Contact lens intolerance (CLI) can hold a different meaning to each patient who experiences its uncomfortable symptoms. For some patients, CLI may mean poor vision, and for others, it might mean extreme dryness, irritation, and discomfort. For all patients who experience CLI, the pain and inconvenience may lead to a cessation of contact lens wear, and a return to glasses—which is not an ideal situation for either doctors or patients.
Intolerance can be an immediate reaction to wearing contacts due to a poor fit or the lens material itself. Conversely, it can also impact patients who have been comfortably wearing lenses for months or years with the advent of recurrent dry eye flares or other ocular surface insults (i.e. past trauma, Demodex infestation, systemic inflammatory disease such as rheumatoid arthritis).
Some patients experience occasional, or transient, intolerance while others encounter moderate to severe discomfort which could cause them to no longer wear contact lenses. In a study conducted to determine first-year retention rates and to identify factors associated with dropout for patients fitted with contact lenses, consecutive records for 524 patients at 29 sites were reviewed.1 After 12 months, the retention rate was 74%, and of the 26% who dropped out, 25% discontinued within the first month and 47% dropped out within 60 days due to poor distance vision, poor near vision, discomfort, and handling problems. A significant number (32%) discontinued use for unknown reasons, which tends to mimic what many optometrists see based on informal or anecdotal feedback. A literature review by Pucker and Tichenor found that contact lens dropout rates across developed countries are between about 12.0% and 27.4%.2
Given that the number of contact lens wearers age appropriate for refractive surgery is about 41.4 million and 20% of contact lens wearers drop out and 74% of those patients resume wear,2 about 2.1 million patients with contact lens intolerance are ideal candidates for laser vision correction.
Contact lens intolerance can cause a level of frustration for optometrists who count on contact lenses and solutions as a reliable source of revenue for their practices. However, there are opportunities to look at these cases through another lens (pun intended). Exploring alternatives to contact lenses can yield positive benefits such as strengthening patient relationships, new referrals, and potential co-management partnerships between optometrists and ophthalmologists. From a business perspective, these collaborations could benefit both parties by increasing surgical and optical volume.
The key to transforming contact lens intolerance into a positive solution for both your patients and your practice often relies on a conversation.
The key to transforming contact lens intolerance into a positive solution for both your patients and your practice often relies on a conversation. While this may sound reductive or over-simplistic, quite the opposite is true. As science and medicine increase in complexity, patients are more dependent upon the professional advice of their eye care providers (ECPs) to make sense of their options. Knowing how to talk to patients about their visual needs can be a difficult discussion at times, especially—telling them they may not be good candidates for contact lens wear moving forward. It is critical to deliver this information in a clear, honest, and concise fashion to turn a frustrated patient into one who entrusts the ECP to build custom solutions to their given situation.
Why does contact lens intolerance occur?
The causes of contact lens intolerance are multifactorial in nature and can be related to either the contact lens itself or the environment,3 including mechanical and physical reactions to lens packaging solutions, improper care or wearing regimen, lens materials, poor fit, papillary conjunctivitis or corneal neovascularization, and new medications, to name a few. For example, reduced lens movement and a tighter fit can be associated with decreased comfort with the added wrinkles of lid wiper epitheliopathy and lid-parallel conjunctival folds.4
The two main factors that tend to drive more chronic symptoms leading to long-term contact lens intolerance are 1) increased friction and 2) uneven or insufficient tear distribution due to contact lenses. Discomfort may also be related to factors such as protein adsorption to the contact lens material or friction during blinking, especially between the front side of the lens and the inner eyelid. All of these factors should be considered when seeing a new contact lens patient for a follow-up appointment with respective modifications made based on case presentation as some—such as care, fit, and wear—are likely treatable.
Furthermore, both localized and systemic allergic reactions are another cause of contact lens intolerance. Contact lens-induced papillary conjunctivitis (CLPC) is a common ocular allergic disease in contact lens wearers. With increased severity, this condition can cause giant papillary conjunctivitis, resulting in contact lens intolerance and the need to discontinue contact lens wear. Antihistamines can add more complexity to the mix for patients who suffer from systemic and ocular allergies since these medications are known to cause dry eye symptoms that may amplify contact lens intolerance.5
When you suspect a patient may have contact lens intolerance
One of the best ways to determine how your patients are faring with contact lenses is to simply ask how often they wear their lenses and gain insight on more specific details about their wear patterns and habits, according to Sonny Goel, MD, who specializes in LASIK, PRK, and SMILE laser eye surgery in his practice, Goel Vision
, in Towson, Maryland.
“When I find out a patient wears contact lenses, I ask them right away how long they wear them every day,” said Dr. Goel. “Is it from morning to night, and if not why? If they only wear them for a few hours or to social occasions, I ask them what their symptoms are. Then we can drill down and determine if they truly have some intolerance.”
Next, Dr. Goel performs a clinical examination looking specifically for certain signs of contact lens intolerance.
“Many times, after ascertaining that a patient might not be having an easy time with their contacts, we’ll see signs of dry eye or giant papillary conjunctivitis, which can cause intolerance,” said Dr. Goel. “Other times I’ll see a keratitis that a patient may not even know they have—they just kind of push through because they don’t know what normal feels like.”
Dr. Goel emphasizes the importance of asking specific questions and listening to patients’ answers, as many may not know what a benchmark “normal” is like for contact lens wear.
“It’s only when you talk to patients about the fact that they shouldn’t be having the issues they’re having in their eyes that they start to understand that their symptoms aren’t normal.”
Dr. Jeff Augustine, OD, FAAO, of ClearChoice LASIK Eye
in Cleveland, Ohio acknowledges in his clinical experience that at least a third of the patients that come through his clinic for refractive surgery have issues with contact lens intolerance.
“A lot of times, after years of wear, patients become intolerant to contacts, secondary to the transient or more chronic dryness6 a patient might go through as they age,7” said Dr. Augustine. “Plus it’s also the frustrations with other things like toric contact lenses and rotation, the cost of contact lenses over time, and the annoyance of patients who are presbyopic and are tired of the inefficiencies of a multifocal lens. Additionally, some patients suffer from allergies that prevent them from wearing contacts, but they also don’t want to return to glasses.”
Are new lenses, artificial tears, and supplements the answer to contact lens intolerance?
In many instances, patients make an appointment to talk about alternatives to contact lenses, they have been dealing with discomfort for some time. Many will have already tried supplements, daily disposable lenses, ocular steroids, immunomodulation, intranasal nicotinic acetylcholine receptor agonist, and artificial tears, as these solutions are often the first approach a clinician may take to solve the patient’s contact lens intolerance.
“By the time a patient comes into either their OD or for a surgery consultation, they’ve already self-selected themselves for having a problem,” said Dr. Goel. “They’ve most likely already tried different brands of contact lenses and different types of cleaning solutions, because these are the logical first steps a provider would recommend.”
When talking to a patient about their contact lens intolerance, compassion and understanding of their discomfort is an appropriate first step, which also opens the door to discussing solutions to their problem, whether these are initial solutions, such as new contact lens materials, drops, and supplements—or a more long-term solution that eliminates the need for contact lenses completely.
Solutions to contact lens intolerance for patients who don’t want to wear glasses
Over the past two decades, laser vision correction (LVC) has emerged as a viable alternative to contact lenses and glasses to treat refractive error, including myopia, astigmatism, and hyperopia. Typically, during LVC, the cornea is reshaped according to refractive error. Phototherapeutic refractive keratectomy (PRK) was approved by the FDA in 1995 to reshape the anterior curvature of the cornea.8 The procedure begins with applying a diluted alcohol solution that acts to loosen and remove the corneal epithelium with a brushing action. An excimer laser treatment is then applied to the exposed stromal bed to reshape the cornea and correct vision. Following surgery, patients may experience some irritation, tearing, burning, and light sensitivity, often requiring short-term medications (can include: topical NSAIDs and/or oral pain meds depending on surgeon recommendations, as well as topical antibiotics and steroids). Additionally, most surgeons also use a bandage contact lens to help with comfort and promote corneal epithelial wound healing.
Laser in situ keratomileusis (LASIK) remains the most commonly performed laser vision correction procedure in the US, following its FDA approval in 1998. During a LASIK procedure, the technique creates a corneal flap using a femtosecond laser, which is then lifted and folded back on the hinge side. An excimer laser is then used to reshape tissue by ablating the underlying exposed stromal bed, followed by the corneal flap carefully being placed back into position while smoothing the edges.9
Most patients tend to be comfortable after the LASIK but may experience itching, scratching and/or burning sensation, which can symptomatically improve rapidly within the first few days post-op. During the first week, patients should be conscious of eye rubbing and may need to reduce activities of daily living to reduce the likelihood of flap displacement.
Transient post-LASIK dry eye is the most common postoperative dry eye condition following ophthalmic surgeries.10 The symptoms typically last for about a month following LASIK surgery, but a small number of patients continue to experience symptoms for more than a year postoperatively.8 As a result, LASIK is generally not recommended for patients with thinner corneas or with dry eye disease (DED) unrelated to contact lens use. Once again, this is where refractive surgeons rely on their relationship communicating with optometrists to learn more about the nature of a patient’s dry eye symptoms to ascertain if it is transient or chronic.
A couple of quick questions may flesh out the patient’s contact lens related issues:
- Does removing contact lenses from the equation alleviate their dry eye?
- Does contact lens irritation worsen at or near the end of the day?
- Are their symptoms caused by meibomian gland dysfunction, persistently unstable and/or deficient tear film causing discomfort and/or visual impairment, accompanied by variable degrees of ocular surface epitheliopathy, inflammation and neurosensory abnormalities?11
What is SMILE and how does it address refractive error in myopes?
In 2016 and later in 2018, the FDA approved the use of small incision lenticule extraction (SMILE), a minimally invasive procedure, which can correct refractive errors, such as myopia and compound myopic astigmatism, respectively. In the initial clinical trials for approval of SMILE for spherical myopia, 99.7% of eyes achieved 20/40 or better UCVA at 6 months postoperative, and 87.5% had 20/20 or better UCVA.12 Similarly, in data supporting FDA premarket approval, which included both spherical and astigmatic corrections (NCT02430428), 98.6% of eyes achieved a UCVA of 20/40 or better, and 84.2% had 20/20 or better UCVA at 6 months.10 Unlike LASIK, SMILE only requires a small incision rather than a flap; and unlike PRK, visual recovery is quick along with the potential for re-innervation of corneal nerves. Currently, more than 6 million eyes have been treated by SMILE globally. To date, the procedure has been featured in more than 700 peer-reviewed articles.13
SMILE uses a femtosecond laser—an ultrashort-pulsed, near infrared laser—which leverages micro-photodisruption to cut at precise and predefined positions and depths within the cornea (the same type of laser is often used in LASIK procedures to create the flap—only with SMILE no flap is needed). The laser’s high peak intensity over a short pulse duration (within a few femtoseconds of time) allows it to harmlessly pass through the upper layer of the cornea while creating micro-precision single holes that form minute cuts in the underlying corneal stroma. The surrounding tissue remains unaffected, and in less than 30 seconds, the laser creates a small, lens-shaped piece of corneal tissue (called the lenticule) inside the cornea. The surgeon then removes the lenticule through a 4 to 6 mm small incision in the outer area of the cornea. This reshapes the cornea and corrects the refractive error.
About 2.1 million patients with contact lens intolerance are ideal candidates for laser vision correction.
How to begin a dialogue about refractive surgery
At ClearChoice LASIK Eye, the ophthalmic surgeon and co-managing optometrist in the practice show all patients a booklet which outlines the features and benefits of PRK, LASIK, and SMILE. Patients are then given a brief description of each procedure and which surgery might be best suited for them. Subsequently, an honest conversation ensues to review the pros and cons of the various techniques between the patient and ClearChoice Team to align the patient’s goals to realistic potential surgical outcomes.
“I use illustrations to show a patient the basic techniques behind PRK, LASIK, and SMILE,” said Dr. Augustine. “Then, I suggest which procedure would be best for their particular refractive error, eye anatomy, corneal thickness, and so on. For example, if the surgeon believes the patient would be most successful with SMILE, I’ll let them know that we’ve seen fewer cases of transient dry eye after SMILE compared to PRK and LASIK and that there is less of a chance of needing a secondary procedure after SMILE,14,15 because it’s a closed system that facilitates rapid biological healing. I’ll also tell them what they can expect in terms of both pre- and post-op steps they will need to take.”
In terms of determining which type of refractive procedure is best for your patient, Dr. Augustine believes that optometrists are integral to opening the conversations that will eventually include a surgeon. While the surgeon will make the ultimate decision about which procedure is ideal for each patient, optometrists play a critical role in preparing patients for the questions to ask and what potential options may be presented to them.
“A surgeon doesn’t want a doctor telling a patient they are a good candidate for a procedure if they may not be, because the patient could be disappointed,” said Dr. Augustine. “At our surgery center, we would rather have the referring doctor be neutral about the solutions available and wait until all the diagnostics are complete before a surgical determination is made.”
What are the advantages of the SMILE procedure?
- Flapless procedure
SMILE laser surgery is a flapless and minimally invasive form of LVC. In fact, the laser is used for only about 30 seconds, and the opening created is about 4-6mm. The entire procedure only takes about 10-20 minutes from start to finish, including the removal of the lenticule.
- Fewer dry eye symptoms
SMILE could lead to a potentially lower incidence of dry eye syndrome.16 Compared with the femtosecond laser used in LASIK procedure, fewer corneal nerves are disrupted with SMILE, which may lead to fewer postoperative dry eye symptoms.
- Faster recovery
Your patients’ vision should stabilize within a few weeks of the SMILE procedure, allowing patients to return to their normal activities quickly, including exercise and wearing makeup.
- Extensive research
Over 6 million SMILE procedures have been performed globally,17 and more than 700 peer-reviewed papers about SMILE have been published.18
Comparison studies between laser in situ keratomileusis (LASIK) and SMILE have highlighted significant advantages of SMILE, such as minimal to no flap-related complications19 and possibly better corneal biomechanics.20,21 SMILE has demonstrated safety, efficacy, long-term stability, and improved contrast vision similarly to LASIK.22
“If I talk to patients about surgical options for contact lens intolerance and they fall within the parameters of SMILE, then we’ll talk about the advantages, including the smaller incision, no need to cut a flap, and therefore, potentially less risk of transient dry eye,”23 said Dr. Goel, “One of the big take home messages they love is that there’s no flap, meaning that with no risk of flap movement, and they are back to their regular activities the very next day. They can hit the beach, the pool, the gym, and even wear eye makeup. All the things they do on a regular basis.”
In published research, SMILE led to fewer indications of transient dry eye disease, and may be preferred over LASIK in cases where a patient has mild dry eye preoperatively.24 In one meta analysis that covered 5 trials that compared SMILE surgery to LASIK, tear breakup time (a method of determining the stability of the tear film by measuring the number of seconds that elapse between the last blink and the appearance of the first dry spot in the tear film) the SMILE group significantly exceeded that in the LASIK group at 1- and 6-month follow-ups. Additionally, the ocular surface disease index (OSDI) scores were lower and more favorable in the SMILE cohorts. No significant difference was found in tear osmolarity and Schirmer tear test (STT) scores between the two groups.25
In terms of preserving corneal biomechanical strength after surgeries, SMILE was superior to either FS-LASIK or LASIK, while comparable to PRK based on the results from ocular response analysis (ORA). ORA measures corneal hysteresis (CH), which is an indication of the biomechanical properties of the cornea. This information is different from thickness or topography, which are geometrical attributes of the cornea. CH represents a measurement of the corneal tissue’s elasticity, which provides more comprehensive information about ocular biomechanics.26,27
What are the advantages of SMILE compared to other laser procedures?
Over 1,400 clinics and more than 2,500 practicing surgeons worldwide currently use SMILE, and millions of eyes with a wide range of myopia and/or compound myopic astigmatism have been corrected with SMILE in over 80 countries.28 Currently, SMILE is FDA-approved to correct refractive errors from -1.00D to -10.00D with or without the presence of astigmatism from -0.75D to -3.00D.
“Virtually 100% of my patients who qualify for SMILE will have SMILE,” said Dr. Goel. “That’s about 80% of my practice, because the 20% who don’t have SMILE performed is because they don’t qualify for certain reasons. My patients who can’t have SMILE fall into about 15% LASIK and 5% PRK.”
“In terms of myopes—who may or may not have up to 3 diopters of astigmatism —and need myopic correction, my go-to has been SMILE for the last six years,” said Dr. Augustine. “It’s one step. One laser. Also, post-operatively, the patients seem to have fewer transient dry eye symptoms affiliated with SMILE because no flap is created. It’s a closed system, so there’s less healing required and a lower chance of a patient needing a secondary procedure compared to LASIK.14,15 Plus, I find with SMILE that patients can resume normal activities like working out and wearing makeup quicker, and the recovery is very swift.”
In fact, during the first year after SMILE treatments, a U.S. military center demonstrated positive early postoperative outcomes. Of 563 treated eyes, 173 underwent SMILE, 304 underwent PRK, and 86 underwent LASIK. In comparing SMILE with PRK 1 month postoperatively, 87.9% of SMILE patients attained uncorrected distance visual acuity (UDVA) >20/20 more than PRK (73.8%). In assessing SMILE vs LASIK, all parameters were comparable, even at 6 months postoperatively.29
The patient experience is another key area in which SMILE differs from other types of refractive surgeries. In order for femtosecond lasers to make precise cuts, the cornea must first be forced into a defined shape and the femtosecond laser must use either a flat or curved patient interface design to achieve applanation. When flat and curved patient interface designs were compared in 46 patients, flat patient interfaces gave rise to higher IOPs, whereas the curved patient interface caused lower IOPs in response to attachment and suction.30
The importance of collaborative care
Surgeons understand that optometrists know their patients best through regular appointments that emphasize primary care of vision and eye health. While surgeons have a unique role in identifying an optimal procedure for a patient, they often rely on optometrists to learn more about the subtle nuances of a patient’s case that may positively or negatively impact a surgical outcome. An ideal relationship between optometrist and surgeon is one that encourages mutual respect and an understanding about the boundaries of each role. Like any healthy partnership, collaborations between optometrists and surgeons succeed to the degree that information can be freely shared.
“I invite optometrists to spend time with me, watching a SMILE procedure,” said Dr. Goel. “I also encourage them to watch a LASIK procedure to see the differences. The first thing that they notice is that they aren’t seeing a flap in SMILE procedures. If that patient is their patient, they’re also not seeing the symptoms with SMILE that they typically see postoperatively with LASIK. Once they see the proof in the pudding and they see the results, that’s when they’re really on board with SMILE.”
Completing the loop on contact lens intolerance
Contact lens intolerance can have a profound impact on patients, specifically their aptitude for intermittent to permanent dropout and ultimately seeking a surgical consult as a potential alternative. It is the role of the ECP to determine the best course of action based on the case presentation. In the end, the goal is to empower patients to take an ownership stake in their care to optimize vision, whether it is glasses, contacts, or surgical intervention.
Drs. Goel and Augustine have a contractual or paid relationship with Carl Zeiss Meditec, Inc. and may have received financial support.