry eye syndrome. Curr Opin Ophthalmol. 2011;22(4):279-82.
 
b. Warm compresses
Please select again. This was not my recommendation. The patient had no clinically significant eyelid disorders such as MGD; there was no indication that he would benefit from warm compresses.
 
c. Vitamin A supplement
Please select again. This was not my recommendation. There is no evidence that vitamin A deficiency contributed to this patient’s condition.
 
d. None of the above
Please select again. I recommended one of the listed therapies to this patient.
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Management after Lens Refitting

The patient returned one month later for follow-up, reporting few changes in symptoms or contact lens wear time. I considered this an indication for advancing his treatment regimen to include therapies that increase tear retention.

While the patient continued with the lubricant therapies, I put in punctal plugs in both eyes and, later, added an eye mask for him to sleep in at night to help the eyes remain closed and moist. By the time he returned again, he had noticed a significant improvement in both symptoms and contact lens wear time. Fluorescein examination found less inferior punctuate corneal staining in both eyes.

Over the next few months, the patient reduced his artificial tear use and eventually was using only LACRISERT® (hydroxypropyl cellulose ophthalmic insert) in the morning for lubrication and an ointment at night to protect against lagophthalmos. He was regularly getting more than 8 hours of comfortable wear from his contact lenses, something he had not experienced in the previous 3 years.

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Jack L. Schaeffer, OD, FAAO

Jack L. Schaeffer, OD, FAAO President, CEO, and chief of optometry at Schaeffer Eye Center in Birmingham, AL & consultant for Bausch + Lomb.

Indications and Usage

LACRISERT® (hydroxypropyl cellulose ophthalmic insert) is indicated in patients with moderate to severe dry eye syndromes, including keratoconjunctivitis sicca. LACRISERT® is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. LACRISERT® is also indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.

Important Safety Information

  • LACRISERT® (hydroxypropyl cellulose ophthalmic insert) is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose.
  • Instructions for inserting and removing LACRISERT® should be carefully followed.
  • If improperly placed, LACRISERT® may result in corneal abrasion. Because LACRISERT® may cause transient blurred vision, patients should be instructed to exercise caution when driving or operating machinery.
  • The following adverse reactions have been reported, but were in most instances mild and temporary: transient blurring of vision, ocular discomfort or irritation, matting or stickiness of eyelashes, photophobia, hypersensitivity, eyelid edema, and hyperemia.

To report suspected adverse reactions, contact Bausch & Lomb Incorporated at 1-800-321-4576 or FDA at 1-800-FDA-1088 or FDA.gov/medwatch.

Click here for full Prescribing Information

Indications and Usage

LACRISERT® (hydroxypropyl cellulose ophthalmic insert) is indicated in patients with moderate to severe dry eye syndromes, including keratoconjunctivitis sicca. LACRISERT® is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions.

Important Safety Information

  • LACRISERT® (hydroxypropyl cellulose ophthalmic insert) is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose.
  • Instructions for inserting and removing LACRISERT® should be carefully followed.

Important Safety Information

LACRISERT® (hydroxypropyl cellulose ophthalmic insert) is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose.